Category Archives: Society

Using Social Media in Moderation

True love. Image by © Zero Creatives/cultura/Corbis
True love…
Image by © Zero Creatives/cultura/Corbis

I’ve been backing off from social media recently. For someone who writes a blog as well as publishing medical apps this may appear to be a risky tactic. In truth this retreat has not been completely voluntary. Something known as “real life” has been seeking my attention and gotten in the way of my online life interactions.

My fascination with social media has always fallen into the “love-hate” category. Maybe “addiction” is a more apropos word than fascination.  Social media addiction has supplanted the previous generation of technological addiction, television. Probably a similar fascination or addiction existed when radio was the dominant medium, but I don’t go back that far. The first reaction to television was amazement: “wow, there are moving pictures on the screen.” It didn’t matter that there were only 3 channels in black and white (later expanded slightly by adding fuzzy, low-budget local programs on UHF).  Nightly TV viewing became a dominant part of American life in the 50s and 60s. With cable, the number of channels rose, but the signal to noise ratio decreased. TV viewing, passive and mindless to begin with, only got more passive and more mindless. Yet the TV addiction, once begun, could not be shaken, at least not until a stronger drug/soporific became available. I’m afraid that stronger drug is social media on the Internet.

Just as voices decried the huge number of hours that the average American sat in front of the TV set in the past, so too some voices have expressed concern over the tightening grip of social media. There is a lot of good that social media does. It brings together geographically separated folks of similar interests. It is much more active than watching television: people text, message, tweet, post, and blog. But by the same token it is much more seductive — and more readily available, now that everyone carries a smart-phone. Despite social media’s mostly bland and not terribly informative content, withdrawal is difficult. There is anxiety about missing interesting tweets or Facebook posts. By nature of  the sheer volume of social media output, the occasional stuff that you might be interested in gets buried in the background noise of cat and baby pictures. So you end up either checking your Twitter or Facebook feed several times a day or living in fear.

Yet somehow the world went on before this torrent of social media posts, and we were none the poorer for its absence or at least living in blissful ignorance of what we were missing. It depresses me to see people walking down the street with their faces buried in their phones, or seemingly talking to the thin air, ignoring what is going on around them; or two people at lunch, staring down at their phones, not talking to each other. How social is social media if it actually decreases our sociability with each other in real life? I am not a Luddite and I don’t want social media to go away completely. Maybe just sometimes. Let’s not lose the delight of person to person conversations over dinner or lunch.  Taking a break from social media, whether due to life events, being out in the middle of the ocean somewhere away from WiFi, or just voluntarily chosen, can be a refreshing, mind-clearing act.  And the real world has a higher pixel density than your iPhone screen.  Take a look!

Mr. Toad’s Wild Ambulance Ride

Another Mr. Toad.  Picture in public domain.
Another Mr. Toad. Picture in public domain.

(Another American health care fable)

The ambulance siren wailed loudly and the madly rushing vehicle careered through the narrow streets. Time was of the essence, as is always the case when a life is in danger.

The occupant, the center of attention of the concerned paramedics, grasped the side-bars of the stretcher. The violent gyrations of the speeding ambulance weren’t helping the pain in his chest or the rapid pounding of his heart.

Just a few minutes before, he, Joseph Toad, a 60ish wealth manager, aiming for retirement in a couple of years, had been at a Starbucks near his office downtown, drinking coffee and waiting to meet a client. Little did he know that events out of his control were about to coalesce into a “perfect storm” of platelet adhesiveness, inflammation, and hypercoagulability. It was Monday. It was morning. He was male. He was 60ish. He had a Type A personality. His father had died when 60ish of a sudden heart attack. He had a big, stressful appointment with an important client coming up. All risk factors for coronary thrombosis. And so it happened.

The ambulance arrived soon after the Starbucks baristas made the 911 call. Electrodes were applied, IVs were started, nitroglycerin was given. The pain in his chest was still sitting there, like the proverbial elephant. It was imperative that he be brought to a hospital in short order.

Despite his chest discomfort, the seemingly reckless ambulance ride was taking even more of a toll on his nerves. “Slow down!” he suddenly shouted.

One of the uniformed paramedics turned to him. “Don’t worry,” he said, glancing up at the rapidly beeping cardiac monitor. The hint of fear in the tone of his voice did little to allay Mr. Toad’s concerns. “We should be at the hospital soon,” he added, trying to be reassuring.

“I’d like to get there in one piece,” Mr. Toad said in a mildly reproachful, joking manner. To take his mind off both the wild ride and his chest pain, he sought to continue the conversation with the paramedic. “Why is it taking so long to get there? We surely must have passed some hospitals by now.”

“Well…no,” replied the paramedic, whose name Mr. Toad could not make out on his name tag. “I think if you’ve lived in this town for any length of time you’d know that all four hospitals are located in the East End of town, within a quarter mile of each other.”

“I hadn’t given it much thought,” stated Mr. Toad. He himself lived in the East End. It was the wealthy part of town. Of the competing hospital systems in town, all had wanted to locate their hospitals closest to those clients who had the best insurance, and the greatest ability to co-pay. Being a wealth manager by profession, this strategy certainly made sense from the economic, if not humanitarian point of view. Mr. Toad briefly cursed the bad luck that had led him to have his heart attack while downtown and not at home, close to a hospital.

“Wait!” he exclaimed, struck by an idea. “What about the University Hospital? It’s downtown. It’s closer.”

Both the paramedics next to him snickered a little at this suggestion. The one who hadn’t spoken yet said, “I’m sure you wouldn’t want to go there. You are nicely dressed and trust me you wouldn’t fit in with the clientele at the University Hospital. Patients there are over 90% Medicaid, Medicare, or indigent. You wouldn’t fit in at all.”

“Besides,” the other paramedic chimed in, “our ambulance service has a contract with several of the Big Players in Healthcare in this town. We’re better off going to one of their hospitals.”

“Better for whom? Me or you? I’m the one with the heart attack!” shouted Mr. Toad. This wasn’t good for his blood pressure, which was rising.

“Whoa, sir. Calm down. My partner here is going to give you a little shot of morphine. That should help relax you and help you with that pain. Your condition looks pretty stable at this point. You will be better off taking a little longer ride, since the East End hospitals have state-of-the art heart cath labs, state-of-the-art equipment and state-of-the-art doctors. Door-to-balloon times are as short as anyplace in the country. At the University Hospital you would be treated by docs just out of medical school, or still in medical school. They probably wouldn’t take you to the cath lab at all. Maybe they’d just give you a thrombolytic, you know, a clot-buster. But that usually doesn’t work. And then you’d be in some ward with four other people, homeless types. And no TV.”  While he was talking the other paramedic prepared the injection and then gave the morphine through the IV.

Mr. Toad calmed down somewhat, though whether it was from the medication or the paramedic’s attempts at reassurance he couldn’t be sure. It still bothered him that by going to a more distant hospital there might be more of a risk of his dying during the ambulance ride. But he supposed they had all the equipment to revive him here in the ambulance if needed. Being a wealthy man he did admit to himself that he would prefer a private room to being in an open ward, and he knew that in the long run he would get better care if he got it in one of the fancy East End hospitals.

For a while he was silent, lost in his thoughts. The pain was not gone, but was down to a 3 out of 10, to use the pain scale the paramedics had taught him. The ambulance sped onward…

One of the paramedics was talking into a microphone. “What’s going on?” Mr. Toad asked.

“We’re radioing ahead to the EDs, you know, the emergency departments,” the other answered. “Sometimes one hospital cath lab is occupied, or there is a bed crunch and the hospital is on divert. Since we have a choice of four different hospitals, and they are all within a block of each other, we have a lot of options.”

“And I suppose you are letting them know my condition.”

“Well, they know you’re having a STEMI — that’s a serious heart attack — and, believe me, they know what they have to do.”

Again Mr. Toad felt reassured. They had to be close to the hospital now, and relief from his pain was probably not far away. Now that it was almost over, the long ambulance ride probably had been the right thing to do after all.

“Problem?” one of the paramedics asked the one at the radio.

“Yeah. Sts. Elizabeth and Bartholomew has closed off one of their cardiac units. They’re upgrading their TVs to 60 inch screens. They’re full and begging us not to stop there.”

“Too bad, probably shortest door-to-balloon time there, but check with Latter-Day-Saints, Haussmann Plaza, and HumanCare.”

Mr. Toad wasn’t really medically savvy, but realized the door-to-balloon time had something to do with how quickly his heart attack could be relieved. He knew that somehow the doctors used a catheter to put a balloon in the blocked artery and blew up the balloon to open the blockage. They then would place a metal stent to keep it open. He had watched something about this on the Discovery Channel, never realizing the information would apply to him.

There was no cause for alarm, but he found the morphine was wearing off, and his pain level was now a five.

“Damn!” the radio-operating paramedic exclaimed. “HumanCare is on divert too. Apparently they’ve been overloaded because of the shut down unit at Saints E and B.” The other paramedic also cursed under his breath, and quickly moved up to the little window at the front of the cab, where he communicated this information to the driver. In response, the vehicle braked suddenly and changed course.

“Heading around the block. Still have a couple more choices,” he informed his patient.

There wasn’t enough time to radio ahead, as they had already arrived at the Haussmann Plaza Hospital ED. The doors at the back of the cab flew open and the paramedics prepared to slide Mr. Toad’s stretcher outside. Looking out the open doors, Mr. Toad could not help but be impressed by the view — despite his mounting chest discomfort. Was it a 7? An 8? He began to wonder what difference it made. Still the view grabbed him and distracted him from his pain somewhat.

Haussmann’s was a glittering glass spire, the newest and most modern hospital in town. He remembered reading about it in the paper. It had the works. All private rooms of course. Amazing views out the huge windows. A huge ornate chandelier of Venetian glass adorned the spacious lobby. World famous chefs manned the wonderful kitchen where gourmet meals were the routine. Huge wall-mounted flat screen TV sets, with hundreds of channels, first run movies, and interactive video games. Free wifi Internet service. And, in addition to state-of-the-art traditional medicine, Haussmann’s also provided access to popular forms of alternative, or, as they termed it, complementary medicine. This included non-traditional remedies such as St. John’s Wort, Ginseng, ground up shark fins, and many herbs and spices, as well as treatments using acupuncture, chiropractic, homeopathy, naturopathy, and basically any -opathy the patients wanted. Holistic healing was the name of the game at Haussmann’s. Mr. Toad, thinking of the amenities, was happy he had ended up here.

“Whoa! Whoa, whoa, whoa, whoa!” someone shouted.

“What?” shouted back one of the paramedics.

“Didn’t you guys call ahead? Didn’t you hear?”

“Hear what?”

“Man, the Food Network’s here today. They’re filming an episode of Cupcake Wars right here in the hospital kitchen. They’re got the hospital Chief Chef on as one of the three judges!”

“Yeah, so?”

“So the place is shut down until tonight. In other words, we’re on divert big time right now. In fact, one of the show’s producers is taking some outside shots and wants your ambulance out of the picture, pronto.”

“Listen, we’re got an acute STEMI in here and he’s not thriving, if you know what I mean!” shouted the paramedic.

“Listen yourself. There’s a bunch of other hospitals within walking distance. Now shove off. Bobby Flay’s around here somewhere and he’s not going to be happy to see you.”

In a matter of seconds the paramedics had jumped back into the cab and the doors were shut. The ambulance took off with a screech of its tires.

“Hotchelds,” the two paramedics said, almost simulataneously.

“What?” muttered Joseph Toad. He was feeling a little dizzy, like maybe he was slipping into shock. He didn’t know what was going on, because he wasn’t a doctor, but he didn’t feel good.

“Hospital of the Church of the Latter Day Saints,” one them said. “It better not be on divert.”

“You going to call ahead?” one asked the other.

“Nah, what difference would it make. We don’t have any other options. And here we are already anyway.”

Once again the doors flew open and this time Mr. Toad was out of the ambulance before anyone could object. In moments he was inside the Emergency Department. The two paramedics were rapidly talking to a triage nurse. The nurse took down a few notes and then came over to Mr. Toad.

“Hello I’m Nurse Kelly, the triage nurse. I hope you’re having a good day. Tell me what hurts.”

“It’s my chest, nurse. It’s been hurting for more than an hour now. It’s taken a long time to get here because the other hospitals were on divert, and I’m worried my door-to-balloon time is going to be too long.”

The nurse smiled. “Oh, I wouldn’t worry about that. The door-to-balloon time only started when you went through our door, which just happened. It’s supposed to be under 90 minutes, so we still have plenty of time.” She brought up her clipboard and a pen. “There is some paperwork we need to complete, some documents and consents you need to read and sign, and we need to make you fully aware of this hospital’s compliance with the HIPAA law.”

“Please, nurse, get me a doctor right away,” Mr. Toad begged. “I think I am dying.”

The nurse looked serious. “Of course that is very serious. I always get worried when a patient says they think they are dying, because, nine times out of ten, they do. It’s like some kind of self-fulfilling prophecy. Look, we’ll skip the unimportant paperwork until later. I just need one crucial bit of information from you.”

Mr. Toad did not look good, even to a lay person. His skin was gray and clammy. His heart rate which had been fast was suddenly slowing down markedly. His pain felt like something trying to burst out of his chest, like the monster in the movie Alien. Weakly he responded to the nurse. “Anything, anything you want. But quickly please.”

“Of course, sir. Do you have your insurance card with you?”

Mr. Toad groaned, but somehow was not surprised by the question. He managed to pull his wallet out and get the card out. He handed it to the nurse.

“Oh,” she said. “Oh, oh, oh. This isn’t looking good.”

Mr. Toad thought she was referring to his condition, but she wasn’t.

“I’m sorry sir. You should have informed the ambulance personnel what insurance you have. We pulled our contract with National Happiness Insurance a month ago. They wouldn’t come to our terms in the contract negotiations. It’s a tragedy really. I had a lot of very nice patients with that insurance.”

Mr. Toad was speechless.

“But, good news. There are 3 other hospitals within a quarter mile of here that take National Happiness. According to federal law, in this situation our duty in the Emergency Department is to stabilize the patient so that he or she can be transferred to a facility that can provide longer term care.” The triage nurse took a quick gander at Mr. Toad, who at this point was beginning to lose consciousness.

“Good Lord, we don’t want an arrest on our hands.” She waved to the paramedics who were still there, having a cup of the awful ED coffee as was their usual practice after dropping off a patient.

“You there. We don’t take this man’s insurance. He can’t stay here.”

The two paramedics rushed over, grabbed the stretcher, and in a moment Mr. Toad was back in the ambulance. The third paramedic, who was the ambulance driver, started the engine and turned the flashing lights and siren back on. One of the other paramedics moved up to the little window that connected the cab of the ambulance with the driver’s compartment.

“University?” asked the driver.


Futurama Revisited

GM Futurama exhibit 1964 New York World's Fair
GM Futurama exhibit 1964 New York World’s Fair

Fifty years ago my parents took me to the World’s Fair in New York. The year was 1964. I was twelve years old. It was a turbulent time in American history. The prior fall John F. Kennedy had been assassinated, initiating a long period of turmoil for the United States.  But it was still the era of America’s post-war technological greatness. The country was gearing up to fulfill Kennedy’s vision of a manned flight to the moon before the end of the decade. Products were still made in America, and we used the phrase “made in Japan” as a joke to mean something cheap and junky. People had savings accounts, and there were no credit cards. At the same time, racial discrimination and segregation were widespread. There was cringe-worthy sexism present, as anyone can tell by watching movies or TV shows from that era. There was no Medicare. US poverty levels were at an all time high. Lyndon Johnson and Congress went on to address some of these issues with the Civil Rights Act and the Social Security Act of 1965 which created Medicare and Medicaid. Johnson declared the War on Poverty in 1964 and poverty levels did fall. At the same time an undeclared war in southeast Asia was to cast a large shadow over his legacy and over the lives of boys turning 18 through the next decade.

Nevertheless it was a beautiful warm summer day when we visited the Fair. I remember the day well. Having devoured the Tom Swift, Jr. books and then science fiction of the 3 grandmasters, Asimov, Clarke, and Heinlein, I was filled with boundless optimism about the future of technology. The Fair was crowded with Americans that didn’t look much like Americans of today.  Neatly dressed.  Thin.  I was old enough to notice the pretty teenage girls who were just a few years older than I, working summer jobs at the fair. I remember riding up the elevator in one of the saucer-like observation towers (you know them, they play a prominent role in the movie “Men in Black”) and shyly eying the cute girl seated on a stool operating the elevator controls. Yes, for you younger readers, elevators used to be manually operated. The fair made a lot of predictions, but I don’t think automatic elevators was one of them.

The General Motors pavilion was aptly named Futurama. There is a YouTube video showing what it was like. I waited expectantly in the heat in a long line that stretched around the rectangular concrete windowless building. Inside we sat on cushioned chairs that automatically moved through the exhibit. There were vistas of a technologically rich future. Spacecraft exploring the moon. Scientists controlling the weather from a station in Antarctica. And in the environmentally naive outlook of that era, large machines cutting down rain forests to build roads to deliver “goods and prosperity.”

This exhibit was a highlight of the fair. Afterwards we went to the General Electric pavilion where we witnessed a demonstration of nuclear fusion (was it real? I honestly don’t know, and the Internet is vague about it). There was a loud bang and a bright light.  All very impressive, especially at my young age.

There have been a number of recent articles (e.g.  here, here, and here)  about the Fair and about which predictions it got right and which were wrong. Curiously there weren’t any predictions about medical science that I remember. Maybe I wasn’t paying attention. I think I wanted to be an astronaut back then. Pacemakers were brand new and digitalis and quinidine were staples for treatment of abnormal heart rhythms. The huge advances in medicine that were to come between now and then could not even be imagined.

I remember there was some stuff about computers, but at the time a single computer with less memory and processing power than that in my cell phone filled a large room. And yet it’s amazing that level of computing power was able to get us to the moon. The thought that everyone would carry their own personal computer/communicator in their pocket was pretty far-fetched. A few years later in Star Trek Captain Kirk would use something that looked like a flip-phone, but gosh, no capacitive touch screen! It did have a neat ring tone however.

The networking together of the world’s computers (aka the Internet) was certainly not predicted. Having the knowledge of the world a few mouse clicks away is probably the most significant advance of the last 20 years or so. It has altered our lives, I believe mostly for the good (except when I read YouTube comments), in a fashion unimaginable 50 years ago. I’m disappointed that the exploration of space didn’t turn out as predicted. Where are our moon colonies, or our base on Mars? But I’m happy with the way the Information Age has turned out, and I wouldn’t trade my ability to spend an evening browsing Gigliola Cinquetti videos on YouTube for anything.

The social changes that have occurred since then have been significant and generally for the good. Communism has been marginalized and the threat of nuclear war diminished. Religious fundamentalism remains a thorn in the side of humanity, as it has always been. Certainly there is still sexism and racism and we have further to go in correcting social injustice. But if I had told my dad back in the 60s that the United States would elect a black president, I’m sure he would have said something like “That’ll be the day!”

In the Catacombs of Paris

DSC01235One night many years ago I was driving my son Kevin to a hockey tournament in Casper, Wyoming. It was winter and Denver had been hit by a snow storm. Although I had left Denver at a reasonable time, the traffic was very slow, so we didn’t arrive in Casper until very late. At about 1 in the morning, on a lonely road between Cheyenne and Casper, we stopped the car to get out and stretch our legs for just a few moments. It was very cold, certainly less than 10 degrees Fahrenheit. The sky was clear and moonless. There were no lights anywhere. We were miles from the nearest town, and there were no cars on the road at that hour. We looked around us, then looked up.

Persons who live in the city or the suburbs never really see the stars. In the city, you may see the planet Venus and some of the brightest stars, like Sirius. In more rural areas the constellations are outlined, and there is a faint glow from the Milky Way.

At 1 AM in the dead of winter in the middle of nowhere in Wyoming, the stars literally blazed in the sky against a pitch black background. There were more stars than I had ever seen before. Stars between stars, and fainter stars between them. Fuzzy blurs of nebulae. The Milky Way, the edge-on appearnce of our own galaxy, which always looked like a faint haze before, was ablaze. The colors of the stars were unmistakable, from incandescent white to electric blue to fiery red.

Standing there, facing infinity, I could not escape the plain evidence of my insignificance compared to the vastness of the Universe. The experience was overwhelming. It’s unfortunate that people rarely see the stars like that. Realizing our place in the Cosmos helps put into perspective how unimportant our petty problems really are.

DSC01241I visited the Catacombs under Paris today. Underground Paris there is a vast network of mines that were used to obtain the gypsum and other material from which the city was built. The mines are ancient, dating from the 13th century, and, except for the Catacombs, are off limits to the public; in fact it is illegal to enter them. It is estimated that they extend for at least 280 km below the city, though no one knows their true extent. The Catacombs are located in one part of these mines. They stretch for 1.7 km. They are filled with bones. In the late 18th century, Paris’s cemeteries were in disrepair, with burial grounds collapsing. A decision was made to move all of Paris’s dead to the underground mines, creating the catacombs.

It is a bizarre and eerie place. The Catacombs are located deep below the level of Metro tunnels,  just above the water table, in a geologic stratum known as the Lutecien, which dates back 40-48 million years, when Paris was covered by an ocean. Chamber after chamber are filled to the brim with bones.  The bones are neatly stacked, femors alternating with skulls in grotesque patterns. The number of the dead is estimated to be between 6 and 7 million.

DSC01240Looking at these anonymous bones, it is impossible not to have a feeling of smallness similar to that I had that cold starry night many years ago. Each bone belonged to a human being who was born, was a little baby, ran around with his or her friends as a child, grew up, had friends, enemies, neighbors and loved ones, and then died. Each one had a name, now forgotten. Each had hopes, dreams, ambitions, misery, pain, happiness — everything that makes us human. All the things that undoubtedly seemed so important to these people are forgotten and of no importance today. Maybe some were my ancestors (I do have some French antecedents). Maybe a particular femur or skull I saw belonged to someone who married someone which made it possible hundreds of years later for me to be born. It’s all very sobering.

Emerging from the Catacombs, the sun was bright, the sky was blue, and the hustle and bustle of Paris had not missed a beat. In one sense the Universe is unimaginably vast and we are very small, here for just a few heart beats and then gone. In another sense the Universe is just an electrical pattern in our brains, and these electrical patterns, that is, our minds and thoughts, are all that we really experience. When I die the Universe will cease to exist from my point of view, since unfortunately mine is the only point of view that I actually experience.  Maybe our activities among our fellow human beings who happen to live at the same time as we do will not make any difference to anyone hundreds of years from now.  Viewed from a cosmological context, nothing seems to matter.  Viewed from the context of a person living in the here and now, our interactions with each other are weighty and important, at least to us.  But seeing as we are all going to end up like the denizens of the Paris Catacombs one day, maybe we should try to be nicer to each other while at the same time not worry too much about our mistakes.

1984 in 2014


I am rereading George Orwell’s 1984.  The first time I read it was in the 1960s.  Reading it again I wonder if he shouldn’t have titled it 2014.  The book is closer to reality now than it ever was.  No, we don’t have a dictator named Big Brother looming over us.  But the ubiquitous electronic surveillance that the book describes has come to pass.  In Britain there is one video surveillance camera for every 11 people.   In the United States the National Security Agency (NSA) has been reauthorized by a secret FISA court to continue recording “meta-data” on all cell phone calls within the country.  It has been revealed that the NSA has been recording all voice calls (including those of Americans traveling or living abroad) in at least one foreign country and has plans to expand the program.  On the corporate front, Google scans my Gmail and search history and presents me with targeted ads.  I voluntarily disclose personal information on Facebook and Twitter.  The IRS knows all about my finances.  My medical records are all digitized and stored in computer servers.  My photos and documents are somewhere in “The Cloud” which sounds better than the reality: on some hard drive on some web server in a location unknown to me, tended by strangers.  My life has been encoded into ones and zeros stored on computers scattered across the globe, and everyone wants a piece of the action.  We have all allowed this situation to develop haplessly, many even welcoming these changes as a necessary response to the attacks of 9/11/2001.  The government was able to take advantage of the fear engendered by these attacks to chip away at our Fourth Amendment rights to protection from unwarranted search and seizure of property.  As Orwell says, from the point of view of our masters, IGNORANCE IS STRENGTH.

The Heartbleed Bug is a reminder of our vulnerability.  He who lives by the sword dies by the sword.  Software is powerful but it is also fragile. We have put all our information into one basket, and, to mix metaphors, Heartbleed revealed it is a leaky basket indeed.  There are bad guys out there who want our data.  My website gets attacked daily with brute force attempts to log in by guessing my password.  I know this because my security software automatically notifies me and blocks the attacking site.  My site has been successfully hacked in the past.  It is a constant battle keeping one step ahead of the attackers.  If you run the program Wireshark which inspects data packets arriving to your computer from the Internet, you can see that brute force password attacks are happening all the time.  And if this happens to a minor target like my website, then more important sites are even more heavily bombarded.  With results.  Witness the Target credit card breach.

Now that all our private medical data has been or is being transferred to electronic form due to government mandates in the US, how safe is it from attack?  I think you know the answer.  Unlike Heartbleed which was a vulnerability in an open source implementation of the SSL protocol, medical electronic health record (EHR) systems provided by EPIC, Allscripts, Cerner, and others are proprietary systems, with closed-source software, not open to review by outside experts.  The Heartbleed code, being open source, was readily reviewable by anyone, and despite this the flaw in the code was not picked up for two years.  Are there flaws in the coding of EHR systems?  As all software has bugs, the answer is undoubtedly yes.  Could a large medical information breach happen akin to the Target credit card breach?  Certainly.

It is frightening to consider the economic value of the medical information that these various private EHR companies are sitting on.  Wouldn’t a potential employer want to know about your history of depression?  Wouldn’t the drug companies love to know what’s in these database files?  Targeted drug ads, anyone?  After being sent home from the hospital following a myocardial infarction, will my Google search page include ads for the latest anti-platelet drug?  There are plenty of companies who would pay a lot of money for this kind of information.  Could your EHR company sell your data?  Not legally, at least not now.  But the data could be stolen and sold.  And, given how the US has become more and more ruled by corporate interests, I wouldn’t be surprised if the selling of your private medical information does become legal some day.  You did read that EULA thoroughly before clicking on the OK button when you signed into your doctor’s office, didn’t you?

In the 1960s television series, The Prisoner, Patrick McGoohan proclaims “I am not a number, I am a free man!”  Like the book 1984, quite prophetic.  Even the tiny video cameras of the 1998 movie “The Truman Show” have come true with cell phone cameras everywhere.  We are a nation of voyeurs and exhibitionists, watching our reality shows and posting everything about ourselves on Facebook.  Giving up our privacy is partly self-inflicted but also the result of data collection by Big Brother in the form of government and big business.  In 1949, when 1984 was published, the technology didn’t exist to implement the invasion of privacy he envisioned.  In 2014 that technology is here and the genie is out of the bottle.


The Root of All Evil

The Tower of Babel
The Tower of Babel

Imprecise language may not be the root of all evil, but it runs a close second. The ability to communicate may be the most basic characteristic that makes us human. If we lose that capability, all sorts of unintended consequences ensue, à la the Tower of Babel.  Which brings us to the recent US Supreme Court decision, McCutcheon vs FEC, overturning limits on aggregate federal election funding.  Chief Justice John Roberts wrote “The government may no more restrict how many candidates or causes a donor may support than it may tell a newspaper how many candidates it may endorse.”   In this ruling the exchange of money has become synonymous with freedom of speech and of the press.

Imprecise speech is sometimes related to tendencies people have to overgeneralize or to use euphemisms so as not to offend.  But it can also be used to advance an agenda or just plain distort the truth.  Just as atheism is not a religion but the lack thereof, and the fact that there is a theory of gravity does not mean that gravity is just a theory,  so money is not speech.  Speech refers to words coming out of people’s mouths, and, by the slightest stretch, those same words written down. When the Supreme Court in 1989 decided that burning a flag was a form of speech, the floodgates of overgeneralization were opened.  I am not against protecting non-verbal and non-written forms of expression under the law. I think they should be protected. I can understand that it’s a lot of trouble to write a new law saying art or music or flag-burning is a protected form of expression akin to speech and expect it to get passed. It’s a lot easier just to interpret the existing First Amendment to cover these particular cases. But once starting down this path, it’s hard to know where it stops. Language becomes devoid of meaning.  Fuzzy language begets fuzzy math.  One plus one can equal three, a corporation is a person, and the exchange of money is a form of speech, protected under the First Amendment.

In the US Constitution it is apparent the founding fathers understood that money was not the same thing as speech.  The Constitution talks a lot more about money than it does free speech and does so in different contexts.  Words for money (money, commerce, revenue, tax, coin, dollar, treasury) are used 30 times in the Constitution.  Words for speech (speech, debate) are used only 3 times. In fact, the First Amendment is pretty much all the Constitution says about speech:  “Congress shall make no law … abridging the freedom of speech.”  It’s not as if the founding fathers ever confused the two concepts. Perhaps the founding fathers would have responded to this Supreme Court decision equating money and speech with the immortal words of Inigo Montoya: “You keep using that word. I do not think it means what you think it means.”

Now that money and speech are the same, so that giving vast sums of money to politicians is just a form of protected free speech, not implying quid pro quo, I wonder if our beloved politicians, the incorruptible beneficiaries of this largesse, will ease up on the laws that prohibit gifts to others. Maybe we doctors will again be able to receive a free pen from a drug company without the suspicion of quid pro quo.  After this Supreme Court decision, how can the pols make laws regulating any donations of money or goods to any professionals, when they themselves are not subject to such regulation?

It may be that I am not crediting the court with enough guile. There may be method to their madness. Perhaps they came to this decision just to show the reductio ad absurdum of equating money and speech, with the intent to force us finally to change our non-democratic plutocracy into something more equitable.  It would be wonderful if this decision effected changes in campaign financing and lobbying laws. Otherwise we are sliding down a very slippery slope indeed.  If the Court has such an agenda I would be surprised.  It appears this latest decision is just a natural consequence to the logic (or lack thereof) of the Citizens United ruling.

The mechanics of elections are the foundation of how our government works. Why should any 9 people (let alone people like Antonin Scalia and Clarence Thomas) have such an influence on this fundamental mechanism? But where is the impetus to change the system when those who have the ability to change it, our elected officials, have nothing to gain and everything to lose?

So that’s why I would vote for imprecise language as the first runner up in the competition for the root of all evil. The winner? Money, of course.

Le Truman Show

The Truman Show
The Truman Show

Le “Truman Show” est un film qui est sorti en 1998.  C’était réalisé par Peter Weir et c’était écrit par Andrew Niccol.  Le personnage principal est Truman Burbank qui est joué par Jim Carrey.  Truman Burbank est un homme normal qui vit dans une ville normale. Son enfance était heureuse. Il es     t réceptionniste pour une compagnie d’assurance, il vit une vie ordinaire, il a une femme ordinaire, un voisin ordinaire et un ami ordinaire qui apparaît de temps en temps avec un six-pack de bière.  Mais Truman n’est pas heureux avec sa vie. Il veut voir le monde

Clip 1

Il veut sortir de son plaisante mais étouffante vie – toujours rangée – pour s’échapper de sa petite ville qui est sur un île au bord de la mer – une ville qui est toujours propre, toujours ensoleillée et en fait, trop parfaite. En réalité, Truman était le produit d’une grossesse non désirée. Son «père» (pas son vrai père), Christof, un producteur de télévision qui Truman n’a jamais rencontré, a réalisé le Truman Show – le plus grand spectacle sur terre – un spectacle dans lequel la vie est en direct – la télé-réalité. En fait, Truman ne sait pas qu’il vit dans un petit monde de de télévision qui a été inventé par Christof parce qu’il a grandi dans ce monde et il était là depuis son enfance. Donc, tout le monde autour de Truman est acteur avec un peu de casque à l’oreille. Même sa femme est actrice qui fait beaucoup de publicités pour le camera à la stupéfaction de Truman.

Clip 2

Un jour, Truman trouve accidentellement une zone de restauration dans un faux ascenseur de son bâtiment de bureaux et devient assez suspecte. Peu à peu, il vient à la conclusion qu’il ne vit pas dans le monde réel.

Truman découvre que tout son monde est un ensemble de film et que tout était contrôlé par Christof, son «père» son “créateur” qui travaille dans un studio dans une ersatz lune du monde de Truman.

Clip 3

Enfin, Truman réussit à s’échapper de son monde irréel. Il repousse son créateur, son père Christof. Truman ouvre une porte dans une peinture de paysage et il va à un monde qui n’est jamais vraiment montré dans le film. Ce monde reste inconnue, c’est notre monde.

Clip 4

Je crois que le film est très prémonitoire.   Au temps de son sortie, le Facebook n’existait pas et la télé-réalité était à son début.  Cependant, le film démontre que la démarcation entre la vie privée et la vie publique est devenu floue.  C’est aussi une critique des effets que la publicité ont sur notre comportement et même nos pensées.  C’est une critique de la vie occidentale (surtout la vie américaine), de la religion, du capitalisme, des médias et de nos perceptions de la réalité.  À la fin du film, en regardant Truman part son monde iréel, on espère que son nouveau monde sera réel. Toutefois, cette question reste sans réponse.

“Le Truman Show” est un film de science-fiction qui est à peine different de la vérité aujourd’hui. C’est aussi un drame philosophique qui provoque beaucoup de pensées et qui peut vous encourager de regarder votre vie un peu plus près.  C’est un film à ne pas rater ou manquer et un film qui a tout pour le revoir.

At Sea and Offline

The North Atlantic
The North Atlantic

Captain’s log, Wednesday, January 8, 2014, 2300 hours, some unknown Atlantic time-zone. At sail in the North Atlantic. Completing the fifth full day of sailing, with one full day to go. Have had up to 7 meter swells, but in general the rocking is very soothing. Lots of food, lots of naps. Good entertainment. Definitely better weather than back in the States, where something has gone wrong with whatever barrier keeps the arctic airmass up around the North Pole, resulting in subzero temperatures. Here it has been windy, but today the air temperature is in the 50s. Not bad.

I had already resigned myself to no cell service in Europe. Wifi onboard might also as well be nonexistent, as bad as it is. It costs about $40 for 120 minutes of Internet service. This may sound like a fair amount of time, but given how slowly the service operates, it goes by quickly. Nothing is worse than spending a few minutes waiting for the Google home page to load. Seeing as we are hundreds of miles from any land mass, having any Internet at all is fairly remarkable. Given this lag, I decided it would be better to forego the Internet until I reach Europe. I might try to upload this to my website tonight, if I can. Otherwise you will be reading this in a few days.

After a day or two of Internet withdrawal, a certain peace sets in — a realization that the emails, Facebook updates, and tweets can wait. Traveling by ship does make one appreciate that there are alternatives to our modern ultra-rapid mode of life. There was a time when the only way to cross the Atlantic was via ship. At that time great ocean liners plied the Atlantic. Now only a few ships such as this one, the Queen Mary 2, make the trip. Most onboard are my age or older. Only the retired seem to have the time to spend a week making a transit that takes only 7 or 8 hours by jet. Yet somehow not too long ago people led productive lives without the “luxury” of jet air travel or the ability to text or look things up on the Internet. I wouldn’t give up any of this permanently. But it is nice once in a while to forego all these modern conveniences and spend some time appreciating a less technological life.

Ask Your Doctor if TV Drug Ads Are Right For You

Separate bathtubs.  Maybe that's the problem.
Separate bathtubs. Maybe that’s the problem.

The only thing more annoying than TV commercials is TV drug commercials. Nowadays the two have become virtually synonymous  Whatever happened to commercials for Tide or the Ginzu knife? Now it’s one mind-numbing Cialis, Pristiq, or Lyrica commercial after another. There’s the commercial with the doctor standing in his white coat out in public next to a giant mirror, not saying a word as people walk up to him. That guy should be arrested. There is the glowing nocturnal butterfly, flying from house to house, presumably flying into the head through your ears while you sleep, to eat your brain. There are sad people who suddenly have drug-induced happiness. There are COPDers, accompanied by elephants. There’s the guy who doesn’t have to make the turn off to the Protime Clinic because he’s on Xarelto, and can go fishing instead. All the commercials have high production values, but many, like the doctor and the mirror, just seem weird. Each commercial follows the same pattern:

Part I: The cheerful narrator sets up the problem and then introduces the drug-based solution. No commercial gets to the point quicker than the Cialis commercial. The awkward, non sequitur intro goes something like this: “It’s the little things she does, you never get tired of. But your erectile dysfunction? That may be a matter of blood flow.” (I tried to google the exact text, but, have you ever tried to search for anything with the word Cialis in it? I warn you, don’t try it.)

Part II: The same narrator reads the list of side-effects, in the same cheerful but somewhat more pressured tone of voice, having only 30 seconds to get them all in (“…stop taking Cialis and seek medical attention if you have an erection lasting more than four hours…” or “…in rare cases Happy Drug X may cause death, suicide, liver failure, kidney failure, and so forth and so on…” or “…if your pregnant wife accidentally mistakes your Axiron for deodorant your baby will be born with two heads…”).

Direct to consumer prescription drug advertising was approved by the FDA in 1997 and is only legal in two countries in the world: the USA and New Zealand. Proponents of these ads argue that they should be permitted by First Amendment free speech and that they are useful to raise public awareness of diseases and their treatment. Opponents argue that this is wasteful spending, adding to the cost of these drugs, and that the ads create pressure on physicians to prescribe drugs they wouldn’t otherwise prescribe. The ads encourage the viewer to self-diagnose conditions like insomnia, restless leg syndrome, or “Low-T”, leading to unnecessary drug treatment of naturally occurring conditions. And, as the commercials warn us in that cheerful, friendly voice, there are some risks associated with these drugs. Even though the $4.8 billion dollars the drug industry spent (in 2008) on direct to consumer advertising is considered trivial compared to the total cost of health care (and is much less than the money spent on direct to physician marketing — which should be another blog post), clearly these ads work for the industry, or they wouldn’t bother spending the money.

I would love to make a policy of not using drugs that are advertised on TV, but the practice is universal, and some of the drugs, like the new anticoagulants are actually useful. I would be cheating my patients if I did that. With Congress being the representative of industry rather than of the people, it is unlikely direct to consumer drug advertising will ever change. Maybe if US physicians united to protest these commercials, then… Whoa! What I am thinking.  Physicians in this country actually uniting to accomplish something? Sadly, I will undoubtedly be reminded of the perils of four hour erections for the rest of my life.

Cruising, 2013-Style

Explorer of the Seas
Explorer of the Seas berthed at St. Thomas

Due to the extremely pricey and slow WiFi (a particularly bad combination) available on board, this post is being written in mid-ocean, but will be posted after I am back on dry land (but see update at end of the post).  My wife and I are on the Royal Caribbean ship Explorer of the Seas.  I’ve nicknamed the ship the “S.S. Geriatric” aka “The Golden Corral of the Seas,” for reasons which will become clearer below.  Compared to my usual life of getting up early, working ungodly hours, taking call nights and working frequently on weekends, the shipboard environment of unlimited eating, sleeping, reading, strolling around the decks, and otherwise being idle is a form of Nirvana.  I must also praise the staff and crew who are very friendly and solicitous.  This is my first ocean cruise on a new style cruise ship, and my first ocean cruise since my honeymoon 36 years ago.  Prior to that, when I was a kid in the early 1960s I went on two Caribbean cruises with my parents.  It’s interesting to compare the current cruise with those remote but still vividly remembered cruises.

Nieuw Amsterdam - Cruising in the 1960s
Nieuw Amsterdam – Cruising in the 1960s

Back in the 60s the ship was the Holland-American line’s Nieuw Amsterdam (not the ship with the same name today), gray with white and yellow trim and two yellow, green and white striped funnels.  The common rooms, bars and lounges were on the upper decks with names like the “Lido deck” and the “Promenade deck,” the latter completely enclosed with windows facing the sea and supplied with ping-pong tables.  The lower decks, labeled A down to E were filled with cabins.  Outside cabins had portholes.  There were no individual balconies that I recall.  The outside decks had wooden planking, and there was never an illusion that you were on anything other than a ship.  The lines of the ship were sleek and the design was elegant.  I don’t think the stabilizers were as good as they are nowadays.  It was fairly common to get seasick on the second day out at sea.

The ship I am on now is certainly an impressive engineering achievement.  But it looks nothing like the ships of that bygone era described above.  All the staterooms have been moved to the top and outside of the ship, so that the vast majority of them have their own little balconies.  This is very nice, but looks top-heavy and somewhat squat and unseaworthy compared to the sleek liners of old.  The common areas have been moved down into the lower central part of the ship, without any windows to the outside.  Here deep in the midsection of the ship is what could pass as a section of your local shopping mall, with clothing stores, liquor stores, bars, coffee shops, and so forth.  If it were not for the gentle back and forth rocking, you would have no idea you were on a ship.  And be forewarned that, other than the food at the restaurants (of which there is plenty, and pretty good at that), everything else costs extra cash.  For example, even having soda required signing up for a “soda plan” that costs extra.  I am so used to free WiFi that I was shocked that not only was there a charge, but the charge was ridiculously high.  At 75 cents a minute, and being about as slow as dial-up, it cost about $10 just to check a few emails.  There is also a Verizon roaming cell service available on board, but if you activate it you immediately get a text message suggesting you turn off your data plan, otherwise you will be charged about $20 a megabyte of data.  So the phone and the Internet have been off, other than when I briefly turned on the phone in San Juan, Puerto Rico, where the Verizon service seemed to work normally.

The biggest (no pun intended) contrast between cruising now and 50 years ago is the people.  The average size of the passengers today is much greater than it was back in the 1960s.  I remember as a child my mother pointing out a certain very rich but overweight woman on one of those long-ago cruises, amazed at how large she was.  In retrospect I would say she probably weighed about 300 pounds, but this was quite an anomaly at the time.   On today’s cruise she would have fit right in without anyone raising an eyebrow.  I would estimate at least 80% of the passengers on the cruise are overweight, probably 50% in the extremely obese category.  People propel themselves around in motorized scooters.   At the buffet plates are piled high with the endless supplies of food available.  A few younger people are seen in the gym or circumnavigating the track on the upper deck of the ship, but most are lounging on the deck chairs, waiting for the next meal time.  Besides the heft of the passengers, their median age appears to be the late 70s.  There are a few younger people on the ship, but not many.  I guess cruising is a retirement type of activity.  It was a reminder though that the median age has increased a lot since the 1960s.  It’s a medical paradox that people live longer but seem less healthy than in the past.  Finally, I think I probably am a little agoraphobic, so I am biased, but the ship is so crowded that it is hard to find a quiet nook to sit and read.  Many people on board are loud and unruly, and, sad to say, the loudest and most unruly seem to be the Americans.

I don’t look back at the past as a golden age.  I realize childhood memories are filtered so that we forget the bad and remember with nostalgia the good times.  I know that in general things are much better now than they were then.  But as is seen in the contrast between the people on my first cruises and of the people on this one, we have become a less healthy population who could use more laps around the deck and fewer visits to the buffet.  And maybe we could be a little less loud and a little more polite.

Stormy Weather
Stormy Weather

UPDATE: Back on shore today.  The last day of sailing was quite exciting, with up to 70 knots of wind gusts and 20 foot waves!  The ship was rocking to the max, with food trays falling off the racks in the Windjammer buffet and plates crashing to the floor.  I don’t believe anyone was hurt, thank goodness.  But after such placid sailing this last day of rough seas was a reminder of the power of the ocean.  If our mighty cruise ship struggled, it is hard to imagine what effect this weather would have had on those tiny ships of Columbus, making that transatlantic crossing back in 1492!