Sarito Carol Neiman : Healthcare on the Ground

Image from Sky Dancing.
Shredding the envelope:
Healthcare on the ground, Part I

By Sarito Carol Neiman / The Rag Blog / September 1, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the first in a series.]

I have spent the past three days doing my best to be a helpful and healing presence in Room 422 of Scott & White Hospital in Temple, Texas. My going-on-85-year-old dad is in that room, doing his best to recover from a 7-hour surgery called, in medical terms, a “decortication” of his right lung.

It was needed because at some time in the past year or few, given the best guess of his surgeon, he suffered internal bleeding as a side effect of taking Coumadin, the trade name of warfarin, which is a blood thinner for humans that started out as a hemorrhaging agent used as rat poison.

The Coumadin website features a couple of happy, healthy-looking, stock-photo human beings -- one of each gender -- on its front page. In my dad’s case, this rat poison turned wonder drug apparently contributed to the creation of a leathery and constricting pouch around his right lung that threatened to suffocate him to death.

Coumadin earned Bristol-Myers Squibb roughly $222 million in the year that I know my Dad was taking it. He might have been taking it for more years, I don’t know, but I remember that particular year because I was in Texas at the time, and saw the alarming and extensive bruising he got from a minor fall, soon followed by an alarming rectal bleeding that prompted a colonoscopy recommended (ridiculously and incompetently, in retrospect) by his GP, for which I served as driver to and fro because Dad was too freaked out altogether to properly handle it on his own. The fact that he actually asked for my help was alarming in itself, given what I knew about him and how he never, ever asks for help.

I told him at the time I thought his blood thinner was to blame. Because he’s my dad and I’m still the kid in his mind, and because he knows perfectly well I’m not a doctor, and because he, like most Americans, suffers from a combo of intimidation and awe-struckness by what passes for a medical profession in this country -- and, probably most of all, because he liked the heart doctor who prescribed that Coumadin in the first place -- he dismissed the very idea out of hand.

Long story short, after a bout of alleged pneumonia in December of last year, Dad found himself making emergency-room visits because he couldn’t breathe, which grew in frequency to around every three weeks or so, to drain a liter or two of fluid from his pleural cavity. His GP finally recommended the local small-town lung specialist, and she decided Dad might be suffering from TB.

That “might be,” under Texas law, required her to report him to the state health department, and in turn, required the state health department to initiate the “might be TB” protocol, regardless of whether any lab results were still in process or inconclusive. Dad was confined to his house, and the capital-S “state” came by in person each day in the form of a nurse to dispense and personally witness the swallowing of massive doses of antibiotics that made Dad itch and feel horrible.

A couple of weeks passed, and a new, alternative diagnosis of some exotic bird flu (suffered mostly by AIDS patients, I discovered in my research) was substituted for the TB. But for some inexplicable reason the visits by the state nurses with their sick-inducing and now-irrelevant pills continued.

At this point my brother and I intervened, working in tandem from New York and Texas, and dragged Dad off to a different, carefully researched and selected as the best in the drive-able neighborhood, “second opinion” lung specialist.

Excellent idea, difficult execution. At their first meeting, which my brother attended to keep himself in the loop of what we had initiated, the new specialist talked more to my brother than he did to his hard-of-hearing, neither well educated nor articulate but by no means incompetent or dumb patient.

As a consequence, Dad felt infantilized and disrespected. He rebelled, and told us to butt out, he would henceforth handle his health concerns on his own. We complied, what to do, he’s the dad.

Image from Why Evolution is True.
Another couple of months (along with another couple of emergency fluid-draining procedures) passed before Dad finally accepted the second-opinion specialist’s recommendation, based on scans showing a massive “black area” on the right lung, to have a deeper evaluation of the underlying problem at Scott & White Hospital in Temple, Texas.

This part of the story in itself was a massively revealing look into the practical, on-the-ground, failings of the American “free market-based” healthcare system. I will have to leave it to others with a more intimate knowledge of the workings of that system, and the details of its economic interests and corruptions, to provide any fact-based insight into the underpinnings of it, or how the recently passed “Obamacare” might actually address any of those failings -- or not.

What I do know from experience is that the way things are set up now, my father -- before my brother and I intervened -- had seen three different doctors over the past several years. A cardiologist, a general practitioner, and the local lung specialist recommended by the general practitioner when he started drowning in his own fluids.

There was never any actual collaboration among the three. Perhaps they had a vague awareness of each other’s existence, a kickback arrangement, or simply a star next to a name in the rolodex. There was apparently no requirement, or even commonsense expectation that they might consult with one another and, based on their common experience of the same human being and his health issues, work together toward a diagnosis of a current health crisis experienced by that human being and decide on a course of treatment.

Apparently, in the case of the local lung specialist (at least in Texas) there was not even a requirement that when a patient asks that his/her records be provided to another doctor, as part of obtaining a second opinion, those records must be provided. Because when the woman who diagnosed Dad first with TB, and then with an exotic bird flu, was asked for those records, she refused to hand them over.

Dad had to undergo a repetitive, unnecessary, and not altogether un-harmful extra round of tests and scans and nuclear exposures in order to replicate what she had already done.

My hunch is that there is plenty that could be done (at the very least, putting aside the overall problems of non-socialized medicine for now) to reform Medicare and free it from its current entrapments in inappropriate, costly, exploitive, and profit-motivated ways of doing business that reward doctors for procedures and tests performed, versus rewarding them for helping people get healthy and stay that way.

But, in keeping with the “Shredding the Envelope” premise, I also have a hunch that we have to tackle the softer and more human dimension first and foremost, before we can deal effectively with the hardware.

That’s the subject of Part II of this post.

I’ll be back.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• See "Healthcare on the Ground II: The Angels" by Sarito Carol Neiman / The Rag Blog / Sept. 7, 2011
• Listen to Thorne Dreyer's July 29, 2011 Rag Radio interview with Sarito Carol Neiman.

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Sarito Carol Neiman : Healthcare on the Ground II: The Angels

Nurse as guardian angel? Art by Amy Jordan / folkartblondes's photostream / Flickr.
Shredding the envelope:
Healthcare on the ground – Part II

The angels are the ones who are doing more than just their jobs.

By Sarito Carol Neiman / The Rag Blog / September 7, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the second in a series. Read Part I here.]

My brother called them “angels” in his email dispatches from the surgery waiting room. By this, I know now that he meant the ones who look you in the eye, who respond to your questions directly and without evasion. Without hollow boilerplate responses, meant to reassure those anxiously awaiting some news or a verdict that nobody yet has.

The angels are the ones who are doing more than just their jobs.

Being a guy, and more specifically a guy who loves understanding the workings of things, my brother was also impressed by the airport-like, huge computer display on the wall of the waiting room that showed which operating room was occupied by which surgeon, how much longer it was expected to be in use… it functioned as a reassurance in itself, like the clock displays on the crosstown Manhattan L line that tell you how many minutes away a train is from where you’re standing.

He and my sister… and whoever else might have been there from the family (who will no doubt forgive me for not remembering just now)... could watch, as the slot representing Dad kept getting extended. From the initial four to a total of seven hours, by the time it was all said and done.

Scott & White has a reputation for being one of the best in Texas. High-tech, computerized in all its dimensions, there is a mini-version of air traffic control opposite each nursing station, where selected vital signs of each patient in each room are on live display, broadcast from a little monitor each of them wears (or not, as needed, I assume) in a pocket sewn into their gowns, with its wires and sensors silently attached to their bodies and capturing heartbeat, respirations, temperature. When a nurse comes into the room, tasks completed and supplementary notes are entered via keyboard and screen attached to the wall next to the door, not on the iconic hospital “clipboard.”

All very reassuring, even laudable. But for the patients themselves, and their families, it’s the angels who count.

I have met many, so far, in the course of this journey. I’d say the majority of them have been “new”… interns, nurses in training, residents. (Maybe “the system” tends to beat angelhood out of people who are in it too long. I sense I should camouflage their names to protect their innocence.)

R, whose extraordinary sensitivity and respect toward Dad, on what had started as a really difficult day, seemed to help him tap into a new reservoir of strength within himself to turn things around by the end of the day.

B, whose eagerness to learn and clear enthusiasm for finding out what was broken and fixing it was so infectious, it earned him immediate forgivenesss for stepping on Dad’s toe the first time he approached his chair. When he came in the next day, clearly with an “assignment” to ask the patient a couple of questions, I saw B’s future as a great among angels reflected in my Dad’s honest, simple responses.

Dad is generally the sort of guy who will say “I’m fine” while bleeding to death from a gunshot wound. He’s also very perceptive. If he figures you don’t REALLY want to know, he will say, “I’m fine.”

B stood exactly in front of Dad, looked him in the eye, and said:

B: “Do you have any questions at all about your treatment that haven’t been answered?”

Dad: “I don’t know what’s wrong with me.”

B: [Clear, simple response to describe Dad’s condition, and the surgery he had just undergone, and why. A nod from Dad. Understood, at last, beyond whatever descriptions he had been given, and had only abstractly/theoretically comprehended, before he went under the knife.] "Is there anything else you want to know?"

Dad: "Why am I not getting better?"

To which B responded that it takes time, it had been a huge ordeal, and actually Dad was doing remarkably well under the circumstances, better even than might be expected. Other people had said the same words, but B really knew those words were true. For the first time, Dad had been told the reality as certainly as it could be known, by a person so transparently honest and sincere that he could take a deep breath and move on to crossing the next river.

There are angels among the oldtimers, as well. Notably “Ida sweet as apple cidah” as Dad introduced her to me (referencing an old song he knows), an ageless woman with a huge presence that just lights up the room when she walks in. I don’t feel the need to protect her innocence, because her face tells you she’s seen it all – and I’m pretty sure the gods of the nursing angels have her under their fiercest protection, or she wouldn’t still be around. Just as she has all “her” patients under her protection, to the extent she’s able.

Or T, who hasn’t yet seen it all but has seen a lot for someone as young as she is, and who doesn’t have such a big sunny presence as Ida but is more the silent and subtle breeze who comes and goes without creating a disturbance, and whose eye never misses the smallest detail of expression on a face indicating that something might be amiss. She catches things even before they happen, an invaluable gift.

Most angels seem to live toward the middle of the healthcare food chain – they are the nurses, or the interns and residents who haven’t yet been professionalized into wearing the straightjacket of “lawsuit aversion” so many doctors seem to have around them, like an invisible shield against genuine human contact.

On the bottom of the food chain are those who are just passing through a minimum-wage job until they can find something better. There are notable, and wonderful exceptions to the “check it off the list” insensitivity of many aides in the modern, large-hospital system. Those exceptions, in my experience of them, are very special angels indeed. Just really, really good folks who love taking care of people and their environments, and making both the person and the environment as comfortable as possible. We should pay them what they deserve, so they can keep doing that priceless work without having to take a second job to support their families.

I feel a third part to this series coming on. And that is to take a look at what are the “anti-angel” forces at work in the system. What they are made of, both on a “systemic” and a human level. It’s going to need a bit of research on the system level (nothing fancy) and maybe a bit more distance on the human level than I can manage right now.

Right now, I need to get back to my Dad’s room in the hospital, and make sure he has something to eat that he enjoys for “dinner” (in real life outside the hospital, dinner for my Dad is usually a light snack. Hospital “nutrition departments” don’t operate in that mode.) And that he’s settled in comfortably for the night.

I’ll be back.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• Read "Healthcare on the Ground, Part I" by Sarito Carol Neiman / The Rag Blog / Sept. 1, 2011
• Listen to Thorne Dreyer's July 29, 2011 Rag Radio interview with Sarito Carol Neiman.

The Rag Blog

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[+/-] Summary only...

Sarito Carol Neiman : The Anti-Angels of Health Care

Cartoon from The New Yorker.
Shredding the envelope:
Healthcare on the ground - Part III:

The anti-angel forces

By Sarito Carol Neiman / The Rag Blog / September 22, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the third in a series. Read Part I here.]

The computer workstation in my dad’s room, according to the sales pitches of companies who sell them, was designed with the best of intentions to improve both the efficiency and quality of care in hospitals.

It would allow Dad’s caretakers to enter the latest information about his care (vital signs taken, medications given, observations observed) and to retrieve any information about him and his condition they might need -- on the spot, without having to go and fetch it from (or take it to) its central location at the nursing station down the hall.

It would allow them (in theory) to spend a little extra time in the rooms with the patients, as they entered or retrieved their information -- assuming they could safely mix “quality time” with the patient and the entry/retrieval of complex data at the same time. (An assumption of multitasking ability whose superhuman dimensions the sales pitches overlook.)

In theory, this computer workstation could be part of a vast network of computers, consolidating input gathered from every healthcare professional who had ever seen my dad for any reason. It could offer a more comprehensive picture of Dad’s medical history and current condition than any single human could possibly manage.

Imagine the possibilities... if such a network had been in place from the beginning of this years-long saga, and if all the professionals involved in Dad’s care had been doing more than just their jobs, he very likely would never have ended up in the hospital in the first place.

Those are some pretty hefty “ifs.” And as good a starting point as any to take a look at the “anti-angel forces” at work in the U.S. healthcare system.

Let’s take care of the big stuff first. Let’s assume that our “inalienable rights” to life, liberty, and the pursuit of happiness include the right to healthcare -- not as a consequence of having the money to pay the going market rates for it, but as a consequence of being human. Let’s assume, in other words, that there is no need for private insurance companies, hence no fear that a person’s medical history will be used to deny coverage, or to charge an arm and a leg for it.

Let’s further assume that we can agree that being a healthcare provider is a very special calling indeed, and that those who take up the calling should be honored and rewarded for making that choice, rather than being thrust into indentured servitude by a mountain of postgraduate debt, forced to pay for that debt by performing procedures rather than spending time with and understanding their patients, and being stalked by “ambulance-chasing” lawyers whose primary motive is to make a buck on their mistakes and on the suffering of the victims of those mistakes.

(More about the whole “tort reform”/malpractice thing at another time.)

So now we’ve taken care of the big stuff, we get to the sticky, non-systemic, human bits.

Of course, a universal “inalienable right” to healthcare would need us all -- hospital administrators, doctors, nurses, aides, and patients, all of us -- to behave sensibly, like grown-ups.

We would understand that sometimes things get broken and can’t be fixed, and not every mistake is the result of malice or incompetence. We would know the futility, even harmfulness, of squandering scarce resources on experimental fixes that are likely to fail, or only extend suffering rather than heal. We would understand that death is a natural and inevitable part of the continuum of life.

We would do our very best to keep ourselves healthy and, when those efforts fail, do our best to comprehend the reasons and take responsibility for whatever part we might play in getting better. We would know when to push on against all odds, and when to call it quits. We would celebrate every small victory, and we would know when to allow ourselves to grieve.

We would, in other words, be able to see every health crisis for the opportunity it brings -- to take stock of our priorities, to allow ourselves to love and be loved, to heal the old and untended wounds that so often seem to surface at these times.

To help us get from here to there, though (it’s unlikely we’re just going to wake up and find ourselves there), we’d have to start with a clear-eyed look at what we’ve got now.

The computer workstation in my dad’s room, attached conveniently out of the way on the wall, was a neutral presence, at first glance. And, as advertised, it was undoubtedly a time-saving, mistake-reducing tool. It wasn’t until it broke down for a few days that I began to understand how it was also being used by “anti-angel” forces.

As long as this tool was functioning, nurses came and went with their tasks-to-perform and medications-to-give on what was apparently a rigid, inflexible schedule. It didn’t matter whether Dad was eating his breakfast, having a phone conversation with a loved one, or peacefully asleep -- the pills had to be given, the BP cuff strapped on, the thermometer inserted. Toward the end of his stay, when he was better able to move around, he discovered that the only way to assert his right to uninterrupted peace and quiet was to go and sit on the toilet.

When the computer workstation tool stopped functioning (and I confess to an irrational fear that I might be blowing the cover of a complex angel-conspiracy) somehow it became fine to let Dad finish his breakfast, or his phone call. To come back a few minutes later to do whatever was on the nursing agenda to be done. Not a problem, said the gracious smiles and body language of the nurses carrying the pills and thermometers. I’ll come back in a little while when you’re done.

And they didn’t forget, either -- it wasn’t as though these important tasks magically disappeared from the “do-list” just for lack of computer assistance.

That’s when it occurred to me that behind the hunched shoulders and grim determination of nursing “business as usual” was a Big Brother element that the nurses were fully aware of, but the workstation sales pitches don’t mention. A function more interesting to hospital administrators and lawyers, say, than to doctors or other actual hands-on providers of Dad’s care.

It works like this: the nurse turns on the computer and scans in her badge (nurse presence accounted for) at a certain time (schedule adhered to and trackable by the minute) followed by scans of medication labels, or keystroke entries of vital signs (asses covered). Checked off the list, tidy and impersonal, easily scanned by those whose interest is that no unpredictable breezes of individual human needs or circumstance should interfere with the hum of the well-oiled (and litigation-protected) hospital machine.

The doctors didn’t have to use this workstation, however. They could, if they wanted to look something up... but they didn’t have to, nor did they have to tell it whatever it was they did while they were there.

My sense was that the whole workstation set-up not only reflects but also reinforces the subordinate and purely functional role of nurses in the system as it is. In most hospitals -- with a few notable exceptions, I have heard -- nurses are told what to do (“doctor’s orders”), expected to pass along requests or problems from the patients, and rarely if ever encouraged (or even allowed) to express an opinion, make a recommendation, or question a decision by the doctor that their best intelligence tells them might not be a good idea. A bit silly, to put a better face on it than it deserves -- given that the nurses spend far more time with patients on an hour-by-hour basis than any doctor can possibly afford to spend.

It also, of course, reflects the fact that as the system is set up now, the actions of doctors and the reasons behind those actions are largely protected from public view, and are not required to be shared with other members of the team unless the doctor chooses to share them.

Doctors.

When I first met Dad’s surgeon, I didn’t like him much. Not because I thought he was incompetent -- on the contrary, I was satisfied that he was the best available anywhere near Dad’s home. My dislike was more in the realm of “bedside manner.”

I can’t really blame him for the fact that at our first meeting he was uninterested in knowing who I was or why I was there, to the point of being dismissive. He had, after all, already met and spoken with several members of the family along the way, and at that point I must have seemed like yet another potential burden of irrelevant and time-consuming human interaction that he would just as soon avoid.

Plus, he’s a surgeon after all, not a GP -- the skill sets required to do an excellent job in those two realms are different. Even if the skills to do more than the job might overlap or even be the same.

Over subsequent meetings our relationship was rocky, with additions of ego-prickliness alongside any deficits in bedside-manner skills. He didn’t like being questioned, especially in front of his entourage. This dislike, it seemed to me, carried the weight of a reflexive assumption that my questions were posed as a challenge, rather than as a sincere effort to understand.

I did my best to accommodate the lesser angels of his nature, to reassure him that I absolutely trusted his medical expertise, while still honoring my own concerns for the rocky spots in Dad’s recovery and whatever support I might be able to lend as a “person on the ground.” In the end, I didn’t want him to change, really -- I thought he could use a good “right-hand” person, more a GP type, whom he trusted and who trusted him, to take care of the squishy bits of listening patiently and explaining things to people like me, and maybe translating my concerns into a language he could better understand and relate to.

We worked it out, somehow -- the mutual respect and understanding between him and Dad was undisturbed, and when he finally came in with the happy news that Dad could leave the hospital and go on to the next stage of getting strong enough to go home, I was as fully included in the sharing of that news as was appropriate, given who was most directly affected.

I was also delighted to hear that during Dad’s recent follow-up visit, the doctor showed him “before and after” X-rays of his lung, and the transformation that had taken place. The news nicely balanced what happened that day when Dad was having such a hard time, convinced he wasn’t getting any better and grumbling about having to go downstairs for a new X-ray every morning.

When the doctor came by, I suggested maybe Dad could see a before-and-after picture, so he could look for himself how things were going. The response was a little explosion of exasperated breath, an energetic (if not physical) throwing up of the hands, and a “that’s not so easy, it’s all on computer” before turning around and (energetically) stomping out the door.

I liked it when I heard the news that the doctor had managed that “show and tell” … because I know it helped Dad, as it would have helped him on that day I suggested it in the hospital, to get a handle on whether the whole ordeal had really been worth it. Maybe, I thought, just maybe he had heard me after all. Maybe he’ll remember it the next time one of his patients is having a hard time convincing himself it’s all worth it.

We all have a lot of work to do if we are going to meet the challenges of providing thoughtful, competent, whole-person healthcare in this world.

We’ll have to figure out the best ways to weed out those who are thoughtless and incompetent and in jobs they aren’t suited for. And we’ll have to work on minimizing the harm done by our natural human tendencies to want magic pills, and to substitute a messy and mysterious wholeness with discrete and manageable, but lifeless, parts.

We’ll need to figure out how to shift our focus from avoiding the worst to striving for the best.

We’ll have to take a deep look at the role of lawyers in the healthcare system, and the hopeless, despairing greediness they so often foster in our lives. We’ll need to acknowledge that no amount of money can alleviate pain and suffering, and that often, all any of us really wants is a heartfelt apology, shared grief, and support for moving through a loss. And yes, too, sometimes, the satisfaction of knowing that an incompetent, greedy, or careless practitioner will never be able to harm anyone again.

It’s a lot of work, and it needs us all to do more than just our jobs. And at the moment, for me, it’s right up there among the top jobs on the list of those most important and meaningful.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• Read "Healthcare on the Ground, Part I" by Sarito Carol Neiman / The Rag Blog / Sept. 1, 2011
• Listen to Thorne Dreyer's July 29, 2011, Rag Radio interview with Sarito Carol Neiman.

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Rag Bloggers : A Conversation about Life, Death, and Washington

Rag Blog Discussion Group. Image from bsimple.com.
A Rag Blogger conversation:
Life, Death, Washington,
and the healthcare universe

By The Rag Bloggers / The Rag Blog / July 13, 2011

The budget/deficit negotiations in Washington have recently provoked a flurry of petition initiatives from the progressive side of the debate, urging the Obama administration to “take off the table” any changes to Social Security, Medicaid, or Medicare. This, in turn, provoked a behind-the-scenes, coast-to-coast discussion among some of the regular (and irregular) contributors to The Rag Blog -- by way of our email discussion group -- about what’s really at stake here, and what it all means.

Thoughtful, wide-ranging, respectful, and touching on everything from how we feel in the presence of newborn babies to what makes us afraid of death -- the kind of discussion that usually can’t be heard above the roar of mainstream media talking heads. We enjoyed it so much, we wanted to share some of it with you.

Thanks to The Rag Blog's Sarito Carol Neiman for putting it all together.


Jane: In case y’all haven’t already received this (see below) here’s something -- especially for those of us who worked to get Obama elected -- to do, to hopefully end his continual compromising sell-out to the opposition. Though myself not much of a FaceBooker, this is what I posted on my page: “I have never been more serious. Cutting Social Security/Medicare/Medicaid is contrary to the Democratic Platform, not to mention contrary to common sense... why should the innocent suffer at the expense of scoundrels?”

Early on in his own presidential campaign, Howard Dean first spoke of “taking our country back.” Now, Democrats are also going to have to take our party back.

Bold Progressives Petition

URGENT: The New York Times reports that President Obama is offering Republicans “substantial spending cuts, including in such social programs as Medicare and Medicaid and Social Security -- programs that had been off the table.”

Will you join 100,000 others who have signed this urgent pledge, which we’ll deliver to the Obama campaign?

“President Obama: If you cut Social Security, Medicare, or Medicaid benefits for me, my family, or families like mine, don’t ask for a penny of my money or an hour of my time in 2012. I’m going to focus on electing bold progressive candidates who will fight to protect our Democratic legacy.” Click to add your name.

Jay: This is among several petitions on the proposed Social Security and Medicare cuts I’ve seen. Though we might discuss “what (else) is to be done?” for starters I’d say: ”sign two, three, many petitions!” The web addresses for what seem to be the most proactive groups working on these issues:

• Alliance for Retired Americans: www.retiredamericans.org
• National Committee to Preserve Social Security and Medicare: www.ncpssm.org

Janet: And why is it more important to provide health care than it is to stop causing disease?

Changing the food in the schools will do far more for the health of our people than trying to fix them once they are sick. It is proven science that environmental toxins and nutrient-free food cause almost all modern disease.

Why worry about “curing disease” (really just covering up the symptoms) and not worry about what is causing it, where Obama is leading the way?

In the sixties I supported single-payer that is not just an arm of the pharmaceutical industry. People today take medicine their whole lives and are never cured.


Val: I think we can do both. Congratulate the Obama administration for the good it does on the disease prevention level and oppose cuts to social services. The statement (accompanying the Bold Progressives petition) that cutting Social Security, Medicare, and Medicaid was something even a Republican president and congress couldn’t do is the kicker for me.

How do folks think of strategy -- do we give support where it’s due, as well as opposition? If not, we have to accept lots of bad with the good -- not only of Obama but of most of the Dems.


Terry: Perhaps we should quit worrying about health care and focus on death and dying:

Cost of Care at the End of Life

• Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending.
  Source: Dartmouth Atlas of Health Care (2005)
• Medicare pays for one-third of the cost of treating cancer in the final year, and 78% of that spending occurs in the last month.
  Source: HemOnc Today (2008)
• One large-scale study of cancer patients found that costs were about a third less for patients who had end-of-life discussions than for those who didn’t.
  Source: Archives of Internal Medicine (2009).

Read more here.

Sarito: Amen, Terry! [Your post] appeared while I was still busy writing mine.

Janet’s point is a very good one -- and the tip of an iceberg that only very few people have been willing or able to address. And as far as social security goes... if rich people (or even foolish ones) want to opt out of the system and turn their future retirement income over to Wall Street, I’d say let them go for it! Just don’t impose that recklessness on the entire country, don’t advertise it as the best and most intelligent thing to do, and for sure don’t let employers impose it on their employees.

And... I personally have no objection to “means testing” when it comes to Social Security, as long as the benchmarks for cutting payments are sufficiently high. I mean, if we can’t get millionaires and billionaires to pay more into the public coffers while they’re still working, then at least we can prevent them from taking money out of those coffers if they truly don’t need it when they retire.

I suspect when we adamantly insist that Medicaid and Medicare be “off the table,” we are avoiding coming to terms with the fact that what passes for our healthcare safety net is deeply, deeply flawed. The entire fee-for-services, disease-oriented, pill-happy, for-profit healthcare system in this country will continue to gobble up increasing amounts of public funds, if we “don’t touch it” -- especially as the Baby Boom generation ages and makes its demands on
the system.

There are many worthy experiments happening around the country that suggest alternative approaches to delivering healthcare, and they are more cost-effective, offer better quality of care, and make both patients and doctors happier than anything an insurance company or HMO could possibly devise. These need to be highlighted and brought into the public discussion much more than the current occasional articles in the New Yorker or other serious “liberal media elite” publications.

And, as the system is set up now, for example -- along with the entire culture of healthcare, in fact -- if we “don’t touch it,” an overwhelming amount of Medicare money will increasingly go toward extending the lives of very ill, very old people, at huge expense in the last months of their lives especially, and in most cases with that so-called “life” confined to a hospital bed. Despite the fact that almost everybody who is asked how they would like to spend their last days would not like to spend them in a hospital hooked up to machines.

But there is a whole “long, drawn-out death industry” adamantly opposed to hospice and palliative care, so you get the “pull the plug on grandma”/“death panels” demagoguery whenever a proposal arises to make those end-of-life care options clear and available to people. Furthermore... have you noticed lately how many general practitioners (who are an essential part of any healthcare system focused on keeping people generally healthy rather than only on treating their specialized diseases) are immigrants from abroad?

That’s because other countries don’t burden their medical students with such a mountain of debt that they either have to take up an exotic specialty or sell their souls to an HMO if they are to have any hope of digging themselves out of that debt. We should give scholarships to every medical student who wants one, in exchange for a commitment to spend 4-5 years (earning a decent salary, mind you) at a community clinic or hospital.

And yes, we need to look at the whole malpractice insurance/litigious aspect of the system as well, I’d guess at least half of which is fueled not by victims of human error or tragic mistake who want to extract a pound of flesh in revenge (rather than just a simple explanation of what happened and a heartfelt apology), but by lawyers who want their hefty share of the proceeds.

It’s both complicated and really simple, it seems to me. But not in the ways we knee-jerk tend to think it is complicated or simple. Because we are still letting the insurance companies, HMOs, big pharma, and their lobbyists define the terms of the debate. So far, I haven’t seen a petition I could sign that begins to address the real issues at stake here.


Roger: Corporatized health care makes a killing through hugely inflated costs during the last few years of a person’s life, which is probably why they oppose single payer so strongly. I saw that during the last few years and months of my mother’s life and death from Alzheimer’s. Even with a “living will,” our family was stuck with high hospital bills and they would not release her until my mother was deemed by the tests to be restored enough to go home and predictably die a few weeks later.

Assisted living is a corporate racket, and the hospitals don’t know the meaning of cost-effective health care. The corporate health care system tried to prevent me from using the best Philippina care giver I can imagine my mother having, because Faye wasn’t part of the corporate system that assisted living tried to impose. They wouldn’t even allow Faye to give my mother her medicine. Compassion and kindness are not part of the care giver resume, when health care is provided through the system, but lawsuit avoidance is a top priority.

I think many people would be happier and get better treatment the last few years of their life living in some third world country, or a country with single payer system.


Janet: The truth is, Roger, that cost-effective health care is illegal. Many long-tried and well proven remedies exist, but FDA will not look at anything but pharmaceuticals or radiation or surgery.

But they go after anyone who is providing these alternative or traditional healing practices, saying they are not approved by the FDA. Of course, they can’t approve them since they won’t consider them.


Jay: We need to take stock of where we are, and where we are is in a position of weakness. The right is defining the terms of the health care debate. Their compelling interest is in “privatization” whereby both Social Security and Medicare are turned, carte blanche, over to the completely for-profit market system. If we don’t defend the advances made by FDR and LBJ, then we stand to lose the whole game. Medicaid may not exist at all.

That’s why it is so important, at this moment, to “save” Social Security and Medicare, pretty much as they are. If impending disaster can be staved off, then maybe we’ll control the terms of the debate, or at least be in a better position to advocate reforms of a progressive nature.

But first things first.


Dick: I thought the suggestion that we have to start encouraging old people to die was meant as a joke! It is not old people who should have to learn to greet death with resignation. It’s the bastards who got us into this mess!


Janet: The “death industry” is one reason Medicare needs some serious reform. I am glad they are talking about it, and hopeful that reason will enter. We got some pretty good stuff for health care in the stimulus package, notably comparative research funding, to see which treatments work best as opposed to just being better than a sugar pill, as well as putting more patient information online so that all your doctors have access to your lab reports, etc. The issues are not just right/left, but more complex.

78% of cancer money spent the last month? Surely many of those patients would be much better off if they were allowed to go home, be with their families, not be tortured by doomed “treatments.”


Terry: Dick, actually, my statement about focusing on death and dying was a double entendre. One meaning was a sort of joke against focusing on single-minded solutions like health care, organic food, exercise, or other single-issue solutions. In reality it will take all of those things and much more to reduce the cost of health care and improve health. The other meaning was more in line with Kübler-Ross’s book, On Death and Dying.

Far from “encouraging old people to die,” the reality is that we will all die, no encouragement needed. However, for some reason our “Christian” society has terrified folks of this inevitability. The fact is, on average Americans spend about 1/3 of their total life’s health care costs in the last year of life, trying to stay alive, and 75% of that in the last month, which is oxymoronic.

We do need good, clean, wholesome food, exercise, clean air, and water, as well as TLC among our families, friends, and society. But many focus on only one of the issues, and I am glad someone does focus, but to deride others’ attempts to find solutions is counterproductive. We are all in this boat together, and no one is getting out alive. The best we can hope for is to leave less of a mess than we inherited.

This goes into huge issues that books are written about. Like the anti-abortion folks that encourage women to carry serious birth-defects like cardiac malformations. The heart defects can cost upwards of $500,000 just to get the child out of the hospital alive. Then as they age, if they live to maturity, they will have the innate desire to procreate, and those defective genes then enter the human gene pool; leading to even more problems down the line.

Modern society has built a pest house of cards that cannot continue forever. I worry about my grandchildren.

Obama Death Panel. Cartoon from The Cartoon Lounge / The New Yorker.

Jane: Here, here, Terry! Great summation of our human dilemma.

As to the destiny for our progeny, the soul of Kahlil Gibran will benevolently overlook my inability to provide the exact quotation right here, in reassurance that I embraced and will never forget the gist of his pondering why we rejoice rather than weep at the birth of a child, when its very first breath eventually leads to its last: from the moment we’re born, we’re on our way to dying.

I think we laugh and giggle over a newborn out of nervous helplessness, in awe and amazement that such a cute little creature has come into being, then will be in our care until the babe grows to adulthood, ably functioning on its own. What mortal wouldn’t feel helplessly inept in the face such a charge, even while being utterly delighted at the prospect of creating a world this precious responsibility deserves.

Nowadays, the closest I come to faking anything, is upon learning of a pregnancy. “How wonderful!” I exclaim, even though I’m secretly weeping inside, thinking, what a terrible time and place to bring forth another innocent.

Incidentally, though the discussion is very interesting, please don’t lose sight of my purpose in originally posting: My thinking is, signing the petition is a formal way of informing Obama that if he agrees to/cooperates with Social Security/Medicare/Medicaid cuts, we don’t give him our money/time/(implicitly our energy/talents). Whether he/his advisers will heed our fair warning is unknown, of course. But there were lots of us -- and for sure more than just Democrats, who sweated and bled to get Obama elected... all the expensive ads in the world don’t/won’t offset that valuable effort.

My further thinking is, signing the petition does not mean we are satisfied with Social Security/Medicare/ Medicaid as it is implemented today. Certainly we want loopholes closed and waste to be identified/ceased, so funds are truly utilized to expand the good. If we had a genuine social democracy in place, we could probably handle both taking care of children knowingly brought severely disabled into the world, if that as a parental option, while also spending boucoups on the jillions of severely dying (meaning prognosis of death is more imminent), with plenty of money left over to take care of all other health needs.

Only those directly involved would have to decide how next to proceed, and the rest of us would respect and abide by their personal choices, comfortable in knowing we have the same latitudes for ourselves.

Oh, I know I have a bad case of everlasting idealism but to me it’s sooo preferable to being greedy and grabby, squealing for room at the trough, I wouldn’t dream of exchanging maladies.


Jay: There’s an intriguing, if not troubling point raised here. It may well be the case that the lion’s share of health care cost is devoted to those in their last year of life. It looks like the argument here is “these people are terrified of death” and they shouldn’t be. It’s also true, as Terry wrote, that Christianity has let a lot of folks down. But if that’s a testament to anything, isn’t it a testament to the fear death holds over many, no matter how devout they may be?

It’s one thing if big corporate health care holds fear of death over people for the sake of profits, little different than how corporate America in general wields fear as one of its major advertising weapons. That should be fought for the abomination that it is.

Many people, who actually may be on death’s doorstep, may not know they’re about to die, or cannot come to terms with that. Maybe fear of dying is irrational, but to delegitimize it is inhumane. There are also many cases where someone in their 80s has a serious, life-threatening illness, maybe even have been read the last rites, but then responds to treatment, or otherwise recovers, and lives another good five, 10, or more years.

Who are we to deny such people hope?

If we want to put health care spending on the chopping block, I’d say let it be bloated overhead and executive salaries, and the whole “for profit” health care system itself! After that, I’d speculate there’d be enough revenue to allow people to make their own decisions about treatment, care, and the end of life, in consultation with family, close friends, and medical professionals who truly have the best interest of their patients at heart. If the end of elderly people’s lives costs some money, I’d much rather pay for that than for Predator drones that end people’s lives early.

Give people honest assessments of their condition and realistic scenarios. Then, “let the people decide.” This applies to the elderly -- and the dying -- as much as anybody else.


Sarito: Jay, I’d not like to be misunderstood as advocating pulling the plug on grandma, or instituting death panels because of some notion that people shouldn’t be afraid of death. There is nothing “illegitimate” about the fear of death, it’s a species-survival instinct we all carry with us. But it is sad, and I would argue “inhumane” to exploit that fear -- whether for profit, as in the medical system and in the advertising by corporate America in general, or for the sake of keeping the Christian faithful devout and coming into the churches.

Fear of hell and greed for heaven is what the Christian church is all about. (Not talking about poor Jesus here, I have the sense he got sold out very early on by his so-called disciples, and not just Judas.)

Yes, there’s a larger community question about how much money we are collectively willing to spend on aggressive medical interventions at the end of life. I suspect, however, that if people are given truly dignified, pain-free, and compassionate alternatives to aggressive medical treatment that (as best as they and their doctors determine) has very little chance of succeeding, they will choose that. For those that still want to fight... they certainly deserve our compassion, and as much help and support as we can give them.

A rather wise person I know has said that the opposite of love is not hate, it’s fear. I think that’s true... and that is the larger, underlying human/spiritual dilemma to be faced in dealing with the fear of death. That is way above the pay grade of any political system or “set of rules” to solve.

But ideally, yes... I would hope we find a way that every single human being can live as long as he or she needs to, to accomplish all they want to accomplish, make peace with everybody they need to make peace with, see their favorite granddaughter get married, whatever it is that they still want to do before they die. A much more worthy use of our common resources than Predator drones indeed.


Terry: I agree with most of what has been said here; however, the real problem with the USA health care system is the “for profit” corporate medicine. It basically changes the Hippocratic Oath of “First, do no harm” to “Your money or your life.” If we had a universal care or universal Medicare system, the overhead and executive salaries would pretty much be brought into line. People would also be able to deal with their physician on a one-to-one basis.

It is the corporate interjection into the system that is getting between the physician and patient. Not only do the corporate preferred provider systems (PPS) tell the patient which physicians in the PPS they can see, it also tells the physicians which diagnostic and therapeutic procedures they may use (or suffer loss of income).

I worked for 20 years with several very competent and compassionate physicians who started to retire in the late 80s and 90s because they got tired of constantly negotiating PPS contracts. I remember one particularly good physician who said, “I didn’t go into medicine to deal with lawyers all the time, and I don’t have to.” He retired before the next annual negotiation cycle, which started as soon as the last contract was signed.

As to “death and dying,” I think this will be much more difficult to change. It is a societal attitude problem. Almost no one wants to die, but we all will. The dilemma is the very last few months before death when the medical professions feel the obligation to pull out all the stops to prevent death, even though it is an impossibility. As one who went into health care 40 years ago in an attempt to recoup my karma after volunteering for Vietnam, I have observed and thought a lot about this.

Jay, you say,

Maybe fear of dying is irrational, but to delegitimize it is inhumane. There are also many cases where someone in their 80s has a serious, life-threatening illness, maybe even have been read the last rites, but then responds to treatment, or otherwise recovers, and lives another good five, 10, or more years. Who are we to deny such people hope?

This is exactly why I say the attitude toward death will be the most difficult to change. I have seen way too many people who were comatose or not competent kept alive for even a few days at great expense, and very few of the “miracle” recoveries from such illnesses at 80 years old. It is at once societal and individual.

As for me, I hope I have a Dr. Jacob “Jack” Kevorkian available when I become so infirmed I can’t wipe my own butt, or am in irreversible pain. I do not want to squander my daughter’s and granddaughters’ inheritance trying to add one month of agony to what has been an otherwise very fortunate and comfortable life.

But, then, that is me, and death is a very personal thing; others may have “hope” eternal.


Jay: Since I live in Florida, trust me, I have not forgotten the infamous Terri Schiavo case, wherein then-Gov. Jeb Bush and a howling right wing mob fought to keep the unfortunate Ms. Schiavo alive, even though she had been comatose for over 10 years and contrary to her husband’s wishes.

We are not talking about those sorts of cases here. What we are discussing is people who are still at least mildly cognizant, and can make something approaching a lucid choice about their terminal care and/or end of life decisions. Situations like that of Ms. Schiavo are a tremendously good reason why everyone should have a “living will” and why that is the basic answer to this question.


Charlie: Fear of dying. Dying is something that humans seem to fear. I am not sure that animals do. They get scared and feel pain but I don’t know enough about animals to know. I do know that from a young child I was taught that I would go to Heaven if I was good and to Hell if I was bad, all of which over the many years of going to various churches and studying various religions turns out to be a lot of hooey.

When my father died he went off to some medical school to be carved up. When my father-in-law died we had a huge battle over what kind of box he needed. I doubt that he cared. Then I cremated my mother and got this box that I have been carrying around for 20 years and don’t know exactly what to do with? I have even lost it a couple of times in the garage. My stepmother shot herself and the church people freaked out and refused to deal with it. She had sinned. She didn’t sin, she just had terminal cancer and shot herself. Again there was a huge flap among the sisters and brothers; eventually she was cremated and that urn was sent to Amarillo.

I think it is the pain of death that we fear most. If we just fell over dead we wouldn’t care much one way or the other. Didn’t the Sioux and other tribes let their old and feeble go off into the woods to expire. Maybe they gave them lots of peyote to make it a fun trip. Christians have some sort of irrational thing about getting to be dead.


Thorne: Though pain is certainly a factor, I think we primarily fear the loss of ego -- loss of “self” or consciousness of self. We invest a lot in this life and the idea that it can (will) be ripped out from under us is a rather chilling concept.

Some disciplines, of course, help us to deal with the question of ego, perhaps to tame it a bit if not to totally banish it. And many belief systems tell us that life continues in some form or another. But these are things we cannot -- at least intellectually -- know to be true.

Bottom line, I think the fear of death derives from the (presumable) fact that life as we know it will be snuffed like a candle.


Terry: Thorne, I agree, it is mainly fear of death that society does not teach us to deal with logically. Of course, fear is the one thing that the R’s are selling right now.

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Dr. Stephen R. Keister : I Cry for my Country

I cry for my country:
The state of health care in America

"Laissez-faire, supply-and-demand, -- one begins to be weary of all of that. Leave all to egotism, to ravenous greed of money, of pleasure, of applause; -- it is the gospel of despair." -- Thomas Carlyle, 1843.

By Dr. Stephen R. Keister / The Rag Blog / November 4, 2011

[Happy Birthday Steve Keister!!!

Our dear friend, Dr. Stephen R. Keister, turned 90 on Sunday, October 9. For the last three years Steve has written -- with a unique and singular voice -- dozens of columns about the sad state of our health care system. And in that time he has become the heart and soul of The Rag Blog. He claims this is his last column, but we promise not to hold him to that commitment! We hope he will continue to share his wisdom with us for many months to come.

In the meantime, look for Sarito Carol Neiman's Rag Blog feature article on the life and times of Dr. Stephen R. Keister. Coming soon to a Rag Blog near you!

-- Thorne Dreyer, for everyone at The Rag Blog.]

Having passed the age of 90 I wish that my final days could be days of happiness and good wishes for those about me; however, it appears that fate has ordained otherwise. It would be a great course of satisfaction to see an enlightened, progressive United States as a homeland for my grandchildren. Instead we find a nation that is descending into quasi-feudalism and subservience of the many to the few.

With that in mind, I approach my final column for The Rag Blog with a few observations about medical care in the United States.

Rarely do I watch television as I find it stultifying, by and large, save for a few generally open and informative presentations on MSNBC. I did, however, watch on ABC news report about a day of free medical care at the Los Angeles Coliseum where hundreds of the poor, underprivileged, uninsured stood in line -- many of them all night -- to gain admission to a day of free care provided by volunteers from the L.A. area.

This is my country! This is the nation that spends twice what any other civilized nation spends per capita on health care! This is what the corporate leaders and their political prostitutes have to offer for the coming years! This is what the Republican presidential candidates condone and would promote for the future health care of our country, and for which the current administration has crafted, for political purposes, a faux health care bill, dictated by the insurance consortium and the pharmaceutical industry.

We, in the United States, have the ultimate in health care rationing -- and it's rationing based on one's ability to pay.

Nation of Change featured an article by Noam Levey titled, "U.S. Health Care Falls Further behind Peers, Report Finds." The article, notes that "The U.S. health care system is lagging further and further behind other industrialized countries on major measures of quality, efficiency, and access to care, according to a new report from the nonprofit Commonwealth Fund, a leading health policy foundation." The report in full is available here.

In its fall newsletter, Physicians for a National Health Policy (PNHP) reveals many more facts that surprised me and may surprise you. For instance:

• 60.3 million Americans (19.8%) were uninsured for at least part of 2010, up from 58.5 million people in 2009, according to the National Center for Health Statistics. 48.6 million Americans (16 %) were uninsured at the time of the interview for the 2010 survey, up from 46.3 million people in 2009, with the majority, 35.7 million Americans (11.7% of all Americans), uninsured for more than one year, up from 32.8 million people the previous year, according to an analysis of data from the National Health Interview Survey.


• Nine million working-age Americans -- 57% of people who had health insurance through a job that was lost -- became uninsured between 2008 and 2010, according to a survey by the Commonwealth Fund.


• Health care premiums will rise 8.5% in 2010, according to a PricewatterhouseCoopers survey of 1,700 firms. Employers are offering workers more meager plans in response to rising costs; 17 % of employers surveyed most commonly offered high-deductible health plans to their workers this year, up from 13% in 2010 (Merrill Goozner, The Fiscal Times, 5/18/11).


• The total cost of a health care plan for a family of four covered by a VA Preferred Provider Plan (PPO) in 2011 is estimated to be $19, 393, up 7.3% from 2010, according to Milliman Medical Index. Employer contributions account for 59%, $11,385, of the total, while employees pay 41% of the cost, $8,008. Employees will pay an average of $3,280 in out of pocket costs. (The Milliman Medical Index ).


• U.S.Physicians spend nearly four times more on billing and related overhead each year ($82,975 vs $22,205) per physician than their Canadian counterparts, with U.S. medical practice staff spending over 20.6 hours per week on bureaucratic tasks, compared to just 2.5 hours per physician week under Canada/s single-payer program (Morra et al., "U.S.physicians practices vs Canadians," Health Affairs, 8/11.)


• The nation's five largest for-profit health insurers netted $11.7 billion in profits for 2010, up 51% from 2008, because medical costs grew more slowly than forecast, as insured patients skimped on medical care to avoid costly co-pays and deductables during the severe recession. UnitedHealthcare was the leader in profitability, taking in over $4.6 billion in profits, followed by WellPoint ($2.9 billion) and Aetna ($1.8 billion).


• CEOs at the nation's five largest for-profit insurance companies garnered $55.4 million in compensation in 2010. The top paid was Cigna's David Cordani ($15.2 million), followed by WellPoint's Angela Braly ($13.5 million), United Healthcare's Stephen Hemsley ($10.8 million), Aetna's Mark Bertolini ($8.8 million), and Humana's Michael McAllister ($6.1 million). (Executive Pay-Watch, AFL-CIO, 2011).


• The pharmaceutical industry spent $6.1 billion in 2010 to influence American doctors, and another $4 billion on direct to consumer advertising, according to IMS Health.

And then there's hospice care:

• For-profit hospices are expanding rapidly and may be cherry-picking the most profitable patients, according to a recent study. The number of for-profit hospices increased from 725 in 2000 to 1,600 in 2007, while the number of nonprofit hospices remained stable at 1,205 in 2007. Overall, 52% of facilities are for profit, 35% are non-profit, and 13% are government owned.


• Hospice care is funded by Medicare on a per-diem basis, with a fixed rate ($143 in 2010) paid to providers for each day a patient is in a facility. Because the first and last days of care are more expensive, to provide, longer care generates higher profit. The study found that patients in for-profit facilities averaged a 20-day stay, compared to 16 days in nonprofit centers. (Your author has a question. In view of the fact that hospice care is designed to provide compassionate, painless death with dignity, what is the method of four days longer survival in the for-profit hospice?)


• Hospice care costs for nursing home patients jumped nearly 70% between 2005 and 2009, from $2.5 billion to $4.3 billion, while the number of hospice patients increased by only 40%, according to the Office of the Inspector General. Hospices with a large share of patients in nursing homes were typically for profit and appeared to seek out patients with certain characteristics associated with life expectancy and lower demand for care. The Medicare program paid for-profit hospices more for patients than it paid non-profit and government owned hospices in 2009. For profit hospices received about $12, 600 per patient while nonprofit and government entities received between $8,200 and $9,800 per beneficiary.

One bit of light is the California Medical Association's resolution to legalize marijuana. A tiny bit of encouragement, but a very long way to go.

This old geezer can find nothing to relieve my depression regarding the future of health care in our fair country. The moral decay, the worship of wealth, and the lack of Christian charity appear to create a situation that worsens by the day.

I find no hope within either political party as both are whores to the corporate interests that dominate our society. The sole voices of hope that appear to reach the public in general come from the "99%" movement and Dylan Ratigan's campaign for a constitutional amendment to do away with money in politics.

Unlike in Europe, where the populace has a basic understanding of the existing domestic situation, the average American appears to be entirely moved by nothing but the sloganeering of the political Right.

I cry for my country, and while asleep I hear in my dreams the mass gatherings of my youth singing, "Arise ye prisoners of starvation, arise thee wretched of the earth, for justice thunders condemnation, a better world's in birth."

[Dr. Stephen R. Keister lives in Erie, Pennsylvania. He is a retired physician who is active in health care reform and is a regular contributor to The Rag Blog. Read more articles by Dr. Stephen R. Keister on The Rag Blog]

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Thorne Webb Dreyer and Sarito Carol Neiman : Bon Voyage, Doctor Keister

Dr. Stephen R. Keister, 1921-2012.
Dr. Stephen R. Keister, 1921-2012:
Bon Voyage, Doctor Keister

By Thorne Webb Dreyer and Sarito Carol Neiman / The Rag Blog / April 12, 2012

It seems the cancer always wins! Tomorrow I go to the Manchester Presbyterian Lodge for final care by Great Lakes Hospice. I am beginning to hear the splash of Old Charon's oars in the waters of the Styx. It ain't all that bad with the memories of all of you fine folks to take along.” – Steve Keister, in a message to his friends and his colleagues at The Rag Blog, February 2, 2012

Dr. Stephen R. Keister left us late Friday night, April 6, 2012, after a long-running bout with prostate cancer. He died in hospice care in his longtime home, Erie, Pennsylvania, at the age of 90.

The cancer may have won but we seriously doubt that Old Charon, the ferryman of Greek mythology (who carried souls of the newly deceased into the world of the dead) succeeded in transporting Steve all the way to Hades.

Steve, ever the philosopher and the reformer, probably recruited the wizened old seaman to his own cause of universal health care and they’re out there now, organizing for a single-payer system in the Afterlife.

Steve Keister, who turned 90 last October, was a retired physician who practiced internal medicine in Erie, PA, from 1950 until 1991, specializing in rheumatology; he was the region’s first practicing rheumatologist.

He attended Duke University where he became interested in the writings and philosophy of Moses ben Miamon, Voltaire, and Sir William Osler. He obtained his M.D. from the University of Maryland and did his postgraduate training at the Mercy Hospital in Pittsburgh and Hamot Medical Center in Erie.

His medical honors were many and after retirement he remained active in scholarship and volunteer work. And Steve found a second passion late in life, dedicating himself to progressive social change, and especially to the cause of universal health care, working with Physicians for a National Health Plan and other activist groups, and writing about health care reform for The Rag Blog.

According to his daughter, Cindy Hepfer, "Steve has always been a voracious reader, continued to play tennis until his 60s when he took up golf instead, and enjoyed having friends in in the evening for drinks and conversation."

And, “after retirement,” Cindy said, “Steve continued his family’s tradition of trying to preserve the tenets of the nation’s Founding Fathers by active membership in People for the American Way, Americans United for the Separation of Church and State, and Amnesty International.”

In a eulogy, Steve's friend Don Swift said that Keister was not only a "gentleman scholar," but that he was also "a mensch, a person of integrity and honor," and that he was "all about trying to heal a broken world."

Fellow Pennsylvania activist and writer Carl Davidson said, “We knew him well here in Western Pennsylvania, especially as an unwavering voice for Medicare for All, and then some. He supported PDA's [Progressive Democrats of America’s] efforts here, but his own views were with the socialist left. Raise a fist and a red rose for him this May Day. He will be missed.”

About her father’s involvement with The Rag Blog, Cindy Hepfer said, “You have certainly given him a mission in these latter years of his life! I thank you for giving Dad a creative outlet and a way to share his goodness and intelligence with others.”

Keister's heavily-researched opinion pieces published by The Rag Blog were rich with personal reference and backed up with facts, figures, and links. They were erudite, yet peppered with wonderful colloquialisms reminiscent of an earlier era, and always filled with quotes and observations from great thinkers, scientists, and philosophers ranging from Rabelais, Pliny the Younger, and Confucius, to Aldous Huxley, Sir William Osler, John Ruskin, and Will Rogers.

And, if you read a column by Dr. Stephen R. Keister, you never had any doubt about where the author stood on the subject.

Though always full of hope personally, Steve became increasingly disillusioned with the medical system in this country and the growing dominance of the pharmaceutical and health insurance companies.

In his writing, he often reflected on the lessons of a lifetime in medicine.

“I entered the practice of medicine in 1950, an idealist, believing in the lesson of the Good Samaritan,” he wrote. “I believed that all persons should be provided with medical care…”

But, “Somewhere in the 1980s medical care, with great planning and premeditation, was usurped by the health insurance cartel in collusion with the pharmaceutical industry. Medicine was changed from a proud profession to a business, and the physician degraded to a ‘health care provider.'"

In his final column for The Rag Blog, entitled “I Cry for My Country,” Dr. Keister wrote:

Having passed the age of 90 I wish that my final days could be days of happiness and good wishes for those about me; however, it appears that fate has ordained otherwise. It would be a great course of satisfaction to see an enlightened, progressive United States as a homeland for my grandchildren. Instead we find a nation that is descending into quasi-feudalism and subservience of the many to the few.

At the time Steve submitted his final column, we at The Rag Blog were aware of his worsening physical condition. We included the following introduction to his piece:

Our dear friend, Dr. Stephen R. Keister, turned 90 on Sunday, October 9. For the last three years Steve has written -- with a unique and singular voice -- dozens of columns about the sad state of our health care system. And in that time he has become the heart and soul of The Rag Blog. He claims this is his last column, but we promise not to hold him to that commitment! We hope he will continue to share his wisdom with us for many months to come.

But we knew it wasn’t likely.


Steve Keister approached death much as he handled life, with vigor, intellectual curiosity, and an open mind. According to his daughter, “He was analyzing the dying process for as long as he could and communicating his thoughts to those around him.”

“He had observed repeatedly to several of us that he was not afraid… and that he always liked to sleep.” Cindy said. "I told him how brave I thought he was and that he shouldn't be afraid to reach out for the sleep that he wasn't afraid of.”

We communicated with Steve during his final weeks and he shared his feelings and observations about the process of dying.


Saying goodbye

"Death is someone you see very clearly with eyes in the center of your heart: eyes that see not by reacting to light, but by reacting to a kind of a chill from within the marrow of your own life." -- Thomas Merton

"The greatest challenge of the day is: how to bring about a revolution of the heart, a revolution which has to start with each one of us?" -- Dorothea Day

How do you say goodbye to a friend? We mean really goodbye -- not “so long, see you later.” Saying goodbye, really, is an opportunity one doesn’t have often or early in life.

When we are young and a friend dies it is usually sudden, unexpected. One day the person is here, the next day that person is gone. And even when we know that death is coming, our culture as a whole does not tend to support the ceremony of saying our goodbyes while that person is still alive. Instead we are supported to remain in denial -- “you can beat this thing, I know you can!”

We are encouraged in so many ways, subtle and not so subtle, to save our goodbyes for when it’s too late for the person who’s leaving to hear them. And by the time we are old enough to see (if we dare to look) the glimmer of our own departure on the horizon, we have no practice in saying goodbye, either as one who is leaving or as one who will remain.

Stephen Keister was a friend. His contributions to The Rag Blog over the past three years have been rooted in a rich lifetime of experience as a physician and proud “secular humanist” and, as such, his insights have been invaluable as we have collectively wrestled with all the implications of the crisis in health care that has plagued the United States now for decades.

His passion for his subject was not abstract or ideological; it was his very life. In his first Rag Blog column, published on Nov. 17, 2008, Dr. Keister was clear where he stood on the question of healthcare reform:

To take the burden off future generations this country must get in step with Western Europe in quality and extent of health care for all. According to the Commonwealth Fund our health care rates 26th in the world and as of Nov. 13 [2008] … U.S. patients, compared to seven other countries, suffer the highest number of medical errors. 44% of chronically ill patients did not get recommended care, fill a prescription, or see a doctor when sick because of costs. 41% of U.S. patients spent more than $1000 in the past year on out of pocket costs, compared to 4% in Britain or 8% in the Netherlands.

We must make sure our elected representatives are not taking baksheesh from the pharmaceutical and insurance industries and support single payer, universal health care devoid of insurance company participation. The nation and your family depend on you not sitting idly on your butt. Call, E-mail, demonstrate!

We lost that battle, obviously. But the war is not yet over, as the sad compromise that became “Obamacare” now finds itself in the Supreme Court. Steve Keister did not live to see the outcome of the current scuffle. But it’s clear, no matter what the outcome, there is still no cause for sitting idly by.


When we heard that it was time to say goodbye to our friend Stephen Keister, we wanted to find a way to honor the occasion. Not to respond with denial, nor to save all our tributes till after he was gone.

So we did what anybody might do if they just found out that a wise and beautiful friend was about to leave for good. We sent him a list of questions, hoping it would offer the opportunity to share what is happening with him now. True to form, he responded both as a scientist and as a humanitarian, the rare combination that has made it such an honor and privilege to publish him over the years.

Here is his response, in his own words. In a sense, this is Steve Keister’s final column. We would like to thank writer and educator -- and Steve's close friend -- Don Swift, for facilitating our final communication with Steve Keister.

Recently I’ve received a request from Thorne Dreyer and his many friends at The Rag Blog, to give him some insight into the situation in which I am involved -- that is, terminal cancer of the prostate, under the care of the good people at the local hospice organization.

Initially, I think we’d better discuss what hospice exactly covers. In my last article in The Rag Blog, entitled “I Cry for My Country,” I refer to several instances of hospices run purely for the financial benefit of the folks in charge. In other words, once again we are faced with the terrible American attitude of money above all else. Therefore, I would suggest that anybody who is interested in legitimate hospice care get a copy of the pamphlet entitled, “When Death Is Near: A Caregiver’s Guide.”

Hospice in the United States is a reasonably new organization, and the hospice in Erie was one of those founded on the basis of charitable giving. Some 25 years ago, Dr. David Dunn, a very capable general surgeon who had spent time in Great Britain during the war, became interested in the hospice movement and spent several months studying the technique as utilized in the U.K. Subsequently he came back to the United States and established a purely volunteer movement, which was soon overburdened, and ultimately taken over by his son, Dr. Geoffrey Dunn at the Great Lakes Hospice, where it remains today.

I became involved in this personally, having been diagnosed with carcinoma of the prostate some 12 years ago. This was treated initially by irradiation and subsequently hormone therapy. Approximately mid-2011, bone scans showed spread of the cancer to the various bones of my body. I tended to ignore this, which was possibly a mistake on my part, because of several factors. At the age of 90 I was enjoying the company of both the Edinboro University retired faculty group, and an 89-year-old lady, who was the best of companions, on the 8th floor of my building.

The question arises, why did I resort to hospice care?

I was not fully aware of the signs of the deteriorating effects of metastatic cancer. I was aware of the fact that we develop painful areas in the bones, but I completely ignored the systemic symptoms of the disease, which are: 1) increased fatigue; one will sleep up to 18 hours a night; 2) complete loss of appetite; one desires nothing, even a glass of milk, for a meal; 3) desire for solitude and lack of interest in things of everyday origin.

These taken together mean something to an alert physician and, happily, Dr. Jeffrey Dunn of hospice stopped by one evening to discuss books, and I discussed my symptoms with him. He said, “Gee, Steve, you’re a candidate for hospice care -- your cancer is spreading.” So the next day I was a hospice patient, and have never regretted it to this day.

Hospice nationally will provide 90 days of care under Medicare. They do not provide inpatient care in a convalescent or nursing home, but otherwise, medicine, equipment, medical care, etc., is provided by the program. I currently am in the Presbyterian Lodge in Erie, and everything is going according to program. I realize I have not long to live, but realize too that I have much to be thankful for throughout my 90 years.

I am also asked how I have rationalized the facing of death, and the question mentions that Socrates, the Zen masters, Jesus, Buddha have all offered alternatives. However, I have somehow avoided these alternatives and looked at this as a purely biological process. We are born in pain, we live largely in pain, and hopefully we can avoid dying in pain.

I’ve been assured by several of the hospice workers that the easiest people to care for are those that are the “secular humanists” who approach each stage of life as a natural event and do not interfere or complicate matters with various philosophical pictures.

While is it true that good hospice care professionals, if possible, provide a role of helping family and friends come to terms with the impending loss of a loved one, some of us are beyond that stage. At the age of 90 we have few living relatives and depend entirely on friends. Happily, I have been blessed with many, many friends in my recent lifetime -- perhaps more so than earlier in my life.

The final question in the submitted list is very interesting and very apropos to the present time. It is: If you could make a new Hippocratic Oath for the 21st century to be given to every student graduating from medical school, what would it be?

This I have given much thought, and do not feel intellectually qualified to answer this at the present time. But I do feel that certain factors should enter into the situation. I do think the philosophy of Dorothea Day and Thomas Merton should play a big part, and within their thinking, we who allegedly feel we are Christians should remember the Sermon on the Mount and the Beatitudes.

In addition to that, from the ethical standpoint we should remember the teachings of two physicians of the last century: Sir William Osler and Dr. W.W.G Maclaclhan of Pittsburgh, both of whom treated people of prominence, the well-known, but at the same time never turned their backs on the poor, the underprivileged or the disabled.

I once again wish to thank my friends in Austin, Texas, my friends in my retired professors' group in Edinboro University, my children, including my daughter Cindy and son-in-law Will (both librarians), and my grandson Jonathan and his wife Alice (both modern musicians with a technique I do not understand but in which apparently they are doing great work). And finally, my dear friend on the eighth floor at 1324 South Shore Drive.

Peace. Peace to all. Thank you.

More of Stephen Keister’s last words can be found in his last columns for the Rag Blog. His final column ended with a challenge for us all to carry on the work of birthing a better world:

I cry for my country, and while asleep I hear in my dreams the mass gatherings of my youth singing, "Arise ye prisoners of starvation, arise thee wretched of the earth, for justice thunders condemnation, a better world's in birth."

Bon voyage, Doctor Keister. You will be missed.

[Thorne Dreyer edits The Rag Blog, hosts Rag Radio, and is a director of the New Journalism Project. He lives in Austin. Sarito Carol Neiman is a freelance editor, author, and actress who lives in Junction, Texas. Together they edited Austin's Sixties underground newspaper, The Rag.]

Find articles by Dr. Stephen R. Keister on The Rag Blog.

Images courtesy of Cindy Hepfer.
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