Category: health care

A Visit With Mom

I walked into Mom’s room and knew immediately that it was a good morning. Despite her pale color, Mom’s eyes were open and clear, and she smiled broadly at me. “Good morning, Linda!” she greeted me with enthusiasm from her bed. She knew it was morning, knew who I was and was happy to see me. That is not the reception I always get. Thankfully she reliably knows who I am, her daughter, but more often she can barely keep her eyes open, and her speech is slurred – a product of the various illnesses, including dementia, she is living with.

The unpredictability of her condition confuses me. I wish I understood it better. I try to emotionally prepare myself for whatever the visit will bring, but it is hard. The variability also makes it difficult to decide what to do about her care. Do we continue to aggressively preserve her life, or do we begin to let her go? I believe Mom’s life at this point is largely sustained by the medications she takes – a high dose of diuretic, as well as heart and blood pressure medications. On the visits that she is foggy and lethargic, spending most of her time sleeping, I wonder if we are doing her any favors. Although she will never fully be herself, on mornings when she is alert, when she is more connected and engaged, then all the medicine and effort make sense.

On this day Mom’s lucidity is a double-edged sword. We enjoy conversation about our family. She is entertained when I read a chapter from Mel Brooks’ autobiography. She listens avidly to his experiences during World War II, which bring back her own memories. But, on the flipside, she is painfully aware of her limitations. She ruefully tells me that she can’t buy the little things she likes to have for her grandchildren and great-grandchildren when they visit because she can no longer go out to shop. She shows deep frustration when she has difficulty getting up and walking to the bathroom. The effort leaves her breathless. It is a titanic struggle to get out of bed (despite having a hospital bed): to sit up, shift weight to her legs and shuffle the few steps to the toilet takes major exertion. And that is even with the assistance of her aide. Given that she is on a diuretic, the need to go is frequent. When Mom returns to bed she is clearly dismayed by her dependence on others and her inability to be in control of her bodily functions.

As the day wears on, Mom gets more confused. The energy and alertness of the morning give way to weariness and confusion. “Maybe they will send me home tomorrow,” she says to me. “Mom, you are home.” “I am?” She thinks she is in the hospital. She is in the same apartment she has been in for the last six years.

I point to the pictures that adorn the room. I show her the table that sits in the dining area just outside the doorway to her bedroom. She nods but then goes on to tell me about how when she was in the Air Force hospital in Texas after giving birth to Steven, they were in a barracks style room. They had to line up to use the bathroom and, “what did I do?” she asks me. “I don’t know.” “I fainted.” She goes on to tell me a convoluted story about them forcing her to get up, but then they put her to bed, and she heard her Aunt Bess in the hall loudly arguing that the nurse should take better care of her. “She made sure I had a silver pitcher, it wasn’t real silver, it was probably silver-colored but that’s not the point, with cold water. Aunt Bess was something.” She was rambling a bit, I thought maybe she was conflating several different experiences. It didn’t matter – I just listened. Then she said again that maybe she would get out of the hospital soon. This time I didn’t try to correct her.

I was getting ready to end my visit. We had talked about the weather forecast, which called for a snowstorm. I told Mom that I wanted to get on the road before the weather turned. She agreed and told me if the roads were bad not to come back to visit the next day. “It isn’t worth taking the chance.” “Thanks, Ma. I’ll stay safe.”

I had no intention of coming back the next day and earlier in the day she knew that. I was going to my apartment in the city to wait out the storm and then drive the rest of the way home to Albany. Mom knows that my house in Albany is a 3.5 hour drive away from her – well, usually she knows that. Depends on the moment.

I walked out to my car reflecting on the visit.

I know what I would want for myself. I firmly and passionately believe that I would not want to live the way Mom is living. I would prefer to stop the life-sustaining medications, take morphine or whatever would allow me to be comfortable while my heart and breathing ebbed, and say my goodbyes. Let nature take its course. Mom’s doctor has said that it is a legitimate, ethical decision – to stop Mom’s diuretic and other meds, make her comfortable and let her go. Though we have made the transition to hospice care, we have not discontinued those essential medications.

Mom is DNR and that decision was made with her full knowledge and consent – she was quite capable of understanding what it meant when we did the paperwork many months ago. I am her health care proxy, but we did not discuss this current scenario. I can’t in all honesty say I know what she would want. If I did it would make this much easier. I comfort myself with the thought that she does not appear to be in pain. Her activities are severely limited, her ability to engage in conversation is variable, her energy is negligible, everything is an effort…is she taking pleasure in her existence? Sometimes, but at best it is a small portion of the day. What is the right thing to do?

So I confer with my brothers and we decide to stay the course…for now.

There are only two things I know. I don’t want this for myself. And, there is no objectively right thing to do. No matter how much I rack my brain, or gut, clarity does not emerge. I need to make peace with the path we are taking and stop ruminating. One way or another, it will resolve itself in time.

In better days: Mom two years ago on the patio of her apartment

Note: I wrote this painful post because writing it helped me process my thoughts. Instead of having a jumble of emotions and images, I understand myself better. I share it because I imagine others may have gone through, are going through or will go through this journey. I think it is important that we talk about end of life choices. Perhaps it will spur conversation in your family.

It Got Me….Finally

Hooray! I moved back into my bedroom this morning. My period of isolation is over! Ten days is a long time – at least in some contexts. After three years of avoiding it, Covid caught up with me.

I went to Boston to give my daughter a hand as she was dealing with a sick husband and child. We thought, based on the diagnosis at the hospital, that her daughter had croup, and that Ben was just under the weather. I figured I would mask while I was there, hoping to avoid getting whatever bug they had. What’s that saying? Something like, ‘woman plans, god laughs.’

I arrived at their apartment, said hello, and picked up a prescription that needed to be filled for the baby, and their insurance card. I went to a pharmacy and then got sandwiches for lunch. When I returned, I helped fold laundry. I removed my mask to eat lunch but sat distant from Leah. We opened a window to increase the airflow. Leah was relieved to have me there. So far so good.

About two hours into my visit, Leah’s phone rang. It was the Somerville Health Department telling her that someone in the household had tested positive for Covid. The baby had been to the hospital the night before. As part of the examination of the baby, they swabbed her for Covid. Given that she was diagnosed with croup, Leah and Ben hadn’t given it a thought. The news came as a shock.

Leah and Ben did a home test and, lo and behold, they were both positive. They called the pediatrician to share the information and find out if it changed anything in terms of the care of the baby. Turned out, it didn’t, which was a relief in some ways. We discussed what I should do.

I decided I would stay at a hotel for that night – I certainly wasn’t going to stay at the apartment. I told them I would bring them dinner and other supplies that evening. I left. Ben, who was feeling pretty miserable at this point (totally exhausted), was going to call his doctor to see if they recommended treatment.

I double masked everywhere I went. I decided I would go home the next morning. If I got sick, I didn’t want to be in a hotel in Boston and I didn’t want to feel too poorly to drive the three hours home. I stayed at the hotel that night after picking up Paxlovid for Ben and dinner for them. I felt fine.

I brought them breakfast in the morning. I was double-masked. Said my good-byes. I felt terrible leaving them, everyone sick. At this point, Leah was having symptoms, too. Great – a cranky baby and two parents who felt like shit. Plus the anxiety of not really knowing how serious Covid would be for the baby. But, what choice did I have?

I still felt fine as I drove home. I tested when I got home – negative. Maybe I would escape. I tested the next morning – still negative. But, now I’m starting to feel poorly. Headache, sore throat, tired.

Covid is a strange virus. It behaves differently in everybody. Plus, you can test negative and still have it. You can test positive and have no symptoms. You can continue to test positive long past the infectious stage. It so hard to know what to do. You hear horror stories about people having long-haul covid.

I went for a PCR test that morning (Saturday) and got a positive result within 24 hours. During the height of the pandemic, it could take 3 days or longer to get a result (which made the test almost useless) – so at least that is better. By the time I got the result, it was clear I was sick. My body hurt all over. I felt exhausted. I started coughing. I called my doctor. They recommended Paxlovid. I have several risk factors for serious illness, so though I am always a bit anxious about taking a new medication because it isn’t uncommon for me to have strange reactions to things (rash, anyone?), I decided it was worth it.

Meanwhile, it is now Sunday, the day I am supposed to read for the Brooklyn Nonfiction Prize. I didn’t want to miss it. I had a strategy. Though I was coughing, it wasn’t that bad (yet). I decided I would take cough medicine in advance. I had throat lozenges at the ready. I took Tylenol, too. I napped for an hour beforehand. The adrenaline kicked in. I was next to the last to read – of 15 people! I did not win. Nothing to be ashamed of – the other essays were good. I was still disappointed. I have to admit, I kind of crashed afterward. I was exhausted. It didn’t help that I was facing 7 more days of isolation.

I moved into Daniel’s old bedroom for the duration. I used what had been the kids’ bathroom. We are lucky to have so much room. Gary is serious about this isolation and masking stuff. He has masked at work from the beginning of pandemic and continues to do so now (he just recently stopped using goggles). We ate separately. We would watch t.v. in the same room, but distant and masked and, as long as it wasn’t too cold, we had a window open. It appears that he has not gotten it. When he had it last Fall, he still blames Las Vegas (we will likely never go back there!), I didn’t get it from him after we followed much the same isolation protocol.

I’m glad I took the Paxlovid. I did have a very unpleasant taste in my mouth for the five days I took it, and my digestive system did not enjoy it, but I recovered pretty quickly. The fever, severe headache and body aches were gone within 24 hours. The fatigue lasted a bit longer and the cough lingered. As of today, ten days into this, the cough is almost entirely gone. That is always the last symptom to go when I have a respiratory illness.

Though I was clearly recovering, I woke up each morning feeling sad. Another day isolated. I felt okay, but not so good that I had the energy to be productive. In theory, there are always things to do in the house – junk drawers to sort, stuff to organize. I didn’t feel up to it. Instead, I binge watched Top Chef. Thank god for that!

Fortunately, the baby, Leah and Ben have recovered well, too. I could hear them cheering all the way from Somerville when the baby could go back to daycare. Ten days cooped up in a relatively small apartment with an 11-month old who is healthy enough to be active, but fussier than usual, with no reinforcements, and little sleep, is an ordeal. They rose to the occasion, as they always do.

One piece of good news: we should all be immune for the next few months! Gary and I have a trip planned at the end of May. I should be able to travel without worrying about Covid. Leah and her family should be able to go out and about the rest of this Spring and early Summer without thinking about Covid, too. And we appear to have weathered the illness without lasting effect. It is always a matter of perspective – and finding the stuff for which to be grateful. It doesn’t come naturally to me to do that, but eventually I figure it out.

The view out my kitchen window. I looked at that a lot over the last ten days. I’m lucky to have such a lovely view

It Shouldn’t Be This Hard

NOTE: Another view from the frontlines written by my husband, Gary Bakst.

I saw a patient for a physical exam and there was a lump found on that exam.  It was not one of those lumps that make you immediately think the worst.  But it also wasn’t a lump that felt obviously innocent.  It would require investigation.  I was concerned but in my gut I thought this is probably going to turn out to be benign.  I also knew that what I needed to do was fairly straightforward.  The work up should be easy.  However, what should be easy is hardly ever easy these days.

I knew he needed a CT of the pelvis with and without contrast to better understand what we were looking at.  However, when I searched our electronic medical record system, there was no option for a CT pelvis with and without contrast.  There was CT abdomen with and without.  There was CT abdomen and pelvis with and without.  There was CT pelvis without any specification as to whether or not it included contrast and there was CT pelvis with contrast.  I have no idea why they made the choices so weird.  Ultimately I decided they must have intended that the CT pelvis (without specifying) was without contrast.  So I ordered CT pelvis with contrast and CT pelvis. 

This electronic medical record system was imposed upon our office.  We did not ask for it and we surely did not want it.  We had an electronic medical record system that was working very well but the larger organization that we are now part of felt it was important to get everyone in the organization on the same platform.  They switched us over a bit more than a year ago knowing they were going to again switch systems for the entire organization in early 2024.  We explained to them that our office is particularly busy and they did not have enough support staff to make this cumbersome system work in the setting of such a busy practice.  They weren’t impressed with that argument. 

When the switchover came, they sent in people to help us with the transition and they were great but the underlying issues were too much to overcome.  Our office became less productive, we were less able to accommodate our patients and new referrals.  The larger organization lost money when they thought they would save money.  Some of our doctors and PA’s became frustrated.  Two have left and one went from full time clinical to half time clinical practice.  We have been able to hire a PA and a nurse practitioner and we hopefully have another physician joining us soon.  Still our productivity is well below where we were before the change.  Belatedly the higher ups came to understand that the transition was a failure and allowed us more staff to deal with it.  Unfortunately, that happened just as the economy got weird and you couldn’t hire anyone.  However, as time went by, we have been able to increase our staffing and it has gotten better. 

We submitted the plan for the CT pelvis to the patient’s insurance company and they rejected it.  We appealed and they again rejected it and said I needed to speak to one of their reviewers.  Ultimately, they finally approved the CT.  Thankfully, it showed nothing terrible.  I had also ordered some lab work for this patient.  Previously, we drew the blood in the office and we also had a very efficient office lab that processed the blood work.  It was accurate and very fast.  The overwhelming majority of lab work was available to me on the day that the blood was drawn.  I would go home from the office and be able to review all of that lab work, call the people who had a problem and create letters to those who had good results so they could know they were fine.  Each evening, that day’s blood work was essentially all dealt with. 

However, the larger organization closed our lab.  We still draw the blood but the plan was to send it to their lab to save money.  We explained that it would lead to delays and be less efficient and not allow us to do as well in dealing with issues that come up with lab work.  However, they felt very strongly that it would be a major savings in lab costs.  To be fair, the higher ups listened to our objections and we were able to speak with them at length about it.  But the decision was made and was not going to be undone.

On the same day that they changed our electronic medical record system, they also closed our lab.  Specimens were to be sent to the hospital but at the same time, the pandemic related supply chain issues got us. There was a shortage of vacutainer tubes needed for blood draws so we had to send all of our labs to Lab Corp except for those patients who have Blue Shield which does not accept Lab Corp.  Lab Corp did pretty well getting us timely results.  They took one day longer than our lab but they were not too bad.  We lost much of our ability to have the lab add on tests as needed or re-run results that were questionable.  Still, it was a moderate, not severe, drop in our function.  For the Blue Shield patients, they had to go to either St. Peter’s labs or Quest labs, both of which were quite slow.  Sometimes we just never got any results and we had to call for them.  Sometimes patients would tell me their results off their portals for those labs and that is how I found out how they were doing.  

Finally, in November, the shortage of vacutainer tubes was over and our hospital lab said they were ready to accept our labs rather than sending them to Lab Corp.  But they were not ready.  We saw labs taking 4 or 5 days to come back.  In quite a few cases, by the time they got to our specimens, they had timed out and it was too late to run them.  For reasons I cannot fathom, they denoted this as “lab accident” and that showed up on patient’s portals.  Patients were naturally concerned about the lab accidents involving their results.  I started sending them to Lab Corp again until the hospital was able to get enough staffing to actually process the labs properly.  They are finally doing better but not great.  

In my patient’s case, there were lab abnormalities that required follow up.  I asked them to add the follow up labs from the blood that we had already collected but they could not do so.  Previously that would have been easily accomplished.  The patient came in for repeat blood work and they did much of what I asked for but somehow left out the most important follow up test.  I am capable of making mistakes but I had correctly ordered it-they just didn’t do the test.  Fortunately, in this case, they were able to run it and it also turned out to be good news. 

I have spent a fair amount of time criticizing the larger organization that owns our practice but I want to make the important point that they are actually pretty good as larger organizations go.  The problem with them is that they are a larger organization.  Speak to doctors anywhere in the country and you will hear similar stories.  Mostly you will hear worse stories.  These guys are really only guilty of being a bit too smart to realize that sometimes when something works, you should let it keep working rather than fix it.  Other organizations do far worse and have more concerning priorities.  The main point is that we now live in a landscape of practices owned by large organizations in which the decision makers are removed from the people taking care of the patients.  They have their own data and jargon and don’t answer to us.  Another part of this is the insurance companies which are increasingly difficult to deal with.  Then there are the ridiculous costs of pharmaceuticals and the shortages of all kinds of common products from blood pressure medications to amoxicillin liquid. 

Ultimately, this patient is well and that is the most important piece of news.  And in the end, we were able to get done what we needed to get done.  But, comparing what it took to make it happen to what that would have involved just a few years ago, the difference is quite stark.  People talk about the problems in health care these days.  You are not imagining them.  This was a fairly straightforward case.  Nobody was hospitalized; nobody had surgery.   It was just a CT and a couple of labs.  But it shouldn’t be this hard. 

Have Things Changed?

Have things changed?

Do you find yourself asking friends or family that question? It has come up in a few different contexts. The other day I was visiting with a friend. She, like me, is involved in the care of her elderly mother who has faced a myriad of health issues. She was telling me about her mother’s frustration with her television set – sometimes it works, sometimes it doesn’t, sometimes she can get the channels she wants, sometimes she can’t. I know from experience with my mom it can be hard to sort out the source of the problem – is it the equipment? is it the technology? Which part of the technology? Is it our mother? I am not terrible when it comes to troubleshooting cable, the internet, and equipment, but I am no tech geek either. I can manage, but how is an 89-year-old or a 92-year-old supposed to navigate it? I have an idea! Senior living centers should have staff specifically devoted to tech support (separate from maintenance) – someone residents can call when their remote no longer changes the channel or their iPad freezes. It would save so many frustrating calls to family members who aren’t nearby or can’t just drop in and fix it. I imagine many people would be willing to pay something extra for the service.

In an effort to make things better, my friend went to Best Buy and bought a new t.v. and arranged for delivery. While I was visiting with her, the t.v. was supposed to be delivered and installed. Everything that could go wrong went wrong. There must have been six phone calls before it was finally determined that the person showing up to do the installation was not the same person who was delivering the set. The installation guy arrived before the t.v., and they had no record of the delivery being scheduled!

In between being beyond annoyed, we had to laugh. The whole thing was preposterous. My friend was sure she had been clear about the delivery address (at first the person on the phone was heading to her house, which is not where her mother lives). Nothing got accomplished – leaving my friend with another series of telephone calls to straighten it out.

Was it always so complicated? Were deliveries routinely screwed up? These days I am so relieved when anything goes as planned. But, maybe I’m just older and more impatient. Maybe I’m focusing on the errors and not all the times things happen the way they should.

I have raised the question before – does all the technology we use make our lives easier? Or, does it introduce more opportunities for things to get screwed up – and make it more difficult for us to get to the bottom of the problem to fix it.

I am responsible for overseeing my mother’s medical care. It makes sense that I play that role since my husband is a doctor and neither my brothers nor their spouses have that expertise. The one problem with this is that I live about 3.5 hours away from Mom. Generally speaking, I am able to work things out to accompany her to appointments. The thing that has been more challenging has been keeping her medicines and medical supplies in stock. I can’t tell you how many times there have been problems. Sometimes the issue is one of supply – the pharmacy to which the prescription was sent (electronically) is out of stock of the particular drug. Do they call me? No, apparently they communicate with the doctor (or maybe, depending on who you believe, they communicate with no one). I have explained to everyone and anyone involved in Mom’s care that they should call, email or text me – in fact in many cases my number is the only one they have. And, yet, I still don’t get notified.

And, when did supplies get to be an issue? I had a conversation with my daughter the other day while she was in search of eye drops, amoxicillin and children’s Tylenol for her baby who had conjunctivitis and an ear infection. She spent hours on the phone calling pharmacies. Finally, after a whole lot of back and forth with pharmacists and the doctor’s office, she called me triumphant. She scored the needed drugs!

Going back to my travails with keeping my mother’s supply of medications.: another issue is, not surprisingly, insurance coverage. I am told that her sensor (Mom has diabetes and finger sticks are just not practical anymore) is not covered by Medicare. Then when the drugstore receives the prescription for it, perhaps reasonably, doesn’t fill it (figuring the patient will likely want an alternative that is covered) and sends an email to the doctor letting her know. Eventually I get informed, and I tell them, just fill it. This happens every month. I believe that the sensor probably could be covered but I would need to appeal the decision and go through the hoops and loops. And they’d probably make me do it every time! I think they are counting on wearing me out – and they have been successful. I don’t want to go down that rabbit hole; I just pay for it. Fortunately, it isn’t crazy expensive.

There are so many layers to this. Sometimes I think systems are deliberately set up to not serve us. Or perhaps, as drugstores and doctors’ offices are bought up by corporate entities, the systems are designed, and the decisions are made too far away from where the service is delivered. Something is lost. When entities were smaller, they could be more responsive. Maybe that accounts for some of the loss in customer service.

Or maybe things aren’t actually that different. As I consider this, I wonder if I’m just an old fogey. People are people, after all. What do you think?

Self-Care: Filling Your Cup

Last week’s blog entry that I entitled Self-Care drew some interesting comments that got me thinking. Gary, my husband, who is also a doctor, pointed out that taking care of oneself was a good investment of time and energy. A number of the things that I identified as self-care were doctor recommendations. I can see his perspective. Rather than resenting the time it takes to do the physical therapy or whatever it is that has been prescribed, one could look at it positively. Time spent making yourself healthier, perhaps pain-free, or with improved mental health, is a good use of one’s time and better than a lot of alternatives. Once again, reframing something has its benefits.

I also received useful feedback from Leah, my daughter. She argued that activities I was including in self-care didn’t necessarily belong there. She suggested that self-care can be thought of as activities that ‘fill your cup;’ things that restore your spirit. I like that notion. While I didn’t specifically list brushing my teeth as part of my self-care routine, it was included as part of what I do to get ready in the morning. I don’t think that should really count as self-care, except in the broadest sense. It is necessary to preserve my dental health but doesn’t do much to restore my spirit. Although, replacing morning breath with minty-fresh breath is a big improvement – I think I’m getting too far into the weeds here. It is safe to say I am over-analyzing this.

Back to the main point: Even if I take a broader view of self-care than the one Leah offered, I like the exercise of thinking about what is restorative. It is helpful to be mindful of the activities that energize us because when we do have a bit of time to spare, we can make a good choice as to how to spend it. Sometimes I take the path of least resistance – turn on the television and vegetate. There is a role for that, occasionally. But, more often than not, spending time on the couch watching something mindless is enervating. I feel worse, not better, afterwards.

What does make me feel better or more full? First and foremost, spending time with my children and grandchildren. Sometimes that isn’t possible so making a plan, having something on the calendar, so that I know when I will see them is wonderful. It doesn’t have to be complicated – we don’t need to be doing anything special – actually the less hectic the day, the better. A couple of weeks ago, our son’s family visited, and we went to the playground, came back and hung out. Our granddaughter set up an obstacle course on the living room floor (it involved navigating a path through pretend lava – paper – and hopping over pretend rocks – crayons) and we took turns. She is four years old and she delighted in first showing us what to do, then telling us if we were successful. I loved it. What better way to spend time?

Another thing I find energizing is travel. While it is fabulous to take trips overseas or to cities or landmarks in the United States, again, it doesn’t have to be that elaborate. I’m happy to explore the hilltowns a few miles away, or take a ride in the Catskills. Anything new is interesting to me and if we can find some natural beauty, a lake, some mountain views, all the better. I am happy just to take in the scenery. Of course, I wouldn’t turn down a trip to Paris or the Canadian Rockies, but clearly those are rare. The trip we took last fall to the national parks in Utah and Santa Fe was sustaining. I look at the pictures every so often and it brings back the exhilaration of seeing those beautiful places. Being in nature is the best way to restore my equilibrium. When my dad was in the hospital in Florida, and he was terminally ill, I either went to sit by the ocean for a few minutes or walked in the bird sanctuary most days and just breathed. If I hadn’t done that, I don’t know how I would have coped.

Reading, particularly a good novel, makes the cut as self-care, too. Not all my reading experiences, though, fall into this category. I have read stories that annoyed me. Why I stayed with the book is a reasonable question, but sometimes even when the main character is exasperating, I still want to find out what happens. Also, if I am reading non-fiction, it can be challenging to find the right balance between what is stimulating to learn about and what is so disturbing that I have to close the book for a while before continuing. Reading anything about the Trump administration would not fill my cup! I guess reading can be a bit complicated.

I can’t leave this topic without also mentioning art museums – I love them! They can be small, like the Fenimore in Cooperstown or Albany’s own Museum of History and Art, or huge like the Metropolitan in NYC, I find looking at the art in relatively calm, quiet spaces to be relaxing and energizing at the same time. Add an outdoor sculpture garden and I am in my element. I don’t even have to love the art itself, though if I can find a few pieces that speak to me that’s all the better. Walking through rooms where the focus is on what people have created and taking it in, is delightful. I think some people may get hung up on thinking they are missing something if they don’t ‘get it.’ I try not to worry about that – I just like looking and generally will find something that is either just interesting or moving.

As I consider this, I realize that I don’t find spa treatments all that fulfilling. The idea of it is more appealing than the actual experience. I like the end result of a pedicure or manicure, but the process just doesn’t do it for me. On the rare occasion where I have gone with a friend or with Leah, I have enjoyed it much more, but otherwise I would rather take a nice walk.

What do you find restorative? Have you thought about it? We might be making certain assumptions about what fills our cup based on popular culture and it may not really work for us.  It would be great if readers would share.

From a local winter walk in the woods – Five Rivers
From a local walk in the woods this past Fall – Thacher Park

Self-Care

If I spent all my time taking care of myself, following all the doctors’ directions, therapists’ advice, self-help manuals, I wouldn’t have time to actually DO anything! And I am a retired person and my children are adults who are living on their own. If I had a full-time job and young children, it would be nearly impossible.

Since last May I have been dealing with chronic hoarseness. After a number of exams and scoping of my vocal cords, I was referred for speech therapy. Fortunately, that testing didn’t find any growths, but noted a combination of the effects of reflux and muscle compression. The speech therapist did a thorough evaluation and recommended vocal exercises. She also gave me papers with foods to avoid (two pages worth) and foods that are encouraged (a small list). I also received some stretches to focus on loosening the neck muscles. I am supposed to do the stretching and vocal exercises 3 to 5 times per day. The protocol takes about 5 to 7 minutes. So far, I have been managing to do it twice a day and feel pretty damn proud of myself.

Another part of the routine recommended by the ENT, to help with congestion, is to use a netti pot and saline spray. I do the nasal rinse once a day and the spray twice. These take another 5 minutes. I’m also supposed to use a humidifier. Setting that up and taking it apart each day is another 5 minutes.

All of the stuff to try and deal with these throat and ear difficulties add up to at about 45 minutes each day.

In theory, these are the other parts of my self-care routine:

  • Waking up – brush teeth, take daily pills, wash face, comb hair – 10 minutes
  • Make the bed – several advice gurus stress the importance of starting the day by making the bed – I subscribe to that idea – 3 minutes
  • Exercise (at least 20 minutes but I actually do 35 either walking outside or on the treadmill) – if it is vigorous enough, it requires showering after, so add another 20 minutes. I am quick in the shower, so 25 minutes allows for getting dressed, too. I also play tennis once or twice every other week, each time 90 minutes (add another hour for driving to and from the courts).
  • Meditation – 10 minutes
  • Shower or bath – if I haven’t exercised and showered, then I will do that and take more time with it – more like a half hour
  • Moisturizing – face, skin, nails – 10 minutes
  • Journaling/affirmations/gratitude journal – 15 minutes (at least)
  • Eating healthy meals (with preparation) – I don’t know how long, but way longer than grabbing fast food. For three meals, it has to be at least 2 hours each day, including the time to eat and clean up.
  • Getting enough sleep  – 8 hours

Some of the things on the list above are aspirational.

I can’t accurately add up the time for those activities because it is so variable, but it is a large chunk of the 24 hours. And, again, that is as a retired person who only takes 10 minutes to get ready in the morning! Most people take longer. I wear no make-up. I don’t do anything special with my hair. I spend next to no time picking out clothing. All of those things could be part of a person’s self-care regime, requiring more time and attention.

My exercise routine is minimalist – better than nothing, but not the amount of time a truly fit person devotes to working out. For someone like, let’s say Jennifer Aniston, it is a full-time job to look like she does. Not that I would choose her as a role model. I don’t make a living on my looks and never did. Unfortunately, though, we live in a world where we set up unreasonable expectations of what we should look like, but the vast majority of us can’t take that much time to nurture ourselves.

Many people face other types of health challenges that require more daily attention. I’m very lucky. Other than this annoying thing with my voice, and the usual minor aches and pains that come with age, I am healthy. In the past I have had occasion to go for physical therapy (for a frozen shoulder or a tweaked back) and there were stretching exercises prescribed. Those kinds of regimens can be hard to stay faithful to.

So, what is my point? First, that doctors and therapists of all sorts need to be realistic and work with folks to figure out a program that can be followed. Second, we need to be honest with ourselves – what are we willing to do? What do we have time to do? Do we believe in the regime that is being prescribed? Lastly, let’s not expect perfection. There’s nothing good about beating ourselves up over falling short of our goals – that can lead us to spiraling into negativity and being more self-destructive.

I want to be able to sing to my grandchildren – that is my main motivation for working on my voice. That and I don’t want to annoy people with my constant rasp. My throat doesn’t hurt, my voice just sounds bad. In a more general way, I want to be proactive about my chronic congestion to help lessen the number of sinus/ear infections I get and preserve my hearing. I will try to stick to the program, but I will also try to follow my own advice. I beat myself up enough about all kinds of things. I don’t need to add this to the list.

Other aspects of self-care: relaxing, reading a book, drinking coffee and spending time with my kitties-now kitty 😦

Random Thoughts on a Holiday Weekend

Yesterday I spent well over an hour online trying to initiate a Medicaid application for my elderly aunt. I had no success. I learned one thing. After completing the first part of what I thought was the correct process, I found out it was not. Buried four clicks in, and after filling out two preliminary forms, and after receiving several error messages and a rejection notice, they finally explained how to initiate an application for someone over 65. After all that, I learned that you are supposed to call the helpline or visit a Medicaid office! It seems that little tidbit could have appeared on the very first screen. A pretty major piece of guidance, if you ask me. Who designs these things? I will call the helpline after the holiday and find out how to proceed. Let’s see how convoluted, complicated and frustrating this process will be. I have such high hopes.

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It may seem odd to be writing about the passing of Ed Asner, but I need to say something. He reminds me of my dad, in the best way possible. He always has. When I watched the Mary Tyler Moore show back in the 70s, and I loved that show for many reasons, I noted the likeness. Some of it was physical. My Dad was built similarly, that burly, Eastern European thing. They both were also balding with a heavy beard. My Dad could probably have shaved twice a day. I suspect Mr. Asner could do the same. But more than that, it was the sense of decency Mr. Asner radiated. The gruff exterior belied a tenderness. Maybe I read too much into Lou Grant and other characters he played, but that is what I sensed.  And that was at the heart of my dad. These last few days, as tributes came through my Facebook feed, each time I felt a pang of loss. Dad was not granted the length of years Mr. Asner was, he is gone more than 16 years, but I still feel it acutely. I mourn Ed Asner’s passing, too.

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I have spent much of the last week under the weather. I don’t want to assign blame, Daniel, but I caught a cold. Of course, since we are in the midst of a pandemic, I was concerned that maybe it was actually Covid. The delta variant has been spreading locally. I tried to make an appointment for a test and found it difficult to get one. All the area pharmacies were booked. I could get a slot the next afternoon, but I’d have to drive half an hour. I took it. In the meanwhile, I asked my husband to try to pick up an at-home test on his way home from work. He called around and found one at a CVS in Schenectady – not that far away. He brought it home. I read the directions carefully, followed them, waited the 15 minutes and found out I was negative. These tests are imperfect, but my son and granddaughter also tested negative, so I took a measure of comfort in that. The cold though wasn’t deterred by that information, it has gone through its various stages relentlessly. Sore throat, headache, sinus pressure, my nose running like a faucet (throw in a couple of bloody noses), then the cough. The cough is the worst part for me and takes the longest to resolve. I know I shouldn’t complain. So many others have it worse. But whenever I am under the weather, I get mad at myself. I take it as a personal failing. So, in addition to feeling poorly, I am angry at myself. I have been down this road many times and I still do it. I am disappointed in my lack of productivity while I am ill. I shouldn’t have gotten sick in the first place! I will not cough!!! The refrains in my head are singularly unhelpful. Maybe now that I have written it down, it will stop. Or it will stop when the symptoms pass…any day now.

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Two more covid -related complaints. We are once again trying to plan the celebration of Leah and Ben’s marriage. We are now three and a half months out. Once again, we are plagued by uncertainty. I am angry. It didn’t have to go this way. My other gripe is of the ‘first world’ variety. Most people are faced with lost opportunities due to the pandemic. College kids deprived of the full experience. Youngsters wearing masks as they start school. Cancelled proms. Job loss or forced career changes. Folks with other health problems having to navigate getting care. Seniors enduring damaging isolation. So much fall out. My issue isn’t serious, but I find myself resentful anyway. I am missing prime-time travel opportunities. Gary and I are in our early sixties. Thankfully still healthy. This would be a time for broader exploration. We are lucky enough to be financially able to do it too. I love travel – minus the hassle of air travel itself, that part sucked even before the pandemic. But that aside, who knows what the future will bring? There are so many places I want to go. Okay, I’m done whining. I know it pales in comparison to the price others have paid, including loss of life. But since I am venting, I thought I would put that out there, too. I invite you to vent, as well. It can be therapeutic – as long as it isn’t directed at an innocent bystander. A journal, online or on paper, may be best. Feel free to use the comment section below.

It Takes a Village

It is painful to watch. Aunt Clair pushes her walker down the carpeted hallway, ever so slowly. After ten or fifteen steps she pauses to catch her breath. I had not realized that the hallway was so long. Seeing my mother and Aunt Clair move through the world, my perspective on all kinds of things has changed.

The hallway from the elevator to my apartment is not really that long, not for a healthy individual. I have taken my health for granted, but my eyes have been opened. I can stand up quickly from a couch or chair without a second thought. Getting up off the floor is a bit more challenging. I can stand at the stove and cook dinner without needing to take a break. I can go to the supermarket, carry my bags into the house and unpack them – all without stopping to rest. I can take a shower without considering whether I am strong or steady enough to do it safely. My mother and Aunt Clair can’t do any of those things.

I have never been particularly grateful for my body. I usually eye it critically. But, seeing what can happen as you age, I am re-evaluating. While I have achy joints, they all work well. Kein ayin hara (Yiddish for ‘no evil eye,’ or ‘I don’t want to jinx myself’), I can play tennis, go for a hike, ride a bicycle. People my age and younger are not able to do some of those things. I have taken to thanking my legs and arms for functioning so well.

Bearing witness to Mom and Aunt Clair’s experience has made me aware of many things I had not given much thought to previously. The cycle of life is on full display. We start as babies, dependent on others to meet our needs. Many end up back in that position. We don’t want to believe that about ourselves. After living independently for decades, taking care of ourselves, making choices about what we eat, when we eat, when we sleep, where we go, that slowly slips away. The fact that it generally happens slowly, may ease the transition. We adjust to the new realities, we lower our expectations. We draw the circle of our life smaller and smaller. We may make peace with encroaching age and the limitations it brings, but at some point it is demoralizing. I don’t know which is worse – watching someone you love go through it or experiencing it yourself. (I know the answer to that, but it is heartbreaking to observe.)

We may become physically or mentally (or both) incapable of the activities of daily living. We need help.

Who provides that help? In some cultures, the expectation is that family steps up and in. Multigenerational homes are the norm. That may work, up to a point. Sometimes the needs go beyond what can be provided. American culture does not have that expectation of families, but it doesn’t compensate for the lack of it. We value rugged individualism too much and the vulnerable among us pay the price. I don’t know what happens in other countries, particularly those that have the long life span that we enjoy. I should do some research. Insight from readers would be much appreciated – please feel free to comment.

In America, if one is financially able, one can pay for assistance. But even if you have means, and insurance, it isn’t simple. Accessing insurance, researching options online, finding reputable agencies or individuals, getting doctors to write the necessary prescriptions, filling out the paperwork or electronic forms to get reimbursement – is challenging and requires persistence and some skill with technology. You would almost think that the system has been set up to discourage claims or deny payment (sarcasm alert!). It shouldn’t be that complicated! Most of our elders are not equipped to take all of that on. So even if you have money, you still need support.

Not all of us have those financial resources. For whatever reason, not earning enough, not planning ahead or suffering an unexpected financial loss (caused by bad health, an economic downturn, a natural disaster or bad luck), one can reach their seventh or eighth decade without much in the bank. Are government programs sufficient to meet the need? I think it is fair to say they don’t. Some services are available, but there are gaping holes. What are we, as a society, willing to pay to provide for our elders? What level of service, what is the quality of life we want to guarantee?

As we live longer and longer, many outlast spouses and friends. Not everyone has children. This is the situation that Aunt Clair faces. She has been single her entire adult life and she didn’t have a child. She is a very stubborn woman which has been a blessing and curse. She fought pancreatic cancer six years ago, surviving treatment – more than surviving. She bicycled to and from chemo….in Manhattan! From her apartment in Greenwich Village to Sloan Kettering, at Third Avenue and 53rd Street, she pedaled each way. Sadly, the cancer returned six months ago. She has resumed treatment. Other unrelated health problems have emerged. For a person so independent, who continues to be mentally sharp, the new limitations are a rude surprise, nearly impossible to accept.

Aunt Clair has experienced both the kindness of strangers and the invisibility that comes with being an elderly woman. New York City has a reputation for being a cold place to live, and it can be, but Clair has stories that show another side. One time recently she had an appointment with a doctor she had not seen before and had difficulty finding the office. Turned out she was on the wrong street. After exhausting herself going up and down the block, a younger woman stopped to help. She stayed with her until they sorted it out and found a cab – Clair was in no condition to walk the two blocks. I am grateful to know that there are good Samaritans out there. I know my mom has benefitted from help when she has needed it, too.

What is my role, as a niece and daughter? Clair has other nieces and nephews, each with a full life and responsibilities, their own challenges. Only one lives in Manhattan, albeit not close to Clair’s apartment, the rest of us are scattered around the Northeast. Mom has two other children, a brother and several nieces who have generously stepped in – and yet, there are still needs. It truly takes a village. Personally, I have no idea how to balance it.

When I returned home from New York City, having visited Mom and helped Aunt Clair a bit for a couple of days, I needed to recharge my batteries. I am fortunate to have a loving, supportive partner in Gary. Together we went for a long walk in the woods. My spirit is improved, but I still have no answers.

Visiting Mom early in the pandemic – before she needed oxygen full time
Me and Aunt Clair four years ago when she was cancer free

A View from the Vaccine Front Lines

Note: The following essay was written by my husband, Gary Bakst, a physician in New York’s Capital Region. Thank you, Gary, for sharing your experience and insight.

It has been a miserable year for all of us dealing with COVID-19.  The virus has killed over 500,000 Americans and infected about 30 million of us.  Some are still dealing with “long haul” symptoms, ongoing effects of the virus.  Sadly, many have lost loved ones to this scourge.  By now, very few of us do not know someone who has had it. 

Beyond the illness itself, the precautions being taken to prevent infection have entirely changed the way most of us live.  We are mostly staying home, working remotely, and avoiding gatherings.  There are no concerts, no theater, no ballgames.  Many of us are not willing to go to restaurants, bars, health clubs or yoga studios. 

For those of us still working in person, teachers, grocery workers, and health care workers, etc., there is the real risk of infection.  And in our office, that concern has similarly been significant.  There are about 90 employees in our office.  We represent substantial diversity in all kinds of ways:  race, age, religion, rural vs. urban, health status, educational and economic status. 

And we have about 300 people who come into our office on a daily basis for doctor’s appointments, to see physician assistants, nurse practitioners, diabetes educators, podiatrists or our surgeon.  They come in for labs and ultrasounds and bone density measurements.  It is a lot of people and a lot of appointments.  Altogether, since the beginning of the pandemic, it represents about 80,000 visits. 

Given the prevalence that COVID has had in our community, it was inevitable that, at some point, people who work in our office would test positive for the virus.  Yet, through the end of November, we had not had one employee test positive.  Our precautions were working. After the Thanksgiving vacation, that started to change. We had first one and then several and then a substantial number of employees test positive.  By and large, it did not feel like transmission was happening within our office although there was quite a bit of worry over that possibility.  Mostly, it was people who presumably became infected outside of work, possibly via contact with asymptomatic people who did not know that they were carrying the virus.

We had at least one example of a physician acquiring infection from contact with a patient who did not know they had the virus.  Personally, I had two consecutive Fridays in which a patient called (or a family member of that patient) that they had tested positive the day after their visit.  Sometimes people just don’t really think they have COVID – maybe they had minor symptoms and got tested but they answered our prescreening questions indicating no such issues. Getting those Friday calls led me to quarantine apart from Linda and certainly raised my anxiety level. Fortunately, I didn’t get the virus and neither did Linda.

Unfortunately, some of my patients have been very seriously ill with COVID-19 and several have died from it.  Many of them were lovely, sweet people with wonderful families.

Most of the employees who tested positive had minor symptoms or were asymptomatic.  Several were more significantly ill.  Several had to miss work for weeks or even months.  Those who were sicker longer have had some issues in terms not feeling entirely themselves even after returning to work. One of the many frustrating things about this pandemic is the unpredictability of the disease.

By early January, I had reached the point where I was seriously thinking that we needed to shut down the office for 10 days.  Then, the vaccine took effect.  I got my first dose on December 28th. It was 2 weeks after we received the first dose that all of this stopped.  Not all of our employees chose to get vaccinated, but the overwhelming majority did. 

Up until that point, the tension, the fear, in the office was palpable among many of our staff. Everyone handled it in their own way.  Some were clearly less concerned, and a few had to be repeatedly reminded to keep their masks on. 

Albany Medical Center saw up to 38 employees test positive on a single day in that period.  After vaccination – just over 90% of their employees chose to receive the vaccine – that number fell to either zero or one positive test per day.  Most of the employees who tested positive were those who chose not to get vaccinated. 

In terms of side effects, many of our staff did have some side effects.  Half of us received the Pfizer vaccine and half Moderna.  I did not notice any difference between those two vaccines in terms of side effects.  I personally only experienced mild arm pain with both doses (of Moderna).  But many in the office had more side effects with the second dose.  Some had fever and chills, some were achy, some had nausea, some were exhausted.  These effects generally lasted typically 12 to 36 hours.  I do not know of anyone in the office who had anything worse or anything that lasted longer.

There have been several concerns that people have raised regarding getting vaccinated.  I want to briefly comment about them:

  1. “They were developed too quickly – something must not be up to standards.”  Actually, they were subjected to exactly as much testing as all of the other vaccines that are produced, it was just that certain steps were done in parallel rather than sequentially.  While all kinds of factors allowed it to be brought to the public more quickly including the promise that our government would pay for many doses, no vaccine went to market until all of the usual safety and efficacy studies involving tens of thousands of people were completed. All three vaccines have been authorized by the FDA.
  2. “Since political pressure was brought to the process it must be tainted.”  While there has been all too much politics involved in so many aspects of our response to the pandemic, those in charge of the vaccine process, thankfully, resisted pressures to short cut the steps we take to ensure that these vaccines work and that they are safe.
  3. “The new technique of using RNA to make a vaccine means that my DNA will be altered or somehow there will be long term effects of the vaccine”.  The messenger RNA does not get into the cell nucleus and does not ever do anything to our DNA.  It is degraded fairly quickly and does not persist in our bodies.  mRNA vaccines have been used before and have been safe and effective.  However, never before has an RNA vaccine been used on this scale so it is absolutely reasonable to continue to monitor for potential adverse effects. 

We are now many months since the first volunteers received the vaccines and their safety record has been very impressive.  Their efficacy has similarly been very impressive as seen in our office.  And the disease that we are combating is dangerous.  We will not overcome it without vaccine.  More than 500,000 Americans have died from it.  With over 50 million Americans vaccinated, not one person has died from vaccine.  The risk of vaccine is so clearly low and the risk of being unvaccinated so very clearly intolerable, even tragic. 

Personally, I am so very grateful to be vaccinated.  I feel less vulnerable and less likely to infect other people.  Being vaccinated has not yet had much effect on the things I choose to do or not to do.  I am still quite careful at work and reluctant to go to places where people gather.  But I am hopeful that much of this will change as more of the people I know receive vaccines and I am encouraged that the availability of those lifesaving shots is increasing week by week.  I hope you are able to access a vaccine soon or have already had one and that it makes your life better and safer. 

Funny Jokes and Serious Matters

Note: This is a guest post by my husband, Gary Bakst, M.D. While I may question whether the jokes are funny (Gary didn’t write them!), I don’t question the seriousness of the subject he addresses. Thank you, Gary.

Jewish Humor – here are some jokes that have been around longer than I have:

  1. Why don’t Jews drink? It interferes with their suffering.
  2. My wife will buy anything that’s marked down. Yesterday she brought home two dresses and an escalator.
  3. A man can’t find a lawyer. He picks up the Yellow Pages and picks out a law firm-Schwartz, Schwartz, Schwartz and Schwartz. He calls up and says, “Is Mr. Schwartz there?  A guy says, “No, he’s out playing golf.” The man says, “All right, then let me speak to Mr. Schwartz.”  “He’s not with the firm anymore.”“Then let me talk to Mr. Schwartz.”  “He’s away in Detroit.  He won’t be back for a month.”“Ok, then let me talk to Mr. Schwartz.”  “Speaking.”
  4. I’d like to help you out. Which way did you come in?
  5. In New York’s Garment District, a little, old man is hit by a car. While he is waiting for an ambulance, a police officer tucks a blanket under his chin and asks him, “Are you comfortable?”  The man responds, “I make a living.”

It is that final joke that I am thinking about as I write this essay.  I grew up in a middle-class family and in a middle-class neighborhood. I remember when Linda and I struggled to make ends meet.  I realize that we are more comfortable today, but I still like to think that I am connected to the struggle of the average person/average family.  The reality is, every so often a patient says something that reminds me that I am not as connected as I’d like to believe.

They will tell me about the cost of an item – perhaps $10 – that is a big deal in their lives.  They are living on fixed incomes or small paychecks.  They have worked their whole lives but cannot afford things that I would take for granted.  While every expense is important, the one that we are most often speaking about is the cost of their medication.

This is a problem that has been mentioned often in the media.  But I don’t think that the real impact on so many people has been adequately discussed.  The stories I see in the news are about the most extraordinary examples.  They don’t convey the reality that I see people face numerous times every day.  The reality is, especially in the world of diabetes care, that we are in a time when there are great medications that can change people’s lives.  They can safely lower their glucose levels, protect their hearts and their kidneys, prolong their lives.

On the other hand, I have never seen a time in which so many people just couldn’t afford their medications.  It was not that long ago that medications were prescribed by doctors and filled at pharmacies and patients picked them up for no copay or small ($5-10) copays.  Now, the doctor writes the prescription and it goes to maybe a pharmacy, maybe a gigantic mail order facility.  The insurance company rejects the charge but doesn’t tell either the doctor or the patient why the med was rejected or what alternative would be covered.

Our staff spends enormous, frustrating hours, expensive hours, working on getting medications approved.  When a medication is approved – not necessarily the medication we had ordered but some theoretically similar drug – the patient is still left with frequently gigantic out of pocket expenses.

Some of this is related to the fact that medications are so much more expensive than they used to be.  The pharmaceutical industry is entitled to make their profits and needs substantial income in order to invest in the next generation of medications.  But too much of that profit comes from the US (as compared to overseas markets) and it seems like the average American is carrying a financial burden that is breaking their back.

On top of this, the insurance companies routinely reject claims, use intentionally opaque methods to keep us and our patients in the dark about what they need in order to approve those claims and even when they cover the medications, they leave too much of the charge on the shoulders of the patient.

Insurance companies typically use ever increasing premiums to herd patients into high deductible plans.  This means that you pay your premiums, but the insurance company may never spend anything on your care.  The situation is similar for those who receive their insurance through the Affordable Care Act (Obamacare).  While it is great that there is insurance that people can access, the insurance is often expensive and comes with high deductibles.  And, for those who get their insurance through Medicare, the development of prescription drug coverage (during the George W. Bush administration) is a great step forward but the coverage comes with that so called “donut hole” which means that you have to pay thousands of dollars out of pocket and then you can get back to where the coverage helps you out.

In the end, we are at a time of crisis in health care affordability and especially medication affordability.  Recognizing that I have no expertise in this topic beyond what I see every day in my office, I would make several suggestions that I do not hear from our politicians of either party.

  1. I would end the policy of not allowing Medicare to negotiate with pharmaceutical companies regarding the price of medications. Medicare needs that tool.
  2. Congress needs to pass a law limiting how much more any medication can cost in the US as opposed to the rest of the developed world. Perhaps up to 20% more but not the 300% more that we often see.
  3. I would outlaw deductibles over $1000
  4. I would limit how terrible any insurance policy can be and still be legal to sell in the US. If you are marketing your policy as insurance, it has to be helpful to people when they get sick or injured.
  5. I would require insurance policies to offer adequate reimbursements to hospitals such that they can hire enough nurses to truly take care of patients. Patient to nurse ratios are becoming dangerous and patients will be harmed.
  6. I would increase reimbursement to doctors and other health care providers for primary care services. This would continue the trend of reduced reimbursement for procedures and presumably make more doctors consider careers in primary care – not enough doctors are going into primary care.
  7. I would require insurance companies to make public how much money they spend on items other than patient care and to make public their procedures for approval of tests such as PET scans and for medications and expensive treatments. It is time to remove the curtain and give doctors and patients a fighting chance to get patients the care they deserve.
  8. Medicare is more efficient in translating money into care and I would require private insurance companies to make strides towards that benchmark in order to operate in the US.

There it is. That is my little manifesto.  The rantings of a comfortable doctor on behalf of his uncomfortable patients.  Now one last Jewish joke:  A Jewish grandfather takes his grandson to the beach when, suddenly, a gigantic wave sweeps the boy away.  Panicked, the grandfather looks up and prays to God, “Oh God, please bring him back.  Let him live.”  Just then, an even larger wave deposits the boy back on the beach unharmed.  The grandfather looks up and says, “He had a hat.”