It’s been a week full of life’s little mysteries. Like why are two of the bathmats from my master bath suddenly missing. And just whose unit above mine leaked water down the pipe alley flooding my utility closet and causing the parquet tiles in the hall to buckle and warp yet again. And why do the cats insist on peeing on any laundry accidentally left on the floor. And how can supposedly competent and educated adults employed by our federal goverment make such idiotic pronouncements on a daily basis.

We are now four weeks into The Tempest rehearsal and have three left to go. The show is staged and the scenes all have their arcs and necessary dramatic shape. Now comes the stitching of all of the pieces together. I have ten rehearsal hours to accomplish that task before we try running the whole thing and see what we’ve got. For the most part, the process has been relatively smooth. I wish people were further ahead on their lines than they are as it’s really hard to judge a performance when the actor’s face is buried in the book. I lost an actor this weekend to another commitment (the joys of community theater) but fortunately, I was expecting something like this to happen and had a secret plan B up my sleeve for dealing with it. All departments seem to have a grasp on what I’m hoping to achieve and seem to be moing towards the finish line with despatch. I’m sure I’ve forgotten some major detail but I’m pretty adept at creative problem solving on the fly. I’ve told the cast and staff that my mantra for the next two weeks is ‘simpler and cleaner’. Whatver the problem, we’re going to take the simplest and easiest path forward.

I was reading an article yesterday on the future of health care in the US and was struck by a statistic that I had not seen before. Somewhere between 10-12% of US physicians will leave the profession before the age of 50. In earlier generations, this was unheard of. Medicine, as much a calling like the priesthood as a profession, was something not to be entered into lightly as you would be spending your working life in a single track. Given that it takes anywhere from seven to twelve years after college to become proficient in a specialty, you aren’t ready to be turned lose until your thirties. Personally, it took me a total of 26 years of education from Kindergarten to completion of my geriatrics fellowship. After that kind of investment, you kind of want and need to stick around. I have. When I retire next year, it will be after 34 years of clinnical faculty positions.

This statistic does not bode well for our future. There is a significant shortage of physicians in this country, especially in primary care fields. (The educational system and the money is all tilted towards subspecialty care). We’ve been able to balance the numbers in recent decades by importing medical trainees and physicians from other countries and they have filled the gaps by taking jobs that US graduates have little interest in, especially in small town and rural America. The current administration, with its anti-immigrant stance, is trying to slam the door on this practice by rewriting the rules. The most recent one is to limit foreign students to four years to complete their course of study. Fine for a Bachelor’s degree or even an MD, but residency/fellowship training is ofen years longer than that

Covid did a number on the health care system. 20% of those working in clinical health positions in 2019 no longer do so. The older generation retired due to the stresses and strains of that period. Younger people reevaluated their lives. For the most part, the physicians soldiered on but now, five years later, things are beginning to fall apart. A profession that had minimal attrition is now due to lose 10% of the providers who should be in their most productive years.

Why are younger physicians leaving? It apparently boils down to four things which anyone who has been employed in health care over the last few decades could easily identify. The first is the hassle factor. Clinicians no longer run the healthcare system. Administrators do. There is a fundamental difference between the training and the thought process of the two. The shift to corporatization means that processes are put in place to benefit the C suite, not the boots on the ground. Healthcare now operates like any other big business, manufacturing patient encounters rather than widgets. Things like the electronic medical record, supposedly for patients and providers, is really designed for administrative tasks and is simply forced into a clinical role. My first job at age fifteen was as a data entry clerk. I have come full circle.

The second is the stress of the job. We spend our days with people on what is often the worst day of their life and we do that every work day, day in and day out. I’m lucky.. Some of my life experienes have given me a large pool of resilence and coping that most human beings don’t get. I have no idea where I would be if that were not true. The stress of the job places great strains on marriages and family relationships. And there is a culture in medicine that says you should be tough enough to take it and they should never see you sweat, much less cry. It’s no wonder the suicide rate in the profession is as high as it is.

The third is the unrealistic expectations of patients and their families. And let me tell you, honey chile we ain’t seen nothin’ yet as this is going to get exponentially worse as the Baby Boom enters its senior years en masse. It’s everything from the refusal of families to accept that their ninetysomething year old relatives will inevitably get sick and die to the people who want to spend hours discussing the research they did with Dr. Google on some spurious website to battles over the correct use of medication to the amount of anger displayed by people having to wait for service. I developed a technique for coping with most of this years ago. I tell patients that I am there to give them expert advice. They can take it or leave it. i don’t go home with them and I don’t run their lives. If they don’t take it or they do the opposite and end up making things worse, I don’t lecture or blame. I just keep moving forward with them. I’m their partner, not their nanny.

The last is a lack of satisfaction with the job. This probably flows from all of the above. Personally, I’m quite satisfied with the job. I enjoy what I do as it suits me so well. My favorite definition of geriatric medicine is ‘creative solutions to unsolveable problems’ and that’s my sweet spot as a person and personality type. If I just had to take care of my patients, I would probably stick around another decade, but the same things that are driving out the young uns are operating in my professional life as well and so I hang up my shingle next year and work on other things.

Yes, I’ve been following the national news. I give up when I read things like the administration wants to punish Canada as smoke from Canadian wildfires is crossing the border and leading to increased air pollution. Last I looked, weather patterns, airflow, and the physics of particulates was not under the control of any particular political apparatus. Where do they find these people who go on national media and make these hare brained statements. Unfortunately, the media, through tis corporate ownership which wants to play nicey-nice with power, finds itself in a position where it seems unable to call out idiocy as being idiocy. I don’t mind doing it for them.

It’s late. I’m going to bed.

I woke up this morning to the news that Senator Lindsey Graham of South Carolina had died suddenly last night. And to speculations of a nefarious assassination due to his recent trip to the Ukraine. Occam’s razor suggests to me that his death was natural causes brought on by an age over seventy, a long history of excess alcohol use (ask any bartender in Charleston), and the inner demons and self loathing that must have eaten away at his soul given his status as a closeted gay man actively working at all opportunities against gay rights and for his abandonment of everything he originally stood for in politics for short term political expediency and a place in the White House inner circle. I’m sure there are people out there who loved and cared about him but I imagine those are far outweighed by those who viewed him and his choices with loathing and opprobrium. You can’t please all of the people all of the time but pissing off the many to please the one for callous political considerations has never been a goal of mine.

This event, of course, changes political calculus going into the midterms, especially since Mitch McConnell seems to have joined the cat inside Schrodinger’s box. All evidence points to McConnell being either dead dead or brain dead but with vital signs making him technically alive. You would think a good investigative reporter could clear it up with a couple of phone calls but the administration and DOJ’s heavy hand on the first amendment in recent months seems to have cowed that branch of journalism into submission. When I was a resident, Racquel Welch checked into UC Davis Medical Center for a surgical procedure so as to be away from the prying eyes of LA. Everyone on staff knew she was there, what room she was in and why within twenty-four hours. And this was a time before cell phones and instant electronic communications. I can guarantee you that pretty much everyone on staff at whatever hospital McConnell is purported to be at knows something.

I haven’t a clue how the midterms will go. It will depend entirely on turnout. If the population gets off their butts and goes to the polls, the Republicans are likely to be routed in the house and just might lose the senate as well. But the Democrats, as an organized body, have a long history of snatching defeat from the jaws of victory through a combination of internecine strife, over reliance on purity tests, and the placing of party standing over electibility. Will the administration try to monkey with the election? They’re already trying and, if there are some more negative monkey wrenches thrown their way, they’re likely to double down. Everything from the SAVE act, which will disenfranchise millions to fix the statistically non-existent problem of undocumented people voting (even the Heritage foundation could only track down fewer than 100 cases by combing through every national election since the Reagan administration), to the vacationg of the Federal Election Commission (thank you SCOTUS for granting the presidency that power) so that there is no functional federal agency to make sure elections happen on the up and up, to the weaponizing of DOJ to go after local election officials.

The administration is also busy firing on the 1st amendment with DOJ issuing subpoenas to reporters who printed a relatively inoffensive story about Trump’s gold plated Qatari jet and how it did not have all the defensive capabilities of the older Air Force One planes. This dissing of his pet vehicle irked Trump so much that he’s determined to find out who gave the reporters that information and is using DOJ to try and get them to reveal their sources to a grand jury, completely against journalistic ethics and constitutional protections. But then again, the only amendment that appears to be sacrosanct to these guys is the second.

After destroying the East Wing and the South Lawn, the administration appears to have started on the North portico. No one really knows what’s going on underneath the tarp but I imagine the ionic columns will reappear as corinthian, likely with gilding as well. The conspiracy theorists have been running amok with stories about new fortifications so that the administration cannot be removed come January 20, 2029. I’m not inclined to believe these as of yet but, once again, I wonder at the lack of investigative journalists asking the workmen what they are doing from day to day. I’m sure they’ve all been forced to sign NDAs but a couple of drinks usually gets around those. The administration has also confused the National Guard with the Praetorian Guard and ordered them to remain on duty in DC through the date of the next inauguration.

So where are we all headed and why are we in a handbasket? I wish I knew. I’m just trying to keep my head down and make it through my projected retirement date at which time, if I so choose, I can isolate myself in my condo and ignore the outside world. Knowing me, that’s unlikely to happen. We have three basic paths to follow over the remainder of my lifespan. The first is the path of fire. The divides infecting politics and the economy spill out into the streets and eventually into military action leading to civil war. Our wealth inequality is greater than the conditions that brought about the French revolution and one could draw parallels to the conditions before the Russian Revolution as well. The second is the path of ice. The federal government ossifies and becomes more and more ineffective. We’re already seeing this in the legislative branch which has, for the most part, has ceased to function in terms of doing the will of the people. The end result of this becomes the Medieval papcy or the World War I era Austro-Hungarian empire. The last is the path of resetting the balance. We’ve done this before. We were in similar times from about 1885-1930 and the reforms of the Progressive era and later the New Deal moved power away from capital and back towards the people keeping either of the other futures from happening and creating postwar America which became the envy of the world. We’ve been busy dismantling that piece by piece for the last fifty years. Those who are proposing a restructuing in that way are being branded as communists (as if the people throwing that term around actually know what it means).

I’m all for capitalism (it’s treated me well) but I strongly believe that it has to be monitored and managed or else, as in Monopoly, one player ends up with all the money and everyone else ends up broke. And that’s no way to run a successful society. Put money back into the commons and get the profit motive out of the sectors of the economy in which it doesn’t belong – healthcare, education, corrections. And let younger generations have their place at the table and bring new ideas and new ways of doing things. The gerontocracy in DC is not healthy for either those participating or the country as a whole. Just because we can now live into our eighties does not mean that we have the bodies and brains of thirty and forty year olds at that age. Take it from the geriatrician

Happy Fourth of July. I can’t say I feel much like celebrating given the current state of our society but we’re not done for yet so I suppose I will get myself up and out of the condo this evening and find myself a place from which I can see the civic fireworks as they explode over the statue of Vulcan, about a half mile down the ridge from me. Those of us over the age of sixty are, I’m sure busy comparing the state of our patriotic celebrations of today to those of the Bicentennial of fifty years ago. Those went on non-stop for over a year and everyone participated. American flags were plastered everywhere you could think to put one. The fire hydrants were specially painted to look like Uncle Sam. We had a Bicentennial Minute every evening on CBS. Of course, it was a much easier time to keep the country united. Everyone watched the same TV shows on the same three networks, comity existed in governance, and the news was limited to half an hour at six for the national and another half hour at 5:30 (repeat at 11:00) for local. If you want a look at the bicentennial in all of its mid-seventies kitschy excess, try to find the 1990 film The Spirit of 76 in which time travelers from the future led by David Cassidy (!) are sent back to 1776 but, due to a glitch, end up in 1976 instead.

The summer of 1976 was a summer of transition for me. I was fourteen and had completed middle school and would be going on to high school in the fall. I was a bit nervous. My parents had decided that I would do better at a private prep school then at the local public high school that most of my friends would be attending. So I was very much in an excited and scared mode. I also finally began to grow. I was just about five feet even when I graduated 8th grade that June and, about five foot five when I started 9th grade that September. We’re late bloomers in my family. The boys don’t grow until age 14. I was very much gawky awkward what with my legs and arms being different sizes from week to week and I began a career of orthostatic hypotension and fainting when I got up from lying down as my blood pressure was not yet used to my brain being somewhat higher than it had been and tripping every time I went up a staircase as my legs were longer than my brain understood and I wouldn’t pick my feet up high enough. It all evened out by about the middle of 11th grade but it did leave some psychologcal quirks. I was a tiny child, usually the smallest boy in my grade level all through elementary and middle school. Even though I topped out at above average height for a man, I still feel somewhat small inside and don’t always understand my height. It does, however, give me certain advantages in terms of looming.

Now in my mid 60s, I’m starting to lose my height in the way everyone does as they age and their spine changes and settles. I’m down about a half to three quarters of an inch. That’s the way the cookie crumbles. I shall not run around, in my older years claiming a height and weight I obviously do not possess unlike a certain chief executive. I have many personality traits but narcissistic personality disorder is not among them. I’m a few pounds heavier than I want to be. (It’s come creeping back a bit since I lost ten pounds with my March illness). But in general, I feel like I am in reasonable shape going into retirement. My major concern is that I do not balance as well as I should so once I get some time back, I’m thinking I need to sign up for yoga or pilates to work on that before I fall over, hit my head on a random piece of furniture, and become a meal for the cats. Speaking of going down at home. Mitch McConnell was apparently found down at home and had CPR in the field before being transported to the hospital. Mr. McConnell is 84 years old and has obviously not been in good health for several years. He appears to have survived the rescussitation but statistically, essentially no one of that age who receives field CPR ever recovers to their prior function. He will not be returning to the senate. I shall not miss him.

The shenanigans in DC are too fast and furious for me to keep track of these days. There’s some sort of State Fair on the mall which appears to be sparsely attended (and which people are being carried out of with heat stroke as you can’t bring in your own food and drink and water is $11 a bottle and there’s a heat index of well over 100). I caught one of the vapid blonde MAGA commentators (I don’t know which one – they alll look the same) stating that the Democrats had geoengineered the heat wave to make Trump look bad. Where do they find these people and why are they given air time? They’re busy arresting people for touching the Reflecting Pool claiming the botched repair job is being vandalized by nefarious actors (with no proof offered). There are plans to bulldoze the oldest part of the famous cherry trees along the Tidal Basin for a golf course. The ballroom boondoggle keeps having new grifts and taxpayer burden revealed.

When government and civic life become entirely about profit and the grift and monetization of the commons to enrich the well connected, there is a hollowing out of society and a fraying of the bonds that hold us together, united in purpose. A few more years of this, and the whole edifice may come crashing down on our heads. The young have already figured this out and are abandoning both the Republican party and the traditional neo-liberalism third way that has been the mantra of the Democratic Party for the last forty years. More than half the population can no longer afford health care. The age of first time home buyers has risen to forty. Forty percent of women of child bearing age have considered emigrating. More and more young people are foregoing children as they can’t afford them We’re trashing our future by continuously adopting policies which harm younger generations and this has never been a recipe for long term societal stability. Democratic Socialists like Mamdani are trying to create a new way of formulating progressive politics. MAGA land simply calls anything that might actually help our young people communist. It’s as if Eugene McCarthy has returned.

The next twenty-five years (also known as the rest of my life span) are going to get awfully interesting. The Boomers will start their die off in about five years and will cease to become a political force. Their hoarded societal wealth will transfer as they aren’t taking it with them but much of it will transfer into the bloated health care system as they desperately try to maintain youth and health far beyond what the dictates of biology allow. We were the one Western nation that was headed into the mid 21st century in reasonable shape demographically due to our welcoming of immigrants (pretty much all of our population growth over the last few generations is from immigration – native born fertility statistics are low). But we’re busy destroying the American Experiment which for several centuries which has always said that anyone can be an American. Come here, work hard, assimilate. The horrific stories that energe from the insta-gulags ICE has been huilding are such that I’m hoping that quite a few of the private contractors responsible end up frog marched into the Hague or some such equivalent. ICE has really upped its numbers in recent months (but have spread their operations out so they aren’t as visible. They learned a thing or two in Minneapolis). There’s something like 100,000 in custody, half a million lost their temporary protected status, and some of the loudest voices want a third of the country deported. I’m just waiting to see what happens when all of the Haitian workers in East Coast nursing homes can no longer work. Then there was the declaration that Venezuela should be made the 51st state. I can’t wait to see what MAGA land says when we have thirty million new Spanish speaking citizens who will be free to move anywhere in the US they choose.

I think it’s time for hard cider and barbecue

I haven’t written one of these essays for awhile. It’s not due to lack of things to write about, rather due to a certain level of mild hysteria as I try to balance the combination of Shakespeare and work over a succession of fourteen hour days with a bunch of other social obligations thrown in. I used to be able to power through this kind of schedule without difficulty. This year, I’m feeling it. I’m wondering if my illness in March, which knocked the stuffing out of me was some sort of liminal border between middle aged Andy who can keep up with anything and older Andy who has to learn to pace himself and allow time for naps and other rest and downtime. I come home from a full work day topped with a three hour rehearsal and I’m not only barely able to move, I feel the need for an additional day of recovery time… which there is no time for.

We’re five rehearsals into The Tempest, or about 20% of the budgeted rehearsals. It’s about 2/3 blocked and the ideas are starting to come together. Most rehearsals have gone smoothly. Tonight’s was a bit more chaotic as I had the first rehearsal with my chorus of spirits (all eight of them) who come in and out and provide a certain amount of comic relief. I’m using them to break up the lengthy exposition scenes that make up the first forty percent or so of the play and to give Ariel some backup. After watching how things went, I know I have to do a lot of refining and shaping but I think my basic ideas are OK.

It’s ridiculously hot and humid locally and promises to stay this way for at least the next ten days. The HVAC in the church cafetorium in which we rehearse and perform is having difficulties keeping up so it’s a bit warm. Fortunately we aren’t having to work under incandescent stage light or anything else that adds to the ambient temperature or we would all be small puddles of sweat by the end of rehearsal. I really despise Alabama summers. Nearly thirty years now and I dislike them as much as ever. October can’t get here soon enough.

Exactly one year from today, I plan on offiially retiring. There are things that might move that date one way or another over which I have minimal control but in my mind, my last day of work will be June 30th, 2027. Let the countdown begin. I should get one of those clocks that shows the number of days untill retirement and watch those 525,600 minutes dribble away. I’m not sure what this next year is going to look like. I don’t have any performance gigs contracted past August. I do have some trips booked, especially in the fall but holiday period is uncertain. There are a few things coming up in the spring I’m interested in getting involved with but I don’t have any dates as of yet to begin piecing things together so I can make decisions on what shows I can audition for and which ones won’t fit.

I have no special plans for the long weekend other than catch up with work. I’m way behind on progress notes. a theater company board retreat, a friend’s cabaret show, a dinner date, a birthday lunch, a play and a few other things ate up this past weekend and I could get little of the usual stuff done. I shall not miss the hours spent every weekend documenting my clinical endeavors once I leave clinical practice. It’s one of the many reasons I’m retiring. The data entry is more important to the system than the actual clinical care. Healthcare has become all about big data set manipulation and management. And the AI boom is going to make all of this much worse. I don’t envy my junior colleagues their careers. Balancing the needs of administration and corporate on the one hand and the demands of the Boomers who do not believe in the realities of aging on the other.

The big news of the day is the Supreme Court actually upheld the constitution and stare decis for the first time in some years when it came to the Birthright Citizenship case. Looking back at the decisions of SCOTUS over the last few years, the contortions of logic proffered to get the result desired by certain political movers and shakers, has given me a severe case of vertigo. While that one may have come down on the side of precedent and textual reading, there are plenty of others which did not such as the Slaughter decision which threw out nearly a century of precedent which protected independent agencies from executive overreach and more or less reinstitutes the spoils system. And then there’s the decision which builds on Citizens United to more or less let unlimited dark money flow through political parties to candidates.

Meanwhile, ICE continues to round up the innocent and shove them in de facto concentration camps, we’re burning through billions in a weird quasi-Iranian war, the social circle of the executive is busy enriching themselves at the public purse, a wholesale destruction of Washington DC infrastructure, a dismantling of the systems that built and supported the post war society with its liberal consensus, a head of CMS who showed he did not understand how health insurance worked in recent testimony, a head of HHS who promotes fringe theories and junk science, and there still hasn’t been a proper release of the Epstein files or a single investigation or prosecution of the crimes contained therein.

I think I need a valium. Or maybe a quaalude

And day one of the three day weekend is waning to the sound of thunder as another summer storm wends its way up the Jones Valley. If I ever leave my adoptinve home of Birmingham, there are certain things I will miss and the suddenness and ferocity of summer thundershowers is one of them. They drop the temperature to the manageable 70s, at least termporarily, leave everything feeling clean and refreshed outside, and keep me from having to pay too much attention to the plants on my deck. Day two is taken up predominantly by social obligations and day three will be running around getting everything done that hasn’t been done already as I not only have to be ready for work on Monday, but also for first read through of The Tempest.

Twenty-one cast members and a half dozen staff are depending on me to lead them through the wilds of Shakespeare over the next eight weeks. I hope I’m ready. It’s the fourth year in a row I’ve done this so I should have a clue what I’m doing but each project is unique and poses different challenges. Last year, it was politics and major technical difficulties. This year it’s going to be integrating all of the elements in a way that make things at least somewhat magical on a a budget of $19.95. I have been assured that the lights will work this year and I have most of my usual team in place and at least they all know how I communicate and operate so we should all reach the finish line on August 6th at least vaguely together.

I have found the news over the last few days at least slightly more encouraging than in weeks past. While there’s all the usual destructive impulses from the administration against the institutions that built the post-war society, there are at least cracks in the facade. The saga of the reflecting pool remains a perfect metaphor for the second Trump term. Take something that has existed for years, fundamentally misunderstand and misinterpret what it is and how it works. Announce an unneeded fix at a low price. Proceed with a crony contract for a much higher figure. Crony contractor, chosen for politics over skill leaves things in worse shape. Announce a brilliant success while the wreckage is in plain view behind you.

The wreckage, of physical infrastructure, economic systems, world standing, health care, academia, immigrant communities etc. is now piling up so high that even the most fervent supporters of those currently in power are cutting their feet as they dance upon it. I saw a poll this past week showing that a majority (51%) of Americans can no longer afford their health care. The skyrocketing price of food, fuel and rent is decimating the lives of more of my firends than I care to count. Farmers are going bellyup. The Pentagon has spent hundreds of billions of dollars on a war with Iran which has gained the USA absolutely nothing as the memorandum of understanding signed with a flourish at Versailles (an ultimate troll by Macron) leaves Iran in basically the same place it was at the start of hositilites plus the ability to continue enriching uranium plus given access to previously frozen funds plus hundreds of billions of dollars to rebuild infrastructure we destroyed. We can’t fight the screwworm infestation effectively as the programs designed to do that were shut down. Flu is sweeping through military installations due to the antivax attitudes of those in charge. I can’t think of a community that isn’t starting to wake up to the fact that they and theirs are being harmed by the policies of this administration.

The opening of the Obama Presidential Library in Chicago was a reminder of what we were and what we can be again. The focus was on the positive aspects of America, the way in which we can come together despite our differences and work towards common goals. The musical acts were a whos who of legendary performers of the last sixty years. Compare that to the official celebration of our 250th birthday in DC, handed off to more crony capitalists which sent most people with integrity fleeing the other direction when asked to participate. From what I last saw, we’re left with a Trump pep rally in a place where half the house has been demolished, the pool is full of algae, and there’s the remains of a cage fight on the front lawn. I do house calls in rural Alabama. I’m used to those neighborhoods but they aren’t usually beamed out over international network news.

The joy of international visitors to the World Cup getting outside of the usual international tourist destinations and discovering Bass Pro Shop and Wal-Mart and Waffle House breakfasts at 1 am is also very good news. It means that the media narrative ordained by the administration and carried out by their minions of the USA being a dangerous place full of violence and suspicious types is being demolished one lovely experience at a time. Bring on the Norwegians doing the row up escalators, the Scots drinking the bars of Boston dry and leaving traffic cones on the heads of the statues, the Algerians adopted and embraced by the people of Lawrence Kansas. That’s the America I live in and believe in.

I spent yesterday on various chores and had every intent of spending the evening at the Birmingham Pride Parade but I started to feel unwell by late afternoon and decided my wisest choice was to stay home and sleep. Sorry to have missed the parade but after some time in bed and a good long sleep, I am feeling better today. I have more chores today but nothing that cannot wait. I’m working my way through all of the boxes of crap that came out of my academic office, tidied up my terrace, and am slowly restoring my nest to some semblance of order after a period of chaos and excess stuff arriving and needing to be processed. I have 54 weeks until full retirement. The goal is for me to have my life in order at that time so that I can work on putting together new life patterns in an environment which will support them.

As the days dwindle down, I find that I am having a harder and harder time just absorbing the administrative nonsense that permeates modern medicine. Usually I let the endless paperwork, the need to fill out the same request three times due to a misplaced comma, the refusals of insurance to pay for what I deem clinically necessary care, the calls and messages from patients about some new snake oil they heard about on social media or late night television, the lack of budget to improve the infrastructure of clinical services, and the poor performance of other parts of the health care system roll off of me but now I’m doing a bit more talking back and calling out stupid as stupid. I’m in a position where I’m no longer angling for any future forward career movement so I can truth tell. Actually, I’ve always told the truth. It’s one of the reasons I didn’t progress farther in my career. I tell those above me what they need to hear rather than what they want to hear.

I’ve had my nose in my script for The Tempest and am starting to work out solutions to specific challenges Shakespeare presents. How do you stage a shipwreck on stage with minimal budget and technical capabilities? How do we handle songs for which no music exists? How do I make the arcane language into something that connects with a modern audience? How do I get my cast of twenty-one working together as an ensemble? Every year when I’ve tackled Shakespeare as a director I kick myself as I feel that I’m really not up to the challenge. And every year what ends up on the stage is pretty good and I get asked to come back and do it again so I guess I’m doing something right. First read through is a week from Monday. I’m ready to launch into what I consider the easy stuff (the court scenes, the love story, the clowning) and hope all my ideas for the hard stuff (the magic, appearing and disappearing banquets, the masque, the shipwreck) order themselves in my brain in such a way that I can communicate them to those who have to help me execute them.

There’s been one bright spot among the barrage of bad news that we’ve all been enduring for what seems like forever. It’s an indirect result of The World Cup. Last week’s news was all about how the State Department and Border Control were abusing their powers and keeping refs and team entourages out of the country and revoking visas of fans who were hoping to see their team play. This week’s news is about the fans who have made it and who are discovering what a great big loveable diverse messy country this actually is behind the headlines and media images. I, like millions of others, have been captivated by the social media posts of Freddy from Germany, Shaun from Scotland, and Nobunaga from Japan amongst others who while road tripping have discovered Buc-ees, Waffle House, the Grand Canyon, and Bourbon Street. How ordinary Americans are throwing visitors backyard barbecues, driving them to the stadia, making sure their order at Chipotle is correct. The media warfare which stokes the red/blue divide for clicks and ratings, and which is exploited in a cynical fashion by politicians for money and power is not the real America. The real America is a thousand kindnesses, and welcoming the visitor, and absorbing new ideas and customs into our melting pot. Take that Stephen Miller.

The administration’s attempts to remake the capital aren’t faring so well. The reflecting pool has been finished and is now full of algae due to their dismantling of the filtration system put in under Obama which brought water in from the Potomac so it wouldn’t become too stagnant. The Lincoln Memorial, which I prefer to see as a backdrop for Marian Anderson and Martin Luther King Jr., became the staging area for an exercise in crass. We got to see Motocross doing stunts in front of the White House. I’m all for extreme sports if that’s your thing but there is a time and a place and the South Lawn ain’t it. Trumps loss of his name on The Kennedy Center has been met with a piece of spiteful malicious compliance with scaffolding and canvas covering the portico and the name of the building. Can’t wait until they start building that monstrous arch. If it is built, I’m hoping we have a nationwide naming contest for it and that the name not have the letters T R U M or P in it. Although, given the internet, it will likely end up as Archie McArchface.

OK I’ve lolled long enough. Time to get up and be constructive.

The day to day work crap has been falling heavier upon my soul than usual the last few days. I’m not sure why. Probably because I can see the light at the end of the tunnel and I’m in the psychological process of beginning to detach myself from the craziness that marks my professional life. And it all appears to be getting crazier at an exponential rate due to the combination of demographic changes and fall out from political impacts on the missions of academic health centers. Eight and a half months before the first phase of retirement kicks in and, if all goes as plans, twelve and a half months until it’s over and out. In the meantime, keep on trudging. The notes will get written. The hands will get held. The referrals will get sent. The refills will get to the pharmacy. They always do no matter how removed I may be feeling.

I’ve been fielding a lot of complaints from friends, acquaintances, patients, learners, and random people on the street on the state of institutional elder care these days. I agree that, at least locally, it’s a bit of a mess. There are a lot of dedicated people in the field but they’re fighting an uphill battle against very strong forces over which we have minimal control and the end result is declining quality, unhappy residents, frustrated families, and a lack of better options. Why is this happening? The usual reason…. money. It’s all about who is getting paid how much for what sort of service.

I’ve gone into excruciating detail in these writings before about the various types of senior living available and how they differ from each other and what sort of services are required. I am not going to write that all out again. If you really want to read it, let me know and I’ll link to all of that in the comments. What’s important in terms of current trends is that the industries (homecare, hospice, senior living, skilled nursing) are subject to the same sorts of market forces as all else in late stage capitalism. Most of these entities began as small businesses, often family run or started by not-for-profit entities such as religious groups for specific social mission. Over the last fifty years, as costs and regulations have increased, it has become more and more difficult for a small operator to exist. This has led to consolidation and larger companies buying up smaller ones to take advantage of economies of scale and centralized management.

If you go up the corporate chain of ownership, there’s been a move over the last three or four decades for the companies at the top of the food chain to be bought or controlled by large investment firms for the purpose of extracting wealth. Amedisys is owned by United Health. Aveanna by Bain Capital. Encompass’s major shareholders are Blackrock and Vanguard. And on it goes. The need to preserve profit plus the centralized management systems means there is very little wiggle room at any individual facility to staff outside of centrally set models, to do things in a different way or to set budgets around community needs rather than corporate needs. Room and board in a reasonable senior facility now runs about $3000 a month with other services added on through an a la carte pricing menu. Need help with medications? You can get those packaged and passed for a modest fee. Need someone to provide actual assistance? That will be $25 an hour four hours minimum daily. (That unskilled sitter isn’t being paid $25 an hour. Going salary is $12-13 an hour. The rest is going up the corporate food chain).

As demographics change, there’s going to be issues moving forward. The owners of facilities understand this which is why the building of new senior facilities has slowed just as the Baby Boom is entering its 80s and the time in the life cycle when they may have need of such places. The owners know that the aging Boomers aren’t interested in the current model and that many of them will not have the resources nor will their family systems have the resources for the hefty price tags associated with senior living. The earlier generations who have taken advantage of them are the last generations who had defined benefit pensions and were able to take advantage of the post war economy to increase their assets in ways that are not currently possible. I haven’t a clue as to what’s going to happen to the Boom as they enter the dementia belt and they and their families will not opt for institutional care and their family systems won’t be intact enough to allow for care at home. Probably a huge spike in elder homelessness, especially if the current administration starts taking an axe to Social Security, Medicare and Medicaid as they are threatening. I’ve had four decades of creative solutions to unsolvable problems. I’m leaving these unsolvable problems for the next generation of geriatricians. We have some bright young things coming up the ranks. They need not worry about unemployment.

I think I have puzzled together my cast for the Tempest. I’m going to sleep on it one more night to make sure I don’t have a stroke of genius in the night and then get a cast list and script out to everyone tomorrow so people will have plenty of time to look things over before we dive into rehearsal in ten days or so. I still have a lot of things to work on and solve. The one I’m trying to get a handle on at the moment is sound, music and songs. There’s a bunch of singing in The Tempest but, of course, no official music. Sir Arthur Sullivan wrote music for all of the songs in the 19th century but it’s way too art song for our concept. I need something much lighter. Perhaps someone in the cast will want to run with doing some composing and arranging. That’s what I did with Midsummer a few years ago and it worked out really well.

I could comment on national politics such as Schrodinger’s cease fire in Iran, the maltreatment of visitors for the World Cup, the attempt to use the post office to circumvent the constitution regarding state responsibility for elections, and the turning of the national mall into a scene out of Spielberg’s AI but I don’t have the inclination or the energy at the moment. Going to watch Law and Order instead.

The worst of the jet lag has beaten back, the work backlogs have been cleared, and now I can turn my attention to various pieces of life that were placed on hold three weeks ago so that I could cavort through various cultural capitals. The rearrangement and decluttering project here at home remains somewhat stalled and there are boxes and bins overflowing, but I at least have them confined to two rooms. Once I get some stuff out of the storage space that is leaving for new homes, there can be a general shift and I can make some progress there. I have broken out my notes on The Tempest. I have about two weeks to find a cast. I have commitments from about 2/3 of the people I need but I have no one on the radar screen for a few key roles. If you’ve ever wanted to dip your toe into Shakespeare in a safe environment, now’s your chance. Drop me a line and let me know you are interested. The third big issue I have to work on is my legal case side business. There’s a couple of attorneys breathing down my neck looking for some record review. That may be this weekend’s major project. I’m trying to decide if I’m going to keep that particular sideline going in retirement or if I’m going to hang up a ‘Gone Fishing’ sign on that as well.

Of course, being back in the good ol’ USA means I’m back in the middle of our broken political system. Here, in Alabama, we’re in the middle of the Supreme Court’s distressing Callais decision where the redistricting maps they demanded in 2023 under the Voting Rights Act were scuttled three years later. Now I know Ralph Waldo Emerson stated that foolish consistency is the hobgoblin of little minds but I’ve always taken the operative word in that sentence to be foolish and that certainly seems to be the case with the current Supremes. To my Black friends who have been fighting these battles for generations: please tell me what you need me to do to help you the most. My soapbox isn’t particularly large but it is at your disposal if there’s something that would be useful.

In terms of my community, recent polls show a significant eroding of attitudes toward LGBTQ rights over the last year or so with us backsliding to where we were a decade ago. It’s not equally distributed. It’s essentially all concentrated among registered Republicans and it’s such a major decline there that it is affecting the national numbers. Those of you who continue to support and finance the Republican party in its current form are taking actions that lead to policies that can cause me direct harm. I am taking notice and I have a very good and a very long memory. It is pride month this month. I usually turn up at at least some of the local celebrations as its important for the young folk to see those of us who have survived and have the battle scars to prove it. My generation endured a hell of a lot to allow younger generations to flourish and I am not going to sit quietly and watch it all get taken away. Every week, the rhetoric edges closer and closer to something along the lines of those with LGBTQ identities should not be allowed to exist in the new MAGA envisioned America. This rhetoric of depersonalization is extremely dangerous and just another step on the road to genocide. Don’t think it can’t happen here. It very much can.

The President’s attempts to remake the capital over in his image (gilded and tasteless) is finally hitting a few snags in the court system. Anything built can be torn down. Anything torn down can be rebuilt. Anything uprooted can be replanted. It takes time and resources, but it can be done. The ridiculous arena on the South Lawn which is due to be used next weekend is hopefully a temporary structure, but even if that’s left up for awhile by Presidential fiat, it can come down again. I read somewhere that GWMs (Gays with Money) are busy buying up all the tickets and are planning on turning the audience into a big old glitter bomb drag enhanced pride party. I hope it’s true.

Then we have the issue of more and more positions of importance being turned over to sycophants and idealogues. Our new attorney general continues to make the DOJ a weapon against the President’s personal enemies list. The new head of Homeland Security is a Dominionist of the worst stripe who seems to think shutting down air travel and cargo in a move of political gamesmanship is a really neat idea. (If that were implemented, the very wealthy who really run things would likely bounce him back to Oklahoma post haste but these days, who knows?) The announced nominee for Director of National Intelligence has no intelligence experience.

Then there’s the reclassification of most senior government positions which have carefully been insulated from partisan politics over generations to allow for continued governmental function no matter who winds the election to at will so that the administration can pretty much fire anyone who is not a sycophant or an idealogue and replace them with people that are. This goes along with the decimation of science, research, environmental regulation, and various attempts to rewrite history so that it fits the ideology that White America never did anything wrong. The Julio-Claudians tried to rewrite Roman history. The Tudors tried to rewrite English history. Stalin tried to rewrite Russian history. It never works. Truth will out.

Having to process all of this is playing havoc with the endorphins engendered by my recent travels. I think I need to make myself a Limoncello spritz and sit on the terrace and watch the sun set.

Dateline: Rome, Italy

And so the sun sets on another vacation. I technically have one more day tomorrow but as that is going to involve `18-20 hours of travel time as I get to Rome airport, fly to ATL, deal with customs and all that jazz and then fly back to BHM I’m not really sure that counts as a vacation day. More of an endurance test. I will have to say that this trip, cobbled together out of a lot of ideas that came from other people’s schedules and travel plans has been a smashing success. 19 days, 18 nights, 4 major cultural capitals, 180 foot miles by my pedometer, 4 planes, 3 trains, an uncounted number of taxis and metro/light rail rides, many excellent meals, theatre, opera, cabaret, museums, ruins, beaches, and most importantly my amazing travel partners and excellent company – Patti Steelman, David Pohler, Jonathan Uday Ramteke, and Thomas Cagle.

This last day was low key. Thomas and I walked over to the last part of tourist Rome we had yet to explore, the streets around the Spanish Steps full of chic designer boutiques with elegant salespeople selling couture well out of either of our price range. We did find some belts that were quite reasonable and satisfied ourself with those. This was followed by aperatifs and light lunch before heading back to the hotel to get him packed up and on his way to his archeological dig. He’ll be here for another month or so looking for fragments of classical Roman life at the site of Hadrian’s Villa. I don’t envy him wielding a pickaxe in the Italian sun day after day but he’s young and he can endure.

After he departed, I took a nap and then headed out fo finish what little shopping I had left to do. My life is a bit overstuffed with things so I tend to be selective when buying for myself. Occasional articles of clothing, pieces of local craft that are small and lightweight, original pieces of art for my gallery walls. That’s about my usual limit. I did look at some mosaic art for sale at the Vatican and there were some pieces I quite liked. Over priced. I shall live without. I then took a bit of a walk through the Trastavere before dinner. I’ve had so much rich food recently that I wanted something simple and comforting for dinner and ended up at a Mexican restaurant with a plate of enchiladas verdes and black beans. As I tend to eat Mexican at least once a week when out on house calls (the Mexican place is usually the only reliable restaurant for lunch in a small Alabama town), it was comfort food (and quite reasonable quality).

I’m going to watch bad TV tonight, dubbed into Italian, and then try to get a long and sound sleep to make up for the craziness that will likely occur tomorrow. In the morning, I may take a walk before heading to the airport as I don’t have to head that way until about 11 am Rome time. (4 AM Birmingham). It will give me one more day of pedometer happiness before heading back to my usual patterns. My stiffening hips have been fairly happy with all the walking. I should really keep it up but finding the time around work and other obligations is always a chore. And I have to launch myself into the Tempest as we’re due to start rehearsing three weeks from tomorrow and I don’t have a cast as of yet. (If you’re interested, drop me a line).

This also means I have to shove myself back into the insanity of American political life again. The quotes and actions I have seen from the president, should they be coming from one of my patients, would lead me to start introducing difficult conversations about the future. I may hide in a bunker for July 4th weekend which he and his team appear to have completely screwed up. There also appears to be some new move afoot to allow political appointees to cancel any federal grant for any vague reason at any time. Scientific and medical research cannot proceed without stable funding sources so if this one goes through, we’re likely to see American science, already moving towards free fall, plummet through the floor. If I were an up and coming young researcher, I would be exploring emigration options and appointments at foreign universities with alacrity

Dateline: Rome, Italy

Thomas and I made a decision this morning that this would be a day to get away from the crowds and the heat of a holiday weekend in Rome. We’ve seen most of what we were interested in seeing so, after breakfast, we explored the Rome Metro, and found our way to the Piramide stop on the south side of the city. There we were able to transfer to the Metromare light rail line and half an hour later we found ourselves in Ostia, Rome’s ancient seaport. We spent the morning making the budding archeologist happy exploring the ruins of Ostia Antica. Think a smaller version of Pompeii and without any crowds. The theater has been rebuilt and is still in use but most of the rest is as it was as the city declined and fell into ruin after the capital was moved from Rome to Constantinople in the late 4th century.

There are some lovely intact mosaic floors, and it’s easy to reconstruct the bustling city that was from the remains of brick with occasional columns and pieces of statuary. Pompeii was wiped out in an afternoon and frozen in time. Ostia survived for centuries and entered a much slower decline and ruin so there are fewer artifacts and no preserved body casts or the like. But it’s easy to get to, easy to explore, full of lovely wildflowers, and blessedly free from the hordes. I enjoyed our hours there very much. And, being close to the coast, the sea breeze kept things relatively cool.

We then hopped back on the Metromare and went a few more stops down the line to modern Ostia and the Mediterranean sea. We had a delicious seafood lunch on the beach at a restaurant named Mamaflo (recommended should you be in the Rome area) and then decided to spend the rest of the afternoon sur la plage. We hadn’t thought to bring swimsuits but a stop at a small resort wear shop solved that and we spent the next few hours relaxing in beach chairs and splashing in the Mediterranean. (Cool but not cold and will obviously warm more as the summer progresses).

Late afternoon, we packed up, got on the train with half of high school aged Rome who had spent the Saturday afternoon of the holiday weekend at the beach doing what the young do when traveling in packs, and made our way back into town. Nap time. Then this evening, pizza and tiramisu for dinner (washed down with a nice chianti) and a walk around the Vatican before bed.

Thomas leaves for his archeological dig at Hadrian’s Villa in Tivioli in the morning. I have one more day in Rome before I have to spend an endless travel day getting back to Birmingham. Haven’t figured out what to do with it yet. I’m sure something will occur to me.