And back to the accidental plague diaries I go. We’re up to about 730,000 cases in the US, 4,300 in the state of Alabama and greater Birmingham is leveling off between 1000-1200 due to our early adoption of shut downs and social distancing. Unfortunately, a certain class of corporate masters seem to have decided that an increased mortality rate is worth it as long as their next quarter profit margins increase and they are getting their minions to agitate for opening things up prematurely. All that’s going to do is cause some flare ups. Fortunately, Alabama is not yet among the states where a Trump rally sans Trump is happening on the steps of the state house. I see pictures of those people rushing and roaring at buildings or at Alex Jones who seems to have been strapped in a barcalounger on top of an SUV, and all I can think of is the zombie hordes in The Walking Dead.

I hadn’t really thought that my job as a physician was going to turn into part call center employee and part tech support. We’re trying to transfer visits to video conferencing software as much as we can. You haven’t lived until you’ve tried to get a ninety year old to download and connect over a video app when neither their cognition nor hearing is what it once was. “I’m sorry you’re having trouble hearing me. Let me use my opera voice”. “No, you need the app store”. “No, don’t open the app, it will run in the background. I’m going to send you a text”. “No, you don’t text me back. You see that link in the text? Just select it”. “No, we can’t do this through Facebook” “Is your daughter there?” “Could you give her the phone? Maybe she can help you.” “Can you turn the camera around? The breakfast table doesn’t help me.” “Yes, I’ll look at your legs but lets not point the camera up your dress.” And on it goes. Every time I successfully complete a video visit, I feel like I’ve won a small victory.

I was somewhat constructive today. I went down to the storage space and retrieved all of the remaining wigs that I could find and put them in the studio so everything would be together when Red Mountain Theater Company comes to pack it all up and take it away this next week. I’m furnishing out the wig room in their new theater complex for them and they’re going to name it after Tommy. Once the studio is empty, I’ll have a staging area for my dejunking of the house. I’m hiring Holly McClendon, Tommy’s wig assistant to be my move coordinator and help make this all go well. As a military wife, she’s moved her family multiple times and knows how to make it all work. I also met the contractor at the new condo and went over all of the minor repairs that need to be done prior to moving and he’s going to get started on them this next week. We both agreed that the bathrooms ultimately will need some updating but that’s a problem for another day. They’re perfectly functional for now. I’m starting to think about colors for the paint job. I keep changing my mind about them. One of my friends has volunteered to come over with her decorator daughter and kibitz next week.

Someone brought up in a comment on a previous plague diary entry that most of the doctors of his acquaintance were quite conservative in their politics and I am not and wondering why that was. First of all, I’m not that far left. I’m a bit left of center for the Pacific Coast. This, of course, makes me somewhere to the left of Vladimir Lenin in the state of Alabama. Second, not all doctors are the same. We’re as varied as any other profession. How the education works is as follows. In order to get into medical school in this country, there are a number of requirements in terms of college level science classes plus the MCAT entry exam. This tends to push most premedical students into majors like biology or chemistry. (I actually majored in both – more fool I). In the 60s and 70s, top grades in science and high scores were all that was necessary and the system churned out great clinicians who were not terribly well rounded people and often had problems with the humanistic aspects of medicine. There was a shift in the 80s (when I was a med student) to trying to admit people who had something else going for them making them a more well rounded person in addition to just grades and test scores. For me, it was my technical theater background. My medical school class included a professional kayaker, a modern dance major,and a table dancer from one of the more notorious bars in Fairbanks. Of course, the education hadn’t changed and most of us round pegs were being pounded into the same danged square holes and were pretty miserable. Everyone gets pretty much exactly the same education over four years.

In your fourth year of medical school, you apply for a residency position. This will determine your specialty. They range from three years for most primary care specialties such as family practice and internal medicine up to six or seven years for the more technical surgical specialties such as cardiac surgery or plastic surgery. Your education will be very different and the demands on you will vary widely depending on what you select. The number of residency slots per specialty is fixed at each institution and the choice of which one to apply for is up to the student so for certain specialties with limited slots and the possibility of a very lucrative career on the far side, there is enormous competition (dermatology, ophthalmology) while others go begging due to lots of slots and low prestige and reimbursement (family practice). I chose internal medicine because I didn’t know what I wanted to be when I grew up. The same process happens again after residency for fellowship (subspecialty training) anything from another additional one to four years depending on what you’re learning. For me, it was two years of geriatric medicine. It’s the second least popular specialty in the country. The least popular is geriatric psychiatry.

Why is that? Because everything about medical training is about diagnosis and cure. In geriatrics, we don’t worry so much about that as we do about how people function and feel. That’s antithetical to the medical mind and makes a lot of doctors very uncomfortable. All of this is a long way of saying that medical trainees start early in their careers to sort themselves depending on interest, drives, and personality types. Surgeons tend to be technicians. They’re good with their hands and they want easily identified problems with cut and dried solutions. Medical subspecialists are problem solvers. They like the puzzle of diagnosis. Primary care docs are nurturers. They want to know their patients as people and recognize that 90% of the issues that bring patients into a primary care office are things that doctors don’t have answers for but the good ones develop strategies that help people anyway. The closer a doc is to the lives his or her patients live, especially if the patients belong to marginalized communities, the more likely they are to understand the downside of what actually goes on in our society and the more likely he or she will advocate for policies or programs that will help the people who entrust their lives to him or her, which in American politics, mean they move left. The technicians, being very removed from the life of their patients and only really encountering them in the artificial world of the hospital, tend to look at the world through the lens of business and personal pocketbook issues.

There’s one huge trend that is pushing these dynamics more and more and that is the influence of women in medicine. Women in this country did not start to go to medical school in any number until the 1970s. There were a few who went earlier (my grandmother graduated from medical school in 1926 – the only woman in her class). One thing I noticed about these pioneers when I started to meet them in the 1980s, fifteen or twenty years into their careers, was that they had to degender themselves to succeed. The feminine had to give way to the asexual. By the time my generation came along, their were enough women in medicine that this was no longer true but there were still some interesting trends. Women were self segregating, for the most part in primary care disciplines. I guess they speak to their nurturing instincts. They are also more flexible in regards to such issues as job sharing and time off which is important when dealing with childbirth and family life. To this day, the surgical specialties still remain heavily masculine but it is changing slowly. A few years ago the scales tipped and there are now more women than men in medical education in this country. I can easily see the entire profession becoming female dominated over the next fifty years and that just might be a good thing.

Enough for tonight. Be well. Be safe. And wash your hands. Holmes and Semmelweis were right.

And just like that, it’s April 15th. In an ordinary year, people would be pounding their heads into their laptops trying to make TurboTax spit out comprehensible numbers and a refund. This is not an ordinary year, however, and taxes aren’t due to July. I actually had everything complete and to my accountant in early February this year, figuring that a late March or early April refund would help fill my coffers for moving expenses. More fool I. I called my accountant late last week and he, like every other CPA is snowed under with stimulus program havoc. Routine tax returns will just have to wait. He’s done my taxes since I moved here during the last millennium so I trust him to do what he knows how to do.

The great shut down of 2020 is, of course, playing financial havoc in more ways than just accountants trying to figure out the byzantine rules of hastily passed small business loan assistance programs. And, as money makes the world go round, the lack of it flowing through the system as everyone retrenches for a more sedentary and less consumerist life, is shaking the powers that be. Conservative ‘grass roots’ protests against shut downs and social distancing are sprouting up. The most visible one today was in Michigan at the state capital in Lansing. Of course what most of the media reports are leaving out is that these are orchestrated by the usual big money conservative families with an agenda – the Lansing rally was paid for by groups tied to the DeVos family of Amway and Secretary of Education fame. i don’t think there’s been much protest on the right wing in decades that hasn’t been paid for by some deep pocket. There are, of course, some economic winners in all of this. The Ravensburger jigsaw puzzle company is having it’s best year in all 138 years of its existence. If you can’t find a jigsaw and are close to me, I have a few I’m willing to give away as I downsize.

The numbers of cases keep going up. There’s some interesting social epidemiological trends happening with fifty states responding in fifty different ways due to a lack of organized central leadership. The one I was most interested in today was South Dakota, a relatively small state population wise, where cases have increased nearly ten fold over the last ten days from about 100 to nearly 1,000. The culprit? The conservative governor’s steadfast refusal to employ any social distancing or shut down orders of any kind. I imagine we’ve only seen the tip of the iceberg there. The pattern will be similar in a lot of rural America. A population that have been fed a diet of misinformation about how it’s a coastal city problem, or no worse than the flu, a hollowing out of health infrastructure through politics and neglect, a hollowing out of community life through the destruction of small agriculture and manufacturing, and the great equalizer – the one large institution where everyone in town meets together day after day. Wal-Mart – the only place left to shop. And we won’t hear about most of the deaths in small town and rural America as it’s outside the ken of most media figures and therefore not really real to them or worthy of much interest.
Tonight’s subject seems to be money. There’s an odd thing going on which at first seems counterintuitive but, on closer examination, makes perfect sense given that we’re operating in a health care industry and not in a health care system. Just at the time that doctors, nurses and other health care workers are being called upon to put themselves in harms way and sacrifice much, including possibly their lives, for the good of American society, they are being faced with pay cuts of 10, 20 and I have even heard some reports of 50%. Why on the one hand are they being lauded as heroes and on the other hand being punished? It’s because health care is big business and it’s a for profit business in most of the sector. Covid 19 is keeping people with other illnesses away from the health care system as they start to realize that whatever is going on with them is not so serious as to risk exposure in a crowded emergency room or urgent care clinic. Visits are plummeting. Doctors are wisely keeping those with chronic illnesses out of hospitals and large clinic buildings where sick people congregate. Outpatient volumes are down 50-75% nationwide and hospital bed occupancy is also way down – to free up more front line staff for Covid cases, and to keep ill people away from active cases as much as possible. Those who are coming in with Covid are, of course, sicker than snot but the numbers are small compared to the numbers of patients that usually show up over the course of the average workday. Without elective surgeries, lab tests, routine check ups and monitoring of diabetes, hypertension, administering of chemo and all the thousand and one other things that happen every day in usual volume, collections are way, way down. If a business isn’t bringing any money in, expenses have to be trimmed. I’m not personally alarmed as I’m a pretty cheap date and I work in a specialty where we all support each other and are socialistic about such things as compensation. It’s going to be different for the young ‘uns, who gave up their youth and put themselves in a huge amount of debt to complete their educations and now won’t be able to manage the loan payments, the mortgage and the kids college fund. The days of the rich doctor were over before I ever entered the profession and primary care and cognitive specialties have never paid terribly well and have had a terrible time recruiting students over the last few decades. That’s going to become harder than ever and I think a number of mid career physicians, when this dies down, are going to look at these trends and get out and do something else with their lives. I’ll keep at what I’m doing. Too old to change.

Speaking of money, as of today I have two mortgages, at least until I sell the house. I am now the proud owner of the new condo as of 2 PM this afternoon. The next couple of weeks will be spent getting it ready for move in and then I’ll figure out some way to actually execute a move in a time of social distancing and corona virus. I’d consider taking some pictures and posting them but it’s all a rather dreary off white color scheme and I think I’ll wait until I get it painted. I don’t think I’m going to go quite for the wild palette Tommy used in the old house, but it’s going to have color and reflect my rather eccentric personality. My favorite type of style is Regency/Empire but, of course, I don’t have much in the way of furniture that actually fits that. Someday. And I can’t go too far that direction in a mid-90s condo block. It would look a bit silly.

I had another topic I was going to tackle tonight, but it’s late and I need to get some sleep before solving the problems of Walker County veterans tomorrow. I’ll take it on in a later entry in the accidental plague diaries.

Be well, be safe, and wash your hands.

And on the other side of yet another socially isolated weekend, it’s time for the next installment in the accidental plague diaries. The date today bookends the date at the start of the weekend. Friday, the 10th was Tommy’s birthday and today, the 13th was Steve’s. If Steve had lived, he would be 72 years old today. I have a hard time envisioning a septuagenarian Steve and I don’t think he would have enjoyed that age much. Perhaps it’s best he left the party a bit early. If someone had told my younger self that by the age of 55 I would be widowed twice and living in Birmingham, Alabama I would inquire just what drugs they were ingesting at the time. Funny how life turns out sometimes.

The Corona Virus caseload locally continues to remain relatively steady meaning that the health system has been able to absorb it and cope with the needs of the ill. From what I can tell, even the more rural areas are starting to understand that they are not immune and are beginning to take social distancing more seriously and doing such things as drive up church where everyone stays in their cars in the parking lot with the pastor on the porch with a PA system. Whatever it takes. When you’re in the more rural parts of the state, there’s not a lot of wi-fi and zoom conferencing available. A decade or so ago, when I was working with the mine workers in rural West Virginia and one of the nurses was having data base problems, she called into tech support (in Minneapolis if I recall correctly) and the tech just wanted her to go down to the local Starbucks and hop on the wi-fi. She had to educate him as to just how rural the hollers of West Virginia actually are and Starbucks would be a three hour trip to Charleston.

I now have a proper video conferencing station set up at my UAB clinic office so I can connect face to face with patients and families with smart phones. It’s not the same as being in the same room, but it’s better than trying to hazard guesses about certain things over the telephone. Now I just have to get the over 80 set to trust smart phone capabilities. Most of them are still tied to their land lines. I’ve considered finally leaving my land line behind when I move to the condo. The problem is that it’s the only thing loud enough to wake me up at night when I’m on call. The cell phone just doesn’t do it. Perhaps if I find a nice klaxon ring tone for it. Tommy was always an early adopter of new technology. He got an iPhone about a year before I made the switch. He would get the latest and the greatest, I would watch him use it for a while, then he would trade up and I would get his old one having finally figured it out. It worked as a system.

Yesterday was Easter Sunday. The Deep South was wracked with thunderstorms and tornadoes and it was a very good day to stay indoors under a blanket with a book and the Xbox. Birmingham proper was fine, just a lot of noise, flash and torrential rains that led to some spot flooding (including the basement of the theater where I do most of my work). There were some tornadoes in more outlying areas but, at last report, no one in Alabama was killed. Mississippi wasn’t so lucky. More storms are due to come through tonight. I was in need of some comfort food and in digging through the freezer, I found a bag of Tommy’s famous chili left over from out last big holiday open house. I thawed it out and had it for Easter dinner – it had lost none of its heat for being in the freezer for a couple of years and, per usual, I had to cut it with a bunch of sour cream in order to be able to eat it. Tommy cared immensely for people. He didn’t always show it and could be a little rough around the edges but he did and the way he showed it best was in cooking for them. He always took great pride in our parties where he basically made everything on the table himself from scratch.

As I’ve been haunted by the ghosts of husbands past this weekend and it has coincided with Easter, I’ve been doing a lot of pondering of life and death. You can’t open social media without seeing a story of some promising life cut short by Covid 19 and we’re all trapped in a miasma of worry wondering whether we or those we love will be next. What do I think about death? I’ve been around long enough and seen enough people die to not be frightened of it. I don’t have any intentions of dying myself in the near future as I don’t think I’m done yet and I’ve barely scratched the surface of my bucket list but, if my number comes up I won’t be able to complain too much. I’ve had an interesting life and accomplished a lot more than most with the time I have been allotted so far. If I do get carried off by Covid 19, I have one request. Whomever puts my obituary together is to call out a certain US president and a certain Alabama governor by name and suggest that my premature demise was unnecessary and directly linked to their inability to follow proper public health protocols in a timely fashion.

Matter is essentially indestructible, just transformable. The matter that makes up our bodies was forged in stars billions of years ago and billions of miles away. We are, literally, made of stardust. We’re allowed to borrow it for a time and then we return it back to the universe where it is recycled in unknowable cosmic plans. What happens to our self, our consciousness, our soul? Frankly, I have no idea, only that whatever it is it’s the same for everyone. The dichotomous afterlife so popular in certain religious traditions makes no sense to me. Each new baby brings light and hope and salvation and, no matter what circumstance or bad choices may bring, that original promise remains buried within so as we all enter the world in the same way, I think we must leave in the same way as well. I do hope to see both Steve and Tommy again after. It’ll be interesting to see what they’ve made of each other and what they’ll think of what I’ve done with the remainder of my life.

Stay well. Stay home. Wash your hands.

I should have written a long post last night, but I was feeling a bit down. It was Tommy‘s birthday (he would be 55 today were he still here) and of course that took me back to memories of his last birthday that we spent together. He was in the CCU recovering from a line infection so he could have cardiac stents placed in what would ultimately be a fruitless attempt to preserve his cardiac function, and by extension his life. Tommy hated what he called Hallmark holidays and didn’t like his birthday commemorated (and heaven forbid if I should give him a birthday present – he eagerly accepted presents on all non-holidays however – part of his contrarian nature). I did ask him that day if he would like anything for his birthday, and he surprised my by saying yes. He really wanted some carrot cake from Continental Bakery (Carole Griffin – he worked for you there at some point in the 90s). So off I went for a small one for dessert that night. I don’t think the nurses were terribly happy as it wasn’t on his diet plan but he had let them know early on that he was going to eat as he pleased, diet be damned. Last year on his birthday, I decided to keep up the tradition and went and got myself a carrot cake. This year, with my trying to minimize community contact, I didn’t go. I did do my once every three week grocery run and while my local Piggly Wiggly didn’t have carrot cake, they had a package of carrot cake Oreos so I bought that instead. I don’t think Tommy would mind, he’d probably find it funny.

This week in April is always a bit hard. Steve’s birthday is this coming Monday. What is it about me and Aires men? I suppose to continue the pattern, if I have a third husband, his birthday will have to be April 7th (and he’ll have to have a first name he doesn’t use and alliterative middle and last names he does. Jon Steven Spivey, Louie Tommy Thompson Jr. ) That may be a tall order. Steve, in contrast, loved birthday presents, the more the better. He also loved parties, especially if he was the center of attention. Tommy loved parties because he loved to see everyone at once and he loved to feed people. Cooking was an innate part of his nurturing instincts. It certainly rubbed off on me, especially about thirty pounds of excess avoirdupois I put on during our time together, which I have been slowly taking off now that I can go back to eating like a thin person.

Enough of my maudlin moment. Time to get back to the accidental plague diaries. Another work week has ended. UAB and the Birmingham VA continue to handle Corona Virus cases without too much difficulty but I am concerned about a few weeks from now when small town Alabama that has not been embracing social distancing starts to manifest infections. A few people of my acquaintance have been infected and recovered. One has died. Most of us have remained healthy to date due to the Birmingham area’s early embracing of shut downs. It helps when the major economic engine of the community is a major research university with a huge medical school. I’ve got the new work patterns down pretty well and we’re holding the geriatrics program together through telephonic work, home health agencies, and creative problem solving.

I checked my official counter – today we surpassed 500,000 cases in the USA (almost certainly a huge undercount as testing remains spotty), 3,000 cases in Alabama and we’re creeping up on 1,000 cases in Metro Birmingham. Despite indifferent political leadership, the medical community has rallied, pooled information, pooled resources and, even in the greater New York area, seems to be plowing forward with what must be done. Of course the pundit class, that thrives on the 24 hour news cycle, has grown weary of social distancing, quarantine and isolation and wants this all to be over so they can move on to the next sensation which will distract us all and make their advertisers happy. Unfortunately, viruses have no interest in human concerns, their only concern being viral propagation and cannot be reasoned with, bribed, or otherwise made to do human bidding. There is a well known series of steps necessary to bring pandemic illness under control but, from what I can see, no one’s that interested in following those stages as it’s difficult to sensationalize or monetize. But, until we start accepting this biologic reality, we’re going to have trouble.

No big plans for the weekend. Nowhere to go. My usual distractions of rehearsal and performance are on indefinite hiatus. It does look like the condo sale will close next week as scheduled and I will have possession by the end of next week. I still haven’t figured out how I’m supposed to move while we’re shut down and in isolation. In the meantime, I am slowly dejunking the house, finding some rather surprising things tucked away in corners. As I’ve only been here four years, there hasn’t been too much time for accumulation but there’s still moments of ‘what the hell is this and why do I own it’. I think a lot of the odder things are the result of Tommy’s late night on line shopping addiction. He would order the oddest things at 3 AM. There were a lot of times when he would show me his latest gadget when all I could think was ‘garage sale in five years’. But it kept him happy… Wherever he is now, I hope he’s just as happy.

Stay well.

I apologize for no long post last night. I’ve tried to be disciplined and keep these up every other evening but last night I felt like a balloon after all the air has been let out of it and I crawled into bed by 9 and slept through until the alarm went off at 7 this morning. I feel fine. I think my brain just needed some off time from the toxic stew of life stresses that we’re all marinating in at the moment. At least the new work patterns are becoming slightly predictable and I’ve been able to stay on top of the crises in three different systems: UAB Geriatrics Clinic, Birmingham VA Home Based Primary Care and Comfort Care Hospice. One day, one patient, one problem at a time – although my phone continues to ding regularly with incoming texts from whichever two sites I’m not currently at.

An anecdote from my very distant past involving a balloon. I must have been three or four at the time. My parents gave me a red balloon, fairly strong and sturdy and rubberized that had a cat face on it. I don’t remember where we got it or why and it had no magical properties, unlike the one in the fabulous French short film by Albert Lamorisse. I was playing with it in the alley behind my house when my friend Jay came out of his house across the way and told me it would be great fun to pop it. Jay was a couple years older than I was so I looked up to him as an experienced man of five or six and said sure, that should be fun. He couldn’t find a rock that would puncture it but finally found a stick and convinced me to poke a hole in the balloon. If it had exploded with a satisfying bang, I might have enjoyed the noise – all boys love blowing things up but instead it slowly leaked air and involuted and started to shrink away. My three year old brain hadn’t considered the possibility that my toy might do that and become less usable and fun. I took my wounded balloon inside to my mother who, to her credit, didn’t laugh at me but rather took it as a chance to teach me a lesson in actions have consequences and some decisions, once made, cannot be undone. I kept what remained of that balloon in my room for quite a while as a reminder to be careful with what I chose – and as a reminder to not always follow someone based on seniority. (I’ve taken that last lesson very much too heart and had major problems arise from it at times, but I think I’m happier bucking the system when I know I’m right rather than going along to get along.) It was probably also my introduction to the second law of thermodynamics although I didn’t figure that out until years later.

The number of Facebook friend requests I’m getting and my blog readership are going up astronomically since I’ve started into what I’m calling my plague diaries. Quite frankly, I’d much rather still be doing travel diaries but one writes about what one knows and journaling comes out of the mundane and minutia of everyday life and all of our everyday lives have become about Covid 19 whether we want them to be or not. I did a podcast recording a couple of weeks ago (https://audioboom.com/posts/7547581-season-3-episode-6-one-doctor-s-life-in-the-time-of-coronavirus) where we talk a bit about this blog. Yes, the title is a nod to Douglas Adams. It’s been years since I’ve read his books, but his wonky sense of humor has always appealed to me and it’s very similar to my own. If you doubt me, read the movie columns. Of course, when Mr. Adams was my age, he’d been dead for nearly a decade so he accomplished a lot more with his writings than I have with my own.

In my last long post, I explored – briefly – why the US has health insurance tied to employment while such a system happened nowhere else in the industrialized world. Tonight I want to say a few words about another aspect of the US health care system that’s unique and which causes us a significant amount of trouble. I’m not passing judgment on why this is or the ethics or social trends behind it, I’m just going to lay it out there.

The vast majority of world health systems, especially those of the developed world, are morbidity driven health systems. The aim of the systems is to keep their populations well. They understand that health is much cheaper for a system than disease and resources are deployed to try to keep the majority of the population as healthy as possible. Healthy adults come from healthy children come from healthy infants come from healthy parents so they put enormous resources into making sure all of their population has access to care, that primary care is funded and available, that there is adequate prenatal and child care, that pediatric care will not stress a family unit, and preventive services that will keep people from falling into ill health by catching disease early are easy to come by. What’s the result? Their populations have higher life expectancies than we do, their systems cost much less (usually 9-11% of GDP while ours is something over 17% of GDP), and no one in their populations worries about medical bills and the possibility of bankruptcy from a health condition is so alien as to be unfathomable.

On the contrast, the US health care system is a mortality based system. We worry about why people die and do everything we can to prevent that occurrence. A death is considered a failure of the system to provide adequate care in some way (and our legal system is always looking to find someone at fault). We view life as linear with death as an endpoint and, if our health system is applied properly, we should never actually reach that spot. There are some generational differences in these ideas but it is most clearly seen in the early Boomers, those now in their early 70s who still view themselves as being forever young. There’s a line from a film which paraphrased is something like ‘How can I be old? I was at Woodstock!’

This cultural need to prevent death leads us to pour huge resources into individuals who are obviously in a dying process. For most people, death is a process – a very quick process for some (almost instantaneous in some cases) and a very slow process for others. Most health professionals know when someone is in that process but we are taught from early in our training how not to take away hope and the ethics of doing everything in our power to preserve life if that is the wish of a patient and family. But, deep inside, we often recognize when the continued treatments are doing no good. The specialty of palliative care which has arisen over the last few decades is capitalizing on this mismatch and showing that there is another way of not being aggressive with treatments during the dying process and they have shown scientifically that, in a lot of cases, people actually live longer with just having their symptoms treated rather than trying to cure the incurable underlying disease process.

Other systems look at us somewhat amused, ‘Those crazy Americans – they see death rates ticking up from cardiac disease and put everyone on aspirin, everyone on a statin, train more cardiologists. And then the cancer rates start to go up so more cancer centers, new chemo regimens, new biologic tumor annihilators. And now it’s an increase in dementia so more work on new drugs to prevent it (so far unsuccessful). Don’t they realize that the numbers always add up to 100% and all you can do is move people from one category to another?’ The problem is, we really don’t when it comes to how our health system actually operates. I am fond of reminding Medicare insurance executives of the fact that everybody dies in meetings when they’re touting how wonderful their product is at keeping people alive. It has not endeared me to them but I don’t mind.

This issue of morbidity vs mortality is going to play out during the current pandemic. I don’t know how yet but it will be interesting to keep comparing the response in other countries to what we have here. I remain afraid that we’re still in early days with this thing, no matter how tired we all may be of our disrupted lives.

Stay well.

Last time I wrote an entry in the plague diaries, it was the end of the work week. This time, it’s the end of the weekend. Was it an exciting and action packed weekend? Hardly, those are in abeyance for the duration but I had a few minor triumphs. In the harsh light of day, I decided the cat hair on the rug was not a lived in, but a sloven look so I broke out the vacuum cleaner and the duster and cleaned the main floor of the house. I also finished sorting the DVD collection for discards and entered all the ones I’m keeping into an app database so I’ll know what I’ve got next time I look for a physical copy of something. I played three very long games of Civilization VI on the Xbox and lost every time to my AI opponents. I read a dozen chapters in the book my sister gave me for Christmas (a zombie apocalypse in Seattle told from the point of view of a tame crow and the pets left behind). I took two long neighborhood walks. And I ‘attended’ on line church with a sermon on the non-canonical gospels entitled ‘The Heretic in the Pulpit’ – let it not be said that we UUs have no sense of humor.

On one of my walks I encountered my old friend Angela Forbus Pruitt and we called a few pleasantries to each other across the street. While we were talking I had a brain flash about what to write this evening. One of the themes I’ve seen as friends have been posting about Corona Virus is the common fear of being stranded without health insurance due to job loss. We are the only advanced society that ties health care and employment together. As most of us grow up in this system, it seems normal to us while most of the rest of the world considers it bizarre. How did we get here and why do we do it?

To answer that question, we have to go back to the 1920s and 30s. In the 1920s, the average American family spent a greater portion of their wealth on cosmetics than on health care. For the most part, you didn’t access the system. Doctoring was done by mom or granny and the vast majority of illnesses were handled at home. The doctors, almost exclusively men, were mainly general practitioners who were part of a community that supported them in a symbiotic relationship: this is where all the stories about paying the doctor in chickens came from. If the doctor had an office, it was often part of his home and he spent most of his time making the rounds in the donkey cart or the model T calling on the sick at home, providing advice and succor as he could. There were hospitals, but they were small and generally used for a few specific purposes: surgery, separation of those who might be dangerous to the greater community (the asylum and sanitarium), teaching, and as a carer of last resort for those without intact family structures who were medically ill. They were owned predominantly by public or religious institutions with a charitable mission to provide care for the ill and were non profit in nature.

Health insurance, as we understand it, was invented in 1929 in Dallas, Texas. Baylor University had constructed a large new hospital and was having difficulty filling the beds. The vice president for health services at Baylor, Justin Kimball, had connections with the Dallas school teachers union and hit upon a plan. If the teachers would pay Baylor a fifty cents a month, they would then be eligible, should they require hospital treatment, to enter Baylor’s hospital free of charge for up to twenty one days. This ensured Baylor a steady stream of income, and a steady stream of patients over the next decade or so.

This original plan morphed over time, as it grew, into Blue Cross: an amalgam of local plans which over the next couple of decades, grew into the organization that those of my generation all remember from my childhood. Blue Shield, which eventually merged with it, had a different origin. It came from a banding together of workers in the logging and mining camps of the Pacific Northwest into fraternal organizations that paid doctors fees if one of their number became ill. Blue Cross and Blue Shield grew piecemeal throughout the 1930s due to the state of the economy.

In the early 1940s, with the United States now at war, many of the heavy construction jobs, especially in the shipyards and airplace factories were taken by women as the men were fighting overseas (the days of Rosie the Riveter). It didn’t take long for the titans of industry to figure out that if these women fell ill, or if their children fell ill, they could not come to work and productivity would be hindered. It started to become the smart business decision for a company to begin thinking about the health of its employees and their families. The leader among the heavy industry types was Charles Kaiser, head of Kaiser alumnium. He led the way in making sure his employees had access to good and timely health care and that the bills would be paid.

In the latter half of the 1940s, after the end of the war and the return of the men to the workforce, heavy industry faced another problem. While the economy was gearing up to meet fifteen years of pent up US consumer demand, not to mention helping the rest of the world rebuild shattered infrastructure, there were still laws on the books left over from the Great Depression, which controlled wages – it wasn’t possible for company A to offer more money than company B for the same job. Corporate America found something else to make up the gap – the benefits package which did not fall under these rules. Health insurance, as it had already taken root in heavy industry quickly became a carrot for getting employees to sign on the dotted line. By the late 1940s, industrial American lobbied congress to change to tax code so that it became advantageous to the owners of industry to offer a health benefit and, before anyone knew it or thought about the consequences, employer tied health insurance was born.

Through the 1950s and 60s, the system worked relatively well. Hospitals were not for profit by both custom and law. Physicians were small independent businesses. There wasn’t much money in the health sector of the economy and, as employment was relatively easy to get in the booming post war economy, everyone was happy. Things started to change with the introduction of Medicare and Medicaid in 1965. They were created to give populations who were not employed or employable access to the health care system – Medicare for the elderly and disabled and Medicaid for the impoverished. But what ended up happening, was a sudden influx of federal dollars into the health care system. Money always catches the eye of the businessperson and this was no exception.

It was Charles Kaiser who went to his old friend Richard Nixon in 1973 and persuaded him to sign a piece of legislation known as the HMO (Health Maintenance Organization) Act. It was in order for him to spin off his health organization into a free standing company (Kaiser Permanente). The unintended consequence was that the language of the act made health care, up to then a not for profit enterprise, into a for profit business. Wall Street took notice and corporate America arrived in health care starting in the late 1970s, determined to remake medicine into a business, one that manufactured hospitalizations and patient encounters, and using the same business principles that had served it well in other sectors of the economy. By the mid 1980s, the field of medicine was very different as we evolved from a health care system, whose goal was to heal the sick and injured, to a health care industry whose goal is to create profit for the owners of industry. These trends have continued over the last four decades (coinciding with my time in medicine – I entered medical school in 1984) and now there is an enormous stress on the system wrought by Covid 19. What will the ultimate outcome be? I don’t know, but I don’t think the health system will look the same or operate the same when we emerge on the other side.

And there you have it. More than you ever wanted to know about the history of American health insurance in seven paragraphs.

Stay well.

And so we come to the end of another work week. My patients are as tucked away as I can make them from a distance, the staff are free for another weekend of social distancing, and the reports of more and more cases overwhelming the greater NYC area keep rolling in. Birmingham has stayed fairly stable this past week due to the early adoption of closures and social distancing. The state of Alabama finally followed suit today but I’m afraid it’s going to be too late for a lot of the smaller towns that have assumed they’re safe being outside of an urban core. The numbers for a lot of the rural counties are starting to spike. i figure we will know where we are locally in about another two weeks.

I do not watch the executive branch daily news conferences. From what I can tell, they consist mainly of contradictions and word salad. The election of someone who promised to take a wrecking ball to government institutions means those institutions are non functional or non existent when you need them. It’s going to be pretty much every state for itself in terms of pandemic response – some have been more proactive than others and you can see that in the numbers. The west coast grows, but at a much slower proportional rate than the deep south. I’m hoping we’re all learning a painful, but necessary lesson in the role of the federal government in times of crisis that effect the whole country equally.

My housekeeper is on furlough with four children suddenly out of school. I came home from work fully intending to vacuum and dust and make the house presentable but the only person that sees it is me and so what if there’s cat hair on the living room rug. It just adds to that lived in look. I played Xbox for a few hours instead, then made myself a gourmet meal of Kraft macaroni and cheese, hot dogs, and salad in a bag. I found some of Tommy’s famous chili and some butternut squash soup he made in the freezer so I’ve put that in the fridge to thaw for dinners this weekend. I am continuing my slow sort and clean out of junk. I still have to tackle the kitchen and the closet in the spare bedroom. Then I’ll have made a first pass on the main living areas. The basement and the garage are being left for later as they are the big bad boys.

I’m trying to think what to write about tonight and absolutely nothing is coming to mind. Perhaps it’s the glass of wine with the mac and cheese robbing me of creative thought. Perhaps I’m just carrying too much psychic weight. Perhaps I’ve told all my good stories already over the last two years. For some reason, I’ve been thinking a bit about early childhood today and I flashed on my first day of kindergarten. The neighborhood I grew up in in Seattle was faculty ghetto for the University of Washington back in the mid 1960s when we moved into the house in which I grew up. I started kindergarten in the fall of 1967, right after the summer of love. It was a half day program and I was in the morning class with Mrs. Easterwood. We were all taught to walk to school, about twelve blocks for me each way but on that first day, my mother brought me. I had been in pre-K so going to school was nothing new and I came in, marched around the room and read all the signs on the walls aloud. Mrs. Easterwood looked at my mother and said something like ‘So, he can read’ and my mother looked somewhat abashed. My parents hadn’t really formally taught me, I more or less taught myself from picture books, being read to and marching up to my parents with book in hand and demanding to be told what this or that word was. It was decided that I would be sent next door to the first grade classroom during reading time as I would be bored silly by the elementary exercises happening in the kindergarten room. I loved school – still do, although my mother chuckled for years about the time I came home, stomped in the house, and started complaining about how Celia Hanley told me what color to color my balloons and I definitely remember Lisa Hurd being much better at cutting circles than I was. And if I remember correctly, Celia was a nurse and Lisa an angel for Halloween that year. I was a pirate.

My first years of elementary school were run on the precepts of the 1940s and 50s. Boys and girls had recess on separate playgrounds. Everything was very formal. Seattle public schools didn’t have its act together on arts education so big black and white televisions were brought in for broadcasting music and visual art class from the local PBS studio. (This is before it was actually PBS). I still remember chanting tah tah tee tee tah along with a lot of other five year olds. Mrs. Easterwood seemed incredibly ancient to me, but was in her mid 40s. I googled her and found her obituary. She made it well into the new century before dying at the ripe old age of 98 having taught several generations of kindergarteners over her life. It’s more than fifty years later and I can still distinctly recall her voice. I seem to have a good ear for voices even after many years. At a public lecture I gave in Seattle a few years ago, a lovely older woman came up to me to thank me and asked me if I remembered her. I didn’t recognize her at all but as she spoke, I knew exactly who she was, Audrey Palmer, my fourth grade teacher (and the only elementary teacher inflicted with all three of the Duxbury children). I don’t run into too many people from my distant past these days but if I do, the voice will tell me who it is.

Today’s children will have a vastly different growing up. One thing I am hoping happens with the current crisis is that families will spend more time together as they stay home and focus on each other. I hope the kids, when they are my age, look back on this time as one full of memories of family togetherness, silliness in the backyard, family games, projects with siblings, and a break from the overly scheduled lives we’ve tended to foist on the young in our quest to mold them into competent and competitive adults. Take the small joys that this time can offer and treasure them.

In the meantime, be well.

It’s hump day evening, I’ve had my leftover chicken masaman from the local Nepalese take out accompanied by a glass of Cotes du Rhone (Tommy’s favorite) and I finished sorting the movie collection and pulling the obvious discards. Must be time to sit down and write again. I’ve never been one to drink alone but as day drags on into day by myself in the house, I’m opening a bottle of wine a week and treating myself to the occasional glass. One less thing to have to eventually move. I still haven’t quite figured out how I’m going to do that in the middle of a societal lock down but that’s a problem for another day.

The Corona Virus counter I check every evening shows that we’re now at roughly a million cases reported world wide (likely a huge under count as the statistics from a number of places are not to be trusted), roughly double the number of cases in the USA than in Italy, and the Alabama number entering four figure territory for the first time. We continue to be able to cope at UAB and at the Birmingham VA with the local needs so far but, two weeks in, there’s a feeling of fatigue and that this is going to get a whole lot worse before it gets better. I figure we’re going to have a better sense of the local parameters of the pandemic in about two more weeks when we see what the behaviors of today are doing in terms of controlling spread. I tend to hang out with relatively intelligent people so we’re all practicing our social distancing and isolation with reasonable success but I can tell from friends social media feeds that there’s a longing for a return to a world of rehearsals, neighborhood restaurant nights, theater parties, and just the plain joy of hanging out with your usual crowd not feeling a need to do much of anything. A friend of mine is trying to work out an on line version of Cards Against Humanity but it’s just not going to be the same.

Today’s musings have to do with trying to battle instinctual behaviors. We all have them. They’re buried deep in the limbic system and tend to make themselves known at times of stress. One of the chief among them, as social animals, is finding solace in the group in times of fear and uncertainty. I absolutely understand why some communities are still trying to come together in religious ritual. It’s a deep and innate longing and need in unsettling times. Unfortunately, our intellectual selves, having mastered an understanding of biology and basic virology, know that this is one of the worst things we can do from an epidemiologic point of view. This leads to a really primitive conflict which we’re seeing played out, especially in the south, between militant church goers and other members of society who recognize that this behavior will endanger others and should not happen. Where do I stand on this? I believe that god will understand is church is in abeyance for a while and god is helping me through this – he/she gave me a brain smart enough to not put myself in a position of danger.

I think I learned the most about battling my own instincts when I took trapeze lessons for about a year a couple decades ago. I’m not going back to it – at my age I’d likely dislocate my shoulder or fracture my hip or some such. I started at a resort in Mexico. Steve and I had booked a vacation there in the spring of 1998 and, the week before we left, UC Davis decided to disband its clinical geriatrics program and handed me a sixty day pink slip. Needless to say, by the time we arrived at Blue Bay Los Angeles Locos, I was fit to be tied and needed something to make me feel like I still had some mettle left in me. They were offering beginner trapeze lessons so I signed up thinking if I could face my acrophobia and do that, I could take on the upcoming work challenges.

Flying trapeze is all about physics. At the peaks of the arc, you’re basically weightless and can do your maneuvering relatively easily. Some of the tricks that look spectacular from the ground are relatively easy. The hardest part is, after being caught, returning back to the original fly bar. I never did quite get the hang of that. When you’re standing on the platform with the fly bar in your hands, everything in your brain is trying to make your body thrust its center of gravity backwards onto the platform so you won’t fall twenty five feet or so. However, to successfully launch, you must do the opposite and puff out your chest, draw your hips in and keep your center of gravity forward towards the bar. It’s difficult to get yourself to do that and requires a sort of zen tranquility to over ride the lizard brain that’s in full flight or fight mode. I took several series of lessons at that resort the next few years, and then continued with a flying school in Atlanta for a time. I stopped when I met Tommy and got interested in other sorts of performing. Joining the circus just wasn’t in the cards.

The apprehensiveness that I feel, that we probably all feel, as we experience this global event has me feeling like I’m standing on a trapeze platform. I want to bend backwards and hold myself in a completely wrong position as it feels like a place of safety. Instead, I know I have to stand tall, stick my chest out, and launch myself into a new and unknown world -it’s scary as hell but I’ve done it before in all sorts of ways. I have to trust that the safety lines and net of my intelligence, my education, my family, my friends, my career, my performing instincts, and all the rest will lead to a successful trick and dismount. And, even if I fall, I have learned how to do it safely and gracefully; it’s the first thing you learn in trapeze as you’re going to do it again and again.

According to the handy dandy little Corona Virus counter maintained by Johns Hopkins, we’re up to nearly 1,000 cases in Alabama. About half of those are in the greater Birmingham area. UAB continues to weather the storm but folk are getting tired and we’re all still on the upswing. My professional life is fairly peripheral to the main hospital where the majority of cases are being treated. Currently, it’s my job to look after my patient population and try to keep them healthy enough so that they don’t need to come into the emergency department or the hospital for any reason. Lots of phone calls checking on medications and refills, making sure people aren’t falling, that fluid status is OK, and nipping UTIs and bronchitis in the bud. Anything I and my colleagues can do to reduce pressure on the hospital system the next few weeks, the better.

The rhythms of my work week are all out of whack. It doesn’t feel right to be a doctor and not be able to see my patients other than the occasional video chat. When you’ve done this job as long as I have (32 years now since I graduated from medical school…), you get this spidey sense about who is sick and who is not and what is normal and what can be safely ignored and what needs to be investigated further and it just doesn’t work without the physical presence of the patient. I’m pretty good at what I do and I’m afraid that the current straitened circumstances are going to lead me into missing something significant. We can still see people in the office, we’re just trying to avoid it as much as possible as we are just down the hall from the emergency department and we want to minimize the risk of exposure to Covid 19 in my patient population.

I’ve been thinking about what to write this evening for a while. This is always a mistake. When I overthink one of these long posts, they get stilted and anodyne and don’t come from the heart the way the ones I write half asleep as pure stream of consciousness do. Good, bad, or indifferent, I really couldn’t think of much that I felt I had to touch on. We’ve all seen the news. We all know that it’s going to be a while before any of this lets up and we’re all in this together. Not just as Americans, but as members of the human species world wide. In this age of globalization and international travel, Covid 19 is going to make its way to pretty much every human population within the next year or so. I imagine even the isolated tribes of Highland New Guinea have some contact with others and it doesn’t seem to take much for it to leap from one person to the next.

For various reasons, I’ve had to cancel my time off in April/May that I was going to use to move. It’s just as well. I still haven’t figured out how to move furniture when one lives alone in a time of quarantine and social distancing. If Tommy were still here, we could make it work (aside from the piano) but he’s not and I am not as young as I once was and even when I was in my prime I could not move a couch by myself. Steve and I moved ourselves a number of times over the years. We were young and energetic and we were always moving within the same neighborhood so a pickup truck and some boxes usually sufficed. He moved in with me towards the end of my internship year. I didn’t ask him to. I just came home one day to find his living room set in my apartment. When I said we should really talk about this first, he got upset and, when I came home from my next call night, the furniture was gone again. I think he drove his living room furniture up and down Highway 99 between Sacramento and Lodi three or four times. It became a standing joke between us. I could tell if he was mad at me if the couch disappeared.

Our first move was upstairs in the same apartment building – the units were slightly bigger. About a year and a half later, we found a condo, the upper story of an old Victorian a few blocks away, so we hauled everything over there for the next few years. Timothy Busfield’s brother, Buck, and his family lived next door and he and Tim were in the process of starting the B street theater in Sacramento at the time so I got a little vicarious theater interaction when we would run into them but, for the most part, it was buckle down and finish residency and fellowship and get the career underway. Our last self move was to a lovely craftsman bungalow a few blocks further uptown once I finished all my training and finally started making a real paycheck. Steve had gotten a deal on some furniture through a friend and we had stashed it in various neighbors basements until we took possession and had a long weekend in which we could retrieve it all.

The house, as a craftsman bungalow style from 1912, had been designed for one level living with an unfinished second floor. A previous owner had finished out the second floor and then Allan Owen had redone it with a grand master suite (including a shower to die for) but the interior stairwell remained small as it had only ever really been intended to be attic stairs. One of the pieces of furniture we had bought was a large white wood desk. Steve had picked it out as he thought a doctor should have an impressive desk in the home office (the old sleeping porch). The sucker weighed a ton and was large enough to be impractical. Steve and I got it into the house and into the stairwell where we managed to get it wedged tightly between wall and bannister. We couldn’t get it up, we couldn’t get it down, we couldn’t back it out. We asked one of our body building neighbors for help. He couldn’t budge it. We finally had to get out a skill saw and cut the legs off of it to free it. We then reassembled it in the office with a little wood glue. It was so heavy, it didn’t budge. When it came time to move to Alabama, we left it in the house. We weren’t about to have a repeat of the prior incident. For all I know, it’s still there.

I’ll figure out the move thing eventually. It’s really not that high up on my list of worries at the moment. But I remain amazed at my long track record of poor timing in real estate transactions. If Covid had hit six weeks earlier, I wouldn’t have been out looking. If it hit six week later, I would already have moved.

Everybody stay well.

Another Saturday night and I ain’t got nobody. Must be time for the next entry in Andy’s plague diaries. I’ve eaten my gumbo and now I’m finishing up a glass of red wine and eating some cookies that Tommy baked for our last holiday open house together that I found at the back of the freezer. We actually were a tag team in the kitchen when it came to holiday baking. He made the dough; we portioned them out together onto the baking sheets and then I was responsible for rotating them through the oven and getting them out onto the cooling racks. After fifteen of those parties over the years, we had it down to a science and were able to do most of the baking in one long evening, with some favorite music on the stereo and each of us with a glass of wine. Neither of us could foresee that some of those last batches would help sustain me through a viral pandemic after his untimely death. Life’s funny sometimes.

It’s the weekend. I don’t have much in the way of work to do. The few little projects that were left over from the week were completed this morning without difficulty and then I cleaned out all the cabinets in the dining room and felt very accomplished. Most of the first floor has been dejunked and is ready for packing with the exception of the kitchen. A lot of that won’t go. I don’t have the talent to cook for 100 at a time so I don’t see the sense of holding on to huge amounts of cookware. I can cook – I was the cook for me and Steve, but I’ve never been terribly interested in cooking for one. Maybe once I get moved I’ll have a dinner party or two but I doubt I’ll have any of the huge soirees that Tommy and I used to throw.

The number of Covid 19 cases continues to climb, both locally and nationally. We seem to be weathering the surge locally OK from what I can tell. Perhaps the relatively early closing down of things locally is starting to pay some dividends. Fingers crossed and all that. We should know by the middle of April if local health systems will do OK or will be buckling at the strain. I think Birmingham will be OK. I am afraid the combination of poverty and ignorance in more rural parts of the state may lead to some serious issues outside of the urban core.

Today, I’ve been thinking about what comes after. Eventually, even this will pass and we’ll all come out of our isolation and have to confront a lot of changes in our lives: social, political, economic. I read somewhere about the choices that one can make after upheaval. Imagine two tribes on opposite sides of the river after some great calamity. The first tribe, being strong individualists, adopts an every person for his or her self mode of survival with each member trying to hoard as many resources as possible. The second tribe, being more cooperative, come together and share resources and skills to reinforce the group as a whole. Which tribe is likely to position themselves for long term success? I think most of us would agree that the second is more likely to win over time. We have to start laying the ground work of that cooperation and sharing now so we can hit the ground running when society begins to resume.

I threw out an idea today to the local theater community. Once upon a time, there was an uber organization, the Birmingham Area Theater Alliance (BATA) that all the companies supported and which acted as an umbrella. It became nonfunctional in the decline of local theater after 2010 when the 2008-9 crash drove a lot of companies out of business. My thought was that this organization needs to be revived to create a mechanism of cooperation and communication between all the local companies that are likely to emerge from this time in dire financial shape. If everyone hares off in their own direction after funding and resources, things aren’t likely to go well. If there is a large and strong lobbying organization on the behalf of everyone, there’s a greater chance for survival. I am not putting myself forward as organizer or any other such thing. I don’t have the time or energy. But I wanted to get the idea out there because the time to start figuring such things out is now. Not after shelter in place and quarantine orders are lifted.

A lot of people I’ve been talking to have been complaining of excess fatigue and needing a lot of naps, even though they haven’t been doing all that much. There’s a basic biologic reason for that. We’re all marinating in a high stress/high anxiety environment and our sympathetic nervous systems are working overtime getting us ready for fight or flight. However, the current situation is not conducive to fighting (how do you punch out a virus?) or fleeing (where you gonna run? where you gonna hide?). Therefore, it’s switching over to the only other alternative – play dead. We all have to remember, we’ve all got that little lizard brain ticking away deep inside our cerebra and no matter how intelligent or witty we may be, it still holds sway in a very primitive fashion.

I’ve been falling down rabbit holes of reading about new antivirals, large numbers of cell service cancellations in China that belie their official numbers, the conditions of hospitals in NYC, trying to separate wheat from chaff and add to my knowledge base and armamentarium so when I get calls from patients this next week, I can sound somewhat authoritative and reassuring. I may not be able to visit with them face to face easily at the moment, but I remain their doctor and will continue to fight for anything they may need to be as healthy and functional as possible. It’s been my calling for decades now and I’m not backing out.

Stay well.