Tuesday, September 1, 2015

acknowledging ignorance

I'll be teaching an introductory class about the United States health system this semester. I opened the class yesterday with a presentation titled "what do we know?" With the first slide being an image capturing Hippocrates' theory of the four humors.

And we talked about how Hippocrates' theory guided medicine for some 2000 years.

In case you're not familiar with the theory, here is an excerpt from one of the treatises attributed to Hippocrates, On the Nature of Man, and describes the theory as follows:

The Human body contains blood, phlegm, yellow bile and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with others.
This theory led to practices such as therapeutic bleeding and therapeutic vomiting.

For centuries everyone knew that if you have fever you had an excess of blood, and so the proper treatment of course was to drain off some of that excess blood. These are the things we knew. They were the most modern science available. Today we look at it as near barbarism.

Medical science has a long history of not acknowledging its own ignorance. In my observation health policy is at least as arrogant. So as we started our discussion of the delivery of healthcare in particular the policies around that delivery, I wanted my students to be appropriately humble and realize how little we actually know. When you acknowledge your relative ignorance, you become less confident about forcing people to do what you think is right.

Saturday, August 22, 2015

Bill Thomas on following the money

I'm on a Bill Thomas kick. I just got two more of his books in the mail today -Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home and What Are Old People For?.

I finished reading another of his books -Second Wind: Navigating the Passage to a Slower, Deeper, and More Connected Life last week. More to say on that one. I mentioned it here earlier today.

Anyway, I've just started reading Life Worth Living and I am immediately struck by this passage:

Because the money that fuels the engines of nursing homes is the money that flows through the pipelines of health care, those funds must pay for treatment. Reimbursement is based on the variety and number of treatments rendered. As a result, the principles of nursing home care have been derived from the logic of medical science and compounded with institutional bureaucracy. For nursing home residents, life is therapy, and therapy is life.
This passage resonated with me because, even in the military, I've seen the influence of money, and how care follows the money, even when the patients are paying. Frankly, I've been instrumental in making this happen. This isn't completely dysfunctional - if the system weren't following money, it would follow something else - usually power, fame, or ease. Finding the right incentives isn't easy. If it were. managers wouldn't be as valuable as they are.

The key Thomas hits on is that the money comes in the wrong form for nursing homes. Incentives matter. But this wisdom applies to the whole medical system. We've been reimbursing the wrong things for a long time.

The ACA is supposed to fix that. It might move us marginally in the right direction. But I don't have great faith that it won't end up derailed and just as dysfunctional as before as guys like me get ahold of the reimbursement system and optimize it for the organization. The only way to stop that from happening is to make the system less rigid - which the ACA definitely does not do. If anything, it does the exact opposite.

More to follow on this book - it looks promising.

the long summer

Summer for me is almost over. What a strange summer. 

It began with flying back to Texas to see my daughter graduate, finalize the sale of our house, send off our kids to NH with their grandparents, say goodbye to friends and former colleagues, and then make the long drive back to NH to our new home.

It's taken most of the summer to get things physically settled as we take our time contemplating where things will go, since this is not a two-year hitch and "just stick it there - it doesn't matter" doesn't really apply.

The kids of course have had the hardest time with not having friends. That's made the summer long for them, and by extension long for us. 

In spite of the seeming lack of responsibility, I find myself behind on my work goals, which is frustrating and raises my stress level. I had so much I wanted to accomplish, and I accomplished very little.

But the kids are going back to school in a little over a week, and the long summer will finally draw to a close. 

I read Bill Thomas's book,Second Wind: Navigating the Passage to a Slower, Deeper, and More Connected Life while N. and I were camping in the White Mountains. One of the things he talks about is our perception of the speed of the passage of time. 

Thomas notes that people of different ages experience time differently. One argument is the relative proportion of your life that each unit of time represents. If you are five, a year is 20% of your life, if you are 50, a year is 2% of your life, so the argument goes that because the relative proportion of your life becomes smaller, the passage of the same unit of time is perceived as shorter.

Thomas allows some truth to that argument, but he doesn't see it as the whole story. The passage of time is also marked by the activities you are engaged in. He talks about how boredom makes time move slower. How slow does time move when you are in a doctor's waiting room or in line at the DMV?

But I think more interesting is the third reason he presents - children perceive time as slower than adults because they are learning more. They are experiencing many things for the first time - coming to understand the physical and social world for the first time, whereas by the time you are 50, you are pretty sure you have most of it figured out. Also new experience matters. The decade of your 20's is likely one of the most change-filled decades of your life: leaving home, finding a career, finding a mate, having children, etc. often happen for the first time in your 20's. In your 50s you have relatively few major changes like this, and so time moves faster. 

The secret to a long (perceived) life, it seems is to either be very bored most of the time, or fill your life with change. Bored seems like a waste. Change is a little scary, but certainly a better alternative. I like the idea of change as learning new things. Change doesn't have to be as radical as moving or starting a new career (though I am doing that very thing right now). Change could also be choosing to learn something new, or taking up a new hobby. I think if you want to live a (subjectively) long life, you have to choose to refresh yourself.

I think my whole family has perceived this past summer to be longer than most we remember because of the second two reasons: boredom and change, sometimes both at once.

For Kandie and I, most of the change has been good. For the kids it's been a mixed bag, but more change is ahead as they head off to school. At least some of the boredom will be gone. Hopefully the change will be good.

This has been a long summer. I am looking forward to the fall.  

GMO labeling the latest in snake-oil

I'm of mixed thoughts about GMO's - I don't know enough about the issue, but I suspect when we use "GMO" in common parlance, we are being far to general. Some things we should probably fear, some we should not - because human beings have indeed been engaging in GMO activities since agriculture began.

Nevertheless, I love when I see hipsters revealed for the fools that they are:
Last year, Evolution Salt Co. proudly put a label on its packages of Himalayan salt proclaiming they contained no genetically modified organisms.
It shouldn’t have been a surprise, because salt has no genes. But Hayden Nasir, chief executive of the Austin, Texas-based company, said advertising the absence of GMOs was good business.
If a competing salt next to Evolution’s “doesn’t say non-GMO on it, chances are somebody will bypass that,” said Mr. Nasir, who said he also supports such labeling in principle.

congratulations to the first female Rangers!

Congratulations to the Army's first female Rangers! And congratulations to the Army for embracing the idea.

http://www.army.mil/article/154253/First_female_Rangers_believe_experience_makes_them_better_leaders/ )

My Army career started out in the infranty, and I quickly realized it wasn't for me. It's not nearly as much fun as movies make it seem. It's far more about grinding endurance and discipline than about being macho.

Is every woman cut out to be a Ranger? Of course not. Nor are the vast majority of men - including me. I don't think I would have passed the course had I attempted it. But that doesn't mean that I wasn't a decent soldier, and that I couldn't make a contribution to the Army. I think I did in my time, but in a different way. The jobs I found myself well suited to do would not have appealed to many of the people who are drawn to Ranger School and similar related fields. It's OK.  The Army, like society, needs all sorts of people to do the many diverse tasks it needs to accomplish to carry out its mission.Who fills those roles should not be a function of demographic characteristics, it should be about best fit. It's a good lesson for society that the Army keeps demonstrating.


Thursday, August 20, 2015

33/52: eat

This week's creativity challenge theme is "eat".

This is a fairly typical breakfast scene for me: coffee, yogurt, at my computer.

I'm not much of a breakfast food person - I'm not a fan of eggs and bacon. I eat a lot of eggs these days - a few of the diets I've tried have pushed me in that direction, but I don't love them. They are efficient. I like a good Greek yogurt, but I'd like to cut back on dairy. 

I love to eat. I love to eat really bad food. Paula Dean kind of food. But I've been trying to move more towards Alice Waters. It's not easy, and I've regressed quite a bit this summer.

I'm hopeful with the coming of the fall and a return to work and more structure back in my life that I will be able to make more improvements.

Friday, August 14, 2015

White Mountains

I casually made plans to do an interview with Robert Mach, a VP at Littleton Regional Hospital in Littleton, NH about 6 weeks ago. Then I looked at a map and realized Littleton was a little more than two hours away from Durham. Not that that's a problem - just caught me by surprise. I need to pay attention to my NH geography! Anyway, Littleton is in North Central NH, in the White Mountains. It's a very cute town.

I decided to invite the girls to come along, with the idea that we could going camping in the White Mountains National Forest after I did my interview for a couple of days.

N. took me up on it. The other two had things to do. After the interview we had lunch at the Schilling Beer Co. which has excellent beer and excellent artisanal pizza. It's actually the little red building in the middle of the picture above.

I tried the Mare Nectaris (Sour Brown Wild Ale) and the Thaddeus (Belgian-style Dark Strong). N. and I shared their white pizza.

Afterwards, we checked out Chutters, a candy store on Main St., home of the longest candy counter in the world.

Here's part of the counter:

I was fascinated by the variety of fruit slices - my favorite candy. This one in particular:

It actually had a bit of a kick to it! There was also a pomegranate fruit slice, which had a vague berry taste.

It was raining, and it looked like it might rain for our whole trip. Have credit card, will travel. So we headed to my favorite store in the world - Walmart! And bought some rain boots on the way to the campground.

During a break in the rain we were able to get everything set up at the campsite. 

There's the Adventure Van doing its part. We stayed at the Zealand Campground in the White Mountains National Forest. Basic sites - no water or electric. There was a portajohn across the street. 

The Ammonoosuc River (I thought it was the Zealand River, but I was looking at the map and I guess I was wrong) ran about 100 feet from our site. We could hear the river rushing by the whole time we were there - it was lovely.

We hiked the Sugarloaf Trail to the southern peak.

N. and I at the summit:

Such a beautiful place - both macro and micro.

Just before we left, I realized our campground was going to be just a few minutes away from the legendary Mt. Washington Hotel where the Bretton Woods Accord was signed in 1944, recreating the monetary system post-WWII, and creating the IMF and World Bank. So of course we had to go visit.

The Gold Room where the Accord was signed:

We ate well on the trip - 

I really had fun making our meals and messing around at the camp site. Though it rained. A lot. And sometimes we just had to get in out of the rain.

I think probably the highlight of the trip was our rock stacking installation we made on the Ammonoosuc:

our installation on the Zealand River

(in case the embed fails: https://flic.kr/p/x3MjV3 )

I had no idea rock stacking is actually somewhat contentious. I'm reasonably sure all of ours are gone by now - they were so precariously balanced that a good wind would have taken most of them down. A change in the water level from the rain certainly would. So I don't think it's the same as some of the dry land stacking efforts people do. Regardless, we had fun.

We packed in a lot in 48 hours. I was glad to get to do it with N., as she is off to college in the fall. 

I think a big part of the fun of camping for me is the sponteneity of it: nothing ever quite goes off as planned. You always have to MacGyver something. I like that, most of the time. Especially if you go into it knowing that that's how it's going to be.

And there is nothing like sleeping in a tent for a few days to make your bed at home feel like a dream.