Happy Thanksgiving

It is Thanksgiving tomorrow and I have more to be thankful for than most.  I am married to "the Amazing Charlo" and have lots of kids around to spend time with and love, the newest is my granddaughter Kiparoo, who is only 7 months old, so she's new on my list of things I'm thankful for.  Am very happy and thankful for having a great team to work with every day at the Cancer Center, and am so very happy that we are doing good work and helping folks.

The Uncommon Thread is out and on sale, and The Hard Times is written and awaiting release in April or May.  I'm excited about our new adventure, China Grove, the literary magazine Luke Lampton and I are starting, this summer.  We are working on the first issue, had a great visit with he and his family in Magnolia and shot some photos of China Grove while we were down south.  Our premier issue is going to feature a new short story by Ellen Gilchrist from her upcoming collection due out in 2014.  We also have some previously unpublished communications from Eudora Welty on the occasion of the publication of her first book, so that's cool.  We have art by Scott Schisler of Virginia, Lesley Wilson, and Cindy McDaniel from here in Mississippi along with whatever dribs and drabs I can come up with as filler from the photo shoot in China Grove.  For those of you who aren't aware of China Grove, it was the setting for the Eudora Welty story "Why I Live at the P.O." and since Ms. Welty gives us our name it is fitting that we feature something by her in our premier issue.  Want to be a part of our new adventure?  We will be accepting submissions for poems, short stories, essays, and art.  We will be using Submittable, keep a eye on this spot and I'll put the details out as soon as they are available, or check in at Chinagrovepress.com.

Once again Happy Thanksgiving!    Scott

Obama Re-Elected or Romney De-Selected?

Everybody take a deep breath and calm down. Obama was and is our president, nothing has changed, America isn't sliding straight down into hell tomorrow, that should take eighteen months at least, just kidding. What will happen is nothing. We have a divided government and a president who did not win the popular vote. There will be two more years of gridlock and then a new mid-term election.

As we look to the future perhaps Republicans should consider who they run for office more carefully, perhaps both sides should take a big step towards the middle, perhaps politicians should get the ___ out of making pronouncements about reproductive issues, perhaps religion should actually be separated from matters of the state as our founding fathers suggested?

The Republican Party has spent billions of dollars shooting themselves in the foot with two inappropriate candidate pairings in a row.

It not enough to be not Obama, or not Biden, or not Clinton.  Candidates should have something distinct to offer.  I will try to say this without gagging, but being "a Maverick" was and is not a campaign, neither is being "Not Obama."

Wake up, redefine how as a party the Republican Party will serve the needs of all Americans and move on to the next election cycle with a plan that has a chance to win.

Halloween

Tomorrow's Halloween, instead of spooks and hobgoblins we have millions of friends worrying about power outages and flooding.  I want to take this oppertunity to encourage all of you with a disaster on your hands.  You'll get through it!  One step at a time, band together, work together.  Do what you can then sit a bit and rest, then go back to work.  That's how we did it down here in Mississippi after Katrina, and guess what?  It works.  We're praying for you and sending you power trucks and good wishes.  Chin up.

So Jesus has a wife and Muhammad needs to buck up-

With the presentation by Harvard Divinity of what they believe is an authentic ancient Coptic tract in which Jesus refers to himself as having a wife Christendom is forced to reattend to a debate that originated around 200 AD which is the question of Christ's celibacy.

Personally, I prefer a married Jesus. If he was sent to experience life as a living man on earth, he would have missed the real flavor of humanity without having experienced marriage. There is so much of good and sorrow that can only be known by a married man.

About 500 years later and 750 miles away Muhammad was having his own problems. Plagued by somewhere between eleven and thirteen wives, he was dealing with the problems of excess. Things went pretty well pre-Hijra, he had a wife fifteen years his senior, wealthy and inclined to support him. They had a happy monogamous relationship until her death twenty-five years later. Then the dam burst. Nobody's exactly sure who he married next, or how many, but suffice it to say there were a bunch of them, one of them only nine years old when the marriage was consummated. Now I know faithful Muslims are okay with that, and some of them feel like they need to kill non-believers who point out how screwed up this looks by modern standards. But they need to calm down and let old Mo fend for himself. If he can handle ten wives in the same kitchen a little humor at his expense 1600 years after the fact is nothing. If the truth offends him he needs to buck up and tough it out, and so do those who follow him.






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Butterfly in the Typewriter

Anyone with ties to New Orleans knows their Confederacy of Dunces, and it's Swiftian derivation. This new biography of John Kennedy Toole has me retreading it. Looking at the story as a manifestation of paranoid schizophrenia, reframes everything entirely, and refocuses our considerations of the causes of Toole's suicide. Worth plowing through the first chapter, which with it's irritating focus on the minutia of the Toole family structure and Toole's mother's predilections is difficult to push through. But do it anyway and you'll come away with new knowledge in what is the first non-fiction biography of Toole. Ignatius Rising was a alternative fiction attempt that was far too determined to push Toole's life into the boxes of the authors' own construction

Stuff is happening

New CT simulator on the horizon for the cancer center. Reviewed BC/BS of Alabama's policies on IMRT, much more reasonable than the national or Mississippi standards. Maybe we can get them to listen to reason if we can get a large enough voice.

Questions for Anyone Interested In Breast Cancer

I have a dilemma and I’ve asked everyone I know to ask, so I’ve decided perhaps I’ll just toss my questions out to the rest of you Americans and ask you to think about them.  First a little background: I am a Radiation Oncologist from Mississippi.  Mississippi has the distinction of being the fattest state in the union.  This isn’t an opinion we’ve got years of statistics to back that up. 

Obesity is a problem on many levels but the one which I’m concerned about in this is that it predisposes to the development of breast cancer and, because obese women have obese breasts, complicates the delivery of adequate therapy to combat the cancer once it develops.  In my practice I have a lot of patients with breast cancer and large breasts or breasts that do not really exhibit ideal geometry for radiotherapy.  Now, despite this fact Blue Cross/ Blue Shield at the national level has decided that this is something that they are entitled to ignore.  That’s my first question: How are they able to do that?  If they are providing coverage in my state, how can they ignore the specific needs of patients in my community?

            The issue at hand is Blue Cross Blue Shield Association Policy # 8.01.46, which is a national policy that states:

Intensity-modulated radiation therapy (IMRT) is considered not medically necessary as a technique to deliver whole breast irradiation in patients receiving treatment for breast cancer after breast-conserving surgery, because the clinical outcomes with this treatment have not been shown to be superior to other approaches such as 3D-conformal radiation therapy, yet IMRT is generally more costly than these alternatives.

The problem comes when after a conformal plan is attempted, and because of breast size or anatomy/geometry the plan fails to meet what are considered to be adequate standards for dose homogeneity.  Dose homogeneity means that all parts of the breast get the dose they’re supposed to get, without unacceptable hot spots or cold spots inside the treatment volume.  Hot spots are areas of overdosage, which result in things like fat necrosis, pain, and swollen large red tender breasts, which do not get better over time.  Cold spots are areas that leave the patient vulnerable to tumor recurrence, what’s bad about that is pretty obvious.  These issues can frequently be overcome by switching to utilizing a different algorithm for treatment planning and delivery, IMRT.

BC/BS would have you believe that IMRT is somehow different than other forms of radiotherapy, that the effects of the given calculated dose is somehow fundamentally different.  But in fact the difference is equivalent to the difference in a set shot and a jump shot in a basketball game.  Scott Serota, the President and CEO of the Blue Cross/ Blue Shield Association is like a basketball coach that forbids the players that are actually playing the game from taking anything but a set shot to get their two points.  So question number two is for him: How do you think that kind of plan would work out in the NBA play-offs?  Hell, in the NBA play-offs the only thing at stake is money and bragging rights.  In the game we’re playing the stakes are human lives, or do you understand that?  Maybe it’s only a decision about money and bragging rights for you too?  In February of this year the Seattle Times published an article claiming that several BC/BS subsidiaries in their area were stockpiling billions of dollars in cash reserves, the highest they’ve ever had, while at the same time raising rates they were charging their beneficiaries, AND THEY WERE OPERATING ON WHAT WAS SUPPOSED TO BE A NOT-FOR PROFIT STATUS in the state of Washington.  Those claims are still under investigation by the state’s insurance commissioner.

This is the unfortunate mindset that permeates the company at this time.  From their origin in 1939 to the Tax Reform Act of 1986 BC/BS was considered a self-funding social welfare program and therefore tax exempt up to that point. After 1986 it was considered not-for-profit until the national corporation became a for-profit entity in 1994, but many of the individual component companies remain not-for-profit at the state level at the present time. 

At every level they have become more predatory.  They are well aware of the steps that they are taking.  Originally they denied coverage for IMRT for breast and lung cancer because it was deemed investigational and unproven.  When the Federal Employee Program (FEP) dictated that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity, BC/BS changed their classification of IMRT from investigational to “not medically necessary.”  Not based on scientific studies, but because they wanted to continue to hoard money.

Medicare, most other insurance providers, even poor little Mississippi’s Medicaid program all understand that IMRT is a tool in the fight against cancer.  It may be over-utilized by the unscrupulous if left totally uncontrolled and that is not what I’m asking for.  But using the appropriate tool, when needed, is what medicine is all about.  Sometimes you need a set shot, sometimes you need a jump shot, or a hook.  The person in the game needs to be the one to decide that.

Here are my last questions:  Who’s in charge of keeping an eye on stuff like this?   We need someone to keep an eye on any collection of companies, like BC/BS, which provides private health insurance to 99 million Americans and has already faced anti-trust litigation in several southern states, to be sure that they are acting in the interest of the patients they serve and not just their bottom line.

Where is the American Cancer Society? Where is the Susan G. Koeman Foundation?  Where are the celebrity breast cancer survivors?  Why aren’t all of you up in arms about this?  Is it because it’s only fat women from Mississippi?  Well, I’ve got a surprise for you, it’s not, it’s national, and it’s insidious.  You need to stand up.  You need to say something.

Mr. President and Mr. Romney this one’s for you:  What are you going to do about it?

Anybody got any answers?

Let me know.

Doctors and Magic

Doctors and Magic

Do you believe in magic?  Sure, no, yes, maybe, it depends on how you define magic are all acceptable answers.  But for the most part I think we, as physicians, tend to be skeptical.  It comes from a lifetime of requiring proof in making the decisions that affect our patient’s lives I suspect.  I wrote about my own personal loss of magic some time ago, and yes I believe in the magic of love.  I believe in the magic of innocence and beauty of the tenderness of Christmas mornings, and tooth fairy nights.  But I don’t much worry about wizards, or witches, or vampires, or evil magicians pitted in old feuds from Arthurian times.  Maybe I’m just obtuse.

I have a group of e-friends I enjoy very much.  I don’t know any one of them personally, but if I have the opportunity on M-W-F from 3-4 pm CST I log into #LitChat and share with other writers and readers from around the globe.   Last week we had begun discussing the book The Night Circus by Erin Morganstern and one of the participants allowed that in her book club, which was primarily composed of physicians, no one seemed to get it.  I felt bad.  I’d started the book when it was first published, and here it was three months later and I still hadn’t gotten a third of the way through it.  The problem was, I didn’t know why. 

Why had I stalled out?  It was beautifully written with luxurious description that creates a magical world straight out of a Tim Burton movie.  The plot revolves around two children selected as participants in an ancient feud and bound to one another in a battle to the death; no matter how long the contest takes.  They both receive different arcane training in the ways of magic until they are grown and then set on a collision course in the contest venue of the night circus, a magical circus that appears and disappears from place to place around the world.  That’s about as far as I got.  It was kind of like surgeons and internal medicine residents on night call appearing mysteriously in the various wards of the hospital to battle with one another over the true manner of healing.

I can hear the voices thundering through those cold gray green halls.

Zanziber, resplendent in his blue scrubs with contrasting Betadyne stains cascading down his thighs declares. “The only way to heal is with cold steel.  Surgery is the only way.  He has a perforated ulcer.”

And then Mortimer, rheumy eyes dull, places his stethoscope in the pocket of his yellowed white coat and responds to the challenge; “You wouldn’t know healing if it bit you on the ass.  It’s pancreatitis.  Look at his blood chemistries.”

Fire flies from Zanzibar’s eyes.  “Chemistries be damned, there is rebound, and where there is rebound is a surgical abdomen.”

And that was my problem with the book.  While it might have been magic for some, it was learned ritual for me, the IV or the blade.  You want arcane magic get a psychiatry resident involved in a case.  A life and death struggle that involves death by exhaustion is nothing to and old-school surgery resident.  The book didn’t take me anywhere that I hadn’t already been intellectually, but now that I had been called out I was damned and determined that I was going to finish it.  I will spare you any further plot details, to keep from ruining the plot for you, but suffice it to say that in the end it all returned to my own personal viewpoint on magic, that it exists in the relationships we pursue and the love we share with one another along the way.  All in all, it was worth the read.  It is a triumph of descriptive writing with a plot worthy of Shakespeare.  Perhaps a plot derived from Shakespeare, but that doesn’t detract from the writing.   

Bloggy Stuff

This isn't so much about as around,
A boat that doesn't float lies aground
Useless for what it's meant for
less than more then before

Take a walk, feed the dog
Neither spinning gear or whirring cog.
The world passes floating spin
And all I do is walk home again.


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Year Six

Three new pieces on the evolution of a golfing obsession, the thirty- foot snake, truck box surprises, a sample of Terrence and the Toilet Fairy, ghosts in my pick-up (three pieces), a Christmas piece from the 1930's, and two other's. How's that sound for next season?


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More and Less

Let me let you in on one of the basic facts of life, and no, you don’t have to be a doctor to know this one.  Everybody wants more!

“More what?”

Who knows? More money for some, more fulfillment for others, or perhaps just more love, a lot of times it varies.  It may be one thing one day and another thing the next. What we want more of is variable.  The feeling that we need more of something is universal. For me what I need more of depends on the season and what mood I’m in.  In the fall I need more jackets.  In the spring I feel like I have a shortage of golf clubs.  Never mind that I have closets overflowing with both and I have more of either than I can ever reasonably use.  I don’t have the one I need now.

 And I’m not unique to this affliction.   Need proof?   Just look in the self-improvement section at your local bookstore, or turn on a little daytime television.   Flip through the channels any day of the week and two thirds of what you’re going to see pouring out at you is how to get more ________.  The blank may change from one channel to the other, but the quest, the need to get more, remains  universal.

Why do we need more?  Well, we need more money so we can get more stuff.  For two decades the U.S. economy has been based on a simple principle…consume, consume, consume.  When our economy hit a bump and consumer spending dropped the first domino fell, setting off a chain reaction that reverberated around the world.

I hate to admit it, but I’m no different from anybody else.  I fall hook, line, and sinker for the lure of the consumer advertisement.  I know that they’re just shallow manipulations of my individual gullibility.  And while I know this intellectually, at some deep basic level, for some reason, I believe what the commercials are telling me.  I need a new Lexus.  That three-year-old bomb I’m driving isn’t cool anymore.  I need the new one.  And yes…yes…yes Lord knows I need that new I-pad.  I can download three million songs and a thousand movies and…and…and, who knows what else? All I’m sure of is, I'm sure I need one.

 Unfortunately, as much as I delude myself into believing it is, my need isn’t real.  I don’t have time to download a hundred movies, much less a thousand.  I have three movies on my current tablet, and yet I’m coerced into believing I need a newer, more technically sophisticated model.  With the rapidity of technological evolution in the modern world, this cycle of need and fulfillment is never ending.  As soon as I buy the new Lexus or I-pad they’ll start advertising a newer model.  One that fuses both of them and comes with a thought activated cell phone in it.  And as soon as I get that, there’ll be an even newer model with both the cell phone and a miniature teleportation device, so I can teleport myself, my Lexus, and my I-pad to Tahiti to drive around for only a nominal fee.  And so it goes ad infinitum.

In a lot of ways medicine is the same way, but instead of ego and vanity being the primary driving forces, it is our very lives that are at stake.  We want more and we want better, the heck with better, we want the best.  Who doesn’t feel like they deserve the best health care?  America is nothing, if not an egalitarian society, in this regard.  Everybody deserves the best health care, right?

Well, I don’t know.  Let me pose a hypothetical scenario.  What if there was a drug that was ninety-nine percent effective in preventing osteoporosis in post-menopausal women?  And, what if it had no identifiable side effects?  Shouldn’t we give it to everyone that could benefit from it?
  
That seems like a “no brainer”.  And it would be, until you find out that it costs twenty thousand dollars a dose?  Ok, well, that does seem a bit steep.  But it really would make so many lives better.  I guess we still should.

The problem is, at that cost, for that many women, most of which will be sixty-five years old or older, the cost of the drug will bankrupt Medicare in a single year.

Now, should we make this wonder drug available to our Medicare beneficiaries?  By the way, I hate the term beneficiaries, almost as much as I hate the term, health care provider.   These are patients; sweet little grandmothers and mamas, wonderful women, and you’re their doctor and you have this wonder drug that will make their lives so much better. No longer will they have to face the chronic back pain and the debility of nerve root compressions that are associated with the pathologic fractures of osteoporosis.  Should you give it to them?  And, if you do who should pay for it?
This isn’t a medical decision.  Medically, the answer is obvious.  From a risk-benefit standpoint the drug is amazingly effective, so it’s all benefit with no risk.  The only risk is to the solvency of the largest health care provider in the United States, Medicare, and by extension the viability of our government as a source for health care coverage for those that have no other way to afford it.

So, this decision becomes not a medical decision but a social decision, a governmental decision, a legal decision, even a moral decision.  It is a decision that will reverberate through the years.

If the recent financial downturn has shown us anything, it’s that consumption has it’s limits, and those limits are imposed by the availability of funds.   Deficit spending and debt are only sustainable so long as there is someone willing to lend us the money that we don’t have. We are currently in a position that requires that we make a decision on how we will impose spending limits because we’re running out of credit.

Because our economy is, to say the least, less robust than it was a few years ago and the increasing number of folks becoming Medicare eligible due to the baby-boomers pouring into the over-65 population like water from a busted dam, things can’t work like they used to.

We need a better system.  Not one dominated by partisan politics, and we need to do it soon.  The system we have now is failing and its loss will effect, not just ourselves, but what kind of future we leave for our children.

Saw Levon passed on today. I don't know where he's gone, but he left a trail where he's been.  He was a part of a culture that is and was a rare time in the world.  See you neighbor.

Working on

Am working on the final run through on The Uncommon Thread. The cover is finished, just need the final graphic layout. Need to done by Monday, that means no more distractions.


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Looka'here

I've decided to change the name of the blog. Apparently a rap song called Looka here was released and anything even close to that is innundated. So since rap isn't something I care to blog about I've retooled. I will go back and import some of the old stuff over so it can vein the archives. Maybe I'll get back to posting more regularly with the new site. Off we go!