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Fat Chance

January – the month when millions of people engage in that time-honored bald-faced lie known as the New Year’s Resolution. “This year I promise I will exercise more, get in shape and lose weight.” (I resolved to get this posted in January, and you can see how well THAT worked out!) It’s about as successful as when my sister-in-law vows to give up throwing F bombs for Lent. One year she made it to 4:30pm on Ash Wednesday; usually she doesn’t make it out the door. Most people have given up on their resolutions sometime between January 12 in Australia and January 17, known as Ditch New Year’s Resolution Day.

Losing weight is one of the most common New Year’s resolutions but often remains an exercise in futility. The New England Journal of Medicine acknowledged the problem in the January 1, 1998 issue, noting ”the vast amounts of money spent on diet clubs, special foods, and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted.” Twenty-some years later the weight loss industry rakes in over $60 billion a year but only about 5% of dieters manage to keep from regaining weight. Most of the Biggest Loser contestants regain most of their weight over time.

So how did we become so obsessed with weight?

In 1901 Dr. Oscar Rogers, Chief Medical Director of the New York Life Insurance Company, reported that overweight men had a 35% higher death rate. Insurance companies latched onto this finding and assumed the obese presented a higher actuarial risk. Rogers also discovered overly tall and underweight men suffered a higher mortality rate, but conveniently left out those data.

In 1930, Louis Dublin, Metropolitan Life Insurance Company’s vice-president and statistician, linked obesity to long-term illnesses – heart and kidney disease, diabetes, atherosclerosis and stroke – and obesity became permanently stigmatized. The obese stood accused of a variety of psychological disturbances, including depression, gluttony, homosexuality, laziness and anxiety.

Met Life published “ideal” weight and height charts for men and women in 1959 and 1983, but they were based on very sloppy data obtained from white collar people who could afford life insurance policies. Some of the data were self-reported; men over-reported their heights and women under-reported their weights. Dublin’s body frame sizes – “small, medium and large” – were arbitrary. No one considered muscle mass and physical activity; by these measures, many highly trained athletes would be considered overweight.

I’m six feet tall with a “large” frame. The Metropolitan Life Weight Chart for Men says my “ideal” weight should be 164-188 pounds. This is what I looked like in 1991: 175 pounds with a 34-inch waist.

I looked pretty good, right? Well, I was in my 30s and had lost 35 pounds because I’d stopped eating for days at a time when I was going through a painful divorce. Over the next few years I gradually gained most of it back, stabilizing at 220 pounds. I gained another 40 pounds from job stress eating in the late 1990s; my weight fluctuated between 260 and 270 pounds for the next fifteen years. A few years ago, I dropped below 250 pounds, but that was the result of two relatively severe respiratory illnesses. I could eat or breathe, but not both.

The hysteria over obesity was compounded in 1993 when two public health researchers, J. Michael McGinnis, MD and William H. Foege, MD, published “Actual Causes of Death in the United States” in The Journal of the American Medical Association, from which the media erroneously concluded “obesity kills 300,000 people each year.” If one bothered to read the article, one found the authors reported “diet and activity patterns,” not obesity, per se, contributed to mortality. The authors cautioned “no attempt was made to further quantify the impact of these factors on morbidity and quality of life,” and the “numbers should be viewed as first approximations.”

McGinnis and Foege compared the National Center for Health Statistics’ (NCHS) list of the most common causes of death – heart disease, cancer, strokes, accidents, diabetes, and others – with factors that contributed to mortality, such as tobacco, alcohol, guns, cars and the aforementioned diet and activity patterns. The NCHS found almost twice as many people died from accidents as from diabetes; however, no one suggested we had a national epidemic of stupidity or clumsiness.

NCHS Causes of Death	Annual Deaths	McGinnis/Foege Contributors to Mortality	Annual Deaths
Heart disease	720,000	Tobacco	400,000
Cancer	505,000	Diet /activity patterns	300,000
Cerebrovascular disease	144,000	Alcohol	100,000
Accidents	92,000	Microbial agents	90,000
COPD	87,000	Toxic agents	60,000
Pneumonia/influenza	80,000	Firearms	35,000
Diabetes	48,000	Sexual behavior	30,000
Suicide	31,000	Motor vehicles	25,000
Liver disease	26,000	Illicit drug use	20,000
HIV	25,000

ARE THINGS REALLY THAT BAD?

Data from the NCHS and other sources suggest the answer is “no:”

Deaths from cardiovascular disease have declined since the 1950s.
Life expectancy in the US, which peaked at 78.5 years in 2012, has dropped three years in a row due to drugs and suicide, not obesity.
The US Army Research Institute of Environmental Medicine compared the fitness level of new recruits in 1978 and 1998 and found the latter were just as fit as the former, albeit 10% heavier.
The relative risk of mortality associated with obesity declines with age.
Obesity is associated with a variety of maladies, but a direct cause and effect relationship hasn’t been established. If 30 percent of overweight people are diabetic, that means 70 percent of them aren’t. If 85 percent of diabetics are obese, and Type 2 diabetes is due to insulin resistance, then which came first, the obesity or the diabetes?
Paradoxically, one research group tracking normal weight and obese patients after being diagnosed with Type 2 diabetes found those of normal weight were more likely to die than their obese counterparts.

So why is it so difficult to lose weight and keep it off?

For decades physicians told us if we all just ate less and got more exercise, we’d all look like Adonis and Aphrodite. If you were fat, it was your own damned fault because you were gluttonous or lazy. Researchers have only recently started admitting that weight gain is far more complicated than “calories in – calories out.” Weight regulation is a complex interaction of genetics, environment and biology, and long-term weight loss is nearly impossible for most of us.

The magnitude of genetics’ role in obesity isn’t entirely clear, but we know susceptibility to “common obesity” involves multiple gene variants, first identified on chromosomes 16 and 18. Studies of familiar relationships found the correlation for BMI in identical twins is twice that of fraternal twins and decreases as genetic separation increases: siblings, parent-child, spouses, and adopted children. Pick your parents carefully if you want to look like a cocaine waif your entire life without the drug risks.

Thousands of years ago, when we chased our dinners across the savannahs (or ran to keep from becoming some critter’s lunch), humans adapted genetically (so-called “thrifty genes”) to hang onto whatever calories they ingested as a hedge against times of famine. Western civilization has brought us a surfeit of food along with soul-sucking jobs that have most of us sitting on our butts for 8-10 hours a day (more if you factor in 2-hour daily commutes in large cities). Our bodies have not adapted to this relatively sudden change.

The Pima Indians of Arizona provide an extreme example of environment rapidly overwhelming centuries of a lifestyle that had kept a genetic propensity for obesity in check. Robert Pool, in his book Fat: Fighting the Obesity Epidemic, described the Pima this way:

“When the white settlers first arrived, they found Indians straight out of a Frederic Remington sculpture. The bodies of the Pimas were thin and sinewy, their legs chiseled by regular running, their arms strong from the bow, the war club and the plow. Today the Pimas are fat. Not just chubby or overweight, like the average American couch potato, but obese.” (Pool, p. 140)

A century and a half after being consigned to a reservation, the Pima have gone from being fierce warriors protecting the weak to a tribe devastated by high rates of diabetes, obesity and kidney disease. Their life expectancies are fifteen to twenty years shorter than the average American. Much of this appears to be the result of a sedentary lifestyle and a diet that has changed from a high-fiber, low-fat, low-calorie diet to one with a lot of empty sugar calories and triple the fat content.

Our own lurch towards diabetes and obesity appears to be linked to the low-fat craze that started in the mid-1970s. “Fat is the enemy!” “Carbs are good for you!” The food industry capitalized on this, producing a large range of low-fat foods, which we all gobbled up – and got fatter. Decades later, we learned the sugar industry started paying off researchers in the 1960s researchers to blame fat for obesity. Ironically, European countries with higher-fat diets had lower incidences of heart disease.

While it’s convenient to blame genetics and environment, biological mechanisms don’t help much. Researchers debate whether there is a single “set point” or multiple “settling points,” but most people who’ve lost weight will tell you how their bodies will fight like hell to get it back. Columbia University’s obesity researcher, Rudy Leibel, compared energy expenditures of twenty-six obese people with static weights, averaging 335 lbs., to those of twenty six normal weight controls. As expected, the obese required more calories than the normal subjects to maintain their weights. (Calories per day/weight (lbs.) = calories per pound)

However, when the obese lost significant weight (about 115 lbs. each), they required FEWER calories than expected to maintain their weights. Their metabolisms slowed in an effort to return to their original weight. Kevin Hall, a researcher at the National Institutes of Health, found the Biggest Loser contestants’ metabolisms remained low even after they started to regain weight.

What should you do?

First, weight alone is a poor indicator of overall health. Jim Fixx, the man who got America running, died of a heart attack in 1984 while jogging in Vermont. Dana Carvey, a perennially skinny guy whose genetically high cholesterol levels (familial hypercholesterolemia), has required four angioplasties to stay alive.

On the other hand, in 2002 the San Francisco Chronicle did a story on Amanda Wylie, a 250-lb. aerobics instructor in San Francisco who had a black belt in boxing, did yoga and the splits, and could probably wipe the floor with me. That same year, Jennifer Portnik, another obese but physically fit aerobics instructor, sued Jazzercise for refusing to sell her a franchise. She opened her own business after being certified by the Aerobics and Fitness Association of America, and Jazzercise dropped its requirement for skinny instructors.

Steven Blair and others at the Cooper Institute for Aerobics Research, found that skinny couch potatoes were at greater risk of dying than men – skinny or obese – who maintained cardiovascular fitness. Exercise isn’t going to make you lose a lot of weight, but it’s great for your heart. So, go take a walk, find a physical activity you like, and minimize couch time.

Recently (February 13, 2019) Samantha Bee took on how media and physicians stigmatize fat people in a Full Frontal segment called “Thicc not Sick.” (I was appalled to find out news outlets refer to stock footage of the obese as “guts and butts”). Twelve years ago, a genetically scrawny medical school classmate badgered her husband into losing weight (I didn’t think he was terribly heavy). I found a Facebook photo from last year. He’s back to his original weight and still looks pretty good.

Realize diets don’t work in the long term because they are merely a temporary change. Anyone can lose weight eating 800 calories per day, but are you willing to do that for the rest of your life? Probably not. Your metabolism will adjust to compensate for the weight loss, rendering permanent weight loss an exercise in futility for most of us.

There is no single, optimum diet for everyone, so find what works. Peg and I have a low-carbohydrate, high-protein diet, but she can eliminate carbs more easily than I can. My blood sugar will plummet in an hour or two if I don’t have a little carb with my meals. (That, and I get really ugly.) The best thing you can do is eat a relatively healthy diet and give yourself rewards in moderation.

Finally, I think the unrelenting stress of our jobs presents the greatest risk to our overall health (Midwestern winters run a close second). Obstetrical nurses often live on chocolate because they don’t have time to eat while working on chronically understaffed units. Corporate America learned how to squeeze more work out of fewer people for less money and they dare not squawk. “If you don’t like it, you’re free to leave and we’ll find someone who is more of a team player.”

Misery loves company. We’re stuck with work but socializing outside of the workplace and fostering supportive relationships will make life a lot easier. And wine. Everything goes better with wine.

Southwestern Christmas

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I grew up in Bisbee, Arizona, a small copper mining town nestled in the Mule Mountains ninety miles southeast of Tucson. The mine closed in the early 1970s; the town has been taken over by artsy hippie types and the Arizona Daily Star named Bisbee the state’s most gay-friendly town. A bumper sticker describes Bisbee as “Like Mayberry on Acid.”

The Bisbee area has several different regions which only becomes important when describing landmarks or certain homes. The part of Bisbee built around the canyon of the Mule Mountains is now “Old Bisbee,” and Warren is now officially Bisbee. Running southeast from Old Bisbee is the Lavender Pit mine and Lowell. A traffic circle (also called a roundabout) at the edge of Lowell splits the highway into three directions. The first right goes to Tintown, South Bisbee, Huachuca Terrace, Don Luis (pronounced “Louie) and the border town of Naco. The middle exit takes one to Bakerville and Warren/Bisbee, while the third one runs to Douglas, about 30 miles away. If you are insatiably curious, look up Bisbee on Google Maps.

I missed out on the delights that are common to Midwestern winters: below zero wind chills; four-foot snowdrifts in your yard; never seeing the sun for five months. I’d never heard of snowsuits, layering or thermal underwear since the temperature was often in the 50s or 60s. No one had a snow shovel or a snowblower, nor had we ever seen a snowplow. We didn’t have sleds or toboggans. I used to slide down a hillside on a piece of corrugated tin roofing in short sleeves and jeans. (One time I tried it without the tin and ripped the hell out of my pants, which didn’t make my mother happy).

Despite that we weren’t strangers to snow as Bisbee’s sits at 5,280 feet. In the mid-1960s we had more snow than my grandmother in Illinois. Bisbee saw eight inches of snow on New Year’s Eve, 2012 and another memorable snowfall on January 10, 2016. The combination of altitude, temperature and moisture content tended to make the snow a little heavier and wet, just right for snowballs. This is me, about 6 years old, pasting my mother with one.

Snow at lower desert elevations creates a surreal, fantastic landscape that has to be seen in person to appreciate. The prickly pear, mesquite and yucca shimmer as sunlight filters through a low ground fog. As the sun rises farther, the fog dissipates, and the snow begins to melt, often disappearing by noon. This shot is from outside of Phoenix in 2013.

We adhered to the traditional Christmas tree ritual. We’d buy a tree from a stand set up in a parking lot in Lowell, except for the time we cut our own. My stepfather would put the tree in the red and green metal stand with the prongs in the bottom that would eventually rust and break off, make sure it was as straight as could be expected, and tighten those big screws. My mother would untangle the lights, the kind with incandescent bulbs that doubled as night lights. Sometimes we had to go through the tedious process of checking each bulb since none of them would light up if one was burned out. I wanted to wrap the strings around horizontally, but Mom insisted on running them vertically. I didn’t think it mattered but I was overruled.

Then we’d drag out two boxes of Shiny Brite ornaments, untangle the wire ornament hangers and put them on the tree, knowing one or more would probably bite the dust each Christmas. After that, we’d hang those skinny silver strips we called icicles, but Midwesterners know as tinsel. (Trust me, Peg and I had a long discussion about the proper term. I still call them icicles!) I thought grabbing a handful and tossing them at the tree was efficient, but Mom disagreed:

“No, you have to put them on a few at a time. Otherwise, it looks sloppy.”

50 years later I still don’t have patience for detail work, so Peg puts the ornaments on the tree while I watch with rapt admiration. Just kidding. I usually haul the tree up from the basement and put it together; then, my work here is finished.

We’d pick one night to drive around town looking for outdoor Christmas lights, which had bigger bulbs and heavier wiring than the indoor ones. There were no inflatable cartoon characters, chasing light strings, or mechanical wire-framed deer, which one year my nephews rearranged into an obscene position. Few people had outdoor lights because they were an unnecessary expense for the average working stiff. Even fewer people had places to put them. There might be huge cottonwoods or scruffy Arizona oaks in someone’s yard; no one would deliberately plant evergreens as landscaping. I remember Mr. Ortega, who owned the shoe store in Lowell, had lights along the roof line and around the front door of his house in Don Luis.

A few new traditions began long after I left Arizona. Stringing lights around barrel cacti, saguaros or up the slender branches of ocotillo is a uniquely Southwestern tradition.

Ristras, wreaths or swags made of dried red chiles, hang on doors or porches instead of the traditional evergreen wreath on their doors.

Luminaria, lights lining pathways, go back at least 300 years when the Spanish created small lanterns on Christmas Eve to welcome baby Jesus into the world. Originally small piñon bonfires, they became votive candles set in brown paper lunch bags weighed down with a base of sand. Now the bags are plastic, the candles are electric, and people put them on rooftops and the cinder block walls surrounding many Southwestern homes, providing illumination throughout the Christmas season and often beyond.

I hope your Christmas was peaceful and your New Year will be hopeful.

Photo Credits
Featured Image
A square in Tlaquepaque Arts and Crafts Village, Sedona, Arizona
© Can Stock Photo / alexeys

Ristra:
© Can Stock Photo / JACoulter

Phoenix snowstorm:
© Can Stock Photo / shutterrescues

Saguaro with lights and Luminaria © Shutterstock

Happy Thanksgiving!

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Of all the holidays, a few of which are aggravating, Thanksgiving is the best. There’s no frantic shopping for gifts and nothing to wrap. I don’t have to stay up until midnight for Christmas Eve Mass or to ring in the New Year. (It’s midnight in New York, so let’s just call it a day and go home, eh?) There’s no blazing heat, no mosquitos and I don’t have to worry about Baxter freaking out over firecrackers. The goals are getting together with family, stuffing ourselves, and waiting for the conversation to deteriorate into the absurd. Politics and religion are off limits; bodily functions and barely credible stories are expected.

Peg and I have developed a routine after 20 years together. I hate the last-minute scramble for staples, so I compiled a shopping list that starts in October and runs through December. We start with non-perishables and frozen stuff: canned pumpkin, evaporated milk and cream of mushroom soup; the oft-maligned cranberry jelly, the kind that comes with rings; gelatin for the Thanksgiving eggnog mold and Jell-O for the Christmas black cherry mold; canned and frozen green beans, frozen corn, deep dish pie shells and those French-fried onions. For those of you who missed it, Dorcas Reilly, the woman who invented green bean casserole died October 15, 2018 at the ripe old age of 92. Generations are forever in her debt.

Peg gets the perishables a week before the holiday, which includes cranberries, an orange, eggnog, onions, carrots, celery, sweet potatoes, rutabaga, biscuits in a can, and the turkey. I like flakey rolls and buttermilk biscuits for variety.

Peg’s sister Michele does the stuffing and the best mashed potatoes I’ve ever had. She used to do the rutabaga but it’s labor-intensive and Peg has more time now that she is, uh, “retired.” (We won’t talk about how a certain man of the cloth is a lying sack of shit.)

Thanksgiving is working out well this year. I’m working on Thursday while the nephews do dinner with their respective in-laws, so we’re celebrating on Friday. Peg has time to leisurely make pumpkin bread, bake and mash the sweet potatoes and make fresh cranberry relish, and I’m not underfoot. This year the turkey thawed out in record time, so we cooked it on Sunday and portioned it into freezer bags for people to take home. That’s a lot easier than doing it after an exhausting day of cooking and cleaning.

Thanksgiving morning follows a familiar pattern. I get up, make a batch of Pillsbury cinnamon rolls in a can and turn on the Macy’s Thanksgiving Day Parade. That is until last year when it became a non-stop ad for NBC programming and stars. So this year we’re going to record WGN’s coverage of “Chicago’s Grand Holiday Tradition,” the Uncle Dan’s Thanksgiving Day Parade, sponsored in the past by Marshall Fields, Brach’s Confections, McDonald’s and Target.

Peg starts to harangue me about getting the turkey into the oven around 11:30 or so. “It’s not going to be done on time and I’m going to be really pissed!”

“How many years have I done this and how many times has it not been ready? Several and never.”

Grumble, grumble, grumble.

There’s still a lot to do, like prep the green bean casserole which goes into the oven as soon as the turkey comes out. We’ll haul out the plates and silverware, get out the champagne glasses and good napkins, and make sure the Finicky One (you know who you are!) has several forks so as not to cross-contaminate her food. Just before everyone starts to arrive, Peg makes a holiday punch with cranberry and pomegranate juice, frozen raspberries and something fizzy, which everyone is free to enjoy with or without alcohol.

The family arrives at our house mid-afternoon and gathers around the kitchen for punch and snacks. It’s all fun and games until the turkey comes out of the oven. Peg gets testy and everyone has learned: get out of the kitchen and no one gets hurt. Not that I’m a paragon of patience. I once chased my ex-mother-in-law out of the kitchen with a meat cleaver.

The casserole goes into the oven while the turkey rests, like it has nothing better to do while we work. I start filling cookie sheets with rolls while Peg makes gravy. We’re fine as long as I stay out of the way. Casserole out, rolls in for 15 minutes and we’re done.

Food goes to the table and everyone sits down. We say the traditional Catholic grace, the words to which I still haven’t learned. “Bless us O Lord…” mumble “…these gifts…” mumble “…thy bounty…” mumble “…In the name of the Father, the Son and the Holy Ghost (or is it Spirit?) Amen.”

Then we start passing food around the table.

“No, clockwise! You’re messing up the flow!”

“Guys, don’t start eating just because you filled your plate! Keep passing.”

“Where’s the butter?”

“It’s right in front of you!”

“Can you pass Dave another roll? No, don’t you DARE throw it!” *Challenge accepted*

“Do NOT let that champagne cork go flying!” (Moi?)

Then we go around the table telling everyone what we are thankful for, though the guys’ priority is food. In the past there’s been an awkward silence, but Bob now volunteers to go first, having grown up and learned the importance of tradition. There are variations on the theme of family, spouses and gainful employment. We’ll toast the memories of Peg and Michele’s mother and father, Gloria and Mike.

Michele’s daughters-in-law are wonderful young women and the girls she never had. A few years back she talked about how thankful she was for them and started crying. We were all sitting there reverently until her son Christopher started giggling. He might have been nervous over the show of genuine affection. Or maybe he was just being a dick. Well, that killed the Hallmark moment. I started snickering, and the rest of table erupted.

“Nice going, Chris!” more giggling

Table talk is predictable. The women will chat about whatever while the guys stuff their faces and look at the clock, anticipating the next football game. Sometimes Chris will launch into a long-winded tale with just a hint of truth embedded somewhere. Smart phones are off limits until after we’ve eaten.

Dinner ends and most of us help clear the table (again, you know who you are!). Leftovers go into storage bags, then out on the deck to cool. Peg begins her cleanup and we all stay clear. “I have a system for doing this and you’re just getting in the way. If you want to be helpful, go sit down!” Needing no further encouragement, the menfolk head for the couch to watch part of the game before becoming comatose. The women sit around the table and talk. Baxter and I have had enough togetherness for awhile and retreat upstairs for a short nap.

The years have provided us with memories of holiday dinners past, some more endearing than others:

I played Harry Belafonte’s “Banana Boat Song” in the middle of dinner and we re-enacted the dinner scene from Beetlejuice.
A much younger Bob laughed so hard he puked into his plate, ending Thanksgiving dinner.
I forgot to put sugar into the pumpkin pie mix. I couldn’t understand why the pies were greyish brown instead of that deep golden color. I took a bite and said, “It’s not so bad.” Everyone else called bullshit and remind me of it every year.
I flambéd the eggnog mold with Bacardi 151. (“Oh my God, you’re going to burn the house down!”)

So, enjoy the holiday. Be thankful for what you have. Cherish the moments with family because they won’t be around forever.

And skip Black Friday. No deal is THAT good.

Changes

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When I was in medical school an instructor admitted, “Half of what we teach you is wrong. The problem is, we don’t know which half.” I could say the same about residency. Some of what I learned as an intern fell out of favor by the time I was a chief resident, such as x-ray pelvimetry to determine a woman’s likelihood of delivering vaginally, or the internist’s casual approach to glucose control in diabetic pregnant women.

The pendulum continued to swing over the next thirty some years of my career. We went from “Once a (Cesarean) section, always a section,” to “Every woman should be offered the chance to deliver vaginally after a Cesarean,” to “Let’s put a little thought into who should be doing this!”

I did a rotating internship after medical school because I had no idea which direction I should take. Obstetrics was the last thing on my mind because the physician with whom I had the most contact could be sarcastic and demeaning. That changed during two months of obstetrics in a completely different environment. I ended up taking the second-year position vacated by one of the first-year obstetrical residents who left to fulfill his three-year obligation to the U.S. Air Force. (I heard he went into radiology when he got back.)

Fast forward three decades. I was working as a locum tenens physician for the medical school I’d once attended. My old obstetrical tormentor had retired from practice but continued to be heavily involved in student and resident teaching. The years had mellowed him, or maybe it was because he didn’t have the stress and burden of a private practice.

One afternoon he asked to join me while I was doing an abdominal hysterectomy. I doubt that he remembered me from so long ago, but I was honored that he’d ask and was truly interested in what I was doing. The circle was completing; the student was now the master and the master was now “master emeritus.” Side note: I’ve never been cocky enough to consider myself a “master.”

A few months ago, I met a delightful young medical student doing her obstetrical rotation. She is intelligent, capable, ambitious and learns quickly. She began her first year as an ob/gyn resident in July, which has prompted me to reflect on what has changed since I was the youngster under the gaze of my mentors, some of whom were approaching retirement.

Ultrasound: Ultrasound has been around since the early 1960s, but the first images looked more like abstract paintings than recognizable body parts. The ultrasound tech would swipe the transducer – a thing about the size of a restaurant salt shaker – that sent and received sound waves – back and forth across a woman’s abdomen. The results looked like this:

I couldn’t tell you what this was, and we suspected neither could most radiologists. More than once we would explore a woman’s abdomen because a radiologist swore “there is definitely an ectopic pregnancy present,” and find nothing.

Ultrasound has evolved. Machines can produce three dimensional images in real time, check on blood flow into and out of organs and measure minute structures in developing fetuses. Emergency departments now have FAST ultrasounds (Focused Assessment with Sonography in Trauma) which can rapidly detect internal bleeding or a pneumothorax (collapsed lung) at the bedside, obviating the need for a CT scan. It’s much better than the old way of diagnosing a ruptured tubal pregnancy, which was sticking an 18-gauge needle through the posterior vagina into the pelvic cavity looking for non-clotting blood.

Gonorrhea testing: Neisseria gonorrhoeae, the bacterium causing gonococcal infections, grows best within an oxygen-poor environment. We used to take a sample from a woman’s cervix, smear it across a culture plate, then stick it in a one-gallon pickle jar with a lit candle and close the lid, burning off the oxygen. By the end of the day we’d have 20 or so culture plates in the jar and the room would smell like burnt wax. Now we look for gonorrhea (and chlamydia) DNA on a cervical swab or in a urine sample.

Fetal monitors and intrauterine pressure catheters: Fetal monitors, which track a baby’s heart rate and a mother’s contractions, were introduced in the late 1960s and early 1970s. Both were accomplished with devices placed on the mother’s abdomen, but the results often were inaccurate. The scalp electrode, created in 1972 by the venerable Dr. Ed Hon, allows us to monitor the baby’s heart directly.

The modern intrauterine pressure catheter (IUPC) measures contractions through a solid, transducer-tipped catheter threaded into the uterine cavity. The early catheters were fluid-filled tubes connected to a small strain gauge transducer which required a dome of water placed directly on the pickup before the cover was screwed on. The transducer then had to be taped to the bed rail at approximately the same height as the uterus. Sometimes we’d use a tongue depressor and thick adhesive tape to keep it in place. Then we’d open a stopcock to “zero out” the system, close the stopcock and hoped it all worked.

Determining ruptured membranes: Back in the old days we determined if a woman had “broken her water” by inspecting the vagina with a speculum for amniotic fluid, testing any visible fluid with nitrazine paper, and then slapping some fluid on a slide, letting it dry and look through the microscope for “ferning.” If there was any question, we’d have the woman wear a pad and check for fluid an hour or so later, or, in rare cases, inject indigo carmine dye into the uterine cavity and look for blue fluid in the vagina. When ultrasound came into widespread use, we looked at fluid levels around the baby.

Then a company created an expensive test to check for an amniotic fluid protein to determine whether membranes had ruptured. Their ad campaign preyed on all our fears by asking, “Are you really, really, absolutely, positively sure?” Hospital administrators took away our nitrazine paper and microscopes because now they had a test for which they could bill. Doctors liked it because it meant they didn’t have to stagger out of bed in the middle of the night to do an exam, or so they thought.

Then in August 2018 the FDA issued an alert reminding physicians “that the labeling for these tests specifies that they should not be used on their own to independently diagnose…ROM (rupture of membranes) in pregnant women.”

A Korean study found a positive test in a third of women in labor with intact membranes. A review of ROM testing published in The Journal of Obstetrics and Gynaecology of Canada was cautiously optimistic about protein assays although they cautioned “Further studies are needed to assess the reliability of the test according to the time from membrane rupture.” So what would make the critics happy?

We do our best, but nothing is perfect.

Hysterectomy: Vaginal hysterectomy has been compared to rebuilding an engine through the tailpipe. The Grand Old Man of vaginal hysterectomies attached to my residency program retired during my second year, so I learned to take out uteri through an abdominal incision. Not that I couldn’t do a vaginal hysterectomy, but I liked being able to see what I was doing. Few things are worse than fishing for a bleeding artery through a vagina.

Laparoscopic-assisted vaginal hysterectomy (LAVH) started to become popular in the 1990s, but the learning curve was steep. I knew physicians who spent seven hours on their first few LAVHs after going to a weekend course, which is no substitution for extensive residency training.

The alleged advantage of LAVH was being able to detach the tubes and ovaries under direct visualization, but one still had to finish the procedure vaginally. Most of the required equipment was disposable and expensive, making it 40% more expensive than a traditional vaginal hysterectomy. Some of us thought LAVH made up for a lack of skill.

Robotic surgery started becoming popular in the early 2000s, but robots were used more for marketing than for patient benefit, and they weren’t cheap. A robot cost $1-$2.5 million up front and came with a $100,000 to $170,000 annual service contract , enough to give any hospital bean counter palpitations.

But, after years of experience and refinement, doing a hysterectomy exclusively with laparoscopic equipment made total laparoscopic hysterectomy (TLH) a truly “minimally invasive surgery.” One surgical assistant told me taking the detached uterus out at the end was like uncorking a bottle. More than one study found there was no advantage to using robotics over TLH. I suspect many of those machines will be gathering dust in closets, sitting next to $100,000 carbon dioxide lasers used to treat precancerous cervical lesions before LEEP (wire-loop cautery used to whack out a chunk of cervix) became popular.

Employment: Physicians were masters of their domains for most of the twentieth century. In the early days, you graduated from medical school, did a year internship to get a license and hung out a shingle as a general practitioner. Specialties (and specialty boards) started appearing during the 1950s, along with residency programs lasting three to seven years, and the old GP would become extinct. Physician practices were still largely independent even into the 1990s. Being employed by a hospital or, worse yet, a “goddam HMO” made you a substandard physician who couldn’t get a job anywhere else in the eyes of the Great White Fathers who still ran things.

But, as I’ve previously discussed, things have changed. By 2017 less than half of American physicians owned their own practices, especially in metropolitan areas. I live in the Chicago suburbs where a large majority of private practices have been absorbed by large medical groups and/or hospitals. New physicians expect to be employed rather than deal with the headaches inherent in independent practices: personnel, equipment, rent, taxes and liability insurance, which can run $150,000 a year for an ob/gyn. We gave up autonomy for financial security and lost both in the process.

Patient care and ownership: The generation of physicians before me cringed when administrators used terms like “customer service,” but in their hearts they knew what it meant. They took good care of their patients because those patients were their livelihood. In a group practice the patients were all OUR patients, rather than MY patients and YOUR patients.

Primary care developed “concierge care” as a backlash to corporate medicine. Concierge care promises same day or next day appointments, access to one’s physician 24/7, unhurried visits and “personalized care,” or what I used to know as “doing my damn job!” I’ve called patients with test results, talked to them at all hours of the night and I made at least one house call to check on a patient’s Cesarean section incision that had opened up.

This “white-glove customer service” comes with annual fees ranging from $1000 to a whopping $25,000! And that is just for the privilege. Actual care still costs money. You can’t use Flexible Savings Account (FSA) or Health Savings Account (HSA) money for the fee, so this isn’t an option practical for the masses.

I’d like to think there’s a new generation of physicians willing to fix what’s broken for everyone, but I’m not holding my breath.

An Epidemic of Stupidity

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I’ve declared the third week of July as National Health Care Stupidity Week, for I’ve never encountered such high levels before.

I saw an ophthalmologist for a problem with my left upper eyelid at the beginning of July and scheduled surgery for three weeks later. We asked the scheduler how much the procedure would cost but she said, “It depends.” That’s not much of an answer to a physician who understands the vagaries of CPT coding and insurance reimbursement. You give the insurance company the codes and your charges. The insurance company laughs their asses off and then tell you “No fucking way. THIS is what we’ll reimburse you.”

The scheduler said, “I’ll ask the doctor what he plans on doing and I’ll call you in two days with the charges.”

I can understand if the physician wasn’t quite sure what he was going to be doing right after seeing me, so we let it go.

The week’s aggravation started at Drugs ‘R’ Us, a national chain, which the threat of litigation prevents me from identifying. I’ve used a maintenance inhaler for life-long asthma, for which there is NO generic. The price has climbed from a $150 insurance copay for a three-month supply from a parasitic mail-order pharmacy benefit manager to $400 for one and NO insurance coverage until (my very high) deductible is met. I brought this up to my pulmonologist last month and asked for a little-known generic equivalent (different medications but should have the same therapeutic benefit).

He said, “Well, Thieving Bastards Pharmaceuticals have this discount card that will give it to you for free if you have insurance. It’s good until December 2018.”

I learned a long time ago there ain’t no free lunch, but if they are willing to part with it for free, I’m in. I took it to Drugs ‘R’ Us and, after 20 minutes or so of fighting with the computer, I got my inhaler. ONE inhaler. I have to go back every month for this charade.

The pharmacy’s robot phone said I could pick up this month’s inhaler. However, the pharmacy tech brought me a bag with three inhalers and a bill for $935 “because you haven’t met your deductible.” No shit, Sherlock. I have insurance with a high deductible and a health savings account (HSA) which is great at a certain income level but completely useless if you’re making minimum wage (in which case you probably don’t have any insurance and you’re a drain on society, at least according to the bastards who’ve been trying to undo the ACA for the past 8 years).

“Last time I got one and it was free! Here’s the card and I’m NOT going to pay almost a thousand bucks for this. I’d rather die a quick and painless death.” (I’m using that phrase more often these days.)

“Well, let me change it but I have to run it through the system again. It’s going to take some time.”

Fine. I sat in one of the uncomfortable chairs in the pharmacy waiting area and perused the local paper, which didn’t help my mood any.

Then my phone rang.

“Hi, this is Brunhilda from the Pretentious Suburban Surgery Center. Your insurance is going to pay 80% of the procedure after you’ve met your deductible, but you haven’t met your deductible, so we want your left testicle ($1305) as a down payment.”

“First of all, why? Second, what is this going to cost me in total?”

“Well, we ask everyone for a down payment.”

No, you said it was because I hadn’t met my deductible but, please, proceed.

“Why? This isn’t a cosmetic procedure and I’ve already signed the boilerplate insurance assignment form that says I’m responsible for the remainder. So, again, what is this going to cost me?”

“We can’t tell you what we charge, and the insurance company won’t let us tell you what they will pay us.”

“Why not?”

“It’s in our contract.”

“You’d tell me if I was paying for all of this out of pocket, wouldn’t you?”

Silence

“Well, my financial adviser has told me that’s not a great idea. I’ve got an HSA funded with pretax dollars and if I overpay you and you then reimburse me directly, I might run afoul of the IRS, which is not known for being gracious. Would you be willing to talk with her as I have to leave town in a few minutes?” (Translation: “If I acquiesce to this extortion, Peg is going to ream me a new one. We’re going to play good cop/bad cop and I’ll let her ream you a new one. You really don’t want to poke this bear, but you’re gonna have to learn the hard way.”)

She says, “I’d be happy to!” and I hung up, snickering.

An older woman came to the pharmacy while I was waiting. She was bent over a wheeled walker, wheezing audibly as she shuffled up to the counter. I suspect she had long-standing COPD and it made my lungs hurt just to hear her breathe.

“They called me and told me my prescriptions were ready.”

“What’s the name?”

She wheezed her name.

“Your prescriptions have expired, and we put a call into your doctor’s office to get authorization for refills.”

“But someone called me and asked if I wanted all my prescriptions refilled. She even listed all of them and I said ‘yes!’ Then I got a phone call from you!”

“That is an automated system and we don’t have any control over it.”

This went on for several minutes with the poor woman protesting that she’d done everything she’d been told but slowly realized this trip had been for naught.

Finally, she sighed, said, “Well, what are you gonna do,” turned around and shuffled out. She was far more resigned than I ever would have been. ( is one of my all-time favorite revenge movies. Just sayin’.)

The pharmacist came out, handed my drug card back to me and said, “We put in a phone call to the company and we’re waiting to hear back. It shouldn’t be too long.”

Twenty minutes later I was still waiting. Finally, I got up and said, “I have to leave town. Can my wife pick this up?”

“That’s no problem. We’ll let her know when it’s ready.”

Then I asked her. “Is there a generic for this because the card expires in December and I can’t afford $400 a month for this.” I gave her the generic medication names.

“It looks like the only one is ‘Yerstillscrewed’ but insurance doesn’t cover it.”

“I KNOW that, but I can get a three-month supply using GoodRx for less than half of what one of the brand-name inhalers costs.”

It’s turns out that Thieving Bastards Pharmaceuticals changed the program so that it only covers that drug up to $200/month. You know, the drug for which they set the price at $400.

I left and started my drive to Springfield. I was just about at Joliet when the phone rang.

“This is Vinnie, the enforcer, uh, business manager from the doctor’s office. I wanted to let you know that your insurance is going to pay 80% of the procedure after your deductible is met, but you haven’t met your deductible, so we want your right testicle as a down payment.” (It’s been two weeks since the initial visit and less than a week before surgery.)

“Why?”

“It’s our policy.”

“I’ve had other procedures and visits, and no one has EVER asked for money up front. You just told me what my deductible is, and you know how much I’ve met, which means you also know I’ve been paying towards it. The surgeon’s fee and the surgery center charges are likely to eat up the rest of my deductible. Again, how much is this going to cost?”

“It depends.”

“What do you mean, ’it depends?’ That’s bullshit. There’s a CPT code for the procedure, and you have a charge for it. I know that because I’m a physician and I’ve had my own charge list. You’re going to give the insurance company a bill with a CPT code. They are going to send me an EOB (Explanation of Benefits) which will tell me what YOU charged, what they allow, what they’ve paid and what my obligation is. So, to pretend this is a deep, dark secret is disingenuous. The only thing that “depends” is how much the insurance company is going to pay you and your contract with them defines their reimbursement. So, to ask me for money up front is insulting. You’re making me sound like a deadbeat.”

“No, no, we do this with everyone.” (Where have I heard that before?)

“Yeah, well no one else has ever asked me for a deposit! No one asked for a deposit before my colonoscopy, or when I went to the ER for a doppler scan for lower leg pain. Look, at this point I’m ready to cancel the whole goddam surgery and find someone else!”

“No, no, no! I’ll talk to the doctor and let him know how you feel and you can discuss it with him.”

I called Peg, who spent the next three days dealing with the office, getting nowhere. Finally, she got a call from the new office manager, a far more reasonable person. They talked for a couple of hours about what appears to the patient to be a hostile approach to payment. It was both illuminating and infuriating.

High deductible health plans are sometimes several hundred dollars a month less expensive than plans with lower deductibles. Some high-deductible plans come with Health Savings Accounts (HSAs), a Republican wet dream Paul Ryan drags out as an alternative to the ACA. HSAs are funded with pre-tax dollars – a maximum of $3450 a year for singles and $6900 for families in 2018 – which can only be used for health care expenses, at least until the account holder reaches 65. Old goats like me (over 55) get to put away an extra $1000 per year in our HSAs. The plans still come with out-of-pocket maximums of $7,350 for singles and $14,400 for families.

This is a great idea if your income level allows you to part with a few hundred bucks a paycheck and you’ve got a tidy sum in your bank account. It sucks if you don’t have the income, the savings, or if you anticipate ongoing medical expenses.

Here’s the problem. Lower income people get high-deductible plans because the premiums are affordable, but they are at greater financial risk because they don’t have the savings to cover the deductible. They may avoid preventive care if they are unaware that most high-deductible plans cover it with no out-of-pocket costs, opting to take a chance they won’t develop a more serious (and costly) illness later. Because they often can’t afford the deductible, they are more likely to default on outstanding medical bills. Hospitals and physicians have caught on and now demand money up front.

Asking for a down payment would be far more palatable if it applied to everyone. It’s no different than a contractor asking for money up front for a pricey remodeling job. Pay some now, pay the rest when the job’s done. But framing it as something required only of people who haven’t met their deductible implies they are deadbeats and is insulting. Further, waiting until a few days before surgery to extort money is infuriating. It should all be explained up front when scheduling the surgery.

The logical solution is universal coverage, but Congress lacks the political will and there are too many people making waaaaay too much money off the current system.

Hang on, because it’s only going to get worse.

Notes from Dr. Dave

Musings from forty plus years as an OB/GYN and a writer.