After being delayed for a year by Covid, specifically the omicron surge of last New Year, the long promised and looked forward journey to London for the New Year has begun. The seven intrepid folk whose common denominator is a background in Birmingham theater circles have all made their way by various routes and redeyes to reunite at the Dorsett Hotel in Shepherd’s Bush. (Holland Park I hear some of you Absolutely Fabulous fans shriek in unison but this is definitely Shepherd’s Bush as the hotel fronts on the Shepherd’s Bush Green on Uxbridge Road.
My personal journey was rather uneventful. Despite the subfreezing temperatures of this week and the complete and utter meltdown of Southwest Airlines, my flight from Birmingham was on time and a reasonable 11 AM hour so I didn’t have to get up at the crack of dawn and stumble blearily through the concourses of Birmingham’s Shuttlesworth International Airport. (A misnomer as I don’t believe an international flight has either departed or landed in the quarter century I’ve been in residence in Aabama.) I met up with old friends, the McMullens who are the other folk still in the Birmingham area and we passed a pleasant afternoon catching up while waiting through a four hour lay over in Atlanta.
That flight wasn’t quite as smooth. I had a prognostication of bad juju when I was stuck on the jetway behind a very zaftig lady who’s idea of proper travel attire was skin tight leggings in a flesh tone so I felt like I was staring at her unclothed derriere for the ten minutes it took to get down the jetway and on to the plane. The flight was delayed an hour for little things like ground crew carrying paperwork away with them and someone having to run fetch it back. But we did eventually take off. And I found myself the only passenger in my row of three seats so I was able to stretch out and doze off and on as we winged our way east.
Deplaning was uneventful at Heathrow although there were still signs of recent baggage handler strikes. There were. piles of luggage standing around in the baggage claim area. The handlers had refused to unload it when the planes landed. It was unloaded some days later, and stacked. Where it has been sitting for some time until the airlines can figure out how to reunite it with passengers long since scattered. I imagine some of them will eventually end up in Scottsboro, Alabama – home of the only thrift store specializing in unclaimed airline luggage.
The weather was pure Seattle when I emerged from the terminal. High forties, gloomy and intermittent showers. A nice suburban was waiting to ferry us from the airport to the hotel as we all straggled in from our flights over the next few hours. First small disaster was finding that I had packed by European plug adapters rather than my British ones. Fortunately the hotel is two blocks away from the biggest shopping mall in the British Isles and that problem was quickly fixed by a trip to Boots, the chemists. Then, as it was still only noon, on to the Underground and off to Central London to do some walking and reacquainting of self with surroundings. This is my fourth trip to London and I know it fairly well but it never hurts to spend some time getting ones bearings again. So walk we did. Oxford Circus to Picadilly, Picadilly to Leicester Square, Leicester Square to Trafalgar. Then down to parliament, the Embakment, down the Mall past Buckingham Palace and a stop at Harrod’s and the food halls before retuning fro nine and a half miles of rambling.
Some dinner and so to bed early, thoroughly warn out to try to sleep my way into the correct time zone. We shall see how I am in the morning.
It’s Christmas Eve again. It rolls around every year around about December 24th whether I’m prepared for it or not. I’m a bit ambivalent about Christmas these days. I think it’s because I’ve had so many wrenching life changes so I don’t feel a lot of continuity in the holiday. And, at least to me, one of the most important reasons for holidays is for there to be a sameness, a uniformity, a tradition that carries on year to year so that we can feel connected to both past generations and those generations yet to come. I had one set of customs with my family of origin, but those have morphed over the years and, as I only make it home for Christmas every few years, most of those changes have happened without my being present for the decisions that have caused them to be implemented. Steve and I developed a different set during our years together. And then Tommy and I developed a completely different set. I haven’t yet figured out what I need to do to replace all of those with something that’s uniquely Andy.
What all of these erratic turns in life has gotten me is bin after bin of Christmas stuff in storage. Decorations bought for different houses and different tastes and different stages of life. No matter how much of it I get rid of or donate to theater companies needing stuff for holiday season shows, I always seem to have more. It breeds like rabbits in the corners and every time I venture down to storage, I find another bin filled with tinsel and baubles of various colors. It doesn’t help that both late husbands were very visual people and fond of holiday decorating. With thirty years between them, I’ve learned a trick or two myself and can put up all sorts of themed trees with a modicum of effort. I just wasn’t able to muster up the energy to do more than my music tree in the living room this year.
For Christmas 2020, the shut down Christmas and my first holiday season in the condo, I hauled all the boxes out and figured out how to put up six trees plus various other decorations. There were no holiday parties or performances that year so I had to content myself with something else. Decking the halls was it. I had a few other people in my bubble so I did have some help getting it all up and in place. I did very little last year as the omicron surge wiped out some plans and allowed me to unexpectedly go home to Seattle for a few days. This year will probably become the norm. One tree, the mantle, a few wreaths… We shall see. If I retire in the next few years, I may make a project of sorting all of the accumulated Christmas crap in new ways and come up with some completely new themed trees of some sort without having to actually buy anything new. I have boxes containing ornaments that haven’t seen the light of day for several decades.
Steve’s parents, especially his mother, grew up poor in rural Indiana. When they escaped the Midwest for Southern California in the early 50s, his mother used her post war prosperity to make beaded silk Christmas ornaments all through the year. Steve inherited several hundred of them, each representing many hours of her labor. We used them on our trees all through our time together. The Christmas after his death, I broke out the box in which they were stored each in their own little baggie. In the bag with his favorite one was a little note from him. ‘Andy – this is the only one I want you to keep. Love, Steve’. I took him at his word. I sent sets to his mother’s sister and cousins. I gave a set to each of my siblings and cousins. I still had plenty left that I used for a few years until I heard from Steve’s long lost niece. I sent her the remainder other than the one he had picked out for me. It’s on the tree in the living room and will always be part of whatever tree I have.
Tommy adored decorating for Christmas. He didn’t like the gift giving and commercialization of Christmas but he was all about holiday entertaining and holiday music. To him, Christmas was about the presence of others and showing them that they were important by feeding them. The first Christmas we had together after he moved in, he went whole hog insisting on the purchasing of a number of trees and swaths of garland. We began our traditions of Christmas Eve dinner and stockings for his family and our soon to become legendary Sunday after Christmas holiday open house. Those last few years, I don’t see how we made it through December. Getting the house ready, family dinner, Messiah with the symphony, prepping and producing the children’s pageant at church, holiday open house, Christmas Eve service. December was a marathon towards a New Years finish line. And then there was the year we were having the house painted in the middle of it and had to do a significant part of it from an extended stay hotel room…
I went to Christmas Eve candlelight service at church this evening. I’m sort of expected to show up when the choir is singing. I’ve always liked Christmas Eve carol services in any denomination. The Congregationalist in which I grew up, the UU to which I now belong. The Methodist and Episcopalian I have attended at various times. There’s something about singing carols that have been sung for centuries by people with the same general hopes and fears that I have that helps me feel grounded in human experience and connected with the world. I’m not especially religious but the nativity with its themes of light and hope in the darkest of times and that new life always brings with it a hope of salvation speaks to my brain on a very primitive level. We need that myth of hope, especially in the times in which we find ourselves.
Tonight’s service was uneventful. The choir sounded reasonable. We’re actually very good for an unauditioned choir without any ringers or paid members. We’re all there because we want to be there. And we have a director who is an excellent musician and who wants us to be the best we can be. And who isn’t afraid to get eclectic with our music selections – tonight’s ranging from a traditional French carol to ‘Holiday Road’ from the National Lampoon’s Vacation movies. It ended with the usual symbolism of candle lighting candle while the congregation sang Silent Night. I always hold my breath at this moment. Fifty years ago, at a similar service, my little brother managed to light the hair of the lady in the pew in front of us on fire with his candle. Her Aquanet went up in a whoosh of flame which my grandmother had the presence of mind to beat out immediately. The startled woman hadn’t a clue what was going on when the woman behind her started hitting her on her head. Fortunately, only her hairspray burned. Her hair and scalp were unharmed.
I have finished all of my must do stuff for the week so I have two days of relative torpor before I get on a plane and fly across the seas for a week. Going into travel diary mode shortly. Until then, Merry Christmas to all and to all a good night and God bless us, everyone.
Three vocal ensembles. Three rehearsals. Three performances. That’s what’s been going on over the last forty eight hours. One was the Messiah (full Christmas section and most of both the Easter and Resurrection sections – 16 choruses in total) with the Alabama Symphony Orchestra. One was a Lessons and Nine Carols (nine choral anthems and nine carols) with East Lake Methodist Church Choir. One was my usual Sunday morning with the Unitarian Universalist Church Choir. Only two choral anthems for this one including ‘You’re a Mean One, Mr. Grinch’ (only the UUs would use that as an anthem in service). Even though I had the bass solo, I felt underused in comparison. Let us just say that I am choral sung out for the season. There is still another rehearsal and a Christmas Eve service with the UUs but that’s going to be a piece of cake in comparison.
I sometimes wonder how I ended up as a choral singer. There was no tradition of it in the family. My father has a nice tenor voice and likes to sing but never sang with any sort of group to my knowledge. My mother was a soprano who would sing in church and with the family but never at any other time. My brother is a decent singer and has been since a very young age and sang in various ensembles when he was in school and has been garage banding off and on during his adult life. He’s also a decent guitarist. My parents strongly believed in developing an appreciation for music in their offspring so we all learned to play an instrument and were taken to musical theater, the symphony, the opera, and other such things from a relatively young age.
I enjoyed musical theater as a kid but it didn’t become a passion until high school. My struck by a thunderbolt moment came in the balcony of the Golden Gate Theater in San Francisco half way through my senior year in high school. We had a Jan term week where you would spend a week exploring some topic in depth over that time and that year, I was on the trip to San Francisco from Seattle (a city I was very familiar with as my maternal grandparents lived there) with a bus load of classmates to take in the cultural sites. Our teacher chaperones bought us a block of tickets to the National Tour of the original production of A Chorus Line. We may have been up in the heights, but that night changed my life. The cinematic staging, the way the story was told as much by the lighting design as by the acting, the honest depiction of gay characters where that was not the central focus of their lives… I don’t think I moved for two hours.
I came out of there determined to learn as much about the art form of musical theater as I could. My high school wasn’t big enough to have a drama program that really did much in the way of musicals so, even though I was heavily into tech theater at this point; all my experience was with straight plays. Back in Seattle, I reapplied myself to learning more about how plays progress from words on paper to a theatrical experience. I stage managed. I built sets. I did costumes and scavenged for props. I got my first chance to direct a one act. I started going to the theater around town more to see what other people did and what was possible with imagination. I did a little performing but I wanted to work with music theater and I didn’t sing. I had never been in a choir or glee club or sung seriously in church. I was pretty sure I couldn’t.
The next year I was off to Stanford and settled into what would eventually become a double science major. But the siren call of music theater would not leave me be. I started off small, helping on some set crews. Then I was asked to direct our dorm play my freshman year because I had at least directed before and no one else had. ‘You Can’t Take It With You’ turned out rather well for a dorm lounge production and some of the more important theater types on campus saw it and decided I had a modicum of intelligence and talent. I was given more and more chances to work on student produced and drama department produced shows and I kept learning. And reading. And studying. And worked my way to the top of the Stanford theater food chain in a few years.
On my return to Seattle for med school, I had the skill set to work my way into the musical theater scene of the mid 1980s. Stage managing, assistant directing, directing for the most part. I made a lot of friends and was slowly starting to climb the ladder. But med school ended and it was back to California for residency. And goodbye to music theater as it simply did not mix with every third night on call. And then there was Steve. Steve put up with my residency and my fellowship and my being gone a couple of nights a week for overnights at the hospital. When that phase ended, he wanted a more settled home life with me. He didn’t want me out at rehearsal every night. I complied. Besides, I had been away from theater for some years and hadn’t established any local bona fides. We made up for it by becoming major theater goers, usually going once or twice a week to something.
I was starting to poke my nose into Sacramento projects and making some friends when we found ourselves propelled to Alabama and, shortly after that, Steve’s illness and death took priority. And here I was, forty years old, widowed, grieving, and with no connections or local reputation. I figured music and theater would be something I would attend moving forward but would have no real space in my life. Surprise. Tommy came into my life from a classical music theater background. He twisted my arm into joining first the UU choir and, some years later, the Opera Birmingham and Alabama Symphony Choruses. He insisted on my taking voice lessons. He told me that my lack of belief in my own singing was just that, a lack of belief and that I simply needed to be taught some rudimentary skills. Something must have clicked for the two of us became mainstays of the local scene within a few years.
Tommy’s death has pushed me into a need to challenge myself and I’ve been auditioning for meatier projects and roles the last couple of years. And sometimes I have surprised myself by actually landing them. The pandemic shut down showed me how much I like singing with others. I’m not really a solo singer. Even with all the lessons and the experience, I don’t have a great instrument. But I’m just fine in ensemble and I can sell a character in musical comedy. (The only roles in the standard opera repertoire I’m right for are Lillias Pastis and Buoso Donati). But I’ll probably stay a choral singer as long as I can read the music and not get lost on my way to stage left. And people seem to like having me around. I suppose it’s because I show up to rehearsal, I’m usually prepared, and I have XY chromosomes.
I suppose I’m living proof that life can change in unexpected and hugely gratifying ways, that you can teach an aging dog a few new tricks, and that you should never say never. Because it’s a very short road from listening to Hotel California on the car stereo to singing choral backup for The Eagles.
“My Covid test was positive”. I’ve been fielding that message multiple times a day over the last couple of weeks. As most of my patients are over the age of 75, their risk for complications and hospitalizations is higher but we’ve been pretty luck so far. Few have been sick enough to need the emergency department and no one has yet needed an ICU bed. It won’t last. I know I’ll lose one of my charges eventually. In the meantime, I and my staff run through our script of how to cope with the virus at home, when to call us, when to head for the emergency room, and we send in the Paxlovid prescription to their local pharmacy. A month or so ago we were getting about one call a week, now it’s ten to twenty so we can tell we’re in a surge even if the media isn’t really covering it.
If you look at the national numbers, the death rate is up about 50% over last month (from about 300 a day to about 450 a day), hospitalizations are up about about 30% from roughly 30,000 to 40,000, and test positivity has crept back up over the 10% mark to about 12%. There’s no particular hot spot when you look at the map, it’s going up pretty uniformly everywhere. If I had to guess why, it’s because it’s roughly three weeks after Thanksgiving and, if you’ll remember our usual pattern, hospitalizations rise two to four weeks after a behavior change. I imagine, going forward into the indefinite future, that the holidays with the travel and gatherings that accompany them, will translate into Covid season and we will tend to see peaks in December and early January for some time.
There is good news. Even though the numbers are up, they aren’t going up to the point that the health care system can’t handle them and we aren’t seeing gurneys parked in tents in the parking lot this year. And, with luck, we won’t be for some time as the pandemic continues to evolve into an endemic phase – a disease that remains part of our environmental landscape but which no longer seems to be ripping our social fabric apart. There have been issues with children’s hospitals and emergency rooms as the tridemic of Covid, influenza, and respiratory syncytial virus have been making the rounds among the younger set. Fortunately, as all students of pediatrics quickly learn, the vast majority of children are pretty indestructible and get better on their own so long term morbidity and mortality have been quite low in that population.
Those who are bearing the brunt currently are the elders, especially those over the age of 75, my population. The vast majority of deaths are within this group and are mainly in those with preexisting chronic illnesses of various stripes. If you’re vaccinated, in reasonable health and under 70, you need not be overly concerned by Covid infection, at least in its current evolutionary form. Mind you it could continue to mutate into something quite different over time, but you need not panic today. Of course, you may want to consider your potential place in an infection chain that could put your parents or grandparents at risk. This is why all my teams continue to mask for clinical encounters.
Personally, I have had two shots, three boosters, and two infections so I figure my immune system is about as primed as it’s ever going to get. I’ll test before getting on an airplane to fly to the British Isles in a couple of weeks. And I continue to keep a mask in my pocket for any situation where I feel things might be a bit dicey. Costco on Saturday afternoon comes to mind… Is the pandemic over? Not really, but we’ve moved out of the acute phase and are settling into a more chronic phase. And it’s not nearly as interesting to write about; although some of the usual suspects continue to provide bang head into the wall moments such as the governor of Florida’s recent announcement that he is calling a grand jury to investigate the CDC for providing ‘misinformation’ about Covid vaccines. Interesting that he feels a need to act there but not against those who were recommending injections of bleach, iodine gargles, or horse deworming paste…
As Covid continues to simmer in this more chronic phase, it’s becoming far less interesting to write about then it was in the past so I’m likely to leave the subject other than the occasional update. I will, of course, return to it with my usual zealotry if there are either major developments in its natural history such as new mutations or late complication syndromes with major implications for public health. It also means that the Accidental Plague Diaries is likely to end in book form after Volume III. And that’s just as well.
It’s giving me some time to actually participate in holiday stuff this year. This week is choral week. Multiple rehearsals for Handel’s Messiah cumulating in one glorious performance on Saturday evening with the Alabama Symphony Orchestra at Alys Stephens Center. I’m also adding to the bass section of Eastlake United Methodist Church choir for their Lessons in Carols and my usual Unitarian Universalist Church of Birmingham is using me for the basso profundo part of ‘You’re A Mean One, Mr. Grinch’ for this Sunday’s service. The UUCB repertoire of anthems is nothing, if not eclectic. Next week is relax week. Pretty much everything on my list with a deadline is done by the 20th. Perhaps I’ll finally get my tree decorated then. I did get it out of the box and up in its place but I haven’t gotten the ornaments on it yet. Part of that is deliberate. With the new cat in the house, I wanted to have it be part of the usual environment before covering it with shiny fragile things and having Binx decide he needs to take a swan dive into it from the piano.
Volume II of The Accidental Plague Diaries seems to be slowly but steadily selling. It and the first volume together make a lovely holiday gift to the readers in your life (hint hint…) I took a set to my dentist’s office last week for the staff. (Due to bad British teeth genes on both sides, I spend a lot of time at the dentist and I’m quite friendly with the staff there). I ended up having to go again this morning as my current temporary crown decided to pop off and go exploring the other side of my mouth a couple of days ago. The receptionist told me she read half of volume one while getting her oil changed and found it hard to put down. Another acquaintance later today told me she was trying to read it during a boring meeting and kept breaking into laughter at inappropriate moments and that she had no idea that the pandemic could be funny. And there you have it. TAPD – providing a little entertainment one reader at a time.
Ava Kofman wrote an article on the for profit hospice industry that appeared in the December 5th issue of The New Yorker magazine. It’s a meticulously researched article detailing some of the more egregious abuses of the Medicare system for hospice payments looking at dishonest recruitment and billing practices, damage done to patients, families and the reputation of the program, and scores of shady hospice programs existing at mail drop addresses. It’s caused a bit of an explosion in the world of palliative care and geriatric medicine. Not because of the immoral and illegal acts documented – every one of us who works in the biz has our own stories – but because of the connecting of the dots to show how the shift of what was a not for profit sector to a for profit sector has pushed even good actors into bad deeds in order to serve the insatiable corporate hunger for profit.
The article begins by detailing some of the shenanigans which went on in southern Alabama after a locally run hospice chain, Hospice South was acquired by Beverly Enterprises, a large national for profit conglomerate, under its AseraCare hospice label. Ultimately, employees at the Monroeville office, appalled at corporate practices, turned whistleblowers leading to a massive DOJ lawsuit which underwent a number of twists and turns over the next decade or so. I’ll let those who are interested read the article. It can be found at the following link. https://www.propublica.org/…/hospice-healthcare….
Reading it carried me back in my career. I first became a hospice medical director in 2001 with Odyssey Hospice here in Birmingham. Odyssey was bought and sold numerous times. It’s current descendent is Kindred Hospice. In 2003, I became the medical director of Hospice South, that was looking to expand into the Birmingham market. It was, small, it was scrappy, and the people who were running the local office and were wanting me to take over the medical end of things, were determined to do things the right way. I accepted the contract and was in place when the agency opened its doors. A year or so later, Hospice South was sold to AseraCare and rebranded. We kept the same staff but we could all feel the corporate pressure to cut corners and to meet admission quotas that weren’t remotely feasible. I refused to do things in any way but the ethical and right way clinically and I and the Birmingham staff pushed back. Ultimately, AseraCare responded by closing the office rather than reduce its profit margin.
I’m in an interesting position when it comes to contract work. As a full time employee and faculty member of UAB, I can take external contracts but they are not made with me as an individual, they are rather made with UAB as an institution. Basically, an external agency can rent a piece of my time from UAB for a price. I don’t set that price, UAB does. I don’t see the money, it’s paid to UAB which uses complicated formulas to determine how much of my time and salary can be defrayed. I am therefore never actually an employee of a hospice or home health agency or case management program that uses my services and they therefore have no real power over me and my clinical decision making.
As the various senior service agencies that used to want my clinical expertise have transitioned to more and more for profit corporate models, I have been edged out. Because of my decades of experience in clinical geriatrics, UAB sets my rates on the high end of the market. The agencies want someone they can get cheaper. They just need a licensed MD and any one will do. I’ve seen more and more medical directors of questionable credentials in play in recent years. They also want people whom they can directly employ and force to toe a line in terms of clinical decision making that will best profit the company. Me with my insulation through UAB has always had the freedom to do the right and ethical thing and the bean counters in the back office haven’t really been able to do much about it other than wave the occasional empty threat in my direction. This is probably why my last hospice medical direction contract ended in mid-2020 and no one has been interested in picking me up since.
To really understand what’s going on here, we have to look back a bit at what hospice is and isn’t. Hospice as a concept was invented by Dame Cicely Saunders, an RN in the UK in the early1960s to treat all the sources of pain in terminal cancer patients – physical, social, and spiritual. She came to the US in 1963 and gave a lecture at Yale medical school outlining her ideas and philosophies which came to be regarded as the founding of the hospice movement in the US. Hospice was slow to catch on, mainly being debated in academic circles until, in 1969, when Elizabeth Kubler-Ross published her seminal treatise ‘On Death and Dying’. This turbocharged thinking about the dying process and symptom relief and changed the cultural conversations. By 1974, Medicare had established demonstration programs in hospice care. It became more widespread with federal funds becoming available and with Joint Commission standards for hospices being developed. It became a permanent part of the Medicare A program in 1985.
Hospice, as originally developed, was a specific program for managing the needs of the actively dying in an interdisciplinary manner. It was presumed that those enrolled would, in general, live no longer than six months, and that a holistic model of care would ease their passage, assist their friends and family, and provide an alternative to fruitless acute care. It was predominantly administered through small agencies run as not for profits, often with religious or public health entity affiliation. Then things started to change. Hospice came on the scene just as the corporatization of American medicine began to take off in all sectors. Its relatively low overheads and steady sources of payment through Medicare started to make them acquisition targets.
Clinically, things were changing as well. The rise of hospice coincided with the HIV epidemic with a lot of previously robust young people requiring terminal care. Hospice learned how to manage medical issues far beyond cancer and it became clear that hospice could provide benefit to many sorts of end stage illnesses – cardiac disease, pulmonary disease, renal disease, dementia. Guidelines were developed on a national level to help hospices and clinicians determine who was appropriate for hospice services and who was not. But here’s where we start to run into clinical problems. Human beings never fit into the nice neat categories that administrators create. At the same time, the enormous increase in the very aged in their late 80s and 90s were overwhelming the systems we have to provide care to the frail elder. Physicians and families would start to wonder why the robust sixty five year old with lung cancer who was still getting out every day and driving to the mall would qualify while the ninety five year old who could not get herself out of bed without assistance but who was suffering from nothing more than the infirmity of age could not. And hospice is an all or nothing program. You’re either in and qualifying for its benefits and assistance (but you give up your acute care treatments under Medicare in exchange) or you’re out and all that is taken away.
In states like Alabama where senior services are practically non-existent, hospice is one of the few mechanisms available to deliver appropriate palliative care for the aged and everyone who works in medicine is aware of that. There’s a push by patients and families and community physicians to qualify marginal people so there’s enough assistance to allow them to stay home comfortably. But then that leads to people being admitted and staying on hospice for years and, if they stabilize because of the extra medical attention, then they have to be discharged for failure to decline, starting up a cycle of decline and readmittance to hospice and discharge when they stabilize again. When relatively easy care patients who are stable appear on the hospice roles, profits go up as they are less resource intense. In a for profit environment, this pushes the system to seek out more of these type of patients and, in unethical hospices, some of the more egregious issues mentioned in the article start to happen. I had one just a few months ago. One of my VA patients, healthy but slightly confused and living in assisted living, was all of a sudden admitted to a hospice without my knowledge. He had no medical problem which would have qualified him. We found out that a hospice marketer was trolling the halls of the facility and having people sign for promises of more help then the usual staff could give them but without real explanations of what they were signing for. We called the hospice suggesting they disenroll him as he wasn’t qualified. They refused. We then called the Medicare fraud hotline. He was rapidly disenrolled the next week.
I always try to do right by patients and balance all of the competing interests – their personal wishes, their family needs, the economic pressures of insurance, Medicare and other payors, my abilities as a physician and a human. It’s just becoming harder and harder to do so as the fault lines uncovered by the pandemic become more and more rigid. How much longer can I keep this up? I don’t know. I’ve made a pledge not to retire during calendar 2023. I haven’t said anything about calendar 2024.
158. It’s just a number, much like any other three digit number. But it’s one that’s going to make a huge difference over the next few decades. It’s the number of medical residents that opted for advanced training in geriatrics this next year. It’s far lower than the nearly 250 from last year (fewer than a hundred of whom were graduates of US medical schools). It’s lower than it’s been for some years leaving the vast majority of training positions (something over 400 nationwide) unfilled. More than half of the training programs across the country have no fellows coming in 2023. This lack of trainees means less hands to do the work. Less people coming up the ranks to provide the specialized clinical care that complicated older people need. And less visibility of the specialty in the health care system making it even harder to attract young physicians our direction.
2023 will see roughly 3.4 million US residents pass from age 64 to 65 and enter their senior years. (There were about 4.25 million babies born in 1958 and roughly 80% of them remain alive). Half of those, at current trends, will be alive in 2043 at the age of 85 or 1.7 million. And these figures remain roughly the same for all of the cohorts five years either way. So, we’re producing roughly one geriatrician for every 10,000 new senior citizens. Even the best and most efficient physicians have difficulty caring for panels of patients much over 2,500 and that’s for a young and healthy population. If numbers like this continue, specialized senior care in this country will collapse. It’s inevitable.
I’ve been fighting the good fight and telling anyone who will listen (and it hasn’t been many) for years about what demographics is going to do to the health system and what sort of things need to happen in order to make geriatrics a more attractive career choice to young physicians. Very little of that work has been done. It doesn’t generate revenue or headlines. And here we are. A rapidly aging population of Baby Boomers, a significant population of Silent Generation in their 80s and 90s still in good health but in need of assistance to maintain that, and a health system reeling from the strains of the pandemic that’s unable to change its entrenched models with any kind of alacrity. A healthcare workforce so burnt out by the last few years that more and more are pursuing early retirement.
I’ve devoted more than thirty years of my life to the pursuit of excellence in clinical geriatrics. I’ve taken care of thousands of patients, trained hundreds of residents, dozens of fellows, lectured to crowds of five and five hundred, and tried to follow the dictum of you save the world one patient at a time. I knew it was an underserved specialty which ranked very low in the hierarchy of medicine when I entered it. In my early years of high energy, I naively thought that I and my generation would change all of that somehow. We didn’t any more than the generation before me or the generation after me has been able to. Usually, when confronted with concrete evidence of how little difference we’ve made like the 158 this year, I shrug it off and move on to the next problem to be solved.
This year, however, it feels different. Maybe it’s my rapidly rushing towards my senior years myself. I keep getting patients with major issues who are younger than I am which is enough to make me feel old and to remind me that we are promised nothing. Maybe it’s the departure of colleagues which has accelerated in the post pandemic era (we had eighteen geriatrics faculty a decade ago – we’re now down to eight). Maybe it’s my continued perusals of demographic charts and constant adjusting to the rapid swings of Medicare policies as the Center for Medicare and Medicaid Services constantly adjusts to both clinical and financial realities. I’m feeling like my major life’s work hasn’t mattered. It’s mattered to individual patients and families, but not in the grand scheme of having made a difference to the world going forward.
But then maybe I’m just hangry because I skipped lunch. Perhaps some chicken masaman can restore my equanimity. At the very least it might give me the energy to haul out the holly and put some Christmas decorations up. But then again, it might just put me into a post prandial torpor and I’ll lie there on the bed watching Netflix and cuddling with the cats. Binx the ghost cat has decided he likes being up on the bed with me and Oliver. He’s even snuggled up a few times and allowed me to pet him. Progress is being made.
If you see my father, wish him a happy 90th. I think he’s a bit bemused by entering his tenth decade as I am from entering my seventh. He remains in good health and does the three things required to maintain it at his age – eat, sleep, and move. And mainly stays away from the one thing that must be avoided, visiting the floor. These days we should probably add handwashing and appropriate vaccinations to the list.
And another long Thanksgiving weekend draws to a close. I’m lying here in bed losing a battle against napping. Perhaps it’s Oliver tucked up against me snoring away. Binx, the ghost cat, will sometimes get up on the bed with us as well but he still won’t come near me and if I make any motion in his direction, he immediately hightails it under the bed for the next quarter of an hour. It’s an improvement over hiding in the fireplace or under the shelves in the guest closet all day I suppose. Someday he may figure out I mean him no harm and am the source of all kitty treats. In the meantime, cat behavior is simply what it is.
Nothing too outrageous happened over my off days. I had two Thanksgiving meals, one with Tommy’s family and one with friends, stuffing myself to the gills and making eating on Friday entirely unnecessary. Good food, good conversation, good company. What more could one want? The rest of the weekend was spent in a combination of torpor, household tasks such as prepping all of my mail out copies of Volume II for a trip to the post office this next week. I also got the family Christmas shopping done so I could put together the traditional gift basket for shipping to Seattle. I have become the dotty old uncle that gives everyone a book. It solves a number of problems when shopping for family whom I do not see all that often: there’s a fairly infinite selection, it’s unlikely to be duplicative, and they’re easy to wrap. This last is not necessarily the least. Wrapping has never been my strong suit. Both Steve and Tommy were quite skilled and could make packages worthy of high end store windows. (Steve’s first career was as the window display designer for the Sears in Santa Monica back in the 1960s). Mine come out lumpy, uneven and dog eared, no matter how hard I try. I did, however learn a few tricks from Tommy regarding the construction of gift baskets. Three bookstores and done. And I made it through my Christmas shopping safe from Whamageddon and Mariah Carey.
I had my first reading today from Volume II at East Lake United Methodist Church as a benefit for their theater program, The Belltower Players (so called as the church building has a rather massive belfry that can be seen from all over that part of town). I’ve been a friend of the church for some years. Someone, I can no longer remember who, suggested I audition for Scrooge in their production of A Christmas Carol some years ago and I’ve been popping in and out ever since, most recently with The Hallelujah Girls this last fall and I am directing Dearly Departed there in January and February of this coming year. The audience was mainly friends so I didn’t have to sell myself, just read and let my words of a year or two ago speak for me. They were very receptive. I’m still amazed at how something I dashed off one evening with minimal thought causes someone to have an emotional response months or years after the fact. Let’s face it, I’m still surprised that these books exist as I had no intention of writing them. If anyone would like to arrange a reading/signing with me as a benefit or just because you’d like to see me appear at your local bookstore, slip into my DMs. I also strongly encourage those of you who want to read this new book to order it through your local bookstore and ask when you order, if they’d get another copy or two and put it on one of their display shelves.
This begs the question of what do I write next? The Accidental Plague Diaries are drawing to a close with the receding of the pandemic in public and social consciousness. The pandemic isn’t over, but the wrenching social changes and huge impacts on health care that marked the last few years have levelled out giving me a lot less to write about on the Covid front. Mind you, we could have a huge resurgence this winter, there could be a new mutation that does something highly unpleasant, or there might be a socio-political development that sends things spinning in a new direction but unless any of these things are overwhelming, I’m pretty much done. There are 790 pages published, an unknown number in Volume III, and when you have over 1,000 pages devoted to anything, you’re just getting repetitive.
I am in the habit of writing 2500-3000 words a week so I think I need to keep that up as a form of self discipline. Do I return to the book on the impact of the Baby Boom on the health care system? (That seems a bit redundant as most of what I was going to say in it came out in The Accidental Plague Diaries in one form or another). Do I take my Mrs. Norman Maine film reviews (sadly neglected these last few months) and edit them into a cohesive whole? Do I try my hand at a work of fiction? If I do, should I write a genre piece (murder mystery? fantasy? romance?) or something more general. My fiction prose tends to be lightly satirical, similar in style to Patrick Dennis or Armistead Maupin, but what would be the subject? Senior living? The social constructs of greater Birmingham? Academic health centers and their internal politics?
There are several things I did not do this weekend despite good intentions. I have not yet broken out the holiday decorations or decided how much of them I’m going to use. I put them all up at Christmas 2020 so I know how to make them work in the condo but the process of hauling all those boxes and bins out of the basement storage and getting things arranged just strikes me as exhausting at the moment. I also have not completed my CME for the year and that must be done before Christmas or the powers that be will come after me with a stick. I know what I need to do to finish them up. I just have to make myself do it. Likely a long dull Saturday afternoon sometime. In the meantime, you all know the drill. Get your booster, wash your hands, complete your licensure requirements.
Backup singer for The Eagles… Not something I’d ever expect to have on my resume, but there you have it. I’ve known about last night’s gig for a couple of months but those of us in the Opera Birmingham chorus who participated all signed non-disclosure agreements and were forbidden to talk about it until after the fact. So now I can sit down and write about and ruminate on what it was like to be part of a major touring concert show. A couple of things to get out of the way: no, I didn’t meet Don Henley or Vince Gill (singing Glenn Frey’s vocals), yes I was paid (medico-legal work pays much better), no I didn’t get to keep the choir robe but I do have my laminated backstage pass on a lanyard as a souvenir.
The Eagles current tour has a big production number at the end of the first act in which Don Henley sings ‘The Last Resort’ which, as the number builds, requires a full string orchestra and a back up choir. It’s a good deal cheaper for the tour to hire these locally at each stop than to pay for thirty instrumentalists and twenty-four singers for several months, not to mention feed and house them. Opera Birmingham got a call from the tour back in September asking if we could provide the chorus. A chance to sing with The Eagles? Getting Opera Birmingham’s name and people in front of an audience of nearly 20,000 at The Legacy Arena? It was a no-brainer and we quickly signed up. Last evening, many of the chorus regulars gathered at the opera offices for a quick rehearsal (eight bars of I-IV-V-I chords on ‘AH’ isn’t difficult to learn) and then caravanned over to the arena.
We were met there by a tour functionary who gave us backstage passes and marshalled us into a large greenroom, later joined by the members of the string orchestra (mainly players from the Alabama Symphony Orchestra) to wait until our cue. We couldn’t see a lot, but when the concert started about 90 minutes later, we could certainly hear it, even if it was a bit muffled by various doors and drapes. About forty-five minutes into the set, the strings were lined up and marched out to their places . We followed about twenty minutes later, dressed in gold choir robes supplied by the tour, winding our way through the bowels of the arena, past the various dressing rooms, craft services stations, wardrobe, make-up, engineering departments and the like. Eventually we came to a loading dock type area full of enormous road cases and foot lockers and a lot of technical types and then were funneled into a backstage area and onto a set of rising platforms.
Hurry up and wait and stand waiting for cue. At the right moments, the platforms with the chorus and the strings rose up behind the band and a dozen cameras started photographing us and projecting us on the huge Jumbotron screen that formed the backdrop. Number reaches climax. We sing our ‘AH’. Number ends. Pandemonium in the house and standing ovation as the audience has recognized locals blown up to forty feet high on screen. Acknowledgement of our contribution from Don Henley and we are lowered back into the depths of the backstage area. Shed robe, collect souvenir merch and we are done.
It was rather an incredible experience and full of firsts. First time to perform for an arena sized audience. First time to perform with an internationally known act. First time appearing larger than life on a Jumbotron screen. Also, as president of the Opera Board of Directors, I am very grateful to have had an opportunity to get the organization in front of a whole new audience, many of whom may not have realized that Birmingham has a professional opera company. We probably reached more new people last night than in the previous few years combined.
The tour was taking standard Covid precautions seriously. Masks on unless actively eating or drinking or on stage. No going backstage into areas you didn’t need to be in. No hanging out with the tour crew other than those responsible for corralling the chorus and orchestra (and after multiple stops, they have it down to a science). A tour like this is a multi-million dollar extravaganza and Covid among the artists would be disastrous.
Generationally, I am in the sweet spot for The Eagles. I was born in 1962. We form our musical tastes generally between ages 12 and 25 (1974-1987 for me). Their Greatest Hits album (the blue one with the bird skull) came out just as I was really discovering pop music. Hotel California came out my freshman year of high school and The Long Run came out my senior year of high school. Their music is very much interwoven with my adolescence and coming of age. Pretty much any of their songs can quickly take me back to a memory of the 70s or early 80s. I’m trying to imagine going back in time and trying to explain to teenage Andy that one day, he would be onstage with that band singing back up vocals before 20,000 people. Teenage Andy would have assumed serious mental illness and looked for the nearest exit. Funny how some of the threads of events and people come and go in the tapestry of our lives.
It’s Friday, the sun is sinking in the West and so we say goodbye to another work week, the last full one before the holiday season begins in earnest. I only have to work a half week next week but I did volunteer to take the clinical call for the long weekend so that those with families and kids wouldn’t have to. I don’t have particular plans for the long weekend. I’ll probably keep up my tradition of doing my Christmas shopping on Saturday during the Alabama/Auburn game when the majority of the population is glued to the television set and the stores are relatively empty. Shopping shouldn’t be difficult. I’ve evolved into that eccentric old uncle that gives everyone books. It just becomes a game of finding just the right title for just the right person.
New books were always one of my favorite things to find under the Christmas tree when I was small. The first Christmas I can remember is the one when I was three (Christmas 1965 for those of you keeping score at home) and there were picture books for me which held more interest than the Tonka bulldozer or the blocks, but maybe not as much as the Viewmaster. I still have a few of my childhood picture books, and many of the good editions of the children’s classics that my father read to me over the years, some of which had been my parents and even my grandparents as children. Reading remains a fundamental pleasure and I try to get through a book or two a month when I have the time and I make it a point to either read or listen to one of the great works of world literature every year that I missed along the way. Recent choices have been Madame Bovary, Anna Karenina, Moby Dick, Barnaby Rudge, and The Mayor of Casterbridge. Next up is Martin Chuzzlewit. I plan to get through all of Dicken’s major works before I die, including the ones that no one ever reads anymore.
Work has been pretty steady without a lot of pandemic issues. There remain a good deal of tangential problems however including short staffed senior care agencies, mental issues in patients and families, worsening disease from delayed care, and general administrative oddness. The biggest problem has been the loss of physician faculty from the UAB geriatrics section. We are down roughly 50% over the last decade and trying to run a similar clinical footprint on half the people is becoming more and more difficult. I don’t know where we’re supposed to get new faculty as no one in US medicine goes into the field. I’ve written extensively in the past as to the reasons why this has happened so I’m not going to repeat them all again. Let us just say there are days where I feel content with work and other days when retirement cannot come soon enough.
The VA system has made a conscious decision to reallocate resources to programs designed to keep veterans out of custodial care and out of emergency rooms so the house call program is gaining rapidly in prestige and finances. We may be able to meet my goal of expanding to a point where every veteran in North Central Alabama who lives within the Birmingham VA catchment area can access house calls within the next two years. I was thinking it would take a decade. I’ll be thrilled if we get the whole thing up and running, taking in the whole territory with strategically placed teams of case management nurses and ancillary services. The biggest obstacle will be in finding qualified and quality team members who are resourceful and motivated to work in the unique niche of home based primary care. It’s very different than working on a ward or in an office. When you enter someone’s home, you’re not the one in charge and you have to respect that shift in power dynamic and learn how to get patients and families working together with you in partnership to improve health and function.
I am getting a new boss at UAB, the new chief of the UAB Division of Gerontology, Geriatrics, and Palliative Care arrives the week after Thanksgiving. He is coming into academic senior care at an, as they say, interesting time. I’ll help him the best I can. I have no idea what his goals or priorities are going to be. I’ll just try to give him the history of the last twenty-five years and let him know what has worked and what has not and why and see what he runs with. It’s hardly the first time I’ve gone through a change in leadership. I’m just glad it’s not me. It’s a very difficult time in medicine and navigating it is not for everyone. I’ll just remain in my own little clinical world saving society one patient at a time. It’s all I can really do.
What’s up with Covid? Well, the pandemic remains unfinished. Cases in Los Angeles are up 50% over two weeks ago. (Thank you Omicron variants BQ 1 and BQ 1.1 which are becoming dominant there). It doesn’t appear that hospitalizations are going up at that same rate but it’s early times yet and hospitalizations are a lagging indicator, usually going up about three weeks after the case rates start going up so we should have a better picture in mid-December. Meanwhile, in New York, the current production of Little Shop of Horrors had to all off a recent performance at intermission as key cast members got sick during the first act and there weren’t enough understudies and swings available to continue. I suppose they could have pulled an Audrey out of the audience. If she had been able to belt out ‘Suddenly Seymour’ without rehearsal, it would have been a real Shirley Maclaine moment.
I’m off to a wedding tomorrow. It’s my first one since the ‘before times’. One of the advantages of my performing arts life is that it keeps a lot of younger people in my social circle so I do still get to go to an occasional wedding and not just have to satisfy myself with pictures of my peers new grandchildren. I’m not sure if wedding etiquette has changed to conform to new social realities in a more virally conscious world. I guess I’ll find out tomorrow. If nothing else, it will give me the excuse of breaking out some fancier clothes. That may help my mood. Time to go put on some Jerry Herman and sing along to ‘Put On Your Sunday Clothes’ from Hello, Dolly!
Another weekend comes to an end with me only having accomplished about half of what I had set out to do. Some of that is due to the never ending stream of electronic health record progress notes I have to write. They take about 15-20 minutes apiece and are therefore impossible to complete during a clinic visit when my attention is supposed to be on patients and their families., leading to a backlog to be finished up over the weekend. This usually takes four to five hours leading to a major dint in my free time. Some is due to my needing to nap every time I sit down and stop moving for more than fifteen minutes. Some of that is due to various social obligations. I’m very good at saying yes to things. Trouble is that means I actually have to follow through sometime down the line.
I’m starting to prep for the show I’m directing after the first of the year, Dearly Departed. It’s another one of those southern fried comedies. It’s darker than the Hope/Jones/Wooten variety, less raunchy than those of Del Shores, and is a favorite of community theaters due to its easy technical requirements and strong characters with a preponderance of female roles. It’s been many decades since I last directed a straight play and we’ll have to see if I remember what I’m doing. I’ve got a visual concept in mind, a way in which I want to approach things thematically, some decent actors on board. I should be OK.
I’ve been watching the hubris of Elon Musk with great interest the last few days. I can’t figure out if he spent $44 billion to acquire Twitter because he wanted to shut it down, if he believes his own propaganda that as an obscenely rich person, he must be smarter than everyone else and every decision he makes must be genius by definition, or if he just stumbled clueless into a business of which he really knows nothing and is trying to figure it out under a very bright spotlight. He obviously did not study the history of the rise and fall of other tech giants such as Yahoo! to see how easy it is to completely muck things up with bone headed decisions and he seems to have the usual right wing misunderstanding of free speech. Free speech means that the government cannot punish you for expressing unpopular or political opinions. Free speech does not mean that every opinion should be given equal weight, especially when some of those opinions are based on misinformation, faulty reasoning, or are pure propaganda. The speed at which Twitter is collapsing makes me think we’re hitting Tumblr 2: Electric Twitterloo territory.
A corollary to the above is the story of Eli Lilly. Musk’s idiotic idea of handing out verified status to pretty much anyone who was willing to fork over eight bucks without actually back checking led to someone posing as the official Eli Lilly account and then tweeting out that their insulin products would be free in the future. It was retweeted and run all the way round the internet in a few hours before it was taken down but not before it tanked Eli Lilly’s stock and sparked a healthy debate as to what Big Pharma in general has been doing with drug prices in general in recent decades. When insulin was first invented and patented in 1923, the inventors refused to profit from it under the belief that the lives that would be saved were more important than their personal enrichment. So why is a drug that was gifted to the world and will be a century old in just a few months costing patients hundreds of dollars monthly? Interesting question. While insulin itself is not under patent, delivery systems, additives, ways of modifying it so as to change its absorbability or distribution in the body are.
Insulin isn’t the only drug where these kinds of games are played. The drug colchicine, used in the treatment of gout, and around since the time of the ancient Egyptians, used to be exceedingly cheap. The trouble was, that the drug was so old that there had never been any real scientific study of its effectiveness. The FDA was going to take it off the market as unproven until a drug company stepped in, did some studies, and showed it worked as expected. The FDA then allowed the company to exert patent rights over colchicine and it is now their exclusive and proprietary property. What was pennies is now many dollars. The common asthma drug, albuterol, had a similar fate. It was generic and cheap for quite some time. When chlorofluorocarbons were banned as aerosol propellants due to the destruction of ozone a few decades ago, that covered albuterol inhalers. The propellant in the cannister had to be changed. As the delivery system was now ‘different’, it allowed pharmaceutical companies to reclaim exclusive rights and it went from cheap generic to expensive brand only overnight.
Covid numbers, both locally and nationally, remain about the same. That’s not necessarily the same with international numbers. There’s been a significant increase in China with their autocratic government imposing more lockdowns and restrictions to bring things back under control. As several of the important industrial cities are included, this means that we will likely continue to have issues with the supply chain of manufactured goods for the foreseeable future. If you need to replace any of your consumer electronics, do it now. My next out of the country trip, coming up in about six weeks, is to the UK. They’re numbers remain relatively low so hopefully there won’t be any serious issues with that trip coming off, having already been delayed by a year.
Time for me to get up from my writings, get dressed, and head out to the next social obligation. A fundraiser for a local theater advertised as a sneaker ball. Dress formally but wear sneakers. I think I can handle that. I’m also wearing hand sanitizer and have a mask in my back pocket should I not like the ventilation available at the venue.