February 25, 2021

Our production will be a bit more socially distanced. (This is Linda Ronstadt and Tony Azito in Joe Papp’s famous late 70s production)

I’m not keen on emotions. I don’t understand them very well. When I feel something swell up inside me, I have a difficult time determining if it’s something positive or negative (I can usually figure it out eventually from context) and what my reactions should be to it. I tend to draw back from it, get quiet and try to analyze it and figure out just what it should be rather than let go and feel it. Perhaps that underlies my affinity for Sondheim as so much of his writing is for characters trying to move from the outside of intellect and analysis to the inside of emotional connection. Time to put on ‘Anyone Can Whistle’ for the umpteenth time. At least I have a new recording of that score to enjoy courtesy of Jay records. It’s also likely why my only successful romantic relationships have both been with men who were creatures of instinct and emotions strong enough to batter down all of my carefully constructed walls. Keep that in mind before you try and fix me up with someone.

I just know that at the moment I am feeling and it’s a combination of positive and negative things. Today was the first live in person rehearsal I have had in nearly a year. I was bouncing up and down in my chair at work all day with excitement. It’s been a rare week I’ve gone without a rehearsal or a performance of some sort since launching myself into my late life performing career back in 2003 and it’s now just two weeks short of year since I last sat in a seat with other people and we joined our voices together to make music. I’m playing one of the policemen in a truncated, outdoor version of The Pirates of Penzance produced by Opera Birmingham going up at Avondale Ampitheater in April. We’re rehearsing masked and outdoors. We’re maintaining social distancing in both rehearsal and staging but when we began to sing the counterpoint of ‘When The Foeman Bares His Steel’ and ‘Go Ye Heroes’ I wanted to cry. It’s my favorite piece of music from the show and to be enveloped in those 150 year old melodies with a group of people just as grateful to be there as I was as special a moment as I have had in a while. We’re rehearsing in a covered parking garage so the acoustics aren’t bad, the cast is talented and full of old friends, and I can’t wait until we have the next one. So, it you’re around 6th Avenue South in Avondale the next month or so and you hear operetta drifting by on the wind, you’ll know what’s going on.

This feeling, which I suppose is joy, is getting thoroughly mixed up with another one which I suppose is sorrow as I continue to work through the impact of Covid on my world. We’re at 508,000 deaths, according to the Johns Hopkins Coronavirus Counter, out of 28.4 million US cases. We’re still a few days from the first anniversary of a death from an observed US infection (February 29, 2020 – the few deaths earlier were traced back months later using blood and tissue samples). We’ll end up somewhere around 510-515 thousand deaths at the one year mark (37th largest city in the USA between the population of Atlanta and Sacramento). That’s roughly ten times the number of flu deaths in the worst flu years and twenty five times the number of flu deaths in light years. Flu is practically non-existent this year. Our good health habits are keeping it from propogating. I know the devestating impact that death of important people has had on my life. Those of you who have not been widowed have no idea how much that process turns your life and your world upside down. This year has created hundreds of thousands of new widows. New single parent families. New orphans. A new crop of parents burying their children before them. And all having to be done while navigating a myriad of new social customs and rules, many of which keep us from being together. There are really only two things that heal grief – time, and the presence of others in our lives and that latter one has been hard. What does grief deferred due to an individual? To a society? I think back on the generations that survived World War II or the Civil War and wonder what lessons they have to teach us about coping in healthy ways.

Steve – 1992

Steve died twenty years ago this year. It’s a long time and I’ve had a whole other life in those years but I can still feel his presence, hear his voice and his laughter as if he had just left the room. His death, as it was a prolonged process of several years, caused me to make some life decisions that continue to have repercussions. When he became ill and I needed to spend more time and energy at home with him, I took myself off the fast track to academic success, leaving behind research interests and the very long hours that would have been necessary to position myself where I would be competitive for the department chair and deans level jobs. Could I have done both? Possibly, but likely at significant cost to my humanity so I didn’t want to try. Plus, I had the added burden of being openly gay at a time when few medical school faculty were and those in my generation learned early and often that if you were open, you had to be twice as good to get half the credit.

With Tommy 2003

Steve’s death boomeranged me into a different career trajectory, maybe not as rewarding in terms of money or professional accolades, but certainly more fulfilling and it allowed me the time and the energy to become a fully realized human being with my rediscovery of theater under the tutelage of Tommy. I’m sure Tommy’s death has also pushed my life in a new direction that’s not yet fully clear. I’ve made certain decisions about what’s important in my professional and personal lives that made me decide that downsizing and simplifying were something I needed to do. They also have made me decide that pulling up stakes and trying to vault up the ladder somewhere else (something I was looking at together with Tommy prior to his death) is not likely to happen. Tommy’s been gone nearly three years now. That wound is far fresher and there are times I mourn. For some reason, last night, rather than doing something constructive (sorry people to whom I owe that Topics in Geriatrics lecture), I opened his Facebook and scrolled through the whole thing back to 2007. Was I feeling sorrow? Was I feeling joy at what was? Was I feeling nostalgic? I really can’t say. I just know that I was feeling. And I think it was brought about by a combination of the joy of impending rehearsal and the sorrow of being surrounded by so much death and despair. The feeling of being alive. (There goes Sondheim again and I didn’t even intend it…)

Be like the singers of Opera Birmingham. Wear your mask (singing through it is… interesting). Wash your hands. Sit six feet apart. Make the world a better place with music.

February 21, 2021

City of Richardson worker Kaleb Love breaks ice on a frozen fountain Tuesday, Feb. 16, 2021, in Richardson, Texas. Temperatures dropped into the single digits as snow shut down air travel and grocery stores. (AP Photo/LM Otero)

Everybody talks about the weather, but no one does anything about it. I wish I could take credit for that particular bon mot, but it’s been floating around for more than a century, attributed to various Edwardian era wits, most frequently Mark Twain. Sometimes I think I missed my century; that I was born to sit around a splendid drawing room in evening wear with a snifter of brandy and a cigar trading epigrams with celebrated names. And then I think of general standards of public health and hygiene at the time and feel thankful to have come of age in post war America. Besides which, I’m not nearly as witty on my feet as I like to think I am. I do my best when scripted or in character in some way. When I’m just being me, my general introversion and insecurities tend to take over.

The weather around here has been cold, but relatively pleasant following the snow and ice of last Tuesday (which was gone by Wednesday). Not so much in Texas where the deep freeze continues to bedevil the population with power outages and lack of potable water. If I understand things correctly, plans were drawn up ten years ago following the last bad winter storm to hit the state but nothing was done to implement any of the recommendations as that would be expensive and cut into profits. The wholesale transfer of the commons to private corporations for purposes of enriching stockholders of the last forty years has consequences. It’s been cast in political terms as a battle between capitalism and socialism but it’s really more about a battle between private greed and public good. To my mind, there are certain sectors of the economy that should be kept public and not for profit because when they become private for profit concerns, the law of unintended consequences hurts us all. These include health care, education, corrections, the military and utilities.

On the Covid front, I remain cautiously optimistic. The numbers continue to decline nationwide. No one is quite certain why. Is it the presence of vaccinated individuals interrupting transmission chains, the surge caused by holiday behaviors being finally behind us (and only to increase again with some new social trend), the numbers of infected individuals rising as a percentage of the population (28 million official cases in the US – about 9% of the population but this is almost certainly a significant undercount), some new and as yet unidentified factor? Inquiring minds want to know. We are at 498,500 deaths today, meaning we will pass the half million mark tomorrow or the day after, less than a year since the pandemic really established itself in North America. It’s hard to understand just what sort of number that is. It’s big enough that the US as a whole lost a whole year of life expectancy during the first six months of 2020 (and that’s before the winter surge – when the final numbers are in for 2020 we may have lost as many as three years in total – something that hasn’t happened in generations).

People don’t really understand what that life expectancy number is. It’s been hovering in the high 70s for the last couple of decades, inching up a bit here and there. It doesn’t mean, obviously, that everyone only lives to that age. It’s the statistical mean age to which the cohort of babies born in that year will live. So the babies born in the first half of 2020 can expect a year shorter life than those born in 2019 due to the impact of Covid on society. Life expectancy is driven down by disease processes that kill the young. It was only in the mid 40s a century ago, not because people died of old age at 50 but because so many babies and children died of what, with public health measures and antibiotics, became preventable diseases. Covid is a preventable disease with proper public health measures but politics got in the way. We can tell that mitigation measures are working, even the imperfect ones we have in place by looking at this year’s flu statistics. The number of flu cases this year is less than 1% of what is seen in a typical year. Socail distancing and masking prevents influenza from being transmitted as well as Covid.

Tartuffe concludes filming this next week and will be available in mid March for your amusement. I’ve auditioned for a few other projects and am waiting to hear. I’m also starting outdoor, socially distanced and masked rehearsals for a condensed production of The Pirates of Penzance later this next week. I have not yet been informed if I am a pirate, a policeman, or one of Major General Stanley’s daughters – or perhaps all three. And last night, I was the MC for the church’s annual fundraising evening – on zoom rather than live this year – 19 years after I first did it (my first Birmingham acting gig and the first appearance of what becaome the Politically Incorrect Cabaret Ansager). I paid an homage to previous years by continuously changing my coats. There’s only so much you can do in front of the webcam. Work has been somewhat busy the last few weeks with various minor projects coming due so between those and theater, I’ve been pretty nose to the grindstone and will be into early March. At that point, it will be time to take up the second edit on the book to try and trim it down to appropriate size so as to stay on schedule for a summer publication. I’ll be looking for early readers after the second edit is finished.

I wrote a compelling essay on why you can’t find a geritarician for your aging parent which I will post, but it’s embargoed until after it goes live on the website I wrote it for. You will all just have to wait. In the meantime, keep those hands washed, those masks on, and that space between you.

February 16, 2021

Snow from my balcony

Snow day! Or at least some white stuff on the ground and some ice on the roads day. I woke up this morning to white flakes drifting dreamily down past my windows, told the VA that they could call me if they needed me, and rolled over and went back to sleep for another four hours. I haven’t been that busy or that active recently so I assume it was some sort of destressing mechanism on the part of my brain, especially as those last few hours were full of wild dreams including a visit to Disney in which I could not figure out how to get inside the park, some sort of cruise to an unpleasant destination and even worse people and a sequence where I kept breaking into my pastor’s house in order to find a nice quiet place to read and recuperate. She kept coming home and chasing me out again – politely, but firmly setting her boundaries for family time.

It would have been nice if I could have spent the snow day in some mindless activity, but alas a phone call from an attorney stating he needed a report in writing tomorrow on the case I have been revieiwing put paid to that idea, and I had to dive back into 2500 pages of mainly unreadable electronic health records trying to extract nuggets of fact that would support my opinions. Success as I found what I was looking for, wrote up five pages, and got it to him by close of business Eastern time and now have the evening to myself. I really should charge more for rush jobs. Reviewing medical records is nowhere near as fun as it was when I first started decades ago. Then I would get a bankers box shipped parcel post full of barely legible photocopies of physician handwriting to deciper. Now I get access to a drop box full of perfectly legible electronic records spat out by some computer, most of which are useless garbage when trying to reconstruct what happened around a particular incident or illness.

There has been some speculation that at least some of the issues of response to Covid and Covid vaccination are tied up in the electronic health record that has become so pervasive. The groundwork for such records was laid in the late 1990s after the invention of the World Wide Web as medicine, along with other industries embraced the ability for information exchange this allowed. Some bad actors early on who were buying and selling health information led congress to pass the Health Insurance Portability and Accountability Act (HIPAA) in 1996 under the Clinton presidency. This law explicity protected the privacy of health information so that it could not be used in inappropriate ways. Unfortunately, it also tied a lot of information exchange to 1990s technology which is why health care, as an industry, still depends on the fax machine. It’s considered HIPAA compliant while newer methods of information exchange are not addressed in the legislation and it has yet to be updated. In the early 2000s, various private companies becan to get into the electronic health record business, knowing it would be the wave of the future. (Cerner and Epic are the biggest but there are lots of smaller ones out there). The VA actually offered it’s in house EMR, known as CPRS, free of charge to the country so that there could be a national standard and all records could be easily traded between states and institutions without difficulty, but the Republican president and congress of the time preferred to let private enterprise take precedent over the public commons and this idea was abandoned in favor of dozens of incompatible systems incapable to talking to each other, leading to a dramatic increase in siloing of health systems along information lines.

Another complicating factor regarding electronic health records is what they are asked to do. When clinicians sold control of the health system to industry and administrators in the late 70s and early 80s, there was a shift in the power dynamic. Where before, the needs of the physician were paramount, after the needs of the industry as exemplified by revenue generation became the most important thing in terms of data management. As administrators were in charge of purchasing health information systems, they looked for systems that could assist with capturing charges, identifying utilization trends, and assisting with quality metrics. The actual needs of an individual provider/patient encounter became subservient to these big data analytic requirements. Administrative systems were modified to fulfill clinical requirements instead of vice versa. This was all put on steroids by the HITECH legislation signed by Obama in 2009 as part of the recovery from the great recession where the health care industry was offered financial incentives to adopt electronic health records and pretty much everyone went digital over the next decade, each in their own way.

The end result is millions of data points that can be spit out at the touch of a button but none of the logical thinking and cohesiveness that a physician mind uses to take all of that and turn it into an understandable narrative. A set of vital signs or a set of lab values taken in isolation don’t mean much. It needs to be combined with clinical reasoning skills, an understanding of the prior medical history of the patient, the unique circumstances of life surrounding the patient, and occasional serendipity to be made to mean anything. You learn to look at voluminous records and recognize that there are only a few sections, those where a clinician is entering data by free text or dication, that can really let you know what you need to know and, when meeting a new record system, learning where those few areas can be found makes all the difference.

In the 1980s, when I began in medicine, pretty much everything was handwritten. That’s why doctors’ penmanship is so notorious. Years and years of having to write so much so fast. In the 1990s, the handwritten notes tended to be interspersed with dictations, especially of summary notes such as admitting histories and discharge summaries. When I first came to UAB, there was no centralized medical record on the outpatient side. If I wanted to know what cardiology was doing with one of my patients, I had to go down to the cardiology clinic, pull their chart, and take a peek. That started to change in the early 2000s where more centralized records became the norm, with dictated notes being accessible throughout the health system and electronic medication lists coming into being which could be updated and modified by any provider. In the 2010s, the full electronic health record went into play. Notes pull information in from various places in the system but, as it is done automatically, there’s no real understanding of relevance and many notes become pages and pages of extraneous numbers and information with no clinical bearing on care. Who knows what the 2020s will bring. I’m hoping for systems programmed more to respond to clinical needs than administrative ones where physicians and other clinicians are part of the teams that develop the programming so that it becomes more intuitive.

Back to the Covid issues: As these systems are now everywhere, but are decentralized, when a national emergency such as the current pandemic hits, it’s difficult, if not impossible, to get health systems to pull together as one as their data systems are completely incompatible. As a UAB physician, I have no way to know what happens to my patients at St Vincents or in the Baptist system unless the providers there are kind enough to send me records of the visit. (It happens sometimes). Those records can be scanned in to the UAB system but they cannot be converted into a format where the data can be taken up and integrated with UAB data. It can make life very interesting when I have a patient who wants to get their primary care from me but still sees their cardiologist at St Vincents and their endocrinologsit at Brookwood and their neurologist at Grandview. With these fault lines, I don’t know how the administrative folk at the Alabama Department of Public Health or at the upper echelons at UAB are supposed to coordinate their efforts or know how well they are doing vaccinating 5 million Alabamians, half of whom fall into a risk group of some sort. That things are going as well as they are is a minor miracle.

Joan Burgess receives an injection of her first dose of the Pfizer-BioNTech Covid-19 vaccine in her car at a drive-in vaccination centre in Hyde, Greater Manchester, northwest England on December 17, 2020. – Covid vaccination at the drive in vaccine hub in Hyde started on December 16 with over-80s registered with a GP in the area being the first to be invited. The British government were set on December 17 to announce their decisions following a planned review of the coronavirus tier restriction allocations for the whole of England amid surging infection rates in London and parts of the southeast which have already resulted in the captial being moved into the highest tier. (Photo by Oli SCARFF / AFP)

A lot of people remain angry that they or their loved one have not yet been able to get scheduled for a Covid shot. The limitation is the amount of vaccine coming into the state. It’s freeing up and supplies are better than they were. Given that it’s a commodity with far more demand then supply, people are turning their frustration on each other. Why is so and so able to get a shot when I have not. Why is this risk group deemed more important than that risk group. The anger is misplaced. It shouldn’t be leveled at vaccine recipients (it’s the sort of divide and conquer that keeps propblematic social structures in place). It should be leveled where it belongs, directly at the previous administration who did little to make the vaccine available in a timely fashion. If they had used the powers of the federal government back in Decemeber when the vaccines were first approved to accelerate manufacture and to coordinate distribution, it’s likely that everyone at risk would be vaccinated at this point. They didn’t, meaning that a true ramp up of vaccine delivery didn’t start until after the change in administration a month later. We’ll get there. I am very optimistic that those at significant risk will all be vaccinated by Easter. That’s forty days from now. (I know this as today is Mardi Gras or, given the temperatures outside, Mardi Froid might be more apropos). It’s going to take more than fractured information systems and the ineffectiveness of administrations past to keep the American people down.

In the meantime, you know what to do: Keep your hands washed, keep your distance, keep your mask on, keep out of indoor locations with lots of other people, keep on keeping on.LikeCommentShare

February 13, 2021

Another Saturday night and I ain’t got nobody. I think somebody else sang that first. And it’s not entirely true, Anastasia the cat is snuggled up to my feet on the bed as I write this, purring away while Oliver is yowling in the next room, hoping I’ll get up and give him more kitty treats as if I didn’t give him a few an hour ago. Tommy’s been gone nearly three years now and people are kindly sidling up to me asking me when I’m going to date seriously again. I don’t know. Next week? Next month? Next year? Next decade? I don’t feel any particular compulsion to pair up again, except when it’s Valentine’s Day Eve and your social media is full of pictures of the happy couples of your acquaintance.
Dating in the gay world is hard. There’s not a lot of social supports for gay male romance, especially in my age group.

The last time I went through all this, twenty years ago, the number of eligible men local to Birmingham was rather small. (Prior to meeting Tommy, I had been dating a man who lived in Michigan – we would meet for the weekend once a month or so somewhere in between). Tommy fell into my life in an odd way. We had been chatting online, he had called me up in my professional capacity to gather information on elder care for a grant proposal he was writing for his job at Birmingham Health Care, and he started turning up at church where he was good friends with some other congregants. When I figured out it was the same guy turning up in all these different areas of my life at the same time, I decided the universe was trying to tell me something so I asked him out and the rest, as they say, is history. It did lead to a very public courtship with the entire congregation of the Unitarian Universalist Church of Birmingham egging us on. If the right guy turns up again in a similar serendipitous manner, I’ll consider a third husband, but I’m not going to actively look.

Covid is, of course, making dating nigh on impossible. There’s no going out to dinner, or for drinks after work or to the movies. I suppose a day hike together through one of the local mountain parks is a possibility but its a bit chilly for that. Maybe later in the spring. In the meantime, I have all my various home projects plus a few extra work things that I’ve taken on to supplement my salary that has this mysterious way of going down rather than up these days due to the crazy impact of the current crisis on the fiscal underpinnings of medicine. I spent most of today wrestling with 2500 pages of medical records for a legal case in defense of a nursing home and next week I get to figure out how to collapse all I know about geriatric syndromes into a 75 minute lecture for a national board review course.

The news on Covid continues to improve. The numbers locally and nationally continue to fall from their peak five weeks ago but they’re hardly going away. We’re up to 27.5 million cases total and we will surpass 500,000 deaths by the end of the month. Our local system for vaccine distribution appears to be working well and I have heard nothing but rave reviews from my patients and their families for the efficiency with which the mass vaccination sites are operating at UAB and in Hoover at the Hoover Met stadium. The only limitation is flow of vaccine into the state but that appears to be happening in a much more predictable fashion than a month ago and most of my over 75 patients who want a vaccine have either had their first dose or are scheduled within the next couple of weeks. Every vaccine delivered is one more person that will not end up in the ICU in a month or two giving our frazzled health system and its providers a bit of breathing space.

As I read through the information on the Pfizer and Moderna vaccines and how they are performing, it’s safe to say that they are doing a very good job at preventing illness and complication. It’s less clear if they are preventing transmission. Some data is coming in suggesting that they do indeed do this as well but we’ll have to wait for the data scientists to capture and crunch the numbers before any definitive statements can be made. If this is indeed true, we should be able to reduce our need for masking and social distancing some this summer. I just want to get back in rehearsal. So much of my social life and my equipoise is tied up in creating art with others in the rehearsal room and on stage that I just feel incomplete without it. I even miss tech.

The political world today progressed exactly as predicted with a pretty much party line impeachment acquital of the former president. For good or ill, I don’t think that particular story is over in the least. The fault lines remain. The former president, if true to character, will not remain quietly off the political stage but will continue to try and exert his will through his usual methods. What that will lead to, I haven’t the vaguest. At the moment, my part of the medical world is just happy that the CDC is authoring recommendations that make scientific sense, the FDA is offering well sourced information about treatment alternatives, and the powers of the executive are working together to get vaccine out in a streamlined fashion. I’ll take it.

I haven’t told a story for a while as corona virus kind of keeps me looking for metaphors and connections between pandemic and other areas of life rather than just thinking back on my past. Here’s one from my early house call days. I went out to take a look at a demented gentleman who kept getting burns on his toes. He and his family didn’t have much money and lived in a rental home that might best be described as a tar paper shack. Like a lot of older homes, it was heated in winter by gas heaters that were attached to the gas line with a rubber hose so that you could place the heater in various parts of the house. The joists and the floor boards were rotted and it was somewhat tricky to pick your way through the living room without putting your foot through to the crawl space. It didn’t take long to figure out the reason he was burning his toes was because when he complained of cold feet, the family wheeled him up to the heater and his diabetic neuropathy prevented him from noticing when they got him a little too close. He was eating badly and we needed to get a weight on him. He couldn’t stand on his own and they only had a bathroom scale so I weighed myself and then, he being a small and somewhat emaciated man, I picked him up and stood on the scale so we could get his weight by subtracting out mine. He peed all down my front as I had him in a honeymoon carry. Meanwhile, his wife (schizophrenic and refusing to take her meds) was frying something up in the kitchen for breakfast. She reached up and opened a cupboard and an enormous winged roach flew out and settled itself on the cooking. WIthout missing a beat, she picked up a can of Raid, sprayed the roach (which flew off elsewhere), the food, and the open flame of the gas stove with it. Fortunately, there was no explosion but she did turn around and asked me if I would like to stay for the meal. I politely declined, finished my visit and hightailed it back to the car for a clean T-shirt and the bottle of Febreze. Geriatrics – the glamour specialty.

Stay well, stay warm, stay distant, wear your mask, wash your hands, use your sanitizer – but keep it off your breakfast sausage.

February 9, 2021

I wasn’t going to write an entry tonight but when I opened up my laptop after work, some siren song seduced me into starting into the woods again. I’ve been doing this long enough now to know that when the muse calls, you better answer because those half formed ideas at the back of your brain won’t be there when you look for them later. I’ve always written best by just letting my brain go into a sort of detatched zone where I’m not really thinking, just letting the words come as they will. When I write these essays, I sometimes have an idea or two, sometimes a whole paragraph is in mind. Other times, I just start writing and off we go. It’s a bit of a dissociative state that lasts usually about 75 minutes or so and I find there’s 1200-1500 words on the screen. I don’t rewrite. I just hit post and hope for the best.

It’s been interesting going back as I edit these Accidental Plague Diaries into book form. They weren’t written with that in mind and the chore of analyzing the ideas in each one, making sure there’s a certain stylistic and thematic unity, getting rid of odd tangents, the occasional major grammatical error, misspelling, or wrong word choice is teaching me a lot about what my writing actually is. The first pass edit is nearly done. A second pass with shorten the manuscript to acceptable length and then there will be something to show people and see if I can drum up any interest outside of my immediate circle of friends. My editor asked me the ultimate question in our last conference. Why is such a book important? I want it to be a primary source document of a particular moment in history written as that history was unfolding from the perspective of someone with some understanding of both the health and sociological implications that are happening all around and the impact the corona virus had on both one person and the country as a whole. We’ll see if I managed to actually do that.

There’s not a lot to report from the battlefield from the last few days. The number of hospitalized cases continue to dwindle locally as the holiday fueled surge continues to recede. UAB hospital, which topped out at about 300 inpatients at the peak, is down to just over half that at the moment. I am breathing a major sigh of relief as that means it is unlikely that I will be called in to work jeopardy inpatient duty later this month. If I was called in, my plan was to go in, tell the residents that I hadn’t really done this sort of work since before they were born (not quite true) and to please lead me gently by the hand through anything for which they needed staff authorization. The vaccination centers are also apparently working relatively well and I see more and more friends outside of healthcare proudly holding up their vaccination cards on social media. We just need to get more vaccine into the state faster. We’ve also got to keep working against some of the more ridiculous disinformation that’s circulating out there. Tyler Perry did a very good PSA on the vaccine aimed at the African American community (it’s on YouTube) which does a nice job dispelling many of the worse myths. The most worrying thing at the moment is the rapid spread of the UK strain that is much more infectious. It’s currently doubling in prevalence roughly every ten days. At that rate, it will be 1,000 times as prevalent in three months and nearly 10,000 times as prevalent in four (ah the magic of exponents).

The creators of modern myths were on full display today as the curtain rose on Impeachment 2: Electric Boogaloo. It’s quite something when the second worst performance by an attorney on a given day involved a zoom court appearance and a cat filter. I try to be evenhanded in my approach to politics but I’m having grave difficulties listening to even sound bites from the pundits trying to gaslight me into believing the Capitol Insurrection was not what it was. The ceremonies will play out. There will be some sort of legalistic coda. But nothing will really change as nothing has been done about the media and political landscape that has let untruth and half truth flourish to the point of having two societies trying to coexist with alternative facts. I don’t know how to fix it. All I can do is try and understand it.

I was thinking about our divided society and how to really grasp what it means when I realized it’s something I deal with everyday, only in microcosm. Perhaps the most common serious health problem for which I am consulted is cognitive change. The memory loss that afflicts the aging which is usually, but not always a dementing illness. It’s relatively uncommon before the age of 75, and then starts to rise exponentially (meaning the Baby Boom is just starting to enter the dementia years this year). Prevalence of significant memory loss is less than 10% at age 75, 20% at age 80, 40% at age 85, 60% at age 90, 80% at age 95 and pretty universal at age 100. There is plenty of evidence that if all humans lived long enough, we would all develop Alzheimer’s type dementia (there’s even some evidence that it’s a life long process, wired into our central nervous system’s design – the price we pay for our intellects). In previous generations, the majority died of other causes long before it would have become apparent. Will the boom, still considering themselves young in their late 60s and early 70s, and living to age in reasonable health be able to cope with the combination of physical health and cognitive failure?

An interesting thing happens to long term married couples where one partner develops dementia with age and the other does not. The well partner is usually the last to come to grips with the changes and deficits in their spouse. Alzheimer’s type dementia is usually of such slow onset and progression that the well spouse unconciously adapts to that change, taking on more and more of the life and life tasks without necessarily understanding that they are doing so. It’s the child who lives out of state who hasn’t been home in several years who arrives for the holidays who can truly see the changes as the delta between what they expect to see and what they do see is large enough.
Once the spouse starts to understand that there partner is not reacting to them in the way they are used to, they try all of the techniques a lifetime of marriage has taught them in terms of cajoling, fighting, teaching, and just being. They don’t work. So they double down and try even harder and get the opposite resutls of what they expect. They show up in my office angry, frustrated, resentful, sad, and not understanding why the dynamics of their relationship aren’t working the way that they think they should. It’s my job to begin the process of teaching them that the demented spouse lives in a different reality with different rules. Time may not exist in the same way. They may both look at the same thing but see something different as the demented brain may interpret signals in unusual patterns. Reality is what our brains tell us it is. As most of our brains function in roughly the same way, we agree on it or, as Lily Tomlin once put it ‘Reality is a collective hunch’. When a brain no longer functions in the same way, reality becomes different and that person no longer lives in our world and we aren’t really capable of visiting their world either.

There are tantalizing clues as to what the world of dementia is like. When one looks at demented visual artists, they pick strong and vibrant colors and simplify line and detail. Other people strip away adult dissimulation and artifice and become plainspoken and absolute truth tellers. It’s no accident that in classical literature the fool is always the one who speaks truth to power. Shakespeare brings it all together in King Lear when the king and the fool confront the storm on the heath. Lear is a portrait of dementia robbing a powerful man of independence, but not self awareness and the fool is the one person who understands him. The relationship between Lear and his daughters is acted out in my waiting room about once a week as adult children try to figure out what to do with daddy as he’s losing his faculties.

Our current society is much like a long term couple where one partner has dementia. (I won’t say which one – people of different political persuasions will pick different sides but the analogy holds either way). Red America and Blue America are trying to exist in two different realities and the relationship is frustrated and foundering because they’re trying to use the same old same old communication methods to get through to each other and all it’s doing is raising the level of anger. Perhaps we all could take a lesson or two from a friendly geriatrician and take a step back and not try to force each other into old roles, but gently explore who we are as new and evolving people in a spirit of mutual respect. Some of my usual suggestions, like distracting each other with cookies to help change brain patterns aren’t going to work but an acknowledgement that we have to move forward towards new ways of rapproachment might be useful.

We’re going to have to do something to get us all on the same page regarding public health if we really want to bring COVID to task. In the meantime, wash your hands, wear your mask, keep your distance, get your shot, have a cookie.

February 6, 2021

One year. 366 days (2020 was a leap year). 527,040 minutes (sorry Jonathan Larson but you’re wrong every fourth year). It was initially assumed that the first US COVID death happened on February 29, 2020 in the Puget Sound area. But, when the pandemic began to take off in March, the medical examiner’s office went back to a couple of mysterious unexplained deaths in otherwise healthy people following a flu like illness and found the presence of the novel coronavirus in tissue samples of individuals who died on February 6th and February 17th. One year later, according to the Johns Hopkins Coronavirus counter, the US is at 460,311 deaths.

How big is that number? If it was a US city, it would be 44th in population, coming in between Virginia Beach and Long Beach, California. It’s 10% higher than US World War II casualties making the pandemic the third largest mass casualty event in US history, bested at this point only by the Civil War and the 1918 Flu pandemic. (And at the rate we’re going, I imagine we’ll top both of those by this summer as we’re more than 2/3 of the way there). It’s enough to fill the 101,821 seats at Bryant Denny stadium four and a half times. It’s enough to have killed one out of every 719 Americans who were alive a year ago. As the average American has a cirle of acquaintance of roughly 5,000 individuals, statistically each of us has lost seven people who were in our lives a year ago. For me, it’s a much larger number than that given the nature of my profession. I lost seven people of my acquaintance during the first week of January alone as the surge driven by holiday gatherings reached its peak.

Fortunately, things are beginning to calm down somewhat. Numbers of hospitalizations, at least locally, are beginning to dwindle. There is one outlier, Tuscaloosa. I was in a meeting at the VA this past week where there was much consternation about a rapid spike of COVID among veterans getting are at the Tuscaloosa VA compared to the rest of the state. All you have to do to explain it is look to the night of January 11th when UA clinched the national football title and the young people of Tuscaloosa poured into the streets to celebrate. Human behavior drives the patterns of viral outbreaks in predictable ways. Most of those young people did not become seriously ill and most elderly veterans in the area were not chugging beers on University Boulevard in the wee hours of the morning. The mass of assembled people, however, allowed for the virus to be passed along to a greater portion of the population at one time. With higher numbers infected and a greater reservoir of potential carriers, older people in the community were just more likely to come into contact with someone infectious, even with normal precautions.

Map of corona virus mutations

WIth vaccines rolling out in fits and starts, there’s a sense of societal ennui in the air regarding the coronavirus. I can’t quite put my finger on it, but its sort of a ‘OK, that’s over let’s move on’ sensibility which fits in neatly with both our short attention spans and need for the new, especially within the infotainment journalism we’ve perfected over the last few decades. COVID is so 2020, let’s move on to the next big story. The problem is that the virus hasn’t gone anywhere and it’s just waiting for us to change our behaviors in ways it can exploit to do its one and only job, propogate. When we allow it to move through the population, we create two major issues. The first is the obvious costs of morbidity and mortality. The second is we give the virus a chance to encounter more types of humans and more environments and increase the chance of mutations. Viruses are relatively simple organisms. There aren’t a lot of pieces so the genetic code isn’t all that long. Errors in transcription of genetic code happen all the time – anything from 1/100 to 1/1000000000 depending on the organism and whether it’s DNA or RNA or mRNA. The more different environments the virus encounters, the more likely one of those mistakes is going to aturn out to be an evolutionary win in a new situation and give a new strain a little bit of an advantage. What is a win for the virus may very well be a lose for us. The novel coronavirus that causes COVID is very closely related to the virus that caused SARS in Asia a couple decades ago. If a mutation occurs which causes this one to develop the same lethality of SARS, we may be in a world of hurt. It’s mortality rate was about 14% compared to about 2% for COVID. With that morbidity, we’d be looking at between 3.5 and 4 million dead in this country to date.

I’m not pooh-poohing the vaccine at all. It’s an incredibly useful tool and it’s a tribute to human ingenuity that it got from identification of the virus to people’s arms in less than a year. But it’s not the be all and the end all and it cannot substitute for good public health practices. It’s going to take a while to get everyone at higher risk from COVID (somewhere between 1/3 and 1/2 the population) vaccinated. The other things that we’ve been working on such as masking, hand hygiene, and social distancing need to continue for a little while longer. It’s still a bit unclear as to what is safe and what is not once you’ve received your vaccines. I’m still not eating out or going to the movies, but I feel better getting together with a couple of people, especially if we’ve all been vaccinated. I need a weekend away for mental health in the near future. I figure as long as I pick somewhere where I can do outdoorsy things.

We’ve still got a huge political problem in this country when it comes to public health. The change in administration, while it did put people who will listen to and follow the science in charge of the pandemic response, did nothing to change the gap between red and blue America. I think the most dangerous thing that can happen over the next year is for the administration and blue America to dismiss the concerns and attitudes of the antimaskers and their ilk as insignificant noise coming from a bunch of uneducated yokels. The analysis of the composition of the mob at the Capitol shows that these are not uneducated or unsophisticated people. They have, for whatever reason, bought into an ideology that those on the opposite side of the political aisle must be destroyed by any means necessary and their ideas must be ridiculed and abrogated. This morning I read an article that the governor of Iowa is eliminating all social distancing/masking and other coronavirus mitigation measures. One does not get to be a governor of any state by being a stupid person. But one does make political calculations based on various competing agendas.

I’m afraid our political split is here to stay unless some significant social surgery is performed (reinstatement of the fairness doctrine, repeal of Citizens United). I am under no illusions that things are over, not by a long shot. The Republican party is in thrall to a radicalized base where any attempt at comity is seen as heresy. As that base pulls itself further and further into a world of ‘alternative facts’, I have no idea what the leadership is going to do or what the economic powers behind the leadership are going to do. My guess is, as radicalization becomes bad for business, the polticians attempting to use those impulses for their advantage will start to see funding sources dry up until they fall back into line but you never know. It always comes down to money in our culture; it’s the only common language. The later millennials and generation Z seem to have figured this out, witness a group of Florida high schoolers eviscerating the National Rifle Association and a bunch of tech bros using the Robin Hood App to bringa hedge fund to its knees.

I feel like I’m blathering on a bit now so I’ll sign off, but not without my usual litany. Washa yo hands. Wear yo mask. Stay yo distance. Get yo vaccine when yo can.

February 3, 2021

Seniors in living facilities beginning to emerge from quarantine

The holiday surge is officially over. Case rates have dropped back to where they were in mid November when the rise really began to take off, a couple of weeks after Halloween parties. Back then, we were at roughly 10 million total cases and 240,000 US deaths. Now we’re at 26.5 million cases and 450,000 US deaths. More than 15 million people sick and more than 200,000 dead because America wasn’t willing to stay home for the holidays. I’m being a bit unfair. If we had all stayed home, there would still have been some cases, maybe a quarter or third of those totals. We’re still looking at a lot of people that didn’t have to die who did because of our social hubris and lack of empathy.

Is the drop off due to human behavior or due to the vaccine finally starting to roll out in significant numbers? Probably a bit of both. About 5% of the eligible US population has been vaccinated at this point and the emphasis on the high risk populations of health care workers and elders in congragate living is likely to have a significant effect on mortality rates moving forward. While the numbers are still difficult to comprehend (roughly 1/730 Americans who was alive a year ago has died of Covid at this point) I’m finally starting to feel hopeful that we’re going to have a bit more normal life come summer. The local vaccination sites are working well, the only limiting issue is the supply of vaccine and my sources within the federal government state that there’s a huge effort within the new administration to get those bottlenecks ironed out as soon as possible. Many of my clinic patients are in the pipeline to get their shots and we are getting shots hand delivered to my housecall patients. I may be able to get back on the road to see them over something other than a computer screen in a couple of months.

The original thesis…

I’ve been working steadily on editing all of these musings of the last year into something that may eventually resemble a book. The rough draft came in at about 115,000 words which is about 30% too long so now it’s time to edit, cut, combine, rewrite, polish, and drive myself generally crazy as I attempt to turn writing that;s generally late at night stream of consciousness into a coherent whole. Fortunately, I have an extremely talented editor in Steve Peha (a man I have known since elementary school) who is leading the way through the thickets of my sometime repetitive prose and we are on schedule to get a full polished draft done sometime in March. (I may ask a few of you to be early readers to see what you think). It’s interesting as I reread things that I wrote months ago to see how much of the book I was thinking about writing about the problems to come with the American health system under the pressure of the Baby Boom is there, only with a more literary quality than that book would have had and with a different thematic spine of the coronavirus and America’s failed response to it. In some ways, that makes the book much more me than the original concept would have been as it straddles the right brain world of literature and memoir and the left brain world of health problems and policies.

When I began these pieces last March, I had no intentions of them being anything other than what they were. My musings on life, the universe, and everything and trying to make sense of my place in it. But when the whole of society was upended and everyone was as uncertain as I, it became clear that I had a certain gift for putting those existential fears into words, finding the threads of hope, explaining the concepts we all needed to know in order to understand both the disease and the societal responses and the feedback I received kept me writing until I realized at first that I was accidentally writing a plague diary and eventually that it was a book about coronavirus, both the government and the health system’s response, and what that meant to one man both inside and outside of health care. If you’d told me a year ago I’d have the rough draft of a book finished and it was well on its way to being edited into readable form, I would have thought you were smoking something.

As Orgon in Tartuffe – with my Amazon costume finds

While I’m trying to not fall behind on the book project, I am taking time out for another zoom theater piece, Moliere’s Tartuffe. I think I first read it in high school and was amazed at how sharp the satire of religious hypocrisy was in something written centuries ago. It was one of those things that helped me understand that while culture and the trappings of society may change, humans remain fundamentally the same. I get the same feeling from Shakespeare and Sophocles. Le plus ce change, le plus c’est la meme chose. I’ve only seen Tartuffe staged once. Katherine BurgueƱo and I went off to a theater in Berkeley to see a friend of hers in it. When I picked it up to study it for this filming (I’m playing Orgon – the wealthy fool who takes in Tartuffe and is fleeced by him), I was struck by how absolutely relevant to this moment in time the play is. A certain segment of religious America has hitched their wagon to some very irreligious charlatans for the promise of wealth and political power and, as the church is pulled away from its principles for temporal ends, the hypocrisy gap widens and widens and diminishes both church and state. I think we’re learning the lesson that in a pluralistic society, both church and state are stronger when they leave each other alone.

I did some acting in elementary school. My first major role was as the title character in Rumplestiltskin as I was the smallest boy in the third grade. I was a tiny child and the Saunders genome is wired in such a way that the males don’t grow until relatively late. I was the smallest boy in my grade level all through elementary and middle school, remaining under five feet until I finished 8th grade (I shot up that summer). Being very small in middle school and having a reasonable intellect was socially problematic and I convinced myself that one of my best defense strategies was to be invisible and not make waves. (It didn’t keep me from being thrown in the dumpster because I was easy to pick up). Being invisible meant staying off stage so I entered high school not interested in performing but still enamored of the process of theater so I became a techie and moved from that to stage management and to directing. Sometimes I wonder what my life might have been like if I had been a different person and had started performing at a younger age. Would I still have gone to med school or would I have tried the NYC thing to see if I had what it takes? Who am I kidding, I would still have gone to med school. As much as I love the theater I made the decision around age 20 that I always wanted to have it as an avocation and a love and never feel like it was work. I also didn’t want to tie my life to a profession that’s more about being the right person in the right place at the right time than it is about actual ability. Of course, there has been a certain amount of the former in my medical career anyway. Sometimes it has worked in my favor. Sometimes it hasn’t.

I’m looking forward to getting back on stage. It’s not ego driven. Tommy always accused me of seeking the spotlight but I really don’t care if I have a lead or am third nobody from the left. I enjoy the process of creation with a team of people, each bringing their individual skills, both on stage and off, to create something ephemeral that none of us could have possibly done on our own. I choose the projects I get involved with based on the other people involved. There are people I like spending time with, people I want to learn from, people whose talent I admire. If there’s a critical mass of that going on, sign me up and stick me where you need me. I’m hoping there will be some outdoor distanced theater this summer and that we may be at a point where we can all gather again indoors in the fall. There are way too many shows on my bucket list that I want to be a part of before I become too infirm to run around backstage platforms in the dark changing clothes as I go.

Get Andy back on stage again. You know what to do to make it happen. Wash your hands. Wear your mask. Social distance. Stay out of crowds. Get your vaccine when you can.

January 31, 2021

Politically Incorrect Cabaret with Ginny Cruickshank and Rodney Davidson

It’s the last day of January, the end of the first month of this new year. And what a month it has been politically. I would like to think that things will start to settle down into the old patterns where the news out of DC simply drones on in the background of life, but I’m not so sanguine as all that these days. We’ve still got an impeachment trial, an ex-presdient who has spent all his time in politics shattering norms and is almost certainly going to continue to do so, and a major political party that seems unable to police itself against spokespeople minimizing sedition, nattering on about nonsense such as ‘Jewish space lasers’ , and certainly doing nothing to dispel the Big Lie that the recent election was somehow stolen. This suggests that all of the forces that have been rending the social fabric won’t be going away any time soon.

I’m no expert in politics, but I have studied my history and have had a career that’s brought me into contact with many different people from all walks of life. It’s one that’s required me to develop my sense of empathy far beyond where it once was and, once you have it, you can’t really turn it off. Emotions, especially negative ones like anger are still running high. There’s a lot of belief that government no longer works to support ordinary citizens. On the left, it takes the form of government is a rigged game benefiting the wealthy at the expense of others. (Currently playing out in the Game Stop short sell market where the tech bros have figured out how to leverage technology to beat Wall Street). On the right, it takes the form of government is taking my hard earned tax dollars and giving them to the lazy ‘other’ (playing out in nativist and white nationalist sentiments). It doesn’t really matter which side you’re on; if enough of the population loses faith in the government for any reason, the government will eventually collapse and we will be left to forge something different. These peiods of revolution and reformation are usually turbulent and violent and I really have no interest in living through one so let’s all put our faith in understanding that government, of any stripe, is the mechanism by which we can help each other beyond the circle of our immediate acquaintance. Big problems like pandemics require big solutions and they can only be provided through government. No other human institution is large enough.

The long and short of it is we’re in interesting times, as the old curse goes, and they’re going to stay interesting times for a while. On the public health front, things are a bit easier locally. The number of hospitalized Covid cases continues to slowly descend and the rate of increase is not what it was a month ago but it’s still a good deal higher than it should be. Vaccines are rolling out, and vaccination centers will start taking everyone over 65 as of February the 8th. A number of high risk occupations are also becoming eligible such as teaching and working in food service and retail. Our local metro area has a number of mass sites up and running, the only limiting factor being supply of vaccine. There are still some issues to be worked out such as the classism of relying on sign up systems that require on line registration.

Work continues apace on editing these musings into a coherent book manuscript. I’m up through last July and has I reread, cut and paste, and take my editors suggestions, it’s been interesting to see where we all were compared to where we are now. It’s only been six to nine months, but we’ve all had to become used to a radically different world bit by bit. I haven’t completely decided what the book is. Is it strictly a diary? Is it a memoir of a certain time? Is it a compendium of my philosophies of health care using the pandemic and our response (and lack thereof) as a structure? Is it a story? I am inclining towards the last. It’s the story of a journey – of an individual, of a society, and of a health care system as it faces down pandemic illness, bringing out its best and its worst.

I like writing stories, but I’ve never been good at writing sustained narrative fiction. Like all of us, I feel like I have the great American novel inside me somewhere but I’ve never been able to get out more than a chapter or two before running out of gas or being side tracked by some other project. Short form has always worked better for me. These pieces. The insane world of MNM and her movie reviews. The one place I have been able to write long form fiction has been in playwrighting, having a number of those under my belt, some of which have gone on to independent life.

I started playwrighting back in the 1980s when I was in medical school. Lauren Marshall, an old friend from Stanford, had also ended up in Seattle after completing both undergraduate and Stanford Law. We had collaborated before in college, most notably when she directed and I assistant directed Hello, Dolly! for the big spring mainstage musical her senior year. In the late 80s, she had this idea for an educational musical that could teach legal concepts to high schoolers. She got some grant funding, we sat down to write book and lyrics together, found a composer and Whadda ‘Bout My Legal Rights? was born. It had grant money attached so The Empty Space Theater picked it up for an Equity tour through Washington High Schools (it was about 50 minutes long, designed to fit in an assembly period) and it’s still available from Samuel French should any of you wish to produce it.
Our next collaboration was a farce, Terrorist in the Family Room, which we drafted out together character and plot wise, but then I was returned to California for residency while she stayed in Seattle so she moved on to other projects. I rewrote and finished Terrorist and send it out occasionally to see if anyone wants to do it. While everyone loves the script, it’s never been produced. I should get it out again and do another rewrite for the age of Trump as its themes that the terror we wreak on ourselves are far worse than what terrorists can do to us are resonating again. People think that the title refers to the central character, an international terrorist taken in by a suburban family by mistake. It actually refers to the TV set. Perhaps I need to change that to social media.

Ten years or so ago, Ellise Pruitt Mayor, then running The Seasoned Performers, the second oldest senior theater group in the country, asked me to write some touring scripts for elder actors to perform for elder audiences, predominantly in senior living facilities and senior centers. Being the good geriatrician that I am, I dutifly went to look up what there was on writing for senior audiences and didn’t find much. So I turned to what I knew from decades of working with older generations including how to communicate with those with hearing/sight impairments, how to work with those with mild cognitive issues, and generational concerns. The result was two scripts. The first was The Green Room, a fantasy in which the traditional fairy tale villains including the wicked witch, the big bad wolf, the troll, and the evil step mother are tossed out of their stories and made to wait together in the green room of the eternal theater while cultural forces beyond their control try to reshape the power of narrative. They escape with the help of the audience by breaking the fourth wall. The second, Nightcall Nurses, had older actresses from a radio drama of that name coming back to the studio as honored guests, recognizing that they’re being belittled for being older, and taking over the broadcast on their terms. I always thought I should write one more and then could publish them as three plays for senior theater.

In between, I’ve written more editions of Politically Incorrect Cabaret than I can shake a stick at. I’ve always wanted to write something serious and dramatic for the stage, but I always seem to veer off into snide humor. When I write comedy, I write it for me and for jokes that I find funny, even if no one else gets them. For instance, in the very first Politically Incorrect, we did a spoof of The Trojan Women as if they were survivors of the Iraq war. It was the midst of the Bush years so Andromache had a line ‘We’re getting our own No Child Left Behind program. They’re starting with my son Astynax.’ I thought it was hysterical but it probably went right over the heads of 99% of the audience.

These pieces to are written for me, to help me understand a changing and changed world through the power of narrative. I’m happy so many of you have jumped on for the ride. In the meantime, wash your hands, wear your masks, keep your distance, and tell the story.

January 27, 2021

It’s Wednesday again. Three weeks ago on Wednesday, the Capitol was attacked. Two weeks ago on Wednesday, the previous president was impeached for a second time. One week ago on Wednesday, the new president was inaugurated. I’m kind of disappointed something momentous didn’t occur today as well. There’s still a couple of hours left before midnight, unless you’re east of Nova Scotia, so I suppose it’s possible we’ll have something major before the end of the day but it may be that it’s just as well that the rule of three is holding and we’re all being given a chance to catch our collective breath. We’ve all been given a lot to absorb and process the last few months and I, for one, could use a little down time. I don’t know how the generation that made it through World War II was able to keep it up for six years.

The news is mixed from Covidland. It hasn’t gone away despite having been driven off the front pages recently by political news. On the good side, it looks like the surge fueled by holidays is definitely starting to recede. Numbers are down in general. Here at UAB, inpatients are down about 25% from the peak from about 300 to about 220. It’s still far too many and the numbers in general remain grim. World wide, the count has broken nine figures with over 100 million cases recorded. (Almost certainly an undercount by a significant margin). In the US, we’re at about 25.5 million. The speed with which we’re experiencing new cases and deaths has begun to slow. Whether that’s due to behavior change, vaccine distribution, or other reasons is not yet clear. On the bad side, the new UK variant that’s significantly more contagious is definitely spreading in the US and this may be enough to knock numbers back the wrong way again. Even here in Alabama, several cases of the new strain have been identified.

Vaccine is finally being more appropriately distributed and everyday I hear from a friend or a patient that they’ve received their first dose and are scheduled for their second. Systems are falling into place at both the federal and state levels to keep supplies up, the current limiting factor. My VA house call program has solved the logistical problems with transporting the vaccine during its safe post thaw window around the state to our bedbound house call patients and we are getting them slowly but steadily taken care of. Large sigh of relief. There’s still a lot of work to be done to reach and educate underserved communities and there’s still significant political stigma associated but that seems to be waning somewhat as the vaccine rolls out with minimal side effects.

It’s been gratifying for me to see the return of the house call to a more prominent place in medical practice in recent years. I have always believed that they are central to helping people maintain good health. Back in the day, before my time, most primary care medicine was done in the home. The doctor made the rounds in a mule cart or Model T and treated what he could, educated families in proper nursing, and always comforted when there wasn’t much else available. Following World War II, doctors migrated into offices, usually attached to hospitals in some way so they could care for both outpatients and inpatients at the same time. They still did occasional house calls. The introduction of the federal payment structures of Medicare and Medicaid and the rise of for profit insurance nearly killed them completely with growing emphasis on time efficiency and volume.

When I entered medicine in the 1980s, there were no opportunities to observe or learn about the art of the house call. I was never exposed to one, even with my wandering around rural communities as part of the University of Washington’s program to create primary care doctors with roots in small town Northwest US. Neither house calls nor geriatrics were part of my curriculum either in medical school or in residency. (I never met a geriatrician until I was nearly finished with my internal medicine training). When I opted for geriatrics, one of my first assignments was to UC Davis’s small outpatient geriatrics clinic. On one of my first weeks there, the ambulance pulled up and offloaded a poor lady on a stretcher. She couldn’t get out of bed at home. The process of transferring her from the bed to the ambulance and then into the clinic had aggravated her arthritis and she was crying from pain. She was demented and not able to tell me much of anyting about her condition. No member of her family had come with her. The ambulance drivers knew little about her other than the address from which they had picked her up. I called her home, got her daughter (she hadn’t been allowed in the ambulance and didn’t have access to a car to have come on her own) and learned a bit about the patient. When I asked where the family lived and figured out it wasn’t more than a few miles from my house, I told them that next time the patient needed medical care, I was going to come to them.

“Can’t you fellas read the sign? I can’t let you wheel him in here.”

I had no idea how to do a house call. I went to the powers that be at UC Davis and told them I intended to do them on certain clinic patients like that one who would otherwise require ambulance transport. There was no objection. I located a group, the American Academy of Home Care Physicians and attended their annual meeting looking for ideas. (It fit in a classroom as there were fewer than fifty members nationwide). I learned that the reason there were so few housecalls was due to the Medicare reimbursement scale for physicians which at that time simply made it financially unfeasible to do them. As a fellow in an educational program, this wasn’t an issue. I learned by doing. I did more.

I started to realize how much I missed only seeing patients in the artificial environment of the clinic setting. I discovered the family where all the medications were poured into a candy dish and grandma picked out the ones she felt like that day. I learned to equate chronic GI issues with unsanitary kitchens and help teach patients food safety. I learned to carry a large bottle of Febreze and spray myself down after visiting certain homes so I wouldn’t smell like an ashtray the rest of the day. I learned how not to touch the furniture in some places. I put up with the occasional case of scabies from unwashed bed linens.

By the time I left Sacramento, I had built a thriving academic house call practice that taught house call medicine to residents and medical students and provided care to a uniquely vulnerable segment of the population. I became comfortable with people on ventilators at home, and families that more or less ran an ICU out of their kitchen. The program disappeared in the collapse of clinical geriatrics at UC Davis that forced me to leave California in search of alternate employment, but when I got to Birmingham, I brought that skill set with me. The Birmingham VA had a functional home care service that I became part of for a while. I’m back with it again after a decade hiatus for other projects. I introduced the UAB system to house calls and more or less did them on my own hook for years and years as they were the right thing to do. UAB eventually saw the wisdom in them and has built a robust house call service over the last few years but for the most part I haven’t been involved as I have simply had too much on my plate.

Going into someone’s home as a physician gives you a unique perspective on a patient. You start to learn about who they are as people. What’s important to them. You meet their families. You meet their pets. You see the photos on the walls and meet their ancestors and their family histories. You also meet them on their own turf. The power relationship is reversed. You are on their ground and they are the ones in charge of what will and will not happen. There are times when I wouldn’t have it any other way.

Sign up for your vaccine when you can. Even if you’ve gotten it, you know what to do: Wash your hands, wear your mask, social distance, don’t take random pills out of a candy dish.

January 23, 2021

Bernie is Everywhere

It’s only been three days since the last one of these entries but it seems like several months have gone by in the interim. Something seems to have happened to my perception of time. It feels normal in the immediate here and now but once something slips into the past, it’s as if there’s a great acceleration. Perhaps its the dizzying pace of events as the country reels from political and public health upheavals. Perhaps this is what happens when you age. My patients have always talked about time moving so quickly in their later years. It’s just that if feels like the inauguration was three months ago rather than three days ago. Or maybe it’s the rapid proliferation of 10,000 Bernie Sanders mittens memes…

With a new administration in place. things are beginning to change for the better in terms of the federal response to the corona virus pandemic. The administration has released its plan for bringing the plague under control and its a common sense compendium of tried and true public health measures, most of which should have been in place last spring. It has taken the availability of vaccines into account and there are now federal plans to utilize the national guard and other elements of the government to get vaccine out as quickly as it can be manufactured.

Locally, we here in Alabama are stymied by shortages in vaccine supply. The Alabama Department of Public Health who controls all distribution in the state has gotten its act together and is getting vaccine out to various points to begin vaccinating those over age 75, however, the complete lack of federal coordination has kept vaccine from flowing into the state to meet demand. Vaccinators often don’t know when they are going to get a shipment until a few hours before it arrives which makes setting up schedules and notifying patients a wee bit difficult. There are plans for several mass vaccination sites in the greater Birmingham area and the logistics are in place but they can’t open them up until there is a supply that can be counted on for both first and second shots.

In the meantime, numbers continue to mushroom. There is some evidence that we have peaked and we may be on the downward side of the hump caused by holiday gatherings and travel from Halloween through New Years. Numbers in the hospital locally are down slightly. The percentage of positive tests is decreasing somewhat (but is still more than double the five percent which is thought to be the level at which we can consider the pandemic under control in a particular area). Anthony Fauci has finally been allowed to share his expertise with the public untrammelled and is now responsive only to science and not to politics and his expression of delight at being able to at long last speak unvarnished truth and swing the CDC and other health organizations toward protecting the public rather than protecting the optics of the White House has been rather refreshing. The next big issue is the spreading of the UK variant which is significantly more contagious than the original strains. If this isn’t slowed, we may barely get a rest from this peak before a whole other surge begins later this spring.

Cabaret – Virginia Samford Theater – January 2020 with Celeste Burnum and Chris Sams

Tonight was the one year anniversary of the opening of the Virginia Samford Theater’s production of Cabaret, the last live stage show I was part of during the ‘before’ times. The cast gathered on zoom to toast each other and watch an archival video of a performance together. I don’t like watching myself in such things – stage perforrmances depend so much on the interaction of the actors with the audience that you always feel removed on both sides of the equation when it’s on screen. However, it was fun to see everyone and to reminisce and to comment on how appropriate that piece was to the political times we have been living in recently. When the local theater world opens back up, we’re going to lobby for the theater to revive that production. One year later and I’ve just started rehearsal on another theater project, a zoom theater version of Tartuffe in which I am playing Orgon. Now there’s another play that’s perfectly in synch with the current political times despite being four hundred years old. That’s what makes great art, something born out of turbulent times that helps a future generation understand the turbulent times in which it finds itself.

Bad times, pandemic disease, political unrest, religious schism – no society is immune from such things. We like to think of ourselves as privileged individuals living in the finest civilization the world has produced, an apogee of comfort and enlightenment. I’m pretty sure the Ancient Sumerians, the Imperial Romans, Tudor British, 18th century French, and all the others felt the same way about themselves and their societies in their day. I think it’s part of the human condition to believe it can’t happen here until it does.

I have no idea how the new administration is going to go about solving the myriad problems in American society that our failed response to the corona virus has exposed. I don’t know what the opposition to President Biden and the Democratic party has planned in terms of response. All I can say is that there’s going to be no linking arms around the campfire and singing Kumbyah. We’re a long way from controlling this pandemic and we must all continue to be vigilant, vaccinated or not. Hundreds of thousands have died, hundreds of thousands more are likely to die but we can each do our own small part to protect each other. You all know what to do. Stay home, wash your hands, wear your masks and social distance.