Occam’s Razor

Democrats choose pragmatism on Universal Health Care

I find it remarkable how much the health care debate has changed in the last few years. Not long ago, it was anathema for many mainstream politicians to even suggest that Americans needed universal health insurance. Now, every Democratic candidate for running for president has his or her own plan. Republican candidates, while rejecting the idea of “government run” health care plans are proposing tax credits and other incentives which they believe will make health care easier to acquire.

By big margins, Americans are saying they have had enough with our current health care “system”. They no longer buy into the notion that America has the best health care. Perhaps it does, if you are independently wealthy. The rest of us are stuck with either substandard insurance through our employer, paying through the nose for our own policy or spending much of our free time praying that we do not get severely ill. Every year, assuming we do not join the ranks of the uninsured, our premiums and deductibles rise. Moreover, the list of covered procedures grows smaller.

Doctors and employers hate our health care “system” too. Unless they spurn insurance altogether, they generally are paid a fraction of their fee. For doctors, it seems like they spend more (uncompensated) time hassling with insurance companies than seeing patients. Insurance companies frequently override their recommendations for patient care. Patients like my wife, who have had several major operations, are sent home after just a night in the hospital. Ideally, surgeries are done on an outpatient basis. As for employers, providing health insurance becomes more problematic every year. Many small businesses do not even bother.

Movies like Michael Moore’s Sicko have documented how other countries are successfully providing universal health care. The fear mongering tactics of the insurance companies and HMOs no longer frighten us. How could anything the government comes up with be scarier than what we already have? How often do you see senior citizens bitching about Medicare? Now we understand that the money insurance companies saved by kicking us out of the hospital too soon is being used instead to coax congressional representatives and senators into making sure the system does not change. Finally, so many years later, it looks like our representatives are finally developing a backbone. Providing we elect a Democratic president and Congress in 2008, the chances for having universal health care in this country are excellent. It is about freaking time.

But which way to go? To me the Republican calls for tax credits are ludicrous and fully worthy of derision. They certainly do not provide universal health insurance. Health care savings accounts are fine if you have sufficient income to put money into them, but they are hardly a panacea to rising health care costs. If you are living from paycheck to paycheck, they are useless. One of the reasons I am so optimistic that Congress will go Blue next year is that Republicans still subscribe to ridiculous ideas like these. It is like saying they believe in the tooth fairy. Get real, Republicans! Not all problems can be solved by the marketplace. That is why governments exist: to step in where the public needs are not being addressed adequately by the private sector. It is right there in our constitution: our government exists in part “to promote the general welfare.”

As a liberal, revolutionary change excites me. Like many liberals, a single payer health care system strikes me as ideal. So why can I not fall in line behind it? I cannot because I know that, at least in this country, massive changes like this one tend to bollix up the whole system rather than solve the problem. Health care in America is too big and too institutionalized to change radically. It will doubtless cost us more, but to effect change that will actually work, we have to incrementally change what we have now, as imperfect as it is.

I spent some time today reading the health care proposals of Democratic candidates. With the exception of known eccentrics like Dennis Kucinich, the candidates are proposing measured and evolutionary changes in order to provide universal health care. Republican candidates are merely sticking their toes in the health care waters. Democratic candidates, on the other hand, are offering pragmatic and workable plans that build on the existing system.

Hillary Clinton was the latest candidate to release her health care proposal. Sometimes being last is best. Perhaps because of her presumed front-runner status, her proposal received a great deal of media coverage. It showed that she had thought through the mistakes she and her husband made in the 1990s. With her plan, if you are satisfied your current health plan you can keep it. If you do not like it, you can select from the many plans that are available to us federal employees, all of which have to take you no questions asked. Otherwise you are free to enroll in a public plan that will look a lot like Medicare. Her plan requires that every American purchase health insurance coverage but premiums are limited to a percentage of income. Rolling back some of the bigger Bush tax cuts for the very rich will help pay for her plan. She also thinks a lot of money can be squeezed from current inefficiencies in the system.

Will all of her savings be realized if enacted? Probably not. Many of these “savings” are likely smoke and mirrors. At this point, our health care system is so complex that it makes our tax code look simple. However, her plan and the many like them proposed by other Democratic presidential candidates are pragmatic steps that provide the universal coverage we need. Making the uninsured pay for even a portion of the cost of their care should mean that you would be paying less for your health care. Your premiums are so high in part because you have been indirectly subsidizing the uninsured all along.

Perhaps over time we can evolve into a single payer system. If so, it will likely take many decades. We will still be envious that other developed countries like Canada, Great Britain and France can provide better care at lower cost through their single payer systems. At least we will at last have some form of universal health insurance. It will not be a perfect system but it will be good enough. Doctors will keep billing. Insurance companies will still take their slice of the health care pie. Yet overall, it will be better. Employers can concentrate on making profits instead of worry about how they will afford double-digit health insurance premium increases. I hope that our doctors will spend more time with patients, and less on the phone haggling with insurance companies. While it will not be perfect, only multimillionaires will want to revert to the health care mess that we have now.

September 21st, 2007 at 09:00pm Posted by Mark | Politics 2007 | no comments

Our stressed out nation

Didn’t you suspect this all along?

Scientists reported yesterday that they have uncovered a biological switch by which stress can promote obesity, a discovery that could help explain the world’s growing weight problem and lead to new ways to melt flab and manipulate fat for cosmetic purposes.

….

Moreover, the stressed-out junk-food eaters put on the worst kind of fat — deposited around the abdomen and laced with hormones and other chemical signals that promote illness. After three months, the animals became obese and developed the constellation of health problems that obese humans often get — high blood pressure, early diabetes, high cholesterol — an increasingly common condition known as metabolic syndrome.

I find a direct correlation between my weight and the amount of stress in my life. I bet the same is true with you. So the conclusion in this article was no surprise. When you are under stress, your body is in an abnormal state. Yet for many of us Americans, modern life is little but stress. Our employment often feels tenuous. Our marriages feel rocky. Our kids are difficult to manage. We work two or three jobs to pay the bills.

Therefore, we look for balms to relieve our stress. These are typically smoking, drinking, drugs and food. Of the four of these, the one that society frowns on the least is food. Unlike drugs, cigarettes and booze, food is both extremely convenient and inexpensive. You will not be carded for being underage and buying a box of Ding Dongs. Solutions to our stresses often involve more stress. If our marriage is under stress, to solve it we either have to endure months of painful and expensive marital therapy with high likelihood of failure or go through the trauma of divorce. If our children are grossly misbehaving, timeouts and a spanking are unlikely to solve the problem. Instead, they likely need to talk to social workers and psychiatrists. Often they will end up on antidepressants. Since their behavior affects Mom and Dad, they often end up on antidepressants too. However, since most stress is situational, treating stress by pill is no cure. At best, it offers only modest and temporary relief.

For many of us the best and cheapest therapy is a pet. Like Prozac, even the most devoted dog can only do so much. Therefore, it is easy to succumb to the temptation to buy that box of Krispy Kremes. A sugar high is easy to achieve and it feels so satisfying. Except of course, it is as successful at solving our stress as a bottle of booze. At best, it helps the stressful feelings recede for a few hours.

Maybe it is coincidence but as I travel America, I feel like I can accurately measure the stress level of a community by the average girth of its citizenry. Throughout much of the South and Midwest, Americans are noticeably more obese than elsewhere. Perhaps poverty in the South contributes toward its problem. Its culture probably contributes as well, which seems to emphasize a diet rich in empty carbohydrates. The filmmaker Michael Moore is quite obese and was raised in Flint, Michigan. Since my wife is also from Flint and we have relatives in the state, we visit Flint periodically. I note no lack of an obesity crisis in Northern Virginia where I live. Even so, when I go to Flint I feel appalled. With the auto industry in permanent decline, the city slipping more and more into stagnation with the passage of each year, it seems Flint’s biggest surplus is in obese people. The residents of Flint seem to have an unhealthy attraction to greasy spoons and donut shops.

As I noted in 2005, there are no lack of greasy spoons and donut shops in Canada either. You can hardly drive a mile without passing a Tim Horton’s donut shop, for which residents of Ontario seem to have an almost unnatural affection. (There is sound reason for their affection; we dined there twice.) I have seen Tim Hortons crowded even during off hours. Yet, at least around the Toronto area, I saw markedly fewer obese people than just a hundred miles away in Buffalo.

Last summer when we visited Paris I was struck by the absence of obese and overweight people. In America the typical person is more likely to be overweight than not. In Paris, you have to look for them. My belief is that because the French in general live less stress-filled lives than Americans do, they have less need to use food to cope with stress. With their nationalized health care system, they never have to worry about whether they can afford to see a doctor. Their law requires a minimum of five weeks of vacation per year. Their national holidays are also more plentiful than ours are. Downtime and safety from many of life’s worst shocks are built into their culture. As a result, the French seem to have institutionalized a form of living that minimizes stress. So, like the mice who were not subjected to stress in the study, I am not surprised that the French look so good. (As I noted then, I think this is partly because Parisians get more exercise than we do. They burn off plenty of calories just walking to and from mass transit. They are less likely to commute by car than we are.)

Our American values emphasize self-reliance. It is practically a religion. We see living by our wits as a competitive advantage. While it may have its benefits, I think it is clear that this form of living also has a dark side. We can see it manifested in our exploding girths. Just the comfort of knowing that we have universal health insurance may do more to combat our obesity crisis than a stack of surgeon general reports.

While I think self-reliance is a terrific virtue, I also note that Europeans with their nationalized health care systems and more socialized governments live longer and have less stress-filled lives than Americans have. You have to look hard for a Western European country with life expectancy rates comparable to the United States (Denmark and Portugal). In France, you are likely to live two years longer than in the United States, despite the fact that most of the French smoke. In Germany, one year longer. In Spain, two years longer. In Switzerland, two and a half years longer. In Canada, with its socialized medicine and rampant numbers of frequently patronized Tim Horton’s donut shops, Canadians live nearly two years and a half years longer than we do.

The common denominator in these countries is that they have institutionalized methods that reduce unnecessary stress on its population. Living by your wits, which is what humans did for most of their existence, reduces lifespan.

For a country that claims to value life, perhaps we can demonstrate it by inculcating a culture that supports it. Perhaps it is time to change our values.

July 4th, 2007 at 11:45am Posted by Mark | Politics 2007 | no comments

Review: Sicko

If you have seen a Michael Moore film or two, you know what to expect. In that sense Moore’s latest film on the sad state of health care in America, Sicko is more of the same. If you hate Michael Moore, you will probably loathe the film. If you like him, you will probably be singing its praises. If like me you are neutral on the guy, you will find merits and detractions in this film, but overall find it a worthy investment of two hours of your time and about ten bucks.

Moore’s films do have a tendency to be harbingers. Some like Bowling for Columbine will push your buttons but, as the Virginia Tech massacre attests, are doomed as far as affecting real change. In Sicko, Moore makes the case for universal health insurance. It may be that with our health care system so dysfunctional that it will contribute toward changing the dynamics of the debate. However, even a rabid Michael Moore hater would have a hard time disputing his assertion, shared by most Americans: our health care system is broken.

If you have not seen a Michael Moore film, do not expect objectivity. Moore makes no pretense at objectivity. He picks subjects for which he has already made up his mind and then assembles the documentary footage to make his statement. He interjects a bit of humor, some self-deprecation and large doses of sarcasm. There are also heaping helpings of scorn at those he does not like. Since almost everyone hates the HMOs and PPOs, it is hard not to cheer Moore on. Little of what we learn in Sicko is actually news. Of course, the health care industry is about making money. Insurance companies would not be profitable if they did not keep an eye on their bottom line. Denying claims and cherry picking clients will always be in their interest. When the consequences are played out with real people, they can be personally disastrous.

Something needs to change. Moore’s solution is to create a nationalized health insurance like those used by most first world countries. He visits Canada, Great Britain, France and Cuba. In each country, he finds that the health care there is far better than what is available in the United States. He busts some myths, including the pervasive one that socialized health care in Canada is worse than in the United States. He does this by visiting clinics, pharmacies, emergency rooms and hospitals in these countries and talking with patients, doctors and nurses. We learn that the founder of Canada’s national health system is considered the country’s biggest hero. We learn that there would be mass riots if Great Britain even considered abolishing its system. In addition, we learn that the French live longer not only because of their excellent health care system (yes, doctors make house calls) but also because of their generous policies regarding maternity and disability leave. In France, working mothers can even get government supplied nannies for a modest cost. There are no complicated forms to fill out. In Great Britain, you need only give your name to get service. If you are poor, the hospital cashier will even give you money on your way out to reimburse you for your transportation expenses. There are never any hospital bills to fret over. Doctors are very well remunerated. Physicians in Great Britain also get bonuses depending on how well they improve the health of their patients. What an idea!

It all sounds great to me. Where do I go to sign up? What Moore omits is some context. In France, for example, the health care system is great, but the costs of its welfare state result in huge deficits. Their unemployment rate is roughly twice ours and their ranking among industrial countries is slipping. Moore surreptitiously takes a group of Americans who have fallen through the cracks of our health care system to Cuba. There they receive the free medical care they were denied in the United States. Drugs costing hundreds of dollars in the United States cost five cents in Cuba. Yes, they have high tech machines like MRIs in Cuba too. Nevertheless, Cuba is a dictatorship. Moore seems more entranced with the free health care than the poverty and the ruthless dictator that runs it, who will tolerate no dissent. It appears that the only place where free universal health insurance is available in the United States is at Guantanamo Bay. To get great free health care in this country, you may have to become a terrorist.

Meanwhile back in the United States, Moore gives us sad vignettes of people slipping through the gaping cracks in our health care system. They will invoke empathy from many of you. An older couple moves into a room in their daughter’s house. Due to their medical conditions, they can no longer afford the house they were living in. A 79-year old man cleans toilets to afford the co-pays for the drugs he needs to survive. A man stitches a gash on his own knee because he is uninsured. A HMO dumps indigent patients on Los Angeles’ skid row. An uninsured man has two fingers cuts off in an accident but can only afford to have one reattached.

Moore traces the rise of HMOs back to the Nixon Administration and shows how they grew in prominence. We learn more things we already know: profits for HMOs and PPOs like Aetna are going through the roof, in part by denying care to those who thought they were insured. We get to relive the fight for national health insurance early in the Clinton Administration. Moore traces the arguably unhealthy connections of health care contributions to political campaigns.

In Sicko, Moore’s primary contribution is to take us first hand into other first world countries and show us how they manage their nationalized health care systems. Much of the rest of the movie simply tells us things we already know, or should know if we have been paying attention. Our health care system is so bollixed up that it would be difficult not to show the advantages of nationalized health insurance. By documenting concrete examples from other countries, he shows a means by which it could also be done here. Moore’s solution though seems more revolutionary than evolutionary. He does not use the words “single payer” but his intent is clear enough: that if other countries can make universal health insurance work, we can too. He suggests that this can only be accomplished by the fed up voters, particularly the disenfranchised demanding that the government act.

As a documentary, Sicko is better than average. However, Moore has done better work. It is hard to escape its obvious conclusion. I see his essential message as this: we have taken the notion of rugged individualism to an unhealthy extreme in this country. While it has been a virtue, it cannot be used everywhere in the marketplace. Trying to make it work in the health care industry has proven to be folly. We need to understand that everyone benefits when health care is provided to all regardless of their ability to pay. By the end of his film, if you are not turned off by all the sarcasm, his conclusion should be hard to disagree with.

July 1st, 2007 at 12:29pm Posted by Mark | Politics 2007, The Arts | no comments

Appalled

If you need more proof that our social fabric is unwinding, this story “Health Care Creates Dilemma for Tennessee’s Poor” today on NPR’s All Things Considered should scare you and make you very angry.

You can read the story on the NPR site, but please listen to it online if you can. As shocking as it is to read, it is even more appalling to listen to it. Linda Warner is a great grandmother who lives on a $600 a month disability check in a doublewide trailer in Cocke County, Tennessee. She is mostly confined to a wheelchair and helps take care of her three-year-old great grandchild. Because she is poor, Medicaid covers her. However, Tennessee got permission from the federal government to provide the poor with a cut rate version of Medicaid called Tenncare. As a result of a state budget crisis a few years ago, the state’s Tenncare program was cut back. Way back.

So this is what is left of our social safety net. Despite being disabled through no fault of her own, despite doing good for her family and her church, the state set a limit. No Tenncare patient, unless their circumstances are “unique and complicated” can receive more than five prescription drugs per month from the state. As you might expect if you are a great grandmother who is living on $600 a month, that does not leave much money for other prescriptions you might need to stay alive. Therefore, Linda Warner, like many of people in the program, has to make painful choices about which medicines she will or will not take.

She gave the pharmacist her prescriptions, but told him not to fill the bladder medicine. Normally, she takes it four times a day.

“It stops me from wearing a diaper, a disposable diaper,” Warner sighs. “I really hate to do without the bladder medicine because I can’t go anywhere without it.”

Along with the bladder medicine, she decided to skip her pain medication for the month. That way TennCare would cover the $28 worth of antibiotics she needed.

“You have to choose,” Warner says. “And I have to have the inhaler … because I have to breathe. It’s OK that I’m wet, but I got to breathe.”

One would hope that she were the exception, not the rule. This is not quite the case according to local physician Dr. Edward Capparelli:

In fact, says Capparelli, since the drug limits took effect, he’s spent almost as much time figuring out how to take people off medications as figuring out which medications to put them on.

“This is a real problem because the clock resets on the first of the month,” says Capparelli. “So if you happen to get your meds on the first, and then on the 15th you get sick, you really are not allowed to get any more prescriptions on that limit until the first of the following month.”

Capparelli says that for relatively healthy people, the five-prescription limit hasn’t been much of a hardship.

“But for people who have more than one chronic illness, it’s impossible to try to pick which is more important,” he says. “And unfortunately, physicians have often had to choose for what’s life-threatening today and give up on what might be life-threatening tomorrow.”

Here is what is left of our social compact. If you lead an honest life, earned an honest wage, yet can no longer work and have to live on a disability payment that keeps you in deep poverty you get to enter a medical Twilight Zone. You probably will not get the health care services you need. You may have to choose between breathing this month and accidentally urinating all over the house. Perhaps when the state’s coffers are a little flusher they will allow you to have an extra prescription per month. You may die or suffer some chronic illness needlessly but that is just too bad: the state only pays for five prescriptions per month. Here is your best advice: stay healthy. Never get sick. The state cares, but not enough to matter if you are old and chronically sick. Moreover, consider yourself lucky that you get any care at all. There are thousands of others in the state worse off than you with no health insurance.

There is no question that health care is expensive. On one level, it makes complete sense for Tennessee to cut back on these rising costs. Unlike the federal government, they do not have a printing press to manufacture money. Yes, there are other expenses for which the state has to pay besides ballooning medical costs for its poorest citizens. Those schools, roads and law enforcement officers do not come free.

Still, how can societies which call themselves civilized being just accept this? How can anyone see this as a situation where the glass is half-full? Why can we not summon the political will to raise our taxes so everyone at least has the medication they need to live their life with some modicum of decency?

Apparently, we are a first world country with third world values. We should be ashamed of ourselves.

June 20th, 2006 at 08:59pm Posted by Mark | Politics 2006 | one comment

What the health care industry can learn from veterinarians

In my last entry, I discussed feline wisdom. Cats have been on my mind lately and not just because my special feline is clearly in his decline. However, because of my elderly kitty’s problems I have seen a lot more of my veterinarian. I find in many ways that I envy my cat’s health care plan.

My cat does not have a plan, of course. His “plan” is to visit the Animal Medical Center in Herndon, Virginia as needed. I pay out of pocket for services rendered. Nor am I necessarily anxious to give up my wonderful physician. Still, when I contemplate the Rube Goldberg invention that is our current health care system I have to wonder why we let it get so complex, expensive and impersonal. It should work more like a trip to my local vet.

Last week I swung by the vet to pick up more prescription-diet cat food for my beloved and elderly cat Sprite. The vet techs behind the counter nearly know me by name now. “Oh yes, how is Sprite doing? Is the prednisone working?” Yes, I reported. He is drinking a lot more water and seems more his normal self. That day the vet happened to be standing at the front counter working on a chart when I arrived. If I had been a physician’s office, I would not expect to even glimpse a doctor until after I had been ushered into the examination room. So naturally, I assumed that the vet was not listening to my kitty problems. Yet she tuned in the whole conversation about how the medications were working out and my feline’s current bowel habits as she worked the chart, and spoke up. She was glad to hear that the medication was working. She suggested staying with the wet cat food because it was moister.

If this conversation had occurred at all in most doctors’ offices, the informal chat would turn into a consultation. My insurance company would be billed and I would be writing a check for a co-payment. However, at my vet’s office such advice comes at no extra charge.

Formal examinations of course come with fees attached. Nevertheless, calls to the vet to discuss a particular situation or to ask advice on a topic are invariably assessed at no charge. If they think the problem is serious enough then they will tell us to bring Sprite in. An examination usually costs us $35-$50, plus medications. If pills need to be cut, they are glad to cut them for us at no additional charge.

Unlike most doctors’ offices, where you are sent to read dated issues of magazines for an indeterminate time, generally our pet sees the veterinarian in within minutes of the arrival. For our amusement the office comes complete with a few roaming “office” cats. You can often find them sitting on a counter, or perched on top of a computer monitor. They generally do not mind being petted by strangers. If we have to wait, there is usually another friendly pet owner with whom to trade pet stories.

Everyone at our vet’s office is glad to see both our pets and us. The feeling of warmth for the animals is palpable. I do not know how your experience is at your doctor’s office. However, feelings of genuine concern for my malady of the moment are not typically what we experience. The crew behind the counter is, however, quite concerned about whether my insurance has changed since my last visit.

I am sure that there are many veterinarian specialists out there, but for the most part our vet’s office is a one-stop shop. They do pretty much everything, including making sure our cat’s nails are trimmed and that he is on the proper diet. Unlike many physicians’ offices that I have visited over the years, they are not anxious to order an expensive test or even prescribe medication. They stick with treating the most likely conditions first, and then work from there as necessary. If the animal is really sick, they can also keep it under observation. Of course, they can also board the animal if needed. Clearly, you will not get any of these services from your physician. They do not exist. Even if you can hardly move, you are most likely to just get a prescription and be sent home to convalesce.

Most of us probably would not want their doctor to cuddle or stroke us like we do with our pets. Yet wouldn’t it be nice when the situation warranted if your doctor gave you a hug, or gently squeezed your hand, or really empathized when you seemed to need it? Instead, your physician is more likely figuring out how to wrap up the conversation so they can get to the next patient. You may get some empathy from the nurse that takes your vitals. Generally, physicians will divorce your physical problems from your mental ones. A general practitioner will point you to a competent therapist, but most will not going to spend more than a couple minutes listening to your situational problems.

Although our pets might disagree if they could talk, most veterinary clinics feel inviting. This is not usually true of physicians’ offices. Instead, you wait until you are called and maybe listen to some bad Muzak. Then you get to wait for an indeterminate time in a small and lonely examination room, sometimes while partially disrobed. However at our vet, pets are welcomed and sometimes even fussed over during their time with the veterinarian. Vets know this personal attention is a part of what the animal expects and that it may help in their healing. For some reason we human animals do not typically receive bedside manners from our physicians.

When your pet is clearly dying and in pain, the vet will do the humane thing and with your consent put your pet to sleep. Yet in our country only Oregon comes close to offering a way for a physician to help you exit your life in a dignified and humane manner. Why is it that what is considered humane for an animal is frowned upon for us human beings? Are we not also animals? I believe that we humans also deserve a dignified exit from this life. How is it more humane to keep us lingering in a narcotic haze until death finally releases us from our misery? Having recently witnessed my mother die this way, I would never choose this for myself. Nor would have my mother have chosen this final exit, if she had had the choice.

I think that the business model underlying our current regular health care needs to radically change. It needs to treat people as human beings, instead of insurable objects who get fifteen minutes or less with a harried doctor. It also needs to insure everyone. Bill Clinton tried to overhaul our health insurance system early in his presidency and failed. Those living off the fat of the current system had undue influence. Yet if we were to rethink American medicine, perhaps a radical overhaul would be in order. A good place to start would be to examine what works so well in our veterinary clinics.

February 23rd, 2006 at 07:48pm Posted by Mark | Politics 2006 | no comments

Advice from Heather

Yesterday I saw a dietician. I mentioned to my doctor at my physical last month that I was having a difficult time maintaining a healthy weight. He suggested seeing a dietician. With obesity rampant in this country, you would think it would be easy to find a dietician. It is not. I have looked in the Yellow Pages before to no avail. He said you find them at hospitals. The only one around where I live with dieticians that saw people on an outpatient basis was Reston Hospital. To see a dietician, I had to schedule my appointment about a month in advance.

Fortunately, I am not obese. However, I am overweight. Like most people, I have tried a couple fad diets, as well as tried upping the exercise and cutting the calories. Each approach worked for a while. Eventually, and sometimes it took a few years, something would happen. It would be easy to say I was getting lazy, or lacked the willpower, but it truly was more than that. This latest weight gain was doubtless exacerbated by my wife’s annual holiday baking cycle. Generally, I have more willpower when junk food is not in the house. When it is constantly in my face, I can easily lose willpower.

I have written about diet and exercise before. Gone are the days where most of us can burn away excess calories through on the job physical activity. If you are like me, you spend your days doing anything but that. Hey, I am a white-collar dude. If I did not walk up the stairs, the most calorie intensive thing I would do at work would be lifting my phone’s receiver. Therefore, I must make time for exercise. I bike to work when weather permits, which is about six months a year. I also hit the gym about three times a week. When I have the time and the weather is nice, I take long bike rides. Yet apparently, I was still eating too much. On the other hand, much of the time I was eating too much of the wrong stuff. These little extra calorie habits, even with regular and vigorous exercise, have a cumulative effect.

So there I was at Reston Hospital registration, getting a band around my wrist as if I were going in for major surgery. Instead, I walked a couple hundred feet down the hall to see Heather. Of course, the dietician is named Heather. I bet there are no dieticians named Gertrude. Naturally, Heather was about five feet three, and weighed about ninety-eight pounds soaking wet. Moreover, she was half my age and stunningly attractive. Considering I had to meet a deductible because the appointment was at the hospital, instead of a co-pay, perhaps I shouldn’t complain about this fringe benefit.

It is all about portion control, Heather told me. Yeah, I knew that I told her. However, I am not the type to sit there and measure 15 grams of carbohydrates at a meal. I am a busy guy. I need to have a plan that will work with me. I need to stick to the same foods during the week, and the foods need to be foods that I will mostly enjoy. Otherwise, after too much deprivation I am going to slip.

She said she would work with me. We also made an appointment for early April so that we could meet again to assess progress and perhaps change the diet. She complemented me on the eight pounds I took off during the last month (not without the usual grumbling) and warned me the weight loss would probably slow.

Yes, success at dieting and maintaining a weight in the end takes hard work and perseverance. Most diets fail, she told me, because we set our expectations too high. Step one is to take off 10% of body weight and maintain it for four to six months. Then, if you want, work at taking off another increment. This is a formula for success. You can get to the summit of the mountain, but you will want to take a couple rest breaks on the way there to make it.

I thought I had read a lot about nutrition. Yet I am still glad that I took the time and considerable expense to consult with a dietician. For I still learned a lot from Heather. I knew about good carbs and bad carbs. However, I did not know about the importance of having protein with every meal. I never gave it a second thought. I usually saved my protein for the evening meal. Protein with any meal will help stave off hunger, Heather told me.

I also thought I was being good by skipping lunch on the weekends. After all, I was not eating until 9 AM or so. Wrong, she said. Eat three meals a day every day. Include proteins and carbohydrates at every meal. You can even enjoy snacks. Just make sure you balance the carbohydrates, protein and fats. Do the usual good things. Avoid high fat foods. Try 1% instead of 2% milk. Make sure your breads have whole grains. And of course limit portions. Needless to say, what you get at most American restaurants do not qualify as normal portions, unless you are a sumo wrestler.

Looking at what was working for me the last month she made some changes. Add food to my breakfast, she told me. A bran cereal is fine; its energy will be absorbed slowly. Using 1% milk is better than 2%. Add those sugar substitutes if you want sweetness. Also, add fruit to the meal if you want. However, make sure you add a serving of low fat meat. This is not a problem; we have plenty of pre-sliced low fat turkey and ham.

If I feel the need for a mid morning snack (I rarely do) try a granola bar (without the fruit filling), or a piece of fruit, or a small box of raisins, or even crackers with peanut butter. Of course, limit yourself to one portion, which might be the size of what you can put your fist.

For lunch, if soup and a salad are working for me now, she recommended keeping at it. Nevertheless, dress the salads up with proteins from sources like beans and nuts. She said to keep eating an apple with lunch as I am doing. It has lots of fiber and no fat. She said I could even add some starchy choices with lunch. A six-pack of crackers works for me but pretzels are even better. If I feel the need for an afternoon snack, the same morning snacks will work for afternoon snacks. Or I could try different types for variety.

During dinner she said I needed to limit myself to four starchy choices, each about 15 grams of carbohydrates each. She said to make sure I got three servings of protein, and lean meat is better. Add as many vegetables as you want, and you can have one fat choice. Of course, a fat choice is not very large. One teaspoon of olive oil is one good fat choice.

This is my diet based on my age and height, so these may not necessarily work for you. Meanwhile, she said not to slack off on the exercise. Do more exercise if I can find the time. It will not hurt, but I should still take off weight regardless. If I can do this I will naturally get the calories I need, and the exercise will help me lose weight.

As for fad diets, Heather said to ignore them. They are all a waste of time because they can only work for a while. That was my experience with the South Beach Diet and the Carbohydrate Addicts Diet. I have seen the same result with others I knew who were on the Atkins diet. Vary your diet, Heather told me. Eat foods that you naturally enjoy, but eat less of them and prefer those lower in calories and fat. Just stay within the portion limits for any given meal.

Perhaps I have finally found a diet that will work for me for life. Time will tell. I know that Heather will be there to help me succeed. She said to make sure to call her if I have questions or am having trouble sticking to the diet. She will help me rework the diet into something I can live with.

My wife scoffed when I told her I was going to see a dietician. “It won’t work for me,” she told me. “There is nothing they can tell me that I do not know.” I knew most of this too going in, but I still was not able to put it altogether. Thanks to Heather, I believe I now have now I have a plan I can live with. And I plan on living well to a very ripe age.

February 9th, 2006 at 09:25pm Posted by Mark | Life 2006 | no comments

The Good Doctor

Ssh! I’ve got a secret. I’ve got an exceptional doctor.

The irony is that I got him by default. Around the turn of the millennium, our last doctor decided that being a mother was more important than being a physician. Before she closed her shop she transferred our records to a new local family practice. Since I did not have any other doctors in mind, I thought I would give him a chance.

I may be unusual for a man in that I prefer women doctors. I go out of my way to look for female personal physicians. Maybe I just had many mediocre male doctors. Maybe I was looking for the empathy that I found more often in female doctors. Therefore, I was a bit suspicious when I made my first appointment with Dr. K. I was ready to go hither in a heartbeat.

Instead, he turned out to be a complete surprise. First, he was younger than I was. That took some getting used to. Now at age 48, it is no big deal but in my early forties, it still felt somewhat strange. He looked like he was in his early thirties. With Dr. K., it is hard to tell. He looks sort of ageless.

I first went to him to get a physical. I was surprised that in addition to doing the usual blood, urine, blood pressure, height, weight and eye tests, that he was asking questions. How do I feel today? He was not necessarily interested in whether I felt sick. He was also concerned about my emotional state. He understood the connection between mind and body.

In addition, he has bedside manners. When he touches you, it is never brusquely, but gently and respectfully. He is funny. He is a bit quirky. Moreover, his medical knowledge strikes me as amazing. I realize that doctors have to know a lot to be certified, but he constantly astounds me. One day I came to him complaining that the blood bank would no longer take my blood. I showed him the report they sent me, and he went on to this amazingly in depth discussion about protein markers. My blood had not changed, but the FDA’s requirements had gotten more stringent. It was good to know because one test showed I had one marker for the HTLV virus did not mean I actually had this virus. Nor was it related to HIV.

With most doctors, I feel reticent to talk about things that are bothering me. This is never a problem with Dr. K. He wants to know what is bugging me. While he is not a therapist, he is very good about knowing when to refer patients to the proper kinds of therapists. He is never curt nor does he feel hurried. He listens carefully to me and explains issues in details, in ordinary words that a layman like me can understand. You should expect that from a physician. Why does it seem so unusual?

Of course, I immediately told my wife about Dr. K., and she was soon in his office too. She also was quickly gaga over him. My wife has many medical issues. Dr. K. was able to sort through all of them. Sometimes I think that without Dr. K. she might now be dead. He worked through her complex case and got her in touch with the right specialists. Yet he also persistently monitors her issues. He insists that she get fasting blood work done once a quarter, and his staff will pester her until she comes in. Wow!

The thing that really cemented my admiration for Dr. K. occurred on a Sunday morning about five years ago. We were just sitting around reading the newspaper as we usually do and the phone rang. It was Dr. K. on the other end. He had some questions for my wife. You see he was reviewing charts and noticed something. I noticed something too. No doctor had ever before called our house unexpectedly. I know physicians have to swear to uphold the Hippocratic Oath when they become a physician. This was the first time I had personally experienced someone who lived out the oath. I consider myself a professional too, but I cannot see myself spending my Sundays doing the equivalent of reviewing case files.

Today I had my physical. I do not look forward to them, but I do look forward to seeing Dr. K. again. Apparently, the plethora of Christmas cookies and other fine but fattening food my wife made helped put on some unwelcome holiday pounds. Needless to say, I was a bit depressed about going back to the eat a lot less and exercise a lot more regime. (During the holiday season, I had been doing many workouts at the Gold’s Gym as normal.) Dr. K. came to the rescue. We talked about nutrition and eating habits in some depth. He told me that for successful weight loss that a calorie reduction strategy had a much better success rate than eating the same amount and increasing the exercise. He suggested some strategies and referred me to a nutritionist.

Doubtless, in a couple days after my blood and urine are analyzed he will call me up to discuss the results. If he sees anything worrisome, I have no doubt that he will point me in the right direction.

His reputation must be growing. His practice now includes another physician, and he employs a physician assistant and a number of nurses too. He is no longer as easy to see as he used to be. For routine colds, I am more likely to see the physician assistant. However, I always ask for him by name when I make an appointment. For urgent issues he can usually work me in.

What is that? You want to know his name? I am not going to broadcast it here to the world. He does not need more patients. However, if you live in the Herndon/Reston area of Northern Virginia you can send me an email. I do not know if his practice will take your insurance. I am not even sure he is seeing new patients. If you are looking for an excellent family physician though, I have a feeling you would be hard pressed to find someone better.

January 4th, 2006 at 07:38pm Posted by Mark | Life 2006 | no comments

Obesity: A Modern American Value

Obesity is becoming as American as apple pie. This should not surprise us. Have you looked at how many calories are consumed in a slice of apple pie? To use one of the more egregious but ready examples: McDonald’s Baked Apple Pie has 250 calories, including 34 grams of carbohydrates, and 11 grams of fat. And remember, the apple pie is dessert. It comes after the meal. The Big Mac has 560 calories and 30 grams of fat. Their large French fries: 520 calories and 25 grams of fat. That medium chocolate shake: 580 calories and 14 grams of fat. So there you have it: a typical fast food lunch at our most patronized fast food restaurant has 1910 calories and 80 grams of fat. If you are a woman who is 5′5″ tall, weighs 130 pounds, is 25 years old and who exercises lightly you have just consumed all but 13 of the calories you need for the day. If you are a guy, same age, six feet tall, 175 pounds you can consume 703 more calories later in the day and not gain weight. And let’s not even get into the percent of calories from fat.

To help us out the USDA has come out with a revised pyramid that is supposed to guide the average American on their dietary choices. New for 2005 is the notion that you should incorporate exercise into your daily life. In fact the new improved pyramid calls for at least thirty minutes a day of moderate or vigorous physical activity. So, if you follow their guidelines will this keep you from getting fat? Not necessarily. Buried in the fine print is this interesting statement:

About 60 minutes a day of moderate physical activity may be needed to prevent weight gain. For those who have lost weight, at least 60 to 90 minutes a day may be needed to maintain the weight loss. At the same time, calorie needs should not be exceeded. Children and teenagers should be physically active for at least 60 minutes every day, or most days.

What wonderful advice. But difficult to follow. Because the reality is that our society conspires to keep us physically inactive and obese. To me it’s a wonder we are not all Fat Alberts. Reading between the lines in this culture unless you have developed and sustained habits by eating healthy and exercising all your life, you are basically screwed. You are going to be overweight. If you succeed in taking off the pounds from your sedentary lifestyle you will still have to exercise moderately for 60-90 minutes a day to keep it off. Forever.

It’s certainly not impossible to get this amount of exercise a day, but it is impractical for most of us. It’s kind of like saying that you could spend 60-90 minutes a day fishing. Consider the typical dual income parents with two children. They are likely up before dawn getting the children ready and out the door. Then they are off in their car to work to spend another exciting day sitting at a desk, vigorously challenging their keyboard with aggressive calorie intensive finger strokes while cursing energetically at their monitors. Most likely they don’t have a health club at work so they can’t go for a mid afternoon jog. And even if they had the time, which they don’t, they have to rush home to pick up the kids before the day care center closes. Once home they then have to make a family dinner, help the children with their homework and take care of the numerous other odd chores that consume their day.

So working parent, what’s it going to be? Your family or your health? Choose one of the two because unless you can survive on a few hours sleep or have an iron will you must choose. Naturally we choose family values. And so we gain weight. And if we’re lucky we steal a couple hours on the odd day off or on the weekend for some exercise. This is family values in action in modern America. Survival of the fittest means you must survive by being unfit.

Of course we want to eat right but since we’re not exercising and our life often feels scripted we find it easier to succumb to temptation. We need something positive to happen during our days. Food is cheap, readily available and extremely convenient. We’re running late and the Wendy’s is right on the corner. So just this once (although it is the third time this week) we’ll do the drive through for dinner. A couple days a week some well meaning but evil employee will bring donuts into the office. We can’t resist. All that fat and sugar sure tastes good and it is more interesting than our boring, sedentary work. Email is easier to read with the taste of sugar in our mouths.

Why are we gaining weight? It’s because unless we are childless, work outdoors, or have a beneficent employer who doesn’t mind two hour lunches so we can get to the health club it is virtually impossible for the average willed human being to consistently make the time to get the exercise needed.

I look at my own habits and realize I still don’t get enough exercise. I bike to and from work, about three miles each way, when weather permits. I frequently climb four flights of stairs to my office in the morning. But this is only forty minutes of vigorous exercise a day. It’s not enough. I need more. I should be doing this and another half hour or so working out on the elliptical machine when I get home from work. And I should be doing vigorous exercise on the weekends too. When time and weather permit I take off on long bike rides or long walks but time doesn’t often permit. To truly get the exercise I need I should give up one of my other activities, like adjunct teaching or blogging.

If we want Americans to be fit and healthy we need is a culture that supports these choices. Instead we have just the opposite. We have employers who want us to work lots of unpaid overtime because it’s good for their bottom line. We have families that require two incomes in order to maintain the standard of living we knew growing up. We have advertising everywhere and much of it encourages us to eat exactly what we don’t need. And if the advertising were not enough it’s virtually impossible to travel down any major thoroughfare without encountering multiple fast food restaurants on both sides of the block. We can’t get affordable housing near our jobs so we end up letting our cars push us where we need to go. As compensation for the 90-minute hellish commute we sip our Caramel Chocolate Frappuccino Blended Crème coffee from the Starbucks drive through on our way to work (460 calories, 60 grams of fat).

Because only supermen have the willpower to consistently endure the new recommended USDA lifestyle we get fat. The rest of us are just human. But we feel the guilt anyway. The guilt makes us feel bad. Since we’re already doomed, why not eat something else? There seems nothing else to do but surrender to the reality and stifle our anxieties with inactivity and more food. With our bellies full of the Papa John’s pizza that we picked up because we had to work late again, all the energy we can muster in the evening is to sink into the La-Z-Boy and tune out our feelings of shame. Let’s watch Survivor and see who will get thrown off the island today.

April 21st, 2005 at 09:58pm Posted by Mark | Best of Occam's Razor, Sociology | one comment

The Agony of the Feet

I have foot problems. I wish it were something minor like a bunion. In some ways I wish it were something major because then at least I would know what was going on. But instead I just have some weird foot stuff going on that seems to never get better nor worse. As I work with my podiatrist it looks like there is no silver bullet. I need to resign myself to months or even years of treatment and discomfort. Ouch!

It’s a mild pain that is usually there. The original symptoms were a numb feeling in the smaller toes of my right foot that sometime felt like it was burning or my skin was scraped raw. Since it went on for a few weeks I finally saw the foot doctor. His hypothesis was that a nerve juncture between two of my toes was inflamed. He prescribed some Superfeet and built up a little spot that should have given the spot in question some relief. And for a couple days it sort of did. And then it didn’t and nothing had changed.

One day I was feeling reasonably okay so I decided to go for a little bike ride. Actually it was 37 miles. But I had done long bike rides before and it had been no big deal on the feet. This ride though was different. Although I don’t recall much pain at the time, for the next several days both of my feet hurt and felt inflamed. I wished I could go back to the numbing feeling again. I was alarmed that I was now getting the feeling in the other foot. The podiatrist suggested it might be all the force I was applying to my feet when I was biking. Terrific. One of the reasons I took up biking in the first place was because the stress from running was causing weird ankle and knee pains. Even getting on the elliptical machine in our basement hurt. What was I supposed to do for an aerobic exercise?

I’d suggest a wheelchair for myself but that wouldn’t solve the problem either. Because resting my feet on practically anything hurts. Even flexing my feet in certain directions and positions, even a little, hurts. I’ve tried mainlining ibuprofen and that didn’t even dull the pain. Certainly there must be some inflammation down there but this didn’t seem to be helping at all.

Certain shoes for some reason hurt more than others. I thought maybe my shoes were too narrow or too short. I do after all sport a pair of Size 13s. But no dice. All my shoes have plenty of wiggle room. Loosening the strings didn’t help. I recently bought a pair of sandals that feel modestly comfortable most of the time. Just looking at them there is no particular reason that I can tell why they would feel better than my other pairs of shoes. So I drag the sandals around with me. I wear my regular shoes to work then slip on my sandals once at work. I look pretty dorky wearing dress socks with my sandals. I guess it’s a good thing I don’t have to wear a suit and tie too.

I wonder if it has something to do the chairs I sit in. I’ve got three chairs in my office and I switch between them a lot because I am rarely comfortable for long in any of them. One accommodates my height well but offers poor back support. Another doesn’t allow me to rock backward, which is important if you are tall like me (6′ 2″) and have long legs. In fact with my long legs pretty much all the chairs out there are inadequate. I need more thigh support but the chairs usually leave a couple inches of my thighs unsupported. The computer equipment I use is not always comfortable to use either. When I started my job and designed my office I did have the office ergonomics expert adjust things to my liking. The problems with my chairs took a few weeks to manifest.

I wonder if it is arthritis that is at the root of my pain but I don’t think that’s it. I’ve had occasional twinges of arthritis in my fingers and it felt different than this. I feel like I need hobbit feet. Perhaps I need more calluses or something on my pads. I think: if my feet had support and the ground was made of rubber maybe it wouldn’t hurt.

A few years back I had a case of Plantar Fasciitis. This is a pain at the bottom of the foot that typically hurts first thing in the morning, or when you try to get out of bed and stand on your feet. There is no telling what caused that problem, although I suspect the extra weight I had at the time played a part. That problem, which took about six months to go away, may have been a consequence of just being 40-something. After all my wife had a similar problem. This pain feels a bit similar but is primarily along the side of my right foot. Applying even mild pressure to the right side of my foot makes it hurt. Standing up and putting weight on the right side of my foot makes it hurt too. Okay so logically shift the weight to the other side of the foot and the problem is solved, right? But that feels unnatural and it makes the bones near the problem spot hurt. So I’m guessing my foot doctor got the diagnosis wrong. It feels like a ligament or two have been stretched too far and are inflamed.

I hope this too will pass but as this has been going on for a couple months now I wonder if this will be some sort of long-term condition that I will just have to live with. It’s not an acute pain but it is annoying and it sometimes throbs. But I remain disturbed that there is no painkiller I can take to make it go away.

So I will continue to live with it and continue to consult with my podiatrist and hope he can find the root cause. But I suspect that this is one of many similar problems inherent in my aging body that I will have to reckon with in the years ahead. Mother Nature is giving me yet another signal that I am not immortal. I need to get with her religion.

Meanwhile, ouch!

April 7th, 2005 at 06:21pm Posted by Mark | Life 2005 | one comment

Uppity Pharmacists

From today’s Washington Post:

Some pharmacists across the country are refusing to fill prescriptions for birth control and morning-after pills, saying that dispensing the medications violates their personal moral or religious beliefs.

To that small minority of pharmacists out there incapable of doing their jobs professionally: it’s time to get another profession. You are in the wrong business. Find some profession where your personal and moral beliefs won’t be so challenged. Sunday school teacher perhaps. Maybe Randall Terry will pay you to stand outside abortion clinics and heckle women going in and out all day. One thing is for sure: if you can’t put your convictions aside and do your job you must not be a pharmacist.

News flash: lots of us are called on to do things every day that violate our personal and moral beliefs. I am a federal civil servant. I find the policies of my ultimate boss, President Bush, to be reprehensible. Still, when it comes time to act on one of his dubious and unconstitutional policies like giving tax money to religious charities I follow his instructions. No, it’s not because I like them. Yet I do it anyhow. Why? Not just because I took an oath, but also because it is part of my job. It is my obligation. I cannot pick and choose which parts of my job I will and will not do. Neither can you, Mr. Pharmacist. So either suck up your personal beliefs like the rest of us or get out of the profession. But don’t tell some paying customer that you won’t fill their perfectly legal prescription. And especially don’t confiscate the prescription in the process, as apparently at least some of you have done.

We have a process in this country. It’s called the law. And part of the law delegates to certain professionals what drugs may be prescribed. The doctor who wrote the prescription has already exercised his legal and professional judgment that the medicine is appropriate for the patient. In many cases, like the woman in the article, they can’t spend days running from pharmacy to pharmacy looking for a pharmacist who will fill their prescription. They may need the medicine immediately. You have no way of knowing and it is not your job to make any assumptions. You are not a judge. Your job is to fill the prescription, answer questions the patient may have about the medicine and take their money. It is not your place to impose your moral judgment on others, such as refusing to provide birth control pills to a woman who might be unmarried. That is a decision she makes, not you.

I think all drug store chains need a clear zero tolerance policy prominently displayed at the pharmacy window. For starters I suggest: “All legal prescriptions are welcome here. We will not employ any pharmacist who refuses to fill any prescription.” But apparently we now need laws to require that prescriptions be filled. It used to be you never gave a second thought that any pharmacist would go against a doctor’s judgment. It appears those nostalgic days are behind us.

I guess we are fortunate that at least physicians take their Hippocratic Oath seriously. There needs to be something with similar teeth in it for pharmacology profession. A doctor cannot usually provide the necessary patient care without the prompt cooperation of a neighborhood pharmacist. So renegade pharmacists are really undercutting the ability of the doctor to perform timely treatment. Rather than respecting the dignity of the patient, these renegade pharmacists are trampling on the dignity and human rights of patients by denying them their right to medicine. Sadly at least some of these renegade pharmacists will scold and humiliate these customers them in the process.

My thanks of course to the vast majority of professional pharmacists out there who have faithfully, promptly and professionally provided the drugs my family and I have needed. I hope these errant pharmacists are few and far between.

March 28th, 2005 at 06:43pm Posted by Mark | Politics 2005 | 3 comments