Dateline – Komarom, Hungary

Not a lot to report on today as it was spent predominantly on a bus crossing the entire breadth of Slovakia. It was only about 250 miles and I could have done it in about five or six hours driving on my own, but it took us about ten given that a lot of the passengers appear to be a generation older than myself and require frequent pit stops and time to stretch their legs for DVT prophylaxis. Plus a two hour lunch break. The logistics of getting ninety people seated and served rapidly being a bit beyond the abilities of small town Slovakia. Actually, they did rather well given that we were given a relatively full menu from which to make selections rather than an ‘ya eat what ya get meal’.

Up early for breakfast and checking out of the Grand Sheraton Krakow before getting on the bus. The weather was grey but the clouds burned off as the day went along and the temperature warmed making my sweater unnecessary, even in the mountains. The road led South, through the Krakow suburbs and then out into the Polish countryside of small agricultural farms and views of fields and copses. After an hour or so, we began to climb into the Tatras Mountains that cover most of upper Slovakia. Past the Polish ski resort of Zakopane, we crossed the border into Slovakia without my even noticing. (Thanks Schengen Zone). The mountains look a great deal like the Appalachians, reminding me much of all my trips to Southern West Virginia and Eastern Kentucky, only the domestic architecture is mainly Mittel European mountain chalet rather than dilapidated double wide.

Lunch was in the resort town of Dolvny Kubin, which seemed to consist of a lot of winter condos, bare ski slopes, a couple of restaurants, a sad looking souvenir stand, and constant construction. I had the grilled chicken breast on a bed or orzo risotto. It was quite good. (Picture elsewhere). A quick constitutional around the town (which didn’t take long – Pigeon Forge it is not) and back on the bus for a nap. The later afternoon brought us out on the Danube plain with small towns and the remains of Soviet era collective farms, and useless factories and worker housing in the middle of nowhere.

The water is apparently seasonally quite low in the Danube. And, as the next phase of the trip is by riverboat, this was causing some consternation among the tour directors as there are shoals in the Danube downstream of where we were to meet the boat so there was a hasty rerouting of the point of embarkation to Komarom and a bit more time on the bus then expected. Fortunately, the boat did not run aground on its way upstream, the bus did not bottom out on the rough road to the dock and we were able to board the MS Joy in record time and after cocktails and dinner, everyone was in a better mood. (Gnocchi for dinner with lava cake to follow). I am now sitting in the lounge enjoying a Rudesheim coffee, a taste acquired on my last trip on the Rhine and Danube). I knew the bar staff could make it as, as luck would have it, this is the same ship on which I made that journey.

Tomorrow we are in Bratislava. I am going to forego their organized walking tour of the town (been there, done that) in favor of some exploration on my own. If anyone knows of an out of the way sight or point of interest there, drop me a line.

Dateline – Krakow, Poland

I.m turning in relatively early this evening as I have to be up early in order to catch the bus down to the Danube. I don’t know which way we’re going, only I know we catch the boat somewhere outside of Budapest so that involves traversing most of Slovakia. My one kvetch about this trip is that there is no stop in Budapest, one of my favorite cities when we are so close. Ah well, I’ll have to make another trip to pick that up again. I’ve been looking at the river cruise from Budapest to Varna down the Danube and at trips to Croatia and Montenegro so I should be able to add on to one of those.

This morning was a trip to Jewish Krakow. More accurate to say what was Jewish Krakow. In 1939, roughly a quarter of the population of the city was Jewish, about 60,000. Today there are two synagogues with a combined total of less than 300 members. The Holocaust wiped out 99% of the Polish Jewish population – 3 million to about 30,000. And there are cases of the survivors being massacred by their neighbors when they returned to try and reclaim their lands and property after the war. I have noticed that those countries of Eastern Europe I have visited with an authoritarian drift in recent years (Poland, Hungary) have taken to downplaying the role of the native populations and governments in assisting the Nazis, trying to place blame solely on the Germans. The Germans couldn’t have been anywhere near as efficient as they were without local help.

The morning began with a trip to the site of the former Krakow ghetto (made famous by Schindler’s List) where many of the original buildings still stand and the park with the hill from which the Germans watched the liquidation is still very much in evidence. What I had not realized until visiting was the actual geography of events. The ghetto, just across the river from the traditional Jewish quarter, was small, and the thought of 50,000 people squeezed into that urban space designed for about 3500 is discomfiting. The Schindler factory, which still stands, is only a short walk away, just outside of the ghetto borders. (The walls and gates have long been dismantled but there are marks on the street where the gates stood). The factory has been converted into two museums, one about the experiences of war time Krakow (not exclusively focused on the Jewish population and a very good use of multimedia exhibits) and a museum of modern art (which I skipped). The limestone quarry and site of the Plaszow work camp where the survivors of the ghetto were sent under the monstrous Amon Goeth is only about a half mile away, just south of the Park with the hill.

Later in the morning, a visit to the oldest synagogue in Krakow still in use, since the 1500s with some of the original decoration still intact, and its attached cemetery with gravestones stretching back centuries. The walls of the cemetery were constructed in modern times from the pieces of the gravestones from the Jewish cemetery the Nazis destroyed in setting up Plazow where they used the broken pieces for paving. They have been cleaned, assembled into a mosaic of memory and it’s very moving. I then poked around the winding streets for a while before heading back to the hotel for a nap and then drinks with Michele DeVita Goodwin and her husband and sister who just happened to be in town this week as well. Much discussion of Birmingham theater. I then had an early supper of carbonara, tiramisu and red wine before heading upstairs to sack out.

My recent immersion in Holocaust history of course brings to mind the horrific happenings in Israel and Gaza this week. I’ve looked at Twitter and Threads where various pundits are trying to boil down an incredibly complicated and nuanced situation down to absolutes, one way or another. It’s messy. (I smell the fingerprints of the last administration and the likely sale of state secrets behind the scenes). I am no fan of Bibi. I stand with Israel on responding to an attack on their civilian population by Hamas. Hamas, funded by the outside, more or less came to power over the objections of most of the Palestinians and their civilians should not be punished for something they had no hand in. Go after the organization left right and sideways but sweeping the Gaza Strip into the sea, when it’s population is mainly women and children, is not necessarily the way to do it. The Holocaust is still living memory, although the current survivors are now in their 90s and older, despite some political forces desire to rewrite history.

Dateline – Krakow, Poland

There is no rest for the wicked or the weary – or for those booked on European tours. Up early this morning for a walking tour of the old city with an experienced guide who actually knew the stories and the history. My knowledge of Polish history, is hazy at best at baseline, consisting of vaguely knowing of various kings with unpronounceable names and that the country has been somewhat of the piñata of Europe, having been bludgeoned and marched across by various invading powers for a millennia – to the point where it ceased to exist for most of modern European history, having been partitioned between Prussia/Germany, Russia, and the Austrian-Hungarian Empire for most of the 18th and 19th centuries, only coming into being again after World War I. What I did learn today is that Krakow was part of the Austrian-Hungarian Empire during this partitioning, and was freer than the rest as the Hapsburgs new they had to allow a certain degree of autonomy to keep such a disparate peoples as the Austrians, the Hungarians, and most of the Slavic states together in a single coalition. I also learned that the city was spared the bombings that ravaged so much of the rest of Mittlel Europa during World War II and that all of the Medieval architecture was indeed original and that the old city still adheres to the plan drawn up after the Mongol Horde sacked the city in the 13th century.

We started out with a short walk along the Vistula to castle hill where Wawel Castle, the royal castle for most of the Polish monarchy sits. It’s a limestone hill with a large cave beneath which was the lair of a legendary dragon (the myth being born out by the discovery of enormous bones in its depths. Modern techniques have shown them to be from mammoths, cave bears, and even a whale rib, dragged there by Neolithic peoples for who knows what purpose. The castle and its attendant cathedral are a mishmash of styles from gothic to renaissance to baroque due to its continuous changing of hands and need for subsequent powers that be to leave their mark. The cathedral is small, as far as gothic edifices go, but richly decorated, mainly with cenotaphs to various important personages and with some rather peculiar baroque chapels grafted on to the main building. The day was cold, gray, and dreary, and it started to rain about half way through our time up the hill so I was letting my mind wander.

Then down the other side of the hill, up the Royal Road into the center of town and a stop at the basilica of the Blessed Virgin. The trumpet of Krakow still sounds hourly from the higher tower, special members of the fire brigade being chosen to play the melody from a window facing each of the four directions every hour on the hour, a sort of medieval smoke alarm continued for tadition’s sake. The melody cuts short of the end; legend being that this is where the watchman, playing the song to warn the town of the impending Mongol invasion, was felled by a Mongol arrow. (Given that this church tower wasn’t built till several centuries after the Mongols, I’m not sure how historically accurate this all is, but it’s a nice tradition.)

After an hour of putting my feet up, it was time to get on the bus to make a visit to Auschwitz. I feel you cannot visit this part of the world without paying witness to the unspeakable for which that word has become synonymous. I know a little about Holocaust history, having done some reading starting at a young age. World War II and its aftermath were the formative years of my parents and I was allowed to look at and read the large Time-Life books about World War II at a very young age and taught to understand what had happened and why. Auschwitz is about an hour and a half out of town in the middle of the Polish countryside, chosen because of its easy rail access and the availability of ready made barracks confiscated from the Polish army. It was grey, wet, the camp streets were full of mud, and it couldn’t have been a more fitting atmosphere in which to walk under the infamous gate inscribed Arbeit Macht Frei.

We spent about an hour and a half at the original Auschwitz camp and then another hour at the nearby Birkenau which was constructed to add significantly more space for prisoners and to function as a death camp for the Jews of Europe. It was dusk when we arrived at Birkenau (we’re relatively far north so dark is coming early) and looking down the tracks through shadows and for to where the selection platform stood was disquieting. My mind was turning another tour group at the far end into a group of SS. I am young enough to have no personal memories of the Holocaust but old enough to have met survivors, to have friends who lost family, to care for veterans were part of the liberation forces and who were tasked with documenting the horrors, and in general feel that it remains part of my formation and life experience. Looking at the exhibits regarding the rise of Nazism and its antisemitism, it is impossible for me not to see the parallels to some of what is happening in modern American politics. The Nazis didn’t start with the Final Solution. It’s where they ended. I wonder sometimes what may happen if certain strains of fascistic American thought continue to grow unchecked. Where will we end up?

One thing I noticed, but I doubt anyone else in the tour group did, was that there was not anywhere in the complex one word or exhibit about those sent to the camps with pink triangles. (In all honesty, I didn’t see everything so maybe there was something I missed). Given the relative conservatism of Polish society (and it seems to be moving in general in the direction of Orban’s Hungary) I wasn’t overly surprised but if the story can’t be told at the foremost site of the Holocaust, where and when can it be told?

After the bus ride back to town, I hot footed it across Old Town in record time to join my church choir director and an old acquaintance for dinner at a very good Polish restaurant. It was a complete coincidence that we happened to be in Krakow at the same time and thought it would be fun to get together. I suggested our next dinner out should be at The Great Wall Chinese place. It’s about 5500 miles closer to the church. Good food and good conversation. And then another trip back across Old Town on foot to my hotel (my pedometer is happy). It was a bit later than I had been on the streets previously and about every 50 yards some young person would sidle up to me and whisper something in my ear as I walked past. Whether they were offering drugs, sex, a combination, or self sharpening Ginsu knives I don’t know as they all assumed I was fluent in Polish. I have no Polish genetics to my knowledge. I’m pretty much 100% British Isles but the locals seem to think I’m a native every time I go into a shop or other establishment. I guess I don’t exude American tourist.

Dateline – Krakow Poland

Ten hours of sleep did much to restore me to my usual state of mind and health and I awoke this morning to a beautiful day. Yesterday’s cloud cover and burned off and the sun was shining but it was still sweater weather with temperatures in the high 50s and low 60s, perfect for city walking. As the organized portion of the tour was not to start until mid-afternoon, I ventured out on my own to explore the Old Town of Krakow on foot. I love European city walking. The old city centers were designed centuries before the internal combustion engine and are very much designed around foot traffic and pace. I had no particular plan in mind, just go wherever the crooked streets looked interesting. My hotel, next to Wawel Castle on the river is more or less one end of the old town, presumably the river port. The old city walls surrounded the medieval fortified town that stretches about half a mile north with most of the interesting sited enclosed within that ring. City walls were made obsolete by gunpowder and most of it was torn down long ago and was replaced by a ring of parkland noted for it’s many old chestnut trees. This being fall, one must dodge the nuts as they come down.

I skirted the castle (a visit is scheduled for tomorrow) and headed up into the center of the old town to the market square dominated by the cathedral, some covered markets, and what I take is the national academy of music. (Live choral and orchestral music throughout the day – they seemed to be doing symphonic arrangements of The Beatles as I was nosing around. Eleanor Rigby is recognizable even with Polish accents.). Some shopping, some marveling at medieval design and architecture (although I think a lot of it is reproduction, replacing WW II damage), some walking. A stop at a chocolate shop for hot chocolate with cayenne and cinnamon. Chocolate bars seem to be as plentiful as coffee shops.

I have not yet figured out the intricacies of the Polish language. Words all seem to have a surfeit of Js, Ws, and Zs, not enough vowels, and the pronunciation seems to have little in common with the spelling. I’m sure there are rules but I’m not likely to learn them in four days. Fortunately, English being the most international European language currently, most things are signed in English as well. I try to see if my in my head translation from the Polish has anything to do with the actual English when I do peek. Perhaps if I start watching Polish TV. I started to figure out a little Hungarian that way,

This afternoon was a new experience, a tour followed by a four course formal dinner 400 feet underground in a decommissioned salt mine. They were actually mining salt here form Neolithic times until they ceased mining operations in the 1990s when they figured out they could make a great deal more money by opening to tourists and have them travel through hundreds of years of mining history and technology carved into the salt deposit. (A prehistoric inland sea that dried up leaving a salt pan that was converted to rock salt over millennia of geologic processes). Many galleries, chambers and steps carved from rock salt, most of what we saw dating from the 17th century but we covered very little of the total despite two hours and several miles of walking. The dinner, in a formal dining room carved out of rock salt with chandeliers decorated with salt crystals was very good.

I lie when I say that the mine no longer produces salt. It no longer produces mined salt but they have to keep pumping water out of it, as all mines much, and as the entire rock structure is salt, the pumped out water is brine. They let that evaporate and harvest that salt for sale and export. Best of both worlds. I have a small bag of it, a lagniappe from the dinner, which I will add to my spice cupboard when I get home. Tommy would approve.

Dateline – Krakow, Poland

It’s been a rather uncomfortable day, at best and I am nodding off like crazy so this travel diary may be relatively brief. Suffice it to say that I have successfully made it back across the pond, this time to Krakow, Poland where I am ensconced at the Sheraton Grand hotel, just across the street from the Vistula River in the old town section where the Wawel Castle dominates the skyline outside of my window. Usually, when I am booked into fancy hotels, I have a lovely view of the parking lot or the construction site next door. This time, however, it’s brick towers with verdigris copper cupola roofs.

It was just over a 24 hour process to get here. I was able to sleep in some on Friday morning (but was too excited to take full advantage of the opportunity) and finished my packing, loading myself into a Birmingham airport bound Uber. I have this rule of being a few hours early for international flights just in case something goes horribly wrong like I’ve left my passport on the dining room table so I have time to cope. Of course, nothing went wrong and at 11 AM, Birmingham Shuttlesworth airport was hardly a hotbed of major activity. The tour company had me booked on United, an airline I haven’t flown since moving away from the West coast some 25 years ago. This meant, instead of a brief hop to Atlanta to catch the transatlantic flight, a two hour flight the wrong direction Houston where I ended up about 550 miles further away from Europe than I had started the day. The flight was uneventful, other than parking for twenty minutes on the tarmac in Birmingham where they did some sort of hard reset on the avionics by turning the plane off and back on again. Not the sort of thing that inspires confidence.

The long flight, from Houston to Munich, was about eleven hours. Enough time for me to watch all three theatrical cuts of The Lord of the Rings Movies with time to spare. Actually watch is the wrong verb. Doze through is more accurate. I managed to miss the entire battle of Helm’s Deep and the passage through the caves of the dead amongst other things. I was off the plane in Munich around 9:45 AM local time. (My internal clock was set seven hours earlier). My flight to Krakow was not until 3:30 PM. Apparently the MUC/KRK run isn’t very popular and that was pretty much the only choice. Not enough time to leave the airport and venture into the city in these post 9/11 days so a lot of sitting in the really uncomfortable hard plastic chairs that populate the Lufthansa terminal departure lounges. I had hoped, as it is Oktoberfest, that there might be an oom-pah band around or someplace to purchase lederhosen and a Tyrolean hat, but I was sadly disappointed.

The hours dragged by, eventually, the Krakow flight was called, and back up in the air for a few more hours. Then collect the luggage at John Paul II International Airport in Krakow, clear customs and find the driver who would take me into town. All went smoothly and I walked into the door of my hotel room around 6 pm local time, a bit over 24 hours after walking out the door of my condo. The luggage made it. The room is nice. The only major issue is I have to write these travel missives on my iPad rather than my laptop as the latter broke yesterday just as I was getting to leave. The tip of the power cord broke off and stuck within the housing of the machine. I’m assuming it’s an easy repair but I had no time to deal with it before leaving. If anyone local to Birmingham has a suggestion on where to take it when I get back to get that fixed, I would be grateful. I’ve written pretty much all of my long posts since Tommy’s death (including the three books) on that machine and I don’t want to unceremoniously dump it quite yet.

I haven’t gotten much of a feel for Krakow yet. It was dusk when I arrived and drizzling (the weather is very Seattle at the moment) so I confined my orientation walk to the river promenade and finding somewhere to get a decent meal. I ended up at a Ukrainian restaurant. (Western Ukraine is not that far east of here) for a meal of some sort of meat dumplings with sour cream with ice cream crepes for dessert. Tomorrow I start exploring in earnest, I can’t say that I know a lot about the city or about Poland, my prior encounters being limited to having read ‘The Trumpeter of Krakow’ when I was nine or ten and enjoying it. (It’s a YA novel from the 20s, one of the first Newberry winners – I remember that it takes place in medieval Krakow, and that the hero is a boy who plays the trumpet in the tower and that the legend of the broken note is involved along with an alchemist and the philosopher’s stone but how the pieces all fit together, I cannot recall). It’s only like 3:30 in the afternoon Birmingham time but it’s 10:30 PM here so I am going to sign off and try to reset my internal clock.

Three more sleeps until a new adventure as my mother used to say. Whenever I know I’m heading out to a part of the world I’ve never been to or don’t get to visit often, I have a bit of a Bilbo Baggins moment as I come flying out of my domicile, dragging a suitcase, certain I’ve forgotten several important things and worried that all my careful planning will come to naught over some unforeseen circumstance. It usually comes out alright in the end, but I will have to admit that the only dragons I’ve encountered along the journey have been metaphorical ones. This trip is going to be a bit of a mix of unfamiliar (Poland – a country I’ve never been to) and old friends (Vienna – a city I love and it will be my second visit in five years). It’s not that far off my beaten path but I’ve been feeling a little put upon by life recently and it was one of the few packages I could find of the type I like that did not charge a single supplement. Someday I will find the ideal travel companion and that latter will cease to be an issue.

In the meantime, I’m running around trying to lash down all of the work responsibilities so nothing much blows away while I’m out of the country. I try not to leave too many loose ends for my colleagues as we’re all up to our ears in it these days and I don’t want to add to anyone’s burdens. I did finish my little study on what I actually have to do in the UAB clinic part of my job by tracking everything in the month of September. I had fifteen four hour clinic sessions last month during which I saw 7-8 patients per session. I taught students, residents, and my nurse practitioners during those sessions. Those sessions also generated something over 1000 messages that needed to be reviewed and answered and I signed off on roughly 300 forms that were mailed or faxed. Basically it takes me five to six hours of work for each four hour clinic session which is why I always have about four to six hours of writing notes and playing catch up every weekend. No wonder I’m tired.

On the Covid front, there’s not a lot to report. It’s still out there. It’s still spreading. It still, fortunately, is not putting too many people in the hospital or the morgue. The new booster is out there but good luck finding it. Without the federal government’s power and distribution system behind it, it’s relying on our frayed supply chain and the profit motive to make it to a pharmacy or clinic near you. I wanted to get one before I left for Europe but danged if I can find one. Every time I hear about it being available somewhere, they’re out before I can get there. It reminds me a bit of being a parent during the holiday season trying to find that hot new toy which is rapidly sold out everywhere. Compare and contrast the roll out of this booster against previous and then tell me that government should have no role in health care and that it should be entirely up to the free market.

A piece of good news was the announcement that this years Nobel Prize in Medicine is going to Kariko and Weissman who did the seminal work that allowed mRNA vaccines to be developed so rapidly. The fact that it was less than a year between the first report of Covid in Wuhan and the mass distribution of effective vaccine was a medical miracle and likely saved millions of lives. I know some of my friends and some of my patients are not fond of vaccines and will not take them. The number of proven deaths and disabilities from the disease is many thousands of times greater than the suspected deaths and disabilities related to the vaccines so I’m going to continue to trust them. I am willing to listen to arguments against them which are well sourced and based in science, but not ones from your google search of antivaccine groups and propaganda outlets.

Volume III of The Accidental Plague Diaries is complete and I simply await a proof copy to check. It will likely arrive while I am away so that task will be delayed a couple of weeks as I am trying not to carry any piece of any of my three careers with me to Europe. I want to unplug and decompress some. That doesn’t mean that the trusty laptop won’t go with me. There’s something therapeutic about writing a travel diary. I have my handwritten one from when I spent two months backpacking through Europe in the summer of 1984. I should get it out and transcribe it one of these days. I don’t think I’ve read any of it since it was originally written and it will be forty years this next summer since that particular adventure. No goblins or dragon on that one either. But there might have been a shapeshifting bear.

The next long post should be from 5000 miles away. I cannot say I am looking forward to the 24 hour process from the time I leave my condo to the time I arrive at the Sheraton in downtown Krakow. But I fancy I’ll survive it as I have survived other uncomfortable journeys involving multiple flights and airports. At least I have learned to wear my compression socks.

I feel like I’m drowning in clinical work. The number of messages, faxes, letters, visits, notes, and general stuff which must be dealt with seems to be accelerating at warp speed over the last week or so. The creeping of the Boom generation into the geriatric age group is leading to more and more people expecting rapid solutions to complex problems and I’ve noted a new trend that I had not predicted. As the oldest Boomers are beginning to enter the dementia belt and are beginning to develop age related Alzheimer’s and related disorders, those with relatively intact physiologies and functional ability are developing a state of defiant denial as to their lack of skills. They have little insight into their deficits, think of themselves as young and vital, and are hitting the warpath when things like refraining from driving for safety are on the table. That’s always been a tough one but it’s leading to more and more battles that take up my time and emotional energy. Let me make it clear. Driving is not a right, it is a privilege. It is a privilege granted by the state and only the state can revoke that privilege. If the state revokes it, you have to deal with the state. I do not grant or remove drivers licenses. All I do is tell the truth about your medical condition should the state inquire. Rant over.

I’ve been keeping a running tally of the number of communications I do through my UAB practice this month. I want some hard data to present on the amount of work outside of clinic hours I put in. Those responsible for scheduling and staffing the clinical enterprise, not being clinicians themselves, seem to greatly underestimate the actual workload and I’m getting a bit tired of it. They do seem to understand numbers and spreadsheets, however, so I’m going to give them a few. At one point, I thought about going back for a masters in Health Administration to be able to argue with the powers that be better on their turf, but then I decided I’d rather use that time to do things that were more nurturing for me personally.

I finished editing the proof pages of Volume III of The Accidental Plague Diaries and they have been returned to the publisher. The next step is the production of some proof copies to make sure that the book looks correct and one last chance to catch stray typos. At that point, I can announce a publication date, throw the switch and the dozen or so of you who read my stuff can buy a copy. Actually, as the whole project will finally be complete, I’ll start figuring out some ways of trying to promote them all and see if I can get some PR going and some sales. That would make my publisher happy. If any of you have connections in the book world, I’d be happy to set up some readings, signings, lectures on elder care topics etc. Just ask. It’s a matter of scheduling it around the other two careers…

Having covered two of the three careers in the above paragraphs, I suppose I can turn to the third one. I had a callback for Into The Woods at The Virginia Samford Theatre this week. Little birds told me that they had an enormous number of submissions for the show so I am grateful that I even made the callback stage. I have no idea if I will be cast or not. I’ll take it if it’s offered. I love the show. I love that venue. And, if the people I saw at callbacks are any indication of the final cast list, I’ll love the people I’ll be playing with in the sandbox. Things are still a bit up in the air about whether I’ll have a holiday gig or not. Watch this space.

This past weekend, a number of us who were involved in my A Midsummer Night’s Dream earlier in the summer schlepped down to Montgomery together to see the Alabama Shakespeare Festival’s production of the play. The ASF is the only LORT house in the state and has a significant budget and brings in actors from all over the country. After watching their Midsummer, I turned to my cast and said something along the lines of you should be really proud of what you did as there were moments in ours that were as good, if not better, and you don’t have the training and we didn’t have the budget. I really liked some things about the ASF show but there was much that was just unclear – the set, a metaphorical clock tower attic did not clarify any of the themes. A framing device involving a child and a book went nowhere. The fairy music was all live bluegrass, which was great, but rather than Shakespeare’s lyrics we got modern songs which clashed with the rest of the language and made little sense. The costumes were pretty, though.

I get on an airplane a week from tomorrow and my goal is to not have to think about any of my three careers for two weeks and to decompress amidst the sights, sounds, and tastes of Europe. This means I’ll be going into travel diary mode again shortly. Some of you have told me that this is your favorite part of my writings. I’m happy to oblige. If you can find anyone who will fund my traveling in exchange for literary output, send them my way. I’d be happy to become the next Paul Theroux or Bruce Chatwin. But for now, though, to bed.

And the proof pages fly by, one by one. I’m now about two thirds of the way through the final proofs of Volume III of The Accidental Plague Diaries and barring something really unfortunate happening this weekend, it will all be signed, sealed, delivered back to the publisher before the end of the month. Then, assuming all goes well in Seattle, I should be able to announce a publication date for late October or early November and then this project, which has been an over arcing theme in my life for the last nearly four years will be done. Unless I have to put significant time into a Kindle edition, an audio edition, and some sort of monologue adaptation. It’s rather odd to think that I’ve spent more time on this than time in high school, college, or medical school. When I do hold Volume III in my hands, I think I’ll have to figure out some sort of valedictory celebration.

UAB has a new social media initiative ‘Humans of UAB’ based on the New York Times series ‘Humans of New York’ which has been running for the last couple of years. For some reason known only to the PR department, they decided that I was a human this month and the piece came out yesterday. I was quite taken with the photograph they took. (It’s my new profile photo) but I’m not sure that UAB truly appreciated the subtext of my remarks. My comments on being human in medicine, on a reread, suggest that to be human and to work within the modern American healthcare industry, one must forever swim upstream, pushing against the way that things are done. And that this gentle refusal to go along to get along, while better for patients, will limit the ability to rise within the system. I’ve certainly seen that play out in my career both with my personal experiences and in watching others battles. And I came to the conclusion a long time ago that I would rather do the right thing and insulate myself somewhat from the system at large than compromise for the sake of a nicer office or a higher salary.

I had a text conversation this morning with an old friend; she has a sister with a complex, chronic autoimmune disease which has led to a lot of interactions with the the health system. She started out with an innocuous enough question. Was I aware of any local primary care physicians who took care of their own patients when they were in the hospital as well as seeing to their outpatient needs. I really didn’t know of any. And then it occurred to me that that was the standard model of care from the turn of the last century and the beginnings of the modern hospital through the 1980s. I was of the last generation of internists who was trained to be able to do both inpatient and outpatient care and who was expected to follow that sort of career path. I finished by residency in 1991, but by 1995-2000 significant economic changes in medicine led to the creation of the inpatient hospitalist who would to the inpatient work leading primary care physicians to focus on outpatient care. This was a major paradigm shift.

Why did this happen? The shift of the system from its not for profit roots to for profit models demanded greater efficiencies from the parts of the system. Having physicians in the hospital to deal immediately with issues and with the more complex medical illnesses that could now be treated with more modern medications and technology rather than the nurses having to track the physician down in his office down the street for new orders allowed a physician to provide services to more patients at once. At the same time, the reimbursements per patient for non technical services, the thought part of medical practice, were being ratcheted down by the system so a primary care physician needed to see more and more visits per work day to keep the funds flowing in the practice to pay themselves and cover their office overhead. The aging of the population and the survival of more and more individuals with chronic illness that would have carried them off a generation or two ago led to more and more demands for good primary care.

Primary care began to involute. More and more medical school graduates decided to avoid it. In my graduating residency class, about half became primary care internists of one stripe or another. Now only about 15% do based on the last national statistics I’ve seen. They become hospitalists (well paid, shift work so no scheduling hassles, basically the same job they were doing as residents so very familiar working conditions) or technical subspecialists with much higher incomes. I can’t say I blame them. If I was looking at putting three or four kids through college and paying for a couple of society weddings, I might make a similar decision but my children have remained safely unborn. This huge gap between supply and demand is what’s led to the rise of the physician assistant and the nurse practitioner. I’d love to see all of my patients every time they come in but I don’t have thirty hours a day nine days a week.

The stresses and strains of the pandemic, with its mass retirements and various shortages of personnel, equipment and supplies, more or less ripped the veneer off the rickety American health system. It’s well known that our system consumes nearly twice the GDP percentage than it does in other wealthy nations and our outcomes are at the bottom of the heap when it comes to the international rankings. 11th out of 11 of the wealthiest nations and 37th out of all countries on the WHO scoreboard, nestled in between Slovenia and Costa Rica. The built in silo between the worlds of inpatient and outpatient, made rigid through various financial systems, makes it very difficult to coordinate care between those worlds. There are some ways around this. Small rural communities still follow the old way of the generalist providing both inpatient and outpatient care but those hospitals are falling like dominoes in recent years due to unsustainable deficit spending. There’s also the concierge model where you can pay a fee to the practice for ‘non-covered by insurance medical services’. That fee brings money in so that the practice doesn’t have to see an enormous number of individuals daily to keep the doors open, allowing the physicians time for longer consultations and time to make hospital rounds (although even then they usually collaborate with hospitalists due to the acuity of most hospitalized patients these days).

Then there are the complications of our new documentation systems known as Electronic Health Records. In theory, an EHR is a very good thing. One integrated health record usable by all so that things won’t fall through the cracks. In practice, however… The systems were created for administrative tasks – big data collection and analysis, QA projects, billing, and other similar things. And administrators working at home for two years had plenty of time to fool around with them and come up with more and more projects of interest. The problem with big data, however, is someone has to collect and enter the data. And that has usually fallen to the person at bedside inpatient (nurse or physician) or in the clinic exam room (same). These systems are now so chock full of boxes to be checked and data points that it’s often very difficult to separate the wheat from the chaff and therefore, as notes grow to six or seven pages of seemingly unrelated datapoints thrown out automatically by the system, more and more of the notes go unread.

My friend, who helps her sister navigate multiple specialists, is meticulous and keeps excellent notes and records regarding her health conditions and provides written copies to physicians of what they need to know. They are dutifully entered in to systems but there is so much there that no one is likely to ever find or read or act on any of this knowledge that has been obtained through years of trial and error. And she has to start over every time a new character enters the stage. My ultimate suggestions – move somewhere where the old system prevails, leave the country for a place with a health system rather than a health industry, or hold your nose and pay a concierge fee. I’m probably going to do that last should I develop health conditions that start to significantly impact my function. And once again, American capitalism creates an unofficial two tiered system.

Another friend contacted me this week about his 101 year old mother resident in a nursing home and how her care keeps falling through the cracks. Not much I can do directly as she is not my patient, but it all boils down to short staffing. The only way for him to effect change is going to be being present as much as possible and demand that the nursing home deliver the care it’s being paid to deliver. He won’t endear himself to the staff, but his mother will do better in the long run. Sometimes you have to be the squeaky wheel. I get a lot of that kind of family interaction in my practice. I’m fine with it. If it’s something within my control, I’ll fix it to the best of my ability but most of the time, the issue is not something within my purview. I listen and sympathize and try to give constructive suggestions. And realize that being there and letting them vent is probably the best thing I can possibly do. But it does get wearing.

No need to remember when cuz everything old is new again… Here I am going through the page proofs of the third and supposedly final volume of The Accidental Plague Diaries while out in the greater world, Covid numbers are skyrocketing. An article came out in Fortune this weekend in which a number of experts opine, based on wastewater samples and other data, that the current surge is on track to equal or surpass the surge of late 2020 or the Delta surge of 2021. The numbers they quote are of 650,000 new infections daily (with roughly 2% of the population currently acutely infected) and the expectation that up to 30 or 35 million will become infected during this wave before things calm down. These are some scary numbers but there are some differences between then and now.

A majority of the country, despite the loud and media amplified voices of a belligerent minority, are vaccinated and most have had a booster or two in their somewhere. The majority have also caught a case of Covid at some time in the last three and a half years giving their immune systems a good defensive primer on the virus and something to build from should they become reinfected. Therefore, the rate of serious clinical disease is not skyrocketing as it did with previous waves. Yes, hospitalizations are climbing. They were at a nadir around June and they climbed about 20% over the summer and they’ve put on another 5-10% in the first half of September but they are nowhere near the numbers that brought the health system to its knees. However, the health system is nowhere near as robust as it was in 2020 given the protracted effects of the pandemic on finances and clinical staffing so smaller insults may have much greater effects going forward. The death rate is also beginning to climb but I haven’t been able to find really good numbers nor numbers that distinguish between deaths from Covid and deaths with Covid.

I’m not panicking (other than at the thought of having to produce a fourth volume in The Accidental Plague Diaries). I have had it twice and had My original shots and three boosters. I’ll get this newest booster as soon as it’s available. When will that be? I don’t know. We keep hearing ‘October’ so hear I sit under the tree like Vladimir and Estragon waiting… I’m also not certain that I want to stake my life planning on an article that appears in Fortune. It’s not necessarily the most pre-eminent of scientific journals. I would like to see this confirmed in more reputable sources and I would love to see some better real time tracking numbers. Unfortunately, with the end of the public health emergency in May, we more or less disassembled a coherent federal response and turned everything back over to the patchwork of state, county, and city public health agencies where the collection and dissemination of data is now somewhat dependent on local politics.

So what do we need to do? Get the new booster (which has been reformulated to work better against current circulating omicron strains) when it becomes available. Should you mask? That’s a tough one. Masking works best when it is universal as it’s more about protecting others from you than it is you from others and it requires a cultural paradigm of care for ones fellows as much as for oneself. If there’s anything the cultural history of the pandemic era has taught us, it’s that that particular ethos has more or less been tossed out the window for political expediency and there are now laws preventing mask mandates in various places. Masking when the world does not won’t hurt you. It might help some. The other thing to do is get back in the habit of keeping those hands washed and sanitized if you’ve gotten out of it. The litany of 2020 still holds true.

On to other topics. I should have the page proofs fully checked and back to the publisher by the weekend of the 23rd. Allow two weeks for those corrections to be made, another two weeks for proof copies to be printed and checked, and then I can announce a publication date for Volume III. Should be just before Halloween. Incidentally, the cover is orange and black which I suppose is fitting. We decided to go with secondary colors for the series. Green/Purple/Orange. Don’t make me have to go all primary as well. The chapter titles come from the work of my third favorite Broadway lyricist after Sondheim and Cole Porter. You’ll have to read the book to discover who it is.

My theater/music calendar is shaping up for the 2023-2024 season. I’m thinking I need to create a graphic like my professional opera singer friends with all my gigs listed out. Unfortunately, a few things are still in flux so I can’t do that as of yet. It looks like a symphony concert (and maybe two) and a play prior to the New Year and a couple of stage appearances, another symphony concert, and a directing gig in the first half of 2024. Should keep me out of trouble. More details to come as things like contracts are finalized.

I went and saw Virginia Samford Theatre’s production of the Rodgers and Hammerstein revue, A Grand Night for Singing, last night. Four of the five performers were old friends whom I have known and worked with for years. The fifth has relatively recently come to town and I hope I get a chance to share a stage with him sometime. R and H is not everyone’s cup of tea these days but boy did they know how to craft a song with a melody and a relatable lyric. The five performers are all terrific in their own right but what blew me away was the blend of their voices when they sang both unison and harmony arrangements. It really did sound like a single unified vocal. Kudos to Debbie Mielke for her work at the piano and with the performers to achieve that. I went to the show with a few friends from church. We met first for dinner at a local Indian restaurant which recently had to relocate after decades. Taj India, now in the late lamented Bogue’s space, remains as good as you remember. Nothing has changed in the kitchen. Ten minutes before we left to go to the theater, the skies clouded over and the sunny day turned into one of those Southern gullywasher rainstorms that drops several inches in the course of half an hour. Intersections were flooded all over the Southside and visibility was near zero but we managed to get to the theater on time, albeit much wetter than we had intended.

I need to start thinking about putting my life together for my trip to Eastern Europe in a couple of weeks, lord willing and the Covid don’t rise. But that’s just modern life. You make your plans and you play the hand that nature deals you, whether it involve infectious disease or planetary change from climate or other issues. If the travel posts start in early October, you’ll know I’ve made it. In the meantime, there are clinics to conduct, house calls to do, legal cases to review, a book to finish, and various choral rehearsals. Plus the occasional Dungeons and Dragons game. We’ve discovered the joys of playing over brunch with mimosas. Highly recommended if you game as an adult. Bandon the cleric has to arm up later this morning for continued adventures in the Feywild.

He washes his hands and believes in the magic of vaccines.

I’m having a lazy Saturday. I don’t get a lot of those. Usually I have to dedicate it to production issues on a show or play major catch up with work but the combination of being between theatrical engagements coupled with the short work week due to Labor Day has led me to a day where I don’t have to plan my time around a whole series of ‘must accomplish’ tasks. There are a few on the list, but none of them has to be done before next week and I have little happening tomorrow besides church and a callback in the evening so those can be safely put off until tomorrow afternoon. The weather has calmed down from infernal to relatively pleasant midsummer so I may take myself out for a walk a bit later.

I like walking. It’s one of the reasons I enjoy traveling to Europe so much. European cities, at least the historic centers where one spends time as a tourist, were all developed when the chief mode of transportation was by foot (or the occasional horse and ox cart for heavier goods). The areas are compact, not devoted to the automobile and parking, and there’s always something interesting to look at in the shop windows. My pedometer shoots up when I’m on vacation from my usual 4-7,000 steps a day to something in the 15-25,000 step range. It’s a healthier way of living. You can see it in this country in people who live in those few urban centers developed prior to the 20th century and the automobile where the general population relies on public transportation and their own two feet. I read somewhere that life expectancy in Manhattan is several years longer than it is in the outer boroughs of New York. The difference being that Manhattanites tend to walk and those in the more suburban areas take their cars.

I leave on my next trip four weeks from yesterday. I’m getting all my ducks in a row regarding the paperwork, proof of Covid vaccination (no, I still don’t know when the next booster is going to be available – the last I heard was October sometime), making sure I have what I’m going to need in terms of travel supplies and putting my compression socks through the wash. I discovered several years ago that this latter was necessary for me on international flights, otherwise I get off the plane with 3+ pitting edema. My first stop is Krakow and then it’s down to Bratislava and up the Danube through Vienna before eventually ending up in Berlin. I looked at the itinerary and saw that the hotel I’m staying at in Berlin is the Adlon. That earned a major ‘Squee’ from me (and would from anyone who has been involved in as many productions of Cabaret as I have been.)

The major project of the next three weeks is to do the edits on the page proofs of Volume III and Volume the last of The Accident Plague Diaries so we can get it out this fall. It’s been a bit delayed due to life issues with my editor but there’s no huge hurry. In some ways, I’ll be glad to be done with the project and in others I’m wondering and worrying what will arise to fill that life gap. I’ll continue to write these pieces but now that I actually will have roughly 1,000 pages and 300,000 words out there in multiple award winning books, I feel a certain obligation to myself to come up with some new writing project that will build upon earlier success. I think I owe it to myself. But I’m not going to make any decisions nor begin anything until all three volumes of The Accidental Plague Diaries are out there. If any of you have an organization that wants to sponsor a reading or a connection with a bookstore that would like me to do a reading/signing, let me know.

So where are we with Covid? It’s causing a significant impact in the local hospitals at the moment, not because the wards are filling up with people dying of lung complications. Admissions, while definitely up over what they were earlier in the summer, are still way below previous surge numbers. The issue is that it’s becoming so widespread that a significant percentage of staff are out on quarantine on any particular day making it difficult to provide adequate nursing and other ancillary services. The physicians aren’t exempt. It’s been running through the residents like crazy the last few weeks. I haven’t gotten it this time around – at least to my knowledge. I suppose it’s possible I’ve had a subclinical case without enough issues to cause me to pause and test myself. Both times I’ve had it, I’ve known I’ve had it with severe symptoms for a day or two and I have had nothing like that although I have had an occasional drippy nose or irritated GI tract.

Looking through my usual Covid news sources, the news is mixed. On the down side, numbers are definitely up nationally and waste water surveillance and other public health measures show a rise of new variants, especially BA.2.86. On the up side, morbidity and mortality numbers, while up from their nadir, are not surging forward as they have in the past suggesting that the combination of vaccines and native infections with antibodies are holding the line. The new variants all remain omicron sub-lineages. There hasn’t been a radical mutation away from that yet. Preliminary data shows that the new vaccine formulations for the booster will be effective against them and that Paxlovid therapy is still working. Big sigh of relief. I don’t believe for a minute that there won’t be some sort of significant new strain coming down the pike in the next year or so and I hope it’s not something with a particularly nasty surprise up its sleeve.

Next task is to call my sister and tell her to get the cover art for Volume III to my editor/publisher. It’s the same character, but in a very different mien, looking a bit how I feel when I contemplate the state of Geriatrics both locally and nationally. I had my annual review yesterday. You will all be happy to know I will continue to be employed next year. My checking account will be happy.