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.

And we’re on to another month, the ninth of this year. In some ways, the year has flown by and in others, it has dragged on at a glacial pace. I no longer trust my perception of time. It’s another gift of the pandemic. That enormous interruption in the usual routines of life and the Groundhog Day repetition of the shut down threw everything all catawampus in regards to my usual understanding of the measured order of time and season and I find myself confusing things that happened six months ago with those that happened six years ago. And things that happened pre-Covid in some ways seems clearer and nearer in time than things that happened in the last year or so. We’re only four months away from the pandemic’s fourth birthday (the first reports of what we would come to know as Covid having been filed in Wuhan on December 31, 2019.) I prefer to think that these wrinkles in personal time are due to psychological coping mechanisms that come into play in times of great societal stress and not the first symptoms of incipient dementia. I feel my mother’s hereditary variant of Pick’s disease hanging over my head from time to time. Fortunately, it doesn’t strike until after age 75.

12 Angry Jurors closed last night. It ended up being quite a good show and was both an artistic success and a success for the company as it encouraged people in Birmingham interested in live theater who had never been to the venue to come check it out. The Encore Theater is the only African-American theater company in town with its own stage. I got to know Marc Raby, the founder and artistic director just after it got up and running when we were cast opposite each other in a production of Choir Boy. We decided we quite liked each other and I’ve tried to help Encore in my own small way at various stages in its development. By doing a larger cast play with a multiethnic cast, they stepped outside their usual wheelhouse of African-American entertainment for African-American audiences and showed that they could put up as engrossing a production as any theater in town. The production was inexpensive, but it was so well cast and the cast truly performed as an ensemble (all the other cast members besides me were onstage for the entire two hours of the running time. I wandered in and out a few times, mainly as a plot device) that the end result was a powerful piece of theater and audiences ate it up.

That’s the end of my scheduled theater life for now. I have a performance of the Faure Requiem with the symphony chorus in October and a show I was cast in last year and which was delayed until this year is scheduled for December. But I am not sure if I will continue with it. It really needs to go into rehearsal early October and I am out of the country from the 6th to the 22nd. I have submitted self tape auditions for a couple of things – a comic monologue for The Man Who Came to Dinner (I have a callback next weekend) and a song for Into the Woods. (No word on callbacks for that one yet – but the Narrator/Mysterious Man part has my name written all over it). My choice for audition song was Kurt Weill’s September Song from Knickerbocker Holiday as Weill is about as close as you can get to Sondheim without singing Sondheim. As I listened to the tape before submitting, I was rather surprised with how decent I sounded. The voice lessons are paying off.

Let me just say that I hate auditioning. I always have. At least the pandemic has rewritten the rules somewhat and we’re not doing as much cattle call sit around the lobby. Rush up on stage, sing your song with an accompanist you don’t know and then try desperately not to fall over in the dance call where you’re feeling like that guy in the ‘On Broadway’ sequence from All That Jazz and wondering why you’re up there as you wrote all over the audition sheet that you aren’t a dancer and never have been. Most of my on stage dancing in recent years has been box step waltz in operetta and that I can handle. I can still do the Hustle as well but there isn’t much call for that these days. Maybe if I get cast in Xanadu. Now we set up an iPad and film ourselves as we emote or sing and send the file off to the theater company where they probably get infinite joy nitpicking on the mistakes. September Song is a good fit for my age and type. I just wish the published key was about a step lower. I can sing it in the published key (and that’s what I submitted) but it would sit better in my voice just a bit lower.

I was looking earlier this week at a study out of UCSF wherein the researchers estimated that in the coming few decades, roughly 25% of the population that will develop dementia will be living alone without spouse, children, or other informal in home supports. For this geriatrician, that’s a rather frightening statistic because I see all of the things that happen when an older adult ages into dementia without an appropriate support system. Finances go to hell as the individual doesn’t understand the basics of math and the moving of money. Bills aren’t paid (or are paid multiple times). Junk mail that looks like bills are treated as such and soon checks for thousands of dollars are happily sailing off to scammers in Jamaica. Taxes are forgotten. Cars are repossessed. Properties are sold at auction without the occupant understanding what’s going on. Driving is a relatively automatic process and demented people tend to operate cars fine. However, navigation is not and the trip to the grocery store ends up with them running out of gas in a neighboring state as they missed the exit, didn’t realize it and just kept on going as they kept looking for it. Getting food on the table is a very complicated process in our society which involves getting out to the grocery (usually farther away than walking distance), navigating the store, affording the bill, schlepping it all home, storing it properly, and then preparing it in the right way at the right time. Things go wrong all along this food chain which is why often the first physical sign of dementia is weight loss. And don’t get me started on trying to manage medications and health appointments when your brain doesn’t work properly. I’ve said for years that in geriatrics we don’t have appointment times, we have appointment suggestions as cognitive issues keep many of our patients showing up at the wrong hour, the wrong day, even the wrong year. Geriatricians know that no adult human being will take medication more than twice a day with any sort of regularity (morning and evening). We work like hell to get medical regimens down to that and then our colleagues in various subspecialties show up and put them on something three times a day, something four times a day, something before meals, something that can’t be taken within two hours of food, and something that has to be half an hour before other medications. Forget it bub… it ain’t happening.

I’m fast forwarding in my head twenty years to 2043. The lead edge of the Baby Boom, the 1946 babies, will be turning 97. (Cher, a 1946 baby, will be on yet another farewell tour). The prevalence of dementia at age 90 is about 60% and at age 95 is about 80%. Most of the early boom will have cognitive impairment and we have done nothing as a society to prepare for this eventuality, regarding it as a private matter rather than one for public solutions. But, as this study says, about a quarter have no private social capital on which to rely so we’re either going to have to have some sort of public system for them or we’re going to have a whole lot of nonagenarian bag ladies all over the boulevards. But that may be the plan, at least on one side of the political aisle. Don’t fund elder services and hope they die fast. I have news… people, if given the chance, will live a great deal longer than you think they should.

It’s nearly 8 PM on a Sunday. I am finally finished with the 37 progress notes I had to write this weekend and my eyes are a little bleary. But that may be the peppers in the left over Szechuan chicken I had for dinner still tap dancing across my nasal and lacrimal tissues. I’m all for capsaicin in my food but a day or two in the refrigerator seems to have leached out a bit more than usual into the fried rice. I really don’t like devoting hours every weekend to finishing up progress notes but it’s one of the curses of primary care medicine. I could do them as I go, but to do that I’d have to cut about ten to fifteen minutes of face time off of every visit and that extended face time is what allows me to be a healer, so that’s not really an option. I could do them in the evening but it’s usually the last thing I want to do after a long day, especially if I’ve had to go from work to rehearsal and am not getting home until between 9 and 10 pm. That leaves the weekend. I tell my patients frequently that on the day I retire, I am going to take one of the EHR computers over to the atrium and drop kick it off the third floor landing. And I’m only partly in jest.

UAB is full and the ER is swamped this past week. I haven’t been able to get a good read on how much is related to Covid and how much is other things. I’m guessing some of it is heat stress on aging and otherwise unhealthy physiologies. We continue to be mired in the high 90s low 100s with high humidity around here making outdoor activity uncomfortable at best and downright dangerous at worse. I don’t go out in this weather. I stay in air conditioned office, air conditioned car (fully recovered from this last week’s little adventure), and air conditioned condo. The complex pool is right next door but it’s too hot for me to even want to walk over there. Covid hospitalizations and deaths are both up about 20% over last week per CDC data and have been steadily increasing all summer. We’re not back where we were by a long shot but all the trends are heading the wrong direction.

Another week, another mass shooting, this one at a discount store in Jacksonville, Florida. By all accounts it was perpetrated by a radicalized young man full of racist and misogynist hate as an act of violence against African Americans. Ron DeSantis turned up at the public memorial today and was promptly booed and had the mic taken away by the assembled crowd. Who could imagine that his policies of allowing anyone to purchase semi-automatic weapons and demonizing minorities would lead to actual tangible results? The stochastic terrorism coming out of the right wing is going to continue until such time as the population as a whole rises up and states enough. I’m not sure when that is going to happen. The politically active classes in our society are far too comfortable in their gated communities, insulated from real concerns by various structures of privilege to flex their muscles as of yet. Someday they will wake up to the fact that they traded the lives of their children and grandchildren for slightly better returns on their 401Ks but today is not that day.

My background in rural health and home care/house calls means that I have been in all sorts of homes over the decades. Apartments inhabited by extended families of newly arrived immigrants, trailer homes of the impoverished rural with the meth lab out back, waterfront palaces, old money mansions smelling of slightly decaying furniture, tarpaper shacks with more animal residents than human. They were all home to someone and home, whatever it may be, exerts a powerful force. I have learned over the years to not stick my nose in things that are not my concern (like the odd person that crawls out of the pile of dirty clothes in the corner and lurches naked to the bathroom), to honor that the place in which I am a guest usually represents a culmination of living and life choices, and to enter into a healing partnership with a patient and family, not march in and lay down the law like some white coated Moses bearing the tablet in the form of a prescription pad.

In times past, at least in cities, the rich and the poor lived cheek by jowl and had at least a limited understanding of each others lives. The invention of the automobile and then the suburb changed that balance and the rich tended to withdraw into bubbles that the poor could not penetrate and left the poor to separate cultural and geographic spaces. Occasionally, due to geography or other factors, they are thrown together again. San Francisco, now being held up by the right as a failed city, is one such place. It isn’t failed. It’s just a city where the rich and poor exist in tight geographic proximity and the rich are forced to confront the real lives of the poor and what fifty years of vulture capitalism has actually accomplished.

I often take med students and residents out on house calls with me. Usually I have one or two a year who is a native Birminghamian, almost always from one of the neighborhoods known here collectively as Over The Mountain (translation – wealthy and white). I take them to places within twenty miles of where they have spent their lives and into homes that they have no idea exist, having never been invited into the home of someone who is not of similar caste. I’ve never lived Over The Mountain. I’ve lived on it but always on the city side. And I don’t feel uncomfortable in neighborhoods and homes different from my own. I figure it’s my time to learn about different ways of living and different perspectives on all sorts of things.

The show I’m currently rehearsing, 12 Angry Jurors (12 Angry Men for a mixed gender cast), is being produced by the only African American theater company in town with its own stage. They usually do African-American shows for an African-American audience but they’re reaching out with this one with a mixed race cast trying to reach a wider audience. Usually when I attend their shows, I’m one of the few white faces in the audience but I am always made welcome and most of the regulars now know me. I would like to challenge my Birmingham theater friends to come on out to this production, explore a new venue, help support artistic excellence for a different group than you usually support. You might be pleasantly surprised.

It’s been a Monday on a Wednesday. Or something like that. Actually, it’s been Monday after Monday so far this week as things are piling up rapidly. Fortunately, I have a slow weekend so I should be able to begin getting things caught up. The Mondays began with the second weekend of performances of A Midsummer Night’s Dream. It ended up being an enjoyable romp in the woods for both cast and audience and there is already talk of another Shakespeare for next summer. I’m not against it. Of course, the one I would really want to direct is King Lear as it’s one of the only works of Western Literature to deal with the catastrophic effects of dementia on family systems – but I don’t think this group is quite ready to go there yet and we better stick with Much Ado About Nothing or Twelfth Night or maybe The Tempest.

And then it’s been multiple issues of craziness at work. The chief one being the flooding of the building in which my VA office is located (burst water pipe). The damage appears to be relatively extensive and despite the multiple Servpro trucks parked all around the block, we’ve been told we cannot get back in for several months. I’ve had to transfer my VA office to my home office for the duration which took several days of cursing various computer systems until I could finally work with the charting system and get into my email. On the UAB front, it appears that all of my patients have decided that this is the week to write long emails through the portal system with multiple clinical questions – and we’re running short staffed due to vacations and illnesses.

To top it all off, while driving on the interstate late this afternoon, through the aptly named malfunction junction (where I-20, I-59 and I-65 all converge just west of downtown), I had a blowout in my right rear tire. Fortunately, I did not lose control of the car, was able to get off the freeway and into a gas station parking lot, and then spent the next several hours in a low budget version of Planes, Trains and Automobiles while I attended meetings on Zoom while dealing with AAA, the Toyota Dealership, a ride across town in a tow truck with a most amiable driver, and a trip in an Uber with a guy who did not seem to understand the function of traffic lights. Needless to say, I am now at home and contemplating a large single malt scotch before bed, something I rarely do these days but I think I deserve it.

So where are we with Covid? It’s definitely everywhere. I’ve been informed that someone who was at the wedding I was at this past weekend has been diagnosed. One of my Midsummer actors tested positive this morning. There was a case in the cast of Twelve Angry Jurors last week. I’ve had a couple of messages a day from patients who have tested positive. The local ERs are full. Hospital rates are still relatively low but anything could happen. Most of what is still circulating are omicron variants. They’ve been given various poetic nicknames such as Eris and Pirola but they are pretty much slightly mutated sub lineages of the omicron that raced through the world during the holidays of 2021. There are some new variants percolating though which, while not widespread yet, could create problems moving forward, especially BA.2.86 which has dozens of variations on the spike protein (important because that’s how the virus latches on to host cells). It’s very different from omicron (although I haven’t seen it assigned it’s own Greek letter yet) and worldwide surveillance has detected it in several countries. Wastewater surveillance has found it in even more places suggesting that it’s spreading undetected through the community. Will it cause a new spike in cases or morbidity and mortality? Time will tell.

People keep asking me what do we do? As politically, we are not going to go back to lockdowns or mandatory masking unless there’s a strain that causes a severe increase in mortality and morbidity in young healthy people, the options are relatively straightforward. You can masks, but unless masking is universal, it’s not all that helpful. If you have been diagnosed, you should mask to protect others for ten days (five days on isolation, five with masking but you can go out). If you have had a known close exposure (fifteen or more minutes within six feet of a known case), you should mask and test if you have symptoms and if asymptomatic, on day five. If you’re negative, the mask can come off then. Probably as important as masking is keeping your hands washed. Thank god my new UAB office suite has sinks in the patient exam rooms (we didn’t have those in our old suite). My hand hygiene is pretty good as I wash before touching a patient. Isolating yourself is an option, but I’ve got too much going on in life so I choose not to at this point. I’m fully vaccinated and boosted. The next booster (which should continue to help against omicron strains. I don’t know about BA.2.86) is supposed to be released sometime this fall and I will certainly get one. I have no more information on when it might be available than anyone else.

I had my first church choir rehearsal of the season this evening, start up with the Alabama Symphony Chorus in a couple of weeks (first up is the Faure Requiem), have been making progress in my voice lessons and have a taped audition for ‘Into The Woods’ due next week so lots of vocalizing around the condo at the moment. The cats are trying to sing counterpoint but they always seem to come in in the wrong key. I’m pretty happy with my audition piece and I hope it’s enough to land me the Tom Aldredge double casting. That’s my role. Although it’s a show I love dearly and I’ll settle for whatever.

Thirty some progress notes, a new legal case, and a lecture to write all teed up for this weekend. Thank god the bailiff in 12 Angry Jurors only has four lines. I was off book walking across the parking lot to my first rehearsal. We tech and perform that next week. Then I think I’m off from things theatrical for a couple of months. It’s probably just as well.

We’re half way through the second weekend of A Midsummer Night’s Dream and the show is holding up well, getting tighter and tighter as the cast becomes more comfortable with the language and more willing to take the play up to comic brio tempo. I’ve managed to arrange things to be at every performance so far, but I’ll miss tomorrow’s as I have a wedding to go to and I promised to attend nearly a year ago. I’ve known one of the brides since she was a child and have enjoyed watching her grow and mature into an accomplished young woman. I will catch the closing performance of Midsummer on Sunday… and be back in rehearsal for Twelve Angry Jurors on Monday. Fortunately, in the latter, I’m playing the bailiff and have all of five minutes of stage time and four lines so it’s not a huge strain.

Covid numbers are continuing to increase at a somewhat alarming rate. Hospital numbers are increasing at about 10% a week (which means doubling every month and a half) and new variants are popping up. They all appear to be omicron strains so far but I won’t be surprised if we move on to a new Greek letter before the end of the year after some radical new mutation comes to light. I don’t think we’re going to go back to the kind of numbers we saw in 2020 and 2021 as vaccines and natural immunity are now widespread but anything is possible and the general weakening of the health system and public health mechanisms in general are going to put us in a bad position if something major comes down the pike. The ER at UAB and the VA has been filling up again but I haven’t been able to track down how much of that is due to Covid and how much is due to other causes. Our unrelenting heat wave is certainly making people with chronic disease more prone to an exacerbation due to dehydration and heat exhaustion. Still haven’t heard any specific information on the availability of a new Covid booster this fall. We’ve been told it’s coming, but not when or by what means. And it’s likely to cost you. The expiration of the emergency back in May means that the federal government is no longer picking up the vaccine tab.

We’ve been lucky with Midsummer that Covid has stayed out of the cast. (Knocking every piece of wood within reach of my arms). Other local shows have not been so fortunate, having to cut runs short or to rapidly redo rehearsal schedules after a couple of people have gotten sick. And it’s happening elsewhere as well. Josh Groban is out of Sweeney Todd on Broadway due to Covid infection. I’m sure his understudy is perfectly competent but people are paying hundreds of dollars a seat for the star. Cancelling shows, which is extremely disappointing to the cast and crew whom have worked so hard, is also financially devastating to small companies that depend more on box office than the larger rep theaters which get much of their operating budget from grants and major donors. The finances of the American theater industry are in a complete turmoil currently and a lack of performance certainty isn’t helping anyone at any level.

Should we go back to masking? It might not be a bad idea but it only truly works if everyone does it. You don’t so much mask to protect yourself but to protect others from you. If everyone masks, transmission declines. If only a small percentage do, it doesn’t make much difference. You can protect yourself with masking, but really only with properly fitted N-95s which are devilishly uncomfortable to wear. There’s certainly no political will to go back to mandatory masking in this part of the country and even locales with a better track record are going to have a hard time with requirements without a major shift in public opinion (which will probably rely on a major shift in mortality and morbidity statistics).

Speaking of mortality… As they continue to dig more bodies out of the ashes of Lahaina, I’m looking for information as to who the dead are. I’m expecting that we’ll find that most of them were members of what I call the invisible population. I see them because of the nature of my work but most of us never meet them because they rarely appear in public space. They include older individuals who have become physically weaker making it difficult for them to navigate public space without a wheelchair, walker, and the assistance of another person or who are losing mentally capacity and who rarely leave the familiarity of home as the complexity of the outside world is too much for them to handle. They are the morbidly obese who have difficulty leaving the house. The bed and chair bound. The seriously ill who have feeding tubes and catheters and oxygen at home. The relatives who may be able bodied but who are devoted to caring for an incapacitated person and who would not dream of leaving them behind in an emergency. They could not possibly outrun a fast moving firestorm with limited warning. We don’t think of the invisible population because it’s convenient for us not to. Their lives are usually governed by laws and bureaucracy put in place by well meaning people with no practical experience in the issues that the invisible face.

I’ve spent my professional life with the invisible. One of the reasons I’m as effective in my job as I am is that they understand that I am one of the rare authority figures in their lives that truly sees them when most do not. I enter their houses. I hear their hopes and fears and dreams and do my best to at least help them achieve what little balance in life their bodies will allow. But, because I work with the invisible, I and my medical specialty are rendered invisible to the majority of the American health care industry. We in geriatrics don’t generate money or brilliant cures or major headlines and this makes us an afterthought at best or, as one of my internal medicine colleagues once told me, ‘Geriatrics is just Internal Medicine when it doesn’t matter’. Geriatrics as an official boarded specialty isn’t that old. It began the same year that I graduated from medical school so I am the first generation that was formally trained in the subject. And I have watched my entire career as it has been shunted aside and is now in a state of collapse, with the looming retirement of the initial cohort of geriatricians, just as the demographics of the country require the knowledge base with the aging of the baby boom. Jerry Gurwitz, the head of Geriatrics at the University of Massachusetts wrote an Op-Ed in the Journal of the American Medical Association thoroughly discussing this issue which is worth reading. You can find it if you google. (Or at this link https://jamanetwork.com/journals/jama/fullarticle/2808221)

How do we make the invisible visible? Danged if I know. But I have an idea of where to start. We’ve changed the culture away from one which idealizes progress and community to one which worships only material gain. I don’t think fundamental change is possible until we start turning back the other way. That used to the role of religion but that seems to have failed as badly in America as our politics and our economics. This is all making my head hurt so I think it’s time to end this post and put on bad TV. After all, tomorrow is another day.