Aproaching March Madness

KK asked me this morning what had happened to my voice. I replied that my voice is recovering from yelling myself hoarse from last night's MSU win over Indiana University at Breslin. MSU played a terrible first half: many turnovers resulting in IU points. At half, IU was ahead by 10 points in a low scoring game. IU had previously beaten MSU at Bloomington by 20 points. MSU needed this win to cement an at-large bid for the NCAA tournement this March although MSU had a signature win over then nationally #1 ranked Wisconsin this last Tuesday. Saturday was "game day" on ESPN with taping beginning at 9:30AM and ESPN with its familiar crew televising live the game itself beginning at 9 PM. KK and I arrived more than a hour early. Immediatedly next to the stairs leading to our nose-bleed bleacher seats, there they were, the ESPN crew prepping and preening infront of the still "on hold" TV cameras. We would see this same setup and crew at the end of the game as they took several "takes" prior to broadcast. At court side, with the play-by-play were Dick Vital and Amy and ... a host of other somewhat knowledgable game analysts. What I saw during the game did not match the commentary of the game by the play-by-play. Dumb plays, bad referee calls: fouls called and not called; but the game as commented upon were the blocked shots, dunks, the shooting and makes, the fans, coaches' and players reactions after shots made, missed, or turnovers. The game I saw was played in the trenches, big men blocking out big men, rebounds fought for, guards rounding screens to get an open shot, balls popping loose from player's hands as they were hacked, elbowed, pushed, moved out of position. Inspite of the bumping and grinding, shots were made; game changing blocks, rebounds, foul shots happened. Fatigue was visible. Star players displayed the joy and elation after a shot or block or steal made. Individual players or coaches sense of disgust was visible after a foul. Anger at the referee for not calling a foul; booing by the crowd; disbelief at what was or was not seen. A hushed quiet (with a few cat calls by scattered IU fans) when MSU went to the foul line. The home crowd yelling and waving arms in the line of site when IU players went to the foul line. Cheers at a miss by IU, "air ball" when IU failed to hit the rim during a shot. Taunting of the player when they touched the ball again "air ball, air ball" until the IU player hit a shot to break the "spell". So the game that I saw, had ebb and flow; streaks of mastery, streaks of one dumb play after another on both team's part. In the end, lock down defense by MSU force IU into poor shot selections; fatigue, as evidenced by jump shots falling short, hitting the front of the rim; throw away passes; panic, when doubled teamed at the end of the game. All the while, there was the din of the student sections: the entire lower bowl filled with students in white tee shirts (white out), all but the seats behind both players benches and scorers table, the "Izzone" (named for coach Tom Izzo), and the entire middle section of the Breslin Students Events Center upper bench seats in the nose-bleed sections KK and I were seated next to, chanting "MSU, MSU,MSU", singing the MSU "Fight Song" lead by the Spartan Brass Band (30 strong), and there I was singing and shouting at the referees and players who made turnover after turnover, clapping and yelling my approval when a play was made. Towards the end of the game, I had lost my voice. KK told me she would be very angry with me if I had allowed myself to become so excited as I precipitated a heart attack. My head and body were certainly into this IU game as well as the one earlier in the week against U of Wisc. I was reassuring myself that I had had, at least on preliminary results, a good stress test the week before, and was in "better than average fitness for a man of my age". So. It is better to go to the game, even in the nose-bleed section, requiring binoculars at times, than to sit at home, watching tunnel vision segments of the game, the ambiance broken by advertisements, with commentators and analysts saying narry a disparaging word towards a referee or coaching or player's mistake. The shear totality of the experience of being there: alive. Even the walk from the parked car to Breslin and then back again. KK and I talking on the way in, anticipating various players "stepping up" and afterwards, walking back, the plays that were made and not made, the coaches comments after the game, and the general feeling of excitement and relief that there was another victory. I spoke last nite with my hoase voice.

Children in America

In the newspaper today there is an Associated Press report on UNICEF's "An overview of child well-being in rich countries." RJ had sent to me the link to the complete report yesterday. I have had a chance to read the 52 page report as the well-being of children has been a life long focus of myself. The AP article was the summary of the first page of the UNICEF report which ranked and gave a report card on 21 nations, those who were in the European Union plus USA, Canada, Iceland, Japan and New Zealand. Several of the former "Eastern Block" countries were given a different heading and ranked in that heading.

Almost any activity which raises myown and the public at large awareness of how to improve the health and well-being of children is a good thing in my book. What I liked the most about this report were the individual questions which were solicited and how an individual country was ranked for each of these questions. Taking the categories in aggregate as reported by AP on the summary first page obscured some of the most important, and addressable (such a word?) issues. The first word that popped into my head as I was reading this report was "Standard Error"; the statistical reflection of how widely divergent the country's reponses to individual questions were in ranking within the same category.

For instance in the Dimension of Children's (0 to 19 years of age) Health Behavior, accounting for eating habits in childhood and adolescence as indicators of both present and future health, the overview has the Netherlands second from the top (good) and the USA being at the very bottom (bad). Several of the individual questions in this category: Mean number of days on which young people reported being physically active (good), the top three were: Ireland, Canada, and USA; and the lowest ranking on the question about being overweight (bad) were: Spain, Canada, and USA. Are these questions, although in the same category, linked? Or do they each reflect some information not easily generalizable?

The large standard error of this category made me query the more indepth reasons for these differences. What I know fairly well, and I am sure most of you have read something about this issue, that obesity in the USA is not homogeneous within our population. Rather, obesity in children is primarily an issue first: Hispanic young women, second: African-American young women, and third: rural Caucasian young women. Physical activity, although the lack of it has been associated with obesity, is primarily a domain of very young children, then there is gender and age separation with boys remaining active as they grow older and young women not.

Therefore the value of this UNICEF report to me is, is to prompt further inquiry, decipher the target population within our country that needs intervention, develop unique strategies for each of the targeted populations at risk, then lobby for and direct the limited resources towards the targeted populations. We know a lot about the "why" in these ethnic categories. In general, the individual questions serve as a template for further inquiry. These categories in and of themselves are but stepping stones across a rather large river of children's issues.

The other overaching impression I got from this report: there are profound differences in the degree of diversity of the populations in the listed countries. The USA has the largest, in terms of percentages, and diverse population. The United Kingdom has a large diverse population, think London and Manchester (at least for this study since the data was for England and not Wales, Scotland). The Northen European countries are highly homogeneous (language, culture, ethnenticty, government) compared to the UK & USA. To me this means, that identifying and targeting populations for intervention will be more efficacious than a one shoe fits all approach. Of course, this mean to some extent racial, gender, geographic profiling; not a politically correct concept. This also means that immigrant populations who come legally or illegally, many from Mexico and Central America, require visibility as well as aculturation to become included into the solution.

I close by saying: "the success in achieving a goal, is to measure its outcomes." (somebody other than myself must have said this although I can't for the life of me remember who)

What do you think?

The Difficult to Treat

Yesterday I met for 2 hours with the "smoking cessation counselor" at the free clinic and found out that that position was being eliminated for financial reasons. The counselor and I talked about her experiences at the clinic and how they mirrored those she experienced in her teaching at an urban charter school, as well as dealing with a familly member whose child has asthma. She reflected that exhortations to "being strong" failed to improve people's lives when the parent lacked life and parenting skills, was seriously depressed, did not or could not bond with their child, used illicit drugs, smoked cigrettes, set their needs above those of their child.

Access to health care was not the primary problem. What appeared to be the problem was the inability to utilize health care: ie, not taking medications, disregarding what was recommended, suspicious of other's motivations, concealing information which made the parent appear to be "bad"; almost as if the parent was aware of what was the right thing to do, but had failed to do what was correct. The counselor described situations that were dysfunctional, and, basically, they appeared to me to be situations where the parent had to change their own behavior to improve their child's health. The child with asthma, because it is a chronic and life long condition, (one does not outgrow it), had medications that were to be given every day whether the child appeared to need them or not. The parent of the child confided to this relative, that she would tell the health care provider that she was giving the medications regularly and that they were not working, when infact, the parent would stop the medications as soon as she believed the child was better. Because the child would have another asthma attack, some of which are very frightening to observe, the parent would take the child into the health care provider for an unscheduled office visit and obtain treatment. After several of these unscheduled office visits, or emergency room visits or even hospitalizations, the health care provider contacted the pharmacy where the parent had said that the prescriptions were filled, and found that either the prescriptions were not filled at all, or were never refilled as recommended. Once the parent was confronted, the parent took the child to another health care facility lamenting how the previous doctor did not know what they were doing. And so the cycle would start again. Each time the parent would keep the child out of school to keep the child from getting sick, or when sick; changing schools; going to a charter school because the public school system "did not know what they were doing"; asking relatives for money so that the parent could move to a warm climate for the sake of the child's health (which of course is a falicy since asthma is just as common and difficult to treat when you don't take one's asthma medications in Hawaii as it is in Minnesota and people who move from cold environments to warm ones do not get better until they actually begin taking their medications every day as prescribed). The counselor reflected how the patients served by the free clinic, those children whom she tried to teach at the charter school, and her own relative were so similar and that one intervention such as smoking cessation, without the other components like health care and its educational component, drug rehabilitation, psychological therapy, parenting and life skills instructions, and a change in how one viewed the health care establishment were all necessary before there was a discernable impact on the child's health.

In my 30 years of practice, these are the difficult to treat patients and require a team approach. Hopefully with a comprehensive approach, the parent will buy into the need for change in their lives, and will make the changes in their own behavior for the benefit of their child; they understand that they must view the child and his/her needs and safety as a parental priority, and not focused upon themselves.I hope a comprehensive approach to the treatment of the child with asthma can be provided when KK and I are at the clinic; otherwise, this will be just another revolving door and dissatisfaction on everyone's part.

What do you think?

The Journey into health care

The journey into retirement means that one does not stop being a doctor, just that one's role as a doctor changes. Both KK and I have our commitment to servicing the difficult to treat. However, on another level, the time available during retirement affords one the opportunity to participate in areas of medicine that previously I was too busy to participate in. Namely, in the politics of medicine and the organized medicine role. The issues of preserving the intimacy of the doctor patient relationship, with the reality of who is going to pay for that relationship and its outcomes, requires a mindset and availability of time to devote to those issures. So, I have been on the "legislative committee" of our county and state medical society for years; interacting with state and national legislators regularly. Now, I have been asked to become one of the State House of Delegates at our State annual meeting. Essentially, this is a process of formulating policy and framing issues that will have national importance. In this era of the question of who is covered by health insurance, and what will it look like, seems to me to be an appropriate time for me to spend the time and effort to use my experiences and provide a framework within which such a debate can occur. I remember well when Hillary Clinton proposed a national health plan and then she proceeded to do the most expensive and least effective thing regarding her own father who had had a stroke and died after weeks in an intensive care unit on life support equipment. What was clear to me at that time, that she would do what other families did, leaving dear old dad in the ICU, on mechanical ventilator, until family members felt comfortable in "letting him go." Everything had been done inspite of clinical evidence that he was gone way before the "family" was willing to let go. There are many other instances where these decisions are relavent. Fully 80% of the health care dollars are spent on the last 6 months of life. What are we doing? Depriving adolescent girls of the Human Papiloma Virus vacination, which will save MILLIONS of women from cervical cancer, sterility, etc. and spending it on dear old dad at the terminal end of his life. The issues are out there. One does not have to go looking for them. These issues come up at the oddest of times and for many times obscure reasons; however, the issues come up, and being poised to address them requires slogging through the mundane and the "business of medicine" issues and being ready to address these more universal and holistic issues once they emerge. We will see what comes of this State meeting. Maybe something will be on the Presidential election 2008 agenda regarding universal health care coverage, or just a footnote in the history of medicine. In either case, I will make myself available for the debate; for, it is only when the groundswell of an issue comes to the fore, that those who are available can make a contribution.

Winter when it is sunny presents contrasts

You can generally see objects better when there is contrast. Such is the case today. The tips of the trees are contrasted with the robin egg blue of the couldless sky. Pine trees, even at distances of hundreds of feet, individual needles are visible. The deciduous trees, the oak, maple, elm, and others whose names escape me, also are stark and uniquely detailed against the sky. The little buds, that will be leaves come spring time, I can see. Against the snow, tree trunks show their knots, bark irregularities and tapering reach upward. Shrubs are highly detailed and all of the above cast their shadows, long onto the snow. Animal tracks cross and recross one another's footprints. The lake is frozen, supporting the deer poplulation that now travels from wetland to houses and edible ornamental plants. Deer tracts remind me that yesterday I resolved the problem of Shag's left over Purina Dog Chow. I walked the storage barrel into the bush and dumped it. When I dumped dog chow that Shag would not eat several years ago, I found the next summer that the dog chow had been eaten, even the ground inwhich some of the flavor had seeped, had also been eaten. I did see three large deer early yesterday morning cross the road and I had dumped the remaining Shag dog food onto their tracts.

A little update on myself, speaking of how information, when shined upon ones self as a spot light and providing contrast from the daily doings of one's life, makes for clarity of vision. I have been experiencing some vague chest pains and associated heart rate irregularities off and on for more than a month; I saw my doctor who ordered a radionucleotide scan at rest and exercise, to see if my heart had areas of poor perfusion: ie, worsening coronary artery disease. The tests results are preliminary, however, and so far, normal. Good news, I will keep you posted if that prognosis is altered by additional information; another spotlight.

A camera lens can not give you the total elation feelings I have regarding the visual sensation from my peripheral and central vision right now, sitting in the sun room, looking to the West and out to this sunny day.

Winter has arrived in spades

Small flaked snow is falling steadily, streaming from the West. The white of the snow fall with the snow on the ground is glaring. One almost needs polarized sunglasses to sit on the sun porch for any length of time. And, it is cold. This morning the temperature was 2 degrees Farenheit and the wind chill was minus 12 degrees. At minus 15 degrees, the exposed skin freezes, frost bite, in 20 minutes. KK recommended our walking in the mall today. I, of course, rejected such a notion as we can bundle up against the cold and snow and wind. Indeed, in Alaska, schools don't close until the wind child is minus 50 degrees! Besides, the mall is a very dangerous place: too many places to stop and spend. Hence, with the cost of gasoline, wear and tear on the car, the likelihood of stopping and buying something, a walk in the snow, wind, and cold is vastly economical. One only has to bundle up.

As a compromise, and in marriage there needs to be compromise, I offered to walk with her in the mall after I had walked our usual two mile circuit.

Instead, we both bundled up: wool hat, over glasses polarized sun goggles, scarf covering our faces, jackets over another layer of clothing, mittens, long pants, wool socks, Gortex lined hiking boots, and slip on ice cleats. Off we went. Within 300 feet, our glasses and then goggles began to frost over from our warm breath rising from our mouths and noses into our glasses. Various efforts at clearing the frost, like putting the goggles in pants pockets to rewarm and evaporate the moisture, all met with very limited success. Eventually, KK walked behind me, alla tradition in some parts of the world, and I led along the walkway, through the wetlands, around the lake, back on the icey sidewalks, and finally back home. We traversed the two miles in our usual 17 minute miles, both a testiment to the relatively cleared pathways as well as a deep desire to get inside and out of the weather.

Across the way, the houses snow covered roofs have their furnace vent stacks spewing steamy vapors which twist and twirl in the breeze. The furnaces are on more than they are off. Swirling snow, coming off the roofs give visible evidence of how multifacited wind direction is. I see the wind by what it carries with it. Usually one only feels the wind, and yet it is visible as well. Wind makes me think of sailing. Thinking of sailing, has me reflecting upon a cresent sand beach, a 16 foot Hobie Cat, in the Bahama's.

Today is Superbowl Sunday. We will be hibernating in the basement, in front of our television, snug as a bear in a rug.