Jul 23

Washington Trails Association Pratt River Trail Work Party 20-22(23)JULY

I do a modest amount of backpacking, and have occasionally encountered trails that were not in the best of shape. I had no idea who cared for the trails, thinking that the forest service did everything. Slowly, I realized how much trail care is actually performed by volunteers. In 2009 in Oregon, I took a 3 day trail design, construction and maintenance course (see http://feuchtblog.net/2009/06/08/4-7jun-trail-skills-college-dee/).  I don’t remember who put it on, but it was a blast. Now that I’m into semi-retirement, I decided to actually do some trail work, and the Washington Trails Association (WTA) provided the perfect opportunity. The Pratt River Trail is within the newly expanded Alpine Lakes Wilderness, one of my favorite places in the whole wide world. There was considerable blow-down of trees from the past few winters and so the forest service requested the WTA to help clean out the timber fallen across the trail. Even though I took the trails skills “college”, I was totally clueless as to what this would actually represent. I e-mailed the WTA about issues, such as if we were going to get really dirty, and they suggested not. Actually, trail work means getting down in the dirt, which means that you will quickly become quite filthy. I wasn’t quite as prepared as I should have been for personal hygiene. True, I had my tooth brush, but then, I wasn’t getting my teeth (literally) into the action. My anxiety led me to arrival at the trailhead meeting point early, and was the first person there besides LeeAnn. The entire party ended up being eight people, with two no-shows. I was the only novice in the group, and truly clueless about what we were about to do.

The party was small enough that it was easy to get to know everybody, but several people stood out. The first was Jim. He was the old geezer of the group, but a true gentleman, and the most knowledgeable of the bunch. Whenever there was a question about a complex or dangerous log clearance issue, Jim was the go-to person, and had actually trained a few of the folk in the party. The work was split up into two sawing groups of 3 people, and two others that assisted and cleared brush. I worked with Rich and Jim, and what a treat it was. Jim was an incredible teacher and a real trooper, while Rich was most patient with me being clueless about running the saws or moving logs.

Jim

Rich and LeeAnne. During a break from work, we walked up to a side trail, leading to a giant Douglas Fir tree just off the trail (sort of)

As you can see, we all had to wear hard hats and gloves. The hard hats didn’t make sense to me, because there was no means of securing the hat to your head, and it was constantly falling off, sometimes when you most wished that it would stay on. LeeAnne was the group leader, and she was a real trooper, really fun to have with. Don was another fairly experienced trail worker in the group, who I enjoyed interacting with. Actually, I really enjoyed everybody, including Monty, Dave, and Emily, though I didn’t get the best photos of them.

Don, loaded to take off

The time transpired as follows. We all met at 8:30, and had an introductory safety session at 9:00. About 9:30, we took off on the trail, walking about 3 miles to a campsite at the point where the Pratt River drains into the middle fork of the Snoqualmie River. We set up our tents, prepared a lunch and water for our day sacks, and then took off to start clearing trail. I didn’t count, but with Jim and Rich, our first day involved clearing about 5-8 trees. Some demanded a moderate strategy and multiple cuts in order to safely remove the tree from the trail. Unlike standing trees, the fallen timber may be under considerable tension with bending, shearing and forces of torsion, which could lead to highly dangerous situations if one were not adequately prepared. Jim taught me much about the safest way to attack a log. After cutting a large log, one still had to move it from the trail. Somehow, we were able to move even enormous logs off the trail by sitting on our butts and pushing the logs with our legs out of the way. Some logs were quite complex to remove, and one situation was a cluster of three logs piled on top of each other, all 2-3 feet in diameter, and all under considerable tension. When fallen logs are under tension, one cannot just saw through the log, because as soon as the saw achieves some depth into the wood, the timber starts to close in on the saw, causing it to jamb. In such a situation, three to five cuts need to be made through the timber, with the space between hacked out with an axe. This means that a large log could take ½ a day just to make a single cut entirely through the log. Here is an example of that occurring on the complex log cluster, with one log already cleared.

Jim supervising, with Don and Rich working the 6 foot crosscut saw. Monty stands off in the distance.

The first day was a bit drizzly, and we were very wet walking through intense underbrush covering the trail. It dried out by afternoon, and the next few days were sunny. We were under a dense forest canopy, and so I didn’t need sunglasses or suntan lotion. The work was intense enough that by afternoon, we would be through several liters of water, and the first order of business on returning to camp was to purify more water from the river.

On the third day, Jim was not feeling well at the end of the day, and after some deliberation, decided that he needed to return home a day early. LeeAnne needed to accompany him out for his safety, but was worried enough about Jim, that she asked me to go with, being that I was a doctor and would have a clue if Jim took a turn for the worse. Carrying some of Jim’s belongings, we got him out safely, and I followed him to North Bend, stopping at a McDonalds to get him some root beer, which seemed to pink up his color considerably.  I felt bad leaving the work crew a ½ day early, and hope that the remainder of the crew all got out safely.

Thoughts on the adventure

  1. My opinion of the WTA skyrocketed. They are not just a lame tree-hugging society, but they really care about people, about trails, and about nature.  I had no clue as to how hard it was to clear a trail, as to how much was performed by volunteers, and as to how dedicated many of these volunteers were, some doing 10 or more work projects per year. It makes my adventure look rather trite.
  2. I know that I need to do more of these, and will try to encourage others to get involved at least one a year on a work party. Anybody that enjoys trails should at least once in a while get out and help with the WTA mission, or with Oregon Trailkeepers and other groups that do this sort of work.
  3. I will be MUCH more prepared next time. I don’t need to bring my ultra-light equipment, but instead have my more durable backpack equipment. Three to seven miles is not too far to walk with a 40-50 lb pack, and a few creature comforts would have helped. My ultralight air mattress had a seam tear out, which meant that there ended being a large bulge in my air mattress making it very uncomfortable to sleep the second night. I will bring a more durable air mattress next time. I will also try to develop a little better first aid kit for the types of problems that might happen on a trail. That might add a pound of weight, but should be tolerable. I’ll possibly also take a refresher course in advanced wilderness life support, offered by the Wilderness Medical Society.
  4. I continue to develop thoughts on the concept of “wilderness”. Perhaps certain rules are a touch crazy, like forbidding trail workers to use mechanized machinery (chain saws, etc.) to maintain existing trails. I wonder how many tree huggers are secretly appreciate the dynamite used to create the Kendall Katwalk, or the Eagle Creek Trail in the Columbia River gorge. I will probably write more on this later, devoting a single blog to my random thoughts on this issue.
  5. I will NEVER again hike a trail without realizing the blood, sweat, and tears that it took to build and maintain that trail. To that I end with my blog with a word of appreciation to all the trail societies (like the WTA, PTCA, Rainier volunteers) that keep up our parks and mountain playgrounds. To the WTA, I might add, sicherlich auf wiedersehen, certainement à bientôt, surely I’ll be seeing you again on a work party.

 

 

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Jul 14

A week ago, Betsy and I took a hike up the Carbon River in Mt. Rainier National Park. The road up the Carbon river was washed out many years ago, and so the park service how keep the road open only for service vehicles, as well as for bicyclists and hikers. It is about 6 miles from the park entrance to the Ipsut Creek campground, where the road ends, and the foot trails begin. It is an absolutely beautiful hike. Here is our Garmin data…

Yesterday, on 13JUL, I took a hike up a trail on the NE side of Mt. Rainier NP, leading to the Crystal Lakes, and then up to a saddle to provide access to the Pacific Crest Trail. The weather was mostly cloudy, but when the clouds disappeared, the view was overwhelming. The above photo is a view of the mountain, with Upper Crystal Lake in the foreground, and below is a view a bit higher up. Here is my Garmin data…

My goal is to finish all of the hikes listed in the book “50 Hikes in Mount Rainier National Park” by Ira Spring and Harvey Manning. I have only 6 more hikes to go. Several I will be doing with Betsy in the next few weeks. Will keep you all posted. When you have the most beautiful park in the world in your back yard, it’s hard not to visit it from time to time. Last Tuesday 11JUL, I also rode my bicycle from Ashford up to Paradise and back. The weather was perfect, it was cool, and most beautiful, but I did not bring my camera. Here is the Garmin data on that…

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Jul 01

The Qur’an

By Kenneth Feucht books 4 Comments »

The Qur’an, by Muhammed

I’ve been quite curious about the contents of the Qur’an since it is so often quoted today in issues regarding to dealings with the Muslims. There are many that quote the Qur’an as a book of violence, though I’ve wondered whether those oft-quoted passages were taken out of context and thus mis-interpreted. The only way to give the Qur’an a fair chance would be to read the book through and through, cover to cover, and let the book speak for itself.

Any criticisms that I might have of the Qur’an are not intended to be criticisms of Muslims. I have many friends that are Muslim, and even a few relatives that are Muslim, and find them to be good people. I would never intend to use my comments on the Qur’an to reflect either good or ill of those people. This is solely a book review and not a person review.

The Qur’an is organized into a total of 114 suras, or chapters, and seem to be organized from the longer to the shorter suras, though not in precise order. Each sura has a title given to it, usually taken from a word or phrase found within the sura. The title is a very poor indication as to the prevailing topic within that sura. The suras are all independent, and none of them connect with others, either preceding or following. To discuss the book, it would be easiest to discuss the prevailing themes of the book rather than individual suras.The particular translation of the Qur’an that I read is by M.A.S. Abdel Haleem, whom I presume is a devout Muslim as well as a scholar in both the English and Arabic language, and thus competent at the task. This particular translation has very few bad reviews, and mostly excellent reviews on amazon.com where I purchased the book, and thus seems to legitimately reflect the real contents of the Qur’an as found in Arabic.

Style of writing in the Qur’an

Amazon describes the Qur’an as the greatest literary masterpiece in Arabic. The Qur’an was written by only one person in one language, and has only one persistent stylistic form. It is a polemic against the heathen. There is no poetry. There is no prose. There are no systematic discussions. There are historical reiterations of Old Testament themes, mostly from the books of Moses, but they are told in a rambling fashion, providing no historical details as might be found in the Old Testament. Mohammed occasionally refers to contemporary history, but he does not elaborate that history, so that the translator must provide footnotes to explain the situation. Thus, the Qur’an is not a work complete in itself. No sura more than several paragraphs long has a consistent theme, but is a compilation of a flow of ideas. The repetition is intense, as sura after sura seems to say close to the same thing. There is no development of ideas, as might be found in Psalm 119, Ecclesiastes or Romans. Mohammed seems to have been forgetful of what he just wrote, but perhaps he was simply repeating himself to drive home a point. There are frequent inconsistencies in the Qur’an, and though those inconsistencies could be viewed as simple interpretative challenges, for the casual reader, it is often difficult to identify exactly what Mohammed was saying. The entire book is more a rant against anybody opposed to Mohammed, than a thoughtful development and argument for the Muslim faith. There is no delight in serving God reflected in the Qur’an as might be found in the Psalms and other passages of the Christian Bible.  As a literary work, the Qur’an does not excel.

What is right about the Qur’an?

There is much right in the Qur’an which orthodox Christians and Jews would agree with. Certainly the word “islam” means “submitted to God” and thus “Muslim” as “one submitted to God”. Christians could all agree that our primary function in life is submission to God. Thus, we would be correct in calling ourselves as Muslims, save that the word now has a very specific connotation. The Qur’an often mentions allah as all-knowing, all-powerful, all-wise, able to create by his word, and is a moral being. This is consistent with Judeo-Christian belief regarding the nature of God. The Qur’an encourages believers to live in a specified manner, maintaining honesty, being charitable to the poor and orphans, and acting with care toward fellow believer. This is consistent. There is a strong distinction between the believer and unbeliever, the faithful and unfaithful, which is also consistent with Judeo-Christian beliefs.

The consequences of unfaithfulness and immoral behavior will eventually need to held in account, as this life is the only beginning of a life after death, and judgement awaits all people, some destined to the fires of hell, and others to the bliss of paradise. This also is found in the Judeo-Christian Scriptures.

Prevailing themes and pertinent thoughts

  1. Paradise and hell
    Many often poke fun at Christianity as a fire and brimstone religion, a religion that focuses on nothing but going to heaven or burning in the fires of hell. Yet, many of those same people will offer sympathies for the Muslim religion. It must be assumed that they have never read the Qur’an, since the topic of paradise (heaven) and hell (the fires) are mentioned in nearly every one of the suras, and often to excessive length in the suras. There is far more about the final judgement and afterlife in the Qur’an than in the Scriptures. From the reader’s perspective, the Qur’an is overly excessive in its mention of hell fire. Muhammed’s mind might have been a little hot in the desert.
  2. The present life on earth
    The Qur’an has a very dim view of life on earth. It is a sub-life, a temporary period of trial for the eventual welcome into paradise. Current life is pictured as a lesser existence, and that our presence here is for testing only. This is contrast to the Judeo-Christian view of life as a good and complete, though fallen existence. Life may be hard and oftentimes seemingly meaningless, but the emphasis is the God created us to enjoy His creation, and gave us good things to help us accomplish that end. Our first duty is to praise God with a joyful heart, something not seen in the context of the Muslim faith.
  3. The believer vs unbeliever
    Similar to all faiths, great contrast is drawn between the believer and unbeliever. The Qur’an suggests a somewhat unique approach for the believer to the unbeliever. The descriptions of the relationship of believers to unbelievers in complex and difficult to sort out. Friendship with unbelievers is highly discouraged, as it could lead to loss of faith. Migration to an unbelieving country is strongly discouraged as is betrays trust in allah. Whenever the Qur’an encourages friendship with others, it specifically refers to friendship with other “believers”, i.e., friendship with other Muslims. There is never a call to charity or help to the unbeliever. Muslims have frequently been very friendly to me, and I can only assume that that friendship is in defiance of the Qur’an.
  4. God
    The Islam view of God is drastically different from the Christian view of God. Mohammed is very careful to emphasize that god never begat a son, and that the concept of Jesus as God is a polytheism or perversion. Thus, he fails to understand the Christian notion of the Trinity, as no Christian would consider the Trinity as a trio of three gods. Mohammed fails to understand that this nature of God defies human explanation or understanding. To fail to comprehend a complex issue does not make it false; it simply means that the complexity of God is only fitting for a “real” god. The Muslim god is a non-complex god. God is all-powerful, but he never escapes having a human-like character in the Qur’an. His size and power ultimately defines his holiness and goodness, and thus are the only things that differentiate allah from man. Allah is gracious and merciful, yet it is a mercy of a human type. Allah would never die to save his enemy, which is exactly what the Christian God did. The pronoun for allah is frequently pleural in the Qur’an (we, us) yet there is no explanation as to why the pleural is used, especially since the Muslim doctrine adamantly states that allah is “one”. The Muslim approach to god seems much different than found in the Judeo-Christian Scriptures, especially referring to the Psalms. There is no reflection on the joy of being under God’s protection. There is no joy reflected in the worship of God. In the Muslim Scriptures, allah calls the believer to prayer at certain times, and those calls must be slavishly obeyed. Allah is definitely a different “god” from Jehovah.
  5. Battle against the unbelievers
    Much ado is made about the Qur’an call for Jihad, or battle against the unbeliever. I frequently see quotes from the Qur’an calling for the death of infidels and those outside the Muslim faith. In fairness, there are occasional passages, but also passages warning against taking undo violence to those outside the faith. Certainly, terrorism is NEVER called for within the Qur’an, and one could assume that terrorists are acting outside of the stipulations of their own Scripture.
  6. Reiteration of Old Testament Stories
    There are many Old Testament stories re-told in the Qur’an, including that of Adam and Eve, Abraham, Lot, Moses, Jonah, and others. The New Testament is occasionally quoted, though the NT stories are not told. The stories as told in the Qur’an are always different from the OT stories, and often different enough as to be impossible to be simultaneously true with the OT account. This would mean that the differences could not simply be accounted for as differing points of view. Which calls into question as to which account is the correct on (assuming that at least one account reflects a true event that actually happened). This issue leads to a deeper problem for Muslims, in that it is known that the Qur’an in its infancy had many forms. How will the Muslim know that his “Scriptures” are really accurate? He can’t know, assuming that even carefully protected text of the Old Testament “failed” to survive and needed “correction” and reinterpretation by Muhammed.
  7. Statements against the Jewish and Christian faith
    While I’d like to assume that the Qur’an has a neutral stance regarding the Judeo-Christian faith, I fear that it is not neutral. There are many condemnations regarding Christian belief. I mentioned above the Old Testament stories. Considering how carefully the OT was transcribed from century to century, it is unlikely that significant textual degeneration occurred in the OT. Muhammed is very confused as to the doctrine of the Trinity, and completely fuddles up the notion of God having a wife and a son (Jesus). The Qur’an issues frequent proclamations that believers in the Trinity will be going to hell. There are no subtleties or hidden suggestions here; it is very overt. In essence, either the Judeo-Christian Bible or the Qur’an is true, but not both.
  8. Women
    Outside of the OT stories in the Qur’an, the Qur’an has no stories, and thus women are mentioned only as a societal element. It is clear that the women of Muhammed are lesser people. One could argue that the Judeo-Christian Scriptures also hold women in a lesser state than men, yet to say so confuses status with hierarchical authority. In the Qur’an, I do not see women elevated to a status of worth equivalent to men. In terms of relations, Muhammed does protect women in the area of divorce by making sure that they are provided for, but never calls to question the issue of divorce itself, and does not give grounds for or against divorce. Thus, the Qur’an pictures women as important but of less value than men.
  9. What the Qur’an doesn’t mention
    I’ve read through the Qur’an only once, and have no intention of reading it through again. I was specifically looking for certain things that are often are associated with the Muslim faith, but that I did not find in the Qur’an. I can think of a few examples. A) Full Burquas are not called for. Women are instructed to dress modestly, but no where does it call for the covering of everything including the eyes. B) 70 virgins are not promised in paradise. Generally, only one maiden is assured of the faithful men. C) Terrorism is prohibited and not condoned by the Qur’an. It is mentioned that to slay another Muslim means condemnation to the fires of hell, yet terrorist self-sacrifice is doing exactly that. Terrorism is never mentioned as a means of absolving all prior sins and gaining favor with allah. D) The touching of pigs is not prohibited but just the eating of pigs, and even then, if pig is eaten out of the desperation for survival, it is promised that allah would be understanding and merciful. E) Strong intoxicating drink is prohibited, but alcohol specifically is not prohibited. F) The mandatory use of only Arabic in the legitimate reading of the Qur’an is hinted at but never explicitly mentioned. G) The call to prayer is not specifically mentioned, and call to prayer five times a day not mentioned. In all, this suggests that much Muslim practice and beliefs are not based strictly on the Qur’an. I realize that Muslims have other writings that they rely on, but how they view those writings in relation with the Qur’an is uncertain to me.

Summary

The dear reader of this review might argue that I inappropriately read the Qur’an with a Christian bias. That is totally correct. The Qur’an makes truth claims, and it is the responsibility of the writer  (Muhammed) to add legitimacy to those truth claims. In the Judeo-Christian Scriptures, truth claims were also accompanied by miracles to substantiate the truth of the prophet. Muhammed is very quick and repetitive in defending the absence of miracles in his time on earth, yet he offers no other valid reason for accepting his truth claims. I have no reason to believe Mohammed over any other person claiming to offer prophecy and truth claims that supplement the Judeo-Christian Bible. The Mormons are a perfect example, and I would be very interested in seeing how a follower of Mohammed might challenge the claims of Joseph Smith, save that Joseph Smith was a polytheist, and thus “clearly” wrong. The Qur’an is not a supplement to the Christian or Jewish faith, but in direct opposition to it. Because it would be inappropriate in this book review, I did not elaborate on the differences in doctrines of the Muslim and Judeo-Christian faith. The most notable difference is that the Qur’an repeatedly calls allah merciful, yet that mercy must be earned. In Judeo-Christian doctrine (which I think is adequately maintained throughout the entirety of the Old and New Testaments), mercy is not something to be earned but is granted to undeserving sinners. Thus, the real meaning of grace in Judeo-Christian thinking is never found in the Qur’an.

There is a high amount of concurrence between Jewish, Christian and Muslim thinking, including the belief in only one God, a belief that God is a moral God, and a belief in an ultimate judgement. Many of the ethical statements are in accord. So, what do we make of the Muslim faith? Historically, the Muslim faith is an offshoot of Christianity. Like so many of the Judeo-Christian heresies, from gnosticism to Arianism to present day Mormonism, Muhammedism is sufficiently deviant from the Judeo-Christian faith both in its description of God and it’s belief system as to warrant the term “heresy”. It remains a heresy of the Judeo-Christian faith since retains much of the skeleton of its original Christian origin.

I am left in great confusion as to the behavior of Muslims based on the Qur’an. They claim to be “people of the book”, yet much of their practice is completely outside of what is mentioned in the Qur’an. My reading of the Qur’an does not draw the illustration of the present day Muslim. Perhaps they might be better known as “people of an Arabic tradition”. I am also confused as to why they don’t stand up against their fellow Muslims that choose to engage in terrorism, being that the Qur’an forbids terrorism. Muslims seem to not really believe their own Scriptures.

I am glad to have read the Qur’an in its entirety, and perhaps multiple readings might soften (or perhaps harden) my position. The question still remains… what is true? Is it the Qur’an? The Bible? Neither? If either the Bible or the Qur’an are true, then there is an eternity of implications for that. It behooves the reader to make than decision.

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Jun 26

 

Bicycle tour Cycle Montana with the Adventure Cycle Association

T minus 9 — I thought I’d get in shape for both cycling and hiking by running up Mailbox Peak. Mailbox Peak (the new route), is just outside of North Bend, WA, and is about 4000 feet of climbing over 4.5 miles. It was stupendous. I tried out some new shoes, the Altra Lone Peak 3, and they worked wonderfully. More nice, they have a loop built-in in front and velcro behind to accommodate Dirty Girl gaiters. The “climb” was dry going up, but continuous rain on the descent, and at the top had to endure a bit of hail. I recorded the hike on my eTrex but messed up so that I was unable to download the trip to the computer.

The summit of Mailbox Peak, with a mailbox! And, no, I am not trying to imitate Mickey Mouse with my gloves. I usually wear cycle gloves while hiking since I always use hiking poles, but decided to try out cheap cotton gloves that jewelers use, and actually liked them better.

T minus 8 —Went up to son Jon who lives in Arlington, WA to do a variant on riding the Centennial trail front which added a bit of hill climbing. I was sore from the day before, but figured it was different muscles being used, so it shouldn’t matter.

T minus 7-3 — now I’m really sore since it was a lot of the same muscles (!). . . too sore to do some serious bike rides. So, I sat at home, resisting to feed my face, since I knew that I still needed to loose 10-15 lb.

T-minus 1 — I woke up early Friday morning, with the car completely loaded with my bicycle, and other stuff. It took about eight hours to drive to Missoula. I was able to get to the ACA offices early, where Arlen was able to give me a tour of the facility. It was quite impressive, but unfortunately I wasn’t lugging my camera around to document the event.

T-0 — this is officially day 1 with the ACA, though there is no riding that occurs. Since the event starts about 3:30 pm, I had time in the am to stop by REI where I got some new touring cycle shoes, made by Pearl Izumi. They were remarkably comfortable. The evening intro, orientation and dinner were standard for ACA rides, and the biggest challenge was that of trying to remember new faces and new names.

T-1 — Missoula to Darby, 66.1 miles, 1752 feet elevation gain.
This day was mostly on a public bike path that headed straight south of Missoula, with a few variants to get us off of the main path, which was a very busy highway. The weather was cool but without rain while riding, though it had rained last night. We spent the night in an RV park. Most things in town were closed, but we caught the closing minutes of a brewery owned by the mayor of town to cherish a Schluck of brew.

Our first (and last!) landmark structure, THE COW!!!!!

First bridge to cross, just while leaving Missoula.

Our eager ACA workers, Brian and Sarah

Sarah hanging out with some scraggly old fart dude that came along.

T-2 — Darby to Wisdom  58.01 miles, 3615 feet elevation gain.
Wisdom was heavily infested with mosquitos, as the campground situated adjacent to the mosquito breeding grounds. To get to Wisdom, we had to go over Lost Trail Pass, which put us briefly into Idaho, and then over Chief Joseph Pass, giving us some fairly substantial climbing. I was riding with Cindy von Gillette, who was giving me a substantial challenge to keep up with her on the hills. We got our obligatory photographs on top of the pass, which was also the Continental Divide. On the lengthy descent, we had a lunch stop at a seriously mosquito infested Nez Perce battle site. Further descent brought us to our campsite. It was uncomfortably hot, which led to our retreat to a local tavern for beer.

Cindy in perfect form, climbing the pass.

Welcome to Idaho

Barely made it up the pass!

In the vicinity of Nez Perce Battle Site, buffalos replaced by bovines.

T-3 — Wisdom to Wise River – 38.8 miles, 518 feet elevation.
During the night, Cindy had been throwing up, and a trip to the Krankenhaus (see previous post for explanation) diagnosed profound hyponatremia and volume depletion. This meant that she had to stay in the hospital for at least a night, leading to her dropping out of the tour. Her husband came to get her, and a day later she dropped by (at Fairmont Hot Springs) to get her bags and say goodby. From then on, I rode mostly alone or with Dave von Seattle, and on day 3, the ride was short and hot. A few people did extra miles, but not this kid. The tavern in town was owned and operated by an old Scottish dude who was at times the lead singer for Van Morrison and Paul Revere and the Raiders. After dinner, some dude from Montana Conservation Commission (I don’t remember the exact name) gave us an interesting talk on the loss of the buffalo. The night was too hot to engage in mental cogitation, and I crashed early.

Without Cindy, we were left with two old farts, me and Dave, leaving the herd.

Beautiful Montana

More of beautiful Montana

T-4 — Wise River to Fairmont Hot Springs 39.8 miles, 1690 feet elevation gain.
This was another short day, and ten miles of the route was doubling back of what we did yesterday. I rode with Dave von S, and it was a most beautiful day. The climbing was not too difficult, but it again was quite hot. We went over an unnamed Pass that crossed the Continental Divide, but which we named Chief Running Dave Pass. A marvelous descent brought us to a large resort where we were staying. We went into the hot springs swimming pool which had quite warm water with much minerals, making it hard to swim in, and deprived us of the coolness we needed for a hot day. Still, the resort had enough luxury to make it a nice place to stay.

Dave now barely making it, using a cane he found on the side of the road.

Dave on the continental divide at a pass which is now named Chief Running Dave Pass.

T-5 — Fairmont Hot Springs to Phillipsburg 73.3 miles, 3451 feet elevation gain. This was a 41 mile route, with an additional 32 mile option that I took. The ride was thankfully quite cool, but VERY windy with a predominant Gegenwind (headwind). The first 8 miles retraced our previous steps, but then entered the town of Anaconda, location of a previous large copper mining operation. The climbing was not challenging, save for the very strong Gegenwind making it feel like a 9-10% grade. The optional 16 miles there and 16 miles back to the Sapphire mine was most worth it, with spectacular beauty, and a nice way to put mileage on the day. Phillipsburg was having its 150th birthday, but I decided that a shower and food and sleep were more fitting for me.

 

Always a welcome site, the water break!

Waterfall seen when coming down from Georgetown Lake.

Sapphire Mine addition

T-6 Phillipsburg to Ovando 64.5 miles, 2031 feet climbing
The morning started out freezing cold, with ice on our tents and bicycles. The ride started later than usual, and I was bundled up with mittens and other accoutrements to maintain warmth. Then I realized that I just wasn’t feeling well. Perhaps it was the same crud that did in Cindy von G. I don’t know. Anyway, it was too cold to stop riding, so I did some vomiting while pedaling away on my bike. I’m glad nobody was with me. I continued to feel ill, and it was miserable climbing over a minor pass, though the temperature became acceptable. I was too cold and feeling too miserable to snap any photos, or to really enjoy the sights. The only memory was that of dodging a cow in the road. It was a night with minimal food, certainly NO beer or cigars, and my only effort was an attempt to stay hydrated. Ovando had awesome ice cream at the village store which will go long remembered.  Sorry, but I was too sick to feel like taking photos.

T-7 Ovando back to Missoula 58.1 miles, 1112 feet climbing

I spent the night having runny diarrhea, which continued into all of the next two days. I didn’t wish to worry the tour directors, and knew that I was otherwise okay, so just bucked up and enjoyed the ride. To play it safe, I decided to ride a bit slower, and just hang out (ride) with Dave von S., who is a most pleasant and enjoyable character. There was a minor amount of climbing, but for the most part, the ride was totally flat, if not a bit downhill. I stopped very briefly by the ACA headquarters and said hello to Emma, and then dashed on, wanting to get home before another diarrhea spell. The drive was very smooth, and I was able to hit the front door before 6:30, a 7-½ hour drive for 493 miles.

My tent

Tent village of a herd of migrant bicyclists
crossing the plains of Montana.

The caterers Jack and Kathy talk with Lisa and Fido

The final road

Thoughts on the ride.

  1. I love the way the ACA does tours, and especially their fully supported tours.
  2. 2. The staff were stupendous.
    1. Arlen is just a super guy, and a perfect tours director.
    2. Dave did a wonderful job at handling problems such as a meeting hall that suddenly became unavailable, and sick riders that needed to drop out.
    3. Sarah was most incredible. She was most certainly the most up-beat, cheerful leader that I’ve had while on ACA tours. You could tell that she loved cycling and adventure as she radiated it. I especially loved her rock quotes, which were different at each of the water stops that she handled.
    4. Brian was probably the best bicycle mechanic that I’ve ever seen on the ACA tours or other bicycle trips. And, he was confronted with multiple challenges, such a broken bottom brackets, fractured derailleurs, etc. I would have loved to work in a repair shop with him for a few months to acquire some of his bike wisdom. Besides, he was a super guy that I really enjoyed being with.
    5. Amy was awesome. She is a real entertainer, and especially funny when it came to the “talent” show. What a delight.
    6. Bill was silent, behind the scenes, but always a most pleasant person. He had the job of hauling all the luggage around.
    7. The ACA gets an award for going out of their way to support bicycling. They really stick to their goals and objectives to encourage bicycling. We had people drop into our camp that were on cycle tours, and they were allowed to share our campsite and…

Now that I’ve met everybody, I’ve gone back over the google group introductions that everybody provided, and it is so nice to be able to put a face and personality to each person. My only regret is that the week went too quickly, and there wasn’t enough time to get to know everybody as well as I would have liked. But then, there is always an excuse for yet another tour.

A quote for Sarah

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May 17

Why I am Leaving Medicine

Kenneth A. Feucht, M.D., Ph.D.

I formally decided to quasi-retire in October of 2016. This meant for me, getting out of the surgical oncology profession. My intention is to continue working until 31MAR2018 in an outpatient wound care clinic associated with the hospital in Puyallup, WA where I live. Remember that training in my profession consisted of 15 years past the 12 years through high school, so that I have completely identified myself as a surgeon, making my profession not easy to give up. I would have liked to continue practice until I was 65 or more, but frustration with medicine and the changes which have occurred since becoming a physician have led to my desire to leave medicine. This is not an easy decision. I have a deep love for my patients, and found the profession to be quite rewarding. It was particularly satisfying dealing with patients not only for the relief of their physical ailment, but also to help them psychologically and spiritually through a major crisis in their life, which is usually the situation when somebody is given a diagnosis of cancer. With my decision to retire a bit earlier than I had wished, I felt that chronicling the root causes for my decision would be appropriate. The list of my grievances with the health care profession is in no way intended to be comprehensive, but to cover the major areas of frustration for me as a surgeon. This is NOT an in-depth, heavily researched paper with references and documentation, but an off-the-cuff rendering of my feelings regarding the status of health care. Perhaps someday I will take the time to render a more academic version of this treatise.

Health Care Orientation

Hospitals began in the fourth century in central Turkey in a region called Cappadocia. At that time, the poor and destitute who were ill were abandoned by the community and sent away into the woods, where they were often eaten by wolves or other forest beasts. This allowed for containment of communicable diseases, but did not reflect well on the care of the ill patient. It was St. Basil who took these poor people and reincorporated them into a caring community environment. Thus, we get our word “hospice” or “hospital” from the latin word which would be translated as “hospitable”. Hospitals became defined as an agency that attended to and offered the patient an ability to return to the community of the faithful while under care.

Germans have two names for hospitals. The most common is “das Krankenhaus”, though they also use the term “das Hospital”. Translated literally, “Krankenhaus” simply means “sick house”. It is a vastly more fitting word for what we have today, and the term “hospital” should go out of existence. Hospitals are no longer places of caring, and they do not offer the patient a gracious return to the community, or hospitality. They are places where patients are treated with sterile rigor, where children dump aging parents once they have become a nuisance, where occupants are considered to be more work for already overworked nurses, where physicians rapidly fly by patients, knowing that they dare not say either too much or to little, but where everything needs to be documented in a complex electronic database, and where nurses spend most of their time making sure that those databases are replete with boilerplate (and thus useless) data to fulfill various government mandates over what needs to be documented. The entire orientation of healthcare is a narcissistic reflection on themselves looking past and ignoring the raison d’être for their existence, the patient!

Defining “Healthcare”

What is healthcare? What is involved? What is health? What is wellness? How do you define something nebulous? The dictionary defines it as “the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.” This definition can be strewn out to as broad of meaning as life itself. Is my mental stress over an upcoming test in school a part of healthcare? Is my desire to become and identified as a female when I started out genetically and physically a male a part of healthcare? Is my carelessness in attending to my mental state when I accidentally kill somebody while driving a motor vehicle under the influence of alcohol actually a healthcare problem?

But, why do we even waste the time to precisely define the full nature of healthcare? Is it really important that we have a narrow versus broad definition of healthcare? From a personal point of view, the manner of defining healthcare is unimportant, but from a health care policy perspective, it is vital. The government promises that healthcare will be paid for, but exactly what that means is quite vague. In Germany, going to the spa for a week or two rest is covered. In the USA, the breadth of coverage constantly changes according to what is politically expedient. Oregon attempted to identify and rank cost-effective treatments to determine what might be covered. Since physician assisted suicide is very cost effective, it ranked quite high up. Is this proper? Assisting somebody in suicide seems to be counter to the entire goal of the medical profession, but nobody could doubt that much expense is saved by terminating the patient. If trans-sexual surgery is covered by government policy, why isn’t all cosmetic surgery covered, since it is aiding to personal well-being and how a person defines themselves? Why isn’t food free, since it is really taken to prevent healthcare problems? Why isn’t our housing and the cost of maintaining housing covered, since it all contributes to me maintaining and improving my health?

What about health itself? How do you define health? Is it just the absence of sickness? If so, then obesity would not be a health problem, or smoking, or any other dangerous activity, until it caused a problem. Some people choose to live through disabilities that would be viewed as insurmountable by others and refuse to identify their disabilities as an “illness”.

A frightening result of having an all-encompassing definition of healthcare that is provided for by government, is that they then must adopt the role of supervising our behaviors in order to maximize the government definition of health and well being. Does somebody really want the government telling them that certain activities are forbidden? Does anybody really want government prescribing exactly what you can eat and how much you can eat in order to stay healthy. When Michelle Obama attempted to regulate school lunches in order to decrease obesity, it was found that the children actually became more obese who were on the lunch program. When do we decide that decisions in our life become none of the government’s business? If we allow that government is responsible for health and well-being, we must realize that we are then completely giving away our freedom.

In reality, the public definition of healthcare is impossible and it would be best if we remove any attempt at defining the realm and coverage of what we think as healthcare.

Government interference

We are constantly being bombarded in the news that a new regime of politicians will correct the messes that former regimes have created in federal health care policy. I will speak of ObamaCare specifically a bit later, but here address specifically issues of government policy in health care. Over the course of the last century, we have gone from a situation where there was no government involvement directly in healthcare, to where government pervades virtually every aspect of the healthcare scene. Government first became involved in healthcare in Germany during the tenure of Bismarck. In 1883, he created a national healthcare system which provided insurance to all citizens. Many countries today follow the Bismarck model, though we do not in the USA. (ObamaCare seemed to be a model that attempted to simulate the Bismarck model though not utilizing many of the most important aspects of the Bismarck model.) Through the introduction of Medicare by president Johnson in the 1960’s, there has been a slow invasion of government into the healthcare scene. Government continues to fund increasing amounts of healthcare, and thus has taken an increasing stance toward controlling health care costs. At the same time, the innocent introduction of internal means of quality improvement (such as the JCAHO, which was started by surgeons as a means of voluntarily improving surgical quality across hospitals in the USA) has evolved into a beast that neither improves the care of patient nor the quality of healthcare delivered. More will be spoken on JCAHO later.

In times past, physicians generally took the Hippocratic oath on graduation from medical school. If not the Hippocratic Oath, then a somewhat similar oath (see article on the Hippocratic Oath, referenced below) was offered. In the Hippocratic Oath, three parties are involved, which include the patient, the physician, and the god(s). Glaringly omitted from the ancient oaths were the health care system, insurers, the government, and anybody else outside of the three mentioned. This is only right, and an article I’ve written on the oath covers why such an arrangement is so vital to the doctor-patient interaction (http://feuchtblog.net/die-veroffentlichungen/the-hippocratic-and-other-oaths/ ). Healthcare is now run by a multiplicity of bureaucrats and idiot savants who love to tell physicians and patients what is best for them without any knowledge of either the patient or physician. Government makes a cookie cutter mold that all diseases and persons are supposed to fit into. Diagnoses have a number assigned to them according to the ICD-10 manual, and no diagnosis will fail to have a specific number. Treatments and procedures also have their number, called the CPT code, with a one-size-fits-all mentality.

Government healthcare is run by bureaucrats. These are the self-serving policy wonks and bean counters that control the health care of all occupants of the United States, citizens and non-citizens, consenting and non-consenting, the sick as well as the healthy, the only exception being the politicians themselves. Most often, these healthcare pundits have been in the health care profession as either physicians or nurses, but are now removed from actually providing care, and thus not experiencing the consequences of the policies they implement. Being removed from health care, they may act with heartfelt concern for their colleagues in the trenches, but will never be able to properly address the constantly changing healthcare scene that affects healthcare delivery. In addition, their policies will fail to address all contingencies and variations in the disease process or patient goals and needs.

The government, since they intend on paying for healthcare, are obsessed with the cost of healthcare. Yet, they strangely seem to be the most clueless as to why healthcare costs so much. Perhaps healthcare costs are high because of government interference?

Two organizations from the federal government have been particularly harmful to healthcare, that of the food and drug administration (FDA) and the other the center for disease control (CDC). The FDA started as a well intentioned idea to protect the public from potentially dangerous drugs. The thalidomide incident in the 1960s is instructive. Thalidomide is a medication designed to decrease morning sickness in pregnancy, but was noted well after the fact to occasionally cause phocomelia, very short limbs, in some of the babies exposed to this drug in utero. I’m not sure that thalidomide babies could have been prevented even if the FDA was functioning as they do now, but a good crisis has not gone to waste by the government. It now takes many more years for a drug to go from creation to market in the USA as compared to Europe and other countries in the world. Drug development costs have risen to exceed a billion dollars to get an new drug to market in the USA. Yet, American patients are not safer than European patients, though we are denied rapid access to potentially useful medications.

While the FDA “protects” us against dangerous drugs, the CDC is here to “protect” us from various communicable diseases. I have less of a problem with the CDC than the FDA, though the CDC remains over-reaching in so much of what they do, and persist in trying to justify their own existence. The flu vaccine is a perfect example. It is close to impossible to predict which flu antigens would be dominant in any flu season, and the antigens of choice are made by “educated” guess. I know of no randomized trials that have proven within reasonable doubt that mass forced administration of the flu vaccine decreases morbidity or mortality from the flu. Health care personnel that work for hospitals are mandated to take the flu vaccine, and we have no other options. It matters not that we might have strong personal preferences against the flu vaccine. Another example, Gardasil, the vaccination against HPV, is sold to prevent genital warts, and thus cervical cancer, and is recommended for all males and females between 10-12 years of age. It is of value only for the sexually promiscuous female, but is strongly encouraged that all children receive this vaccine. Long term effects of the vaccine are essentially unknown. The CDC would love to have this vaccine mandated, and there is great pressure on all children to receive the vaccine, even from family physicians. This represents an over-arching hand that doesn’t allow for patients to make personal choices regarding their behaviors and actions, but assumes that all patients (or children) will be irresponsible and not have to take account of their actions. The CDC in effect takes the roll of parent, and displaces the biological parents as having a say in the behavior of your children.

ObamaCare Mess

ObamaCare is presented as the great revolution in healthcare, the solution to all of our problems, the defining policy that will allow all people in America to have adequate health care without obstruction from inability to pay. The health care bill was so voluminous that nobody in congress was able to read it in its entirety, and the proponents demanded that the bill be passed before one could discover what was in it. I won’t belabor the nature of ObamaCare because I have not read the bill, nor have any interest in reading the bill. What I will discuss is how it has affected physicians attempting to care for patients.

Obamacare wished to improve everybody’s access to healthcare, including that of illegal aliens. To do so, health care insurance was mandated to all. If you didn’t purchase healthcare, you were fined. You could either purchase private insurance, or the state would provide options. The rules were tightly defined for enrolling or switching health care plans. The presumption is that all people then had health care. Wrong! The cost of healthcare has continually escalated, and all plans had a copay for any service rendered. Copays were intended to prevent flippant and casual care. In actual fact, it has served to be more restrictive than anything to actual access to care. There are many patients that have turned down a proposed treatment plan for them simply because they could in no way afford the copay. In essence, care became more difficult to get.

ObamaCare also sought to assure that increased value was offered. This had multiple aspects, including patient satisfaction surveys, increased demands on providers to be fully “educated” through CME (more on this later), and increased demands of JCAHO. Patient satisfaction surveys were reported through what are called Press-Ganey scores. For employed physicians, bonuses were heavily dependent of the Press-Ganey scores. While Press-Ganey scores reflected how patients feel about their physician, it had minimal correlation with the competence of the physician. A physician that is the bearer of bad news, no matter how well it is delivered, will often be viewed with less favor than a physician bearing good news. Physicians oftentimes need to reprimand patients or cajole them into healthy behaviors, which is usually not viewed favorably by the patient. Some physicians are quite excellent, but do not have jovial personalities, which patients don’t like. Or, they have a jovial personality but are incompetent, something that a patient might not realize until it is too late. ObamaCare has allowed feelings to supplant honesty and truth, and the end-result will ultimately be disaster. Meanwhile, ObamaCare has flunked in its attempt to define quality in health care, and I’m not sure the ObamaCare act really cares about quality; they simply want the illusion that everybody is getting quality healthcare.

Are people truly having good coverage of their health care problems? The answer is complex, as there are a few people that have coverage that otherwise would have been out. Before government got involved in healthcare, most large cities and all counties had a county hospital that would take care of the indigent. Everybody ultimately received health care. Pharmaceutical firms were good about providing reduced rates on expensive drugs to the poor, and almost all people were able to survive. Now, coverage is actually worse, and many no longer have actual coverage of expensive treatments because they are responsible for a copay, which might be unaffordable. The only group of people who are better covered are those who should not have coverage, such as illegal aliens, or those who are mostly responsible for their own illness, such as burned out drug addicts.

Are the physicians getting rich? Definitely not! Over the last thirty years, physicians had to work harder and longer and more hours to make commensurate pay of the past. As a result, physician burn-out has become a true problem. The solution for physicians has been to become employed. I won’t belabor the problems of employed physicians, save to mention that employment essentially strips them of the definition of a true professional. They are nothing but expensive, sophisticated hired hands, and they will behave as such. People who serve administrative positions in health care are getting rich, and hospital CEOs as well the insurance companies are making out quite well. For the most part, physicians are getting poorer.

ObamaCare has not addressed the reason why healthcare is so expensive, and has diverted the attention from health care costs to health care availability. I am grateful that illegal aliens can receive the best health care in the world for free at my expense. In fact, I am waiting eagerly for anybody to provide an honest analysis of health care costs, and an explanation as to why health care costs in the US are much higher than in Europe or the rest of the world. I can think of many reasons, and simple explanations such as the absence of free markets deflects from serious analysis of costs, which has multifactorial roots.

Physician Regulations

The state has deemed it vital to make sure that physicians are competent. In order to define competence, the state has had to set some sort of prevailing standard, which is an amalgam of current practice and best practice recommendations based on the latest research. This assumes that best practice can be codified and then enforced. It assumes that current prevailing practice is the standard for all physicians and all patients,  and that our knowledge of disease pathology and physiological processes for disease are correct and well understood. Sadly, history is replete with countless times where the medical profession has been wrong and has had to eat their words. It is no wonder that much of what I had learned in training had to be unlearned as simply wrong. Medical practice is in constant change, and not necessarily in the correct direction. One dares not fight the system if the system is going in the wrong direction.

The state needs a way of making sure that physicians are keeping up with the latest and greatest developments in health care. The current standard is to require physician recertification, usually every ten years. The other is the requirement for continuing medical education, or CME. There are serious problems with both of these systems. For recertification, the physician needs to be placed in a box that defines who they are. These boxes are the selected specialties that the physician identifies with, whether that be in family practice, pathology, internal medicine, general surgery, or a host of other specialties. But, these specialties are too vaguely defined, such as in my specialty of general surgery. I am a surgical oncologist, and the American Board of Surgery only recently created a board specific for surgical oncology. Surgical oncology itself is heavily fragmented, between melanoma surgeons, breast surgeons, hepatobiliary surgeons, sarcoma surgeons, and a smattering of other organ specific surgeons. Within the last 20 yars, surgical oncology has essentially lost head and neck surgery, endocrine surgery, thoracic surgery, and colorectal surgery. True, one would like their surgical oncologist proficient in all aspects of cancer surgery, yet reality states otherwise. Regional referral patterns and practices also affect a surgeon’s expertise. Certain diseases are just more prevalent in some areas as compared to other areas of the county. In Chicago, I saw much pancreatic pathology. In Seattle, there is very little pancreatic disease, but a proliferation of other diseases. The truth is that as a professional, one is always reading and educating oneself, and each individual physician will develop a differing broad area of expertise. A simple test imposed by the state is not capable of defining what only the test of real life scenarios can clearly define. Recertification has become a horrid pain to take. I’ve re-certified twice, have done well in my re-certifications, but swore on the last re-certification that I would never do it again, ever, for any reason. Most physicians reach the same conclusions as I have, and the net result is to drive out the aged but experienced physicians. The only exception is in academia, where the surgeon is somewhat protected.

Keeping up with CME is a pain. It is not enough to simply subscribe to various specialty journals and read them on a regular basis. Now, one must answer sets to test questions to assure that you’d acquired the information attempted to be taught by the article. The Journal of the American College of Surgeons would do this for four articles each month, and I dutifully answered their questions for a number of years. About 2 years ago, I realized the stupidity of most of the questions, and how they were usually completely unrelated to my field of practice. The questions were intended to quiz whether you had read the article, but often assumed you had knowledge well beyond that of the article; thus, there was no education of the physician, and failure to judge whether I’ve read and learned from the article. The problem is compounded when articles relate to my own specialty, since I usually read into the question the controversies involved and uncertainty about the information in the article. The multiple guess questions really fail to assess my true knowledge of a subject, yet is mandated in order to assess whether I’m actually staying on top of my specialty. CME updates are demanded by the American Board of Surgery every three years, and I will be letting the next update slide.

Increasing surveillance of physician behavior is happening. This relates to both social behavior, as well as practice outcomes. Hospitals are simply not turning a blind eye to behaviors that would be publicly unacceptable. There has been a change from historical norms, where previously the physician acted mostly without accountability. This is a good thing, and physician antics with the treatment of patients, colleagues or nurses must be now accounted for. The only problem is that it is the hospital that is performing most of the policing, and they have a very strong bias for protecting themselves. Thus, there is predictably unfair judgement against unemployed physicians, and usually it is by someone clueless. I recall, for instance, being reprimanded by the chief medical officer at my hospital for not responding in person to an emergency room call, even though I was in the middle of a case in the operating room. I informed the CMO to no avail that it would be considered unethical and immoral by the American College of Surgeons for me to leave a patient open on the table to attend to another person. Such madness has only gotten worse under ObamaCare. Physicians are still held liable as “captains of the ship” yet are not given the power or authority to maintain that captainship. We are constantly being told to alter our behavior or practice in the most minute ways that have no real bearing on patient outcomes or hospital well-being. The focus has turned from outcomes to process, without any evidence-based data to suggest that behavior changes would be good.

The discussion of “captain of the ship” bears more intensely on issues of hierarchy within the hospital structure. Traditionally, physicians were the main drivers for hospital decisions, dominated the board of directors of a hospital, and were held as primarily responsible for the success or failure of the hospital. Now, responsibility falls to the CEO and his minion of subordinates, most of whom are not physicians, though they might be nurses, pharmacists, physical therapists, or simple business types with no training in medicine. Because of the increasing commercialization of medicine, spread sheets and the color of the bottom line have become the most vital aspect at determining the survivability of a hospital. The physicians have silently gone from being the leaders of the hospital to being nothing but another cost center to be dealt with.

Documentation/HIPPA issues

Until recently, documentation was performed in paper charts, usually a combination of typed text and handwritten notes along with printed reports, lab work, and outside information. Marginal notes would be made in the chart to facilitate jogging the memory of the physician. A typical note would take a few minutes to write, but would be highly effective at documenting an encounter. With the rise of third party indemnification (insurance), the desire to have confirmation of services rendered demanded improved documentation. The saying, “If it isn’t documented, it wasn’t done” became the hallmark message for mass documentation. This led to automation of means of documenting, including boiler plating encounters and procedures. This naturally led to the reverse problem of the past, in that much “documentation” might not have ever been performed. Because boilerplating made possible getting information quicker into electronic format, and with the rise of improved databasing and need for distribution of data, the electronic medical record (EMR) saw its rise. What was once a convenience became a mandated necessity. Many payors no longer accept handwritten charts, and the federal reimbursement systems require EMR for full reimbursement. EMR systems are very expensive, not only to implement, but also to maintain. They solve the problem of a plethora of charts and storage of these charts, as well as issues of lost charts, and the need for multiple simultaneous access to these charts. The down side is harder to see but more destructive. With a combination of requirement for increased documentation, and through the use of boiler plating, excess information now exists, and it is quite challenging to quickly identify the relevant information on a patient. Because of multiple sources for input to the EMR and restricted ability of access users to correct faulty information, the EMR slowly becomes less and less reliable. Errors become quite plentiful, from basic patient information, to diagnoses, medications and treatments.

Meanwhile, privacy of the data has become a greater concern. Physicians were instructed not to talk about patients in the elevator with outside people present, or to share patient data with people outside of the immediate family, unless given permission by the patient. Now, privacy has become a fanatical issue. In the past, I would walk onto a ward, and at the nurses station, a chalkboard list of all the patients and their room number was present. At the door of each room, the patient(s) name(s) were again posted, allowing for re-identification of the patient. This doesn’t happen any more, all in the name of patient privacy. The problem is that it is now easier to confuse or mix up patients, and more errors occur because of that.

Privacy in electronic data is a greater issue. The need for highly secure servers to manage patient data has become the norm, all mandated by HIPPA (federal policy). Yet, the skill of hackers has not been thwarted from obtaining any private patient data that they wish. True privacy is a myth, but the expense that we go through to maintain this illusion of privacy is astronomical. Indeed, true privacy is impossible. Perhaps all patients should present themselves to the physicians office or hospital in full covering like a Burqua or KKK outfit? Yet, the one area where privacy is zilch is with the government. They now know EVERYTHING about you. I fear the government more than I fear some stranger knowing that I happen to be on a β-blocker or some other medication. Yet, the feds have access to every aspect of my health care record.

Big Pharma

I don’t view big pharma as an intrinsic evil, and much of their perceived evil comes from government and legal policy imposed upon them. There is no doubt that the large equipment and pharmaceutical firms have vastly improved the quality of healthcare in our country, as well as throughout the world. It is without a doubt that drugs exist and are available today that never would have been possible without these large companies. But, the large pharmaceutical and equipment firms comes at a terrible cost to all of us.

The large pharmaceutical firms must deal with a host of regulatory agencies, the FDA being the largest of them. One would think that big pharma would be fighting the FDA tooth and nail, yet the opposite is the case. The pharmaceutical firms have seen the FDA as a wonderful means of keeping out smaller competition, which is why you don’t see small pharmaceutical firms in this country. The assistance of the FDA in the assault on the nutritional supplement and vitamin industry is shameful. Big pharma has relished the protection to their industry by the FDA, leading them to become even more powerful at controlling the drug market. Concomitantly, we see larger firms buying up the smaller pharmaceutical firms, and thus becoming ever more powerful.

A secondary problem is created when insurers pay for medication costs, so that the consumer never sees those costs. This becomes problematic if a patient is unable to perform a cost-benefit relationship to determine whether a drug is worth taking. A perfect example are the statin drugs to lower cholesterol. I wait eager to see any statin demonstrate improved survival over the best alternative therapies out there. Statins have a high chance of significant side effects, yet has never been shown to be significantly effective at preventing death from atherosclerotic heart disease. And, they are expensive drugs. Too often, the patient assumes that the physician is using critical judgement in determining the need for a drug, yet the greatest determinant tends to be how good of lunch the drug representative brings to the doctor’s office.

Insurance

A system of third party payment for health care has created the worst possible solution for healthcare. It is a serious misnomer to title health insurance as such, since it does not operate like insurance, but simply as a mode of funding. Insurance supposedly should be most active when there is an acute need, such as with a car accident or a heart attack or a new diagnosis of cancer. Instead, it covers every possible aspect of health care, including runny noses in kids to health maintenance examinations. Under ObamaCare, health insurance is not an optional decision, but mandated by the state. In such a situation, you would expect the health care insurers to making out quite well, and for the most part, they are, with executives of the major insurance companies making exorbitant profits. Yet, there are strains on the system. Insurance is not able to reign in the ever-rising cost of health care, and can only raise premiums and copays to a limit before the system breaks. And, the system is about to break.

Ultimately the big winners in todays system are the insurance companies, but that is a bittersweet win, as they continue to merge with other systems in order to survive. Time will ultimately pass a severe judgement on insurance companies.

Legal Aspects

If you read the popular press, they would suggest that legal issues are a small portion of what’s “broken” in medicine. Whenever malpractice tort reform becomes a subject of referendum up for vote for the public, the advertisements and press attest to litigation being a small part of costs for doing medicine. Yet, those most entrenched in the health care system and actually paying attention what is going on realize that legal aspects of medicine are probably our worst enemy, and that politicians and lawyers who know little of the actual functioning of healthcare are essentially orchestrating how things should be done in the health care world. If a physician suggests changes in the legal world, lawyers tend to attack the physician as ignorant, befuddled, or clueless as to how law actually works. Perhaps outsiders see the legal world a little more clearly than lawyers? Yet, it is most true that lawyers and political meddling in the world of medicine have only left medicine far worse off.

When a physician attends conferences, there are numerous sessions offered on how to avoid or deal with lawsuits. It is made very clear that the physician should understand that everybody gets sued, and that a lawsuit often is the “luck of the draw”, and that a physician should never take a lawsuit personally. Yet, in court, it is presented as just the opposite, and the claim is that there is something wrong with the physician that caused the medical “error”. I place the word error in quotes because it is too often that an error is not an error at all but simply the course of the disease. The lawyer presents a disease process as an entirely controllable phenomenon, and that good outcomes will happen when the standard of care is closely followed. Of course, they will deny this mentality until they are in court, where acts of “nature” serve to reward the lawyer quite generously. In public referenda regarding tort reform, there are usually two most serious claims. The first is that bad physicians need to be punished in order to improve the system. This goes contrary to all evidence yet seen. The second claim is that the tort system preserves patient rights. In actual practice, it does just the opposite, and patients end up with less options and choices in their care because of the malpractice climate which physicians and hospitals have to work in.

Whenever a referendum for tort reform hits the public, the claim defending current practice is that malpractice claims are actually decreasing and that malpractice premiums continue to be less expensive on the physician. Especially after a referendum, this is briefly the case, until the public forgets about matters, after which lawyers come back in force, hungry for more litigation. The malpractice situation has not improved, but remains a crapshoot, where a physician remains highly likely, no matter how excellent they are as a physician, to get sued and lose. The tragedy is that physicians can oftentimes see colleagues that truly are dangerous and yet manage to avoid suits. Cases that hit the public scene are often the most revealing. A few years ago, the leading transplant center in the USA made an error in typing an organ, leading to a hefty lawsuit. But, to what avail? This transplant center defined excellence in care for their service. Does human error necessitate lottery type outcomes for the lawyers and unfortunate patient? That is what happened in the transplant error to a distinguished center of excellence. There are many more similar stories.

What about if the legal profession is eventually proven to be wrong? Do they refund their ill-gotten gains then? I recall the colossal sums won against Dow Corning for the silicone breast implant lawsuit. Not very long later, it was proven beyond doubt that the manufacture of the implant or the nature of silicone did not lead to the alleged autoimmune diseases that the lawsuit purported to have happened. In this situation, the funds should have been returned, at least in part. This only shows that truth and justice are not served in courts of law, and the legal system has no interest in pursuing what is right.

My claim that litigation raises cost of everything is quite easily supported. Think about matters for a brief second. When you stay overnight in the hospital, with minimal attention rendered to you, you could expect a bill for upwards from $20K. I cannot think of any but the most exclusive hotels in the world that would even approach a fraction of that cost, even with servants and the most lavish attention. Why does it cost so much? Medications that are sold for veterinary use typical cost under 10% of what they charge for exactly the same medication with adults. Why? Medical equipment tends to be quite unreasonable in cost compared to similar products in the non-medical market. Oftentimes it is absurd, from a simple little staple gun costing several hundred dollars which if sold as a non-medical item would be several dollars. Why? Incorporated in those costs are both the higher cost of development for the human market, and the potential for litigation. Cows don’t sue, but people do. Yet, there are other subtle cost drivers. Physicians assuredly often act against their best judgement by over-ordering tests and x-rays, and over-treating, all in an effort to protect themselves against litigation. The patient is not given a choice in the matter, or allowed to assume risk. This is because with informed consent, it is still assumed in court that physicians should know better and not have offered choices to the patient if one choice was not assumed to be “standard-of-care”. The physician can’t win, and so plays the game by following the rules, even when the rules are wrong or don’t make sense.

JCAHO

This actually belongs in the “government interference” paragraphs, since the JCAHO is a government organization. Yet, it is so pervasive to all aspects of healthcare, with such overreaching influence on the way medicine is practiced, that it deserves a category of its own. As I write this, my hospital is currently undergoing a JCAHO inspection, and the anxiety of the administration is sky high. They have come by, and declared how various improvements must be made, how there are defects to the system which has so capably served patients. In essence, they are fixing “issues” that are not problems, never were a problem, and never will be a problem. Typically, the fixes are expensive, time consuming, but also require extensive documentation to prove that the fix is actually implemented by the hospital.

One of the most troubling changes in recent years has already be discussed, which are regulations imposed by HIPAA in order to preserve patient privacy. Sadly, HIPAA has failed to recognize that if somebody wishes to bust into the system, it can be done regardless of how intense the security measures are applied to the electronics of the system. The result is the physicians can no longer speak easily with each other about a patient’s care, and the detriment is ultimately to the patient.

JCAHO has long filled any possible useful purpose for itself. Yet, it has become a burgeoning business that must be sustained at all cost. Thus, they have sought desperately to find ways of justifying their own existence. They have accomplished that by creating new and novel regulations each year which they impose on hospitals. They will review hospitals every third year, and if sufficient inadequacies are found, will return a year after their visit to review the hospital for correcting their “mistakes”. During the triennial visit, they will disclose the new regulations, holding the hospital immediately responsible to correct their behaviors and adapt to the regulations. This causes a fleury of anxiety, panic, and hasty development of new hospital policies to match the new regulations. One year, they decided that if a patient was placed in restraints (usually in the ICU), then the order for that had to be renewed weekly. This had never before been a problem, and when there were restraint problems, they were of a nature that a policy would not fix. Another year, it was decided that used instruments or laundry could not be transported to their appropriate destiny in an open environment but had to be completely enclosed. One could hypothesize that bacteria could be spread with these instruments and laundry in open air, yet there has never been an instance where this had ever been a problem. The fix is indeed costly, and must be done in order for a hospital to continue operations. But, the hallway transportation rule defies notion that the hallway itself or the patient room could be transmitting disease between patients. Perhaps the entire hospital needs to be systematically sterilized between patients?

But, JCAHO will continue to work their evil deeds. Health care will become more complex, impersonal, and expensive, and ultimately, less safe. JCAHO is an organization that holds others responsible, but submits to nobody else’s authority. It is a true creature from the black lagoon.

Commercialization of Healthcare

It used to considered immoral for physicians or hospitals to advertise. Pharmaceutical firms were forbidden to advertise prescription products to the public. The American Medical Association held policies forbidding their members from advertising, as found in their code of ethics. The goal for these rules was to keep medicine out of the realm of commercial enterprise. All of that changed in the year 1975, when the federal trade commission considered the AMA policy as an illegal restraint of trade. The AMA rolled over dead. What was immoral one day was considered right and proper the next day. Advertising among health care emerged slowly. Early in my private practice, there was a rule that physicians in our community would not advertise, or even to have their name in bold print in the yellow pages. That disappeared slowly. Soon, one could see a plethora of drug advertising, with elderly patients in perfect health dancing vigorously across the tv screen, proclaiming the miraculous benefits and health giving effects of a medication with multiple side effects and toxicities. A few little lies won’t hurt, would they?

The end result of healthcare commercialization is that it has caused anybody and everybody to seek for a portion of the health care dollar. The highest paid person in a medical community is often the CEO of the hospital. While hospitals still designate themselves as “not for profit”, the non-profit hospital has gone the way of the dodo bird. Quite often, the most vigorously trained physician taking the greatest risks and responsibilities get the least cut of the health care dollar. The pharmaceutical and medical equipment suppliers are making massive profits unheard of in yesteryear.

One could argue that commercialization has led to improved competition and desire for innovation. Yet, competition has always occurred in health care, and innovation has also taken a great toll on our profession, not commensurate with the benefits offered. The most heavily advertised physicians are oftentimes the most marginal physicians. It would be hard to argue that patients are truly better off with advertising. For the reader interested in a erudite discussion of this issue, please read this article… https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563279/ .

The Flexner Report and its Evil children

The Flexner report was funded by the Carnegie foundation, supporting Abraham Flexner in a review of the existing medical schools in the early 20th century. The report was published in 1910, and intended on promoting standardization of medical education and the removal of marginal medical schools. We now see the evil children of the Flexner report, with regulation of the health care professions at an unprecedented level. The net effect we have had on physicians is increased regulation and requirement for continuing education, which was previously discussed. It has restricted the number of physicians in the health care community, and medical schools have not been able to keep up with the demand, especially in an age where increasing numbers of physicians retire early. It is difficult to just build more medical schools, since the cost of medical education is prohibitively expensive, and the state has had to bear part of the burden of these costs in order to keep the supply of physicians at adequate numbers.

There have been several ways in which the health care community has met the demand. First is through the influx of ever greater numbers of foreign medical graduates (FMG’s) from countries where health care education is not so aggressively monitored. The second is the rise of alternative providers, which include physician assistants and nurse practitioners. Both of these groups of providers have much shorter training periods, which would fail the current minimal standards for medical school training as defined by the results of the Flexner report. In essence, the Flexner report has forced its own extinction, and bred an alternative to the physician.

Conclusion

I am not unhappy that I ever became a physician, and feel that it has been a rewarding career. I am very unhappy with what has happened to medicine. It is like a public good has been stolen and no hope for recovery.

I am particularly sad that most people do not identify root causes for problems, but continually ask for immediate, self-serving, quick fixes to the health care problem. It is a truism that until congress and all of government has to live under the same health care plan that they impose on others, there will be no hope for improvement. I wouldn’t count on it ever happening in my lifetime.

Ultimately, health care will kill itself. It is unsustainable. It has lost its soul. Its original driving force was a Judeo-Christian Weltanschauungen, specifically, the belief that all people, young and old, born and unborn, of all races and creeds, were created in God’s image and of intrinsic value. Humans were not viewed as the accidental product of the primordial slime. Human relations were viewed as important as health itself. Suffering had meaning, which oftentimes led patients to delay in seeking a remedy. Pleasure and euphoria (feeling good) were not considered goals of worthy pursuit. Among health care professionals, the pursuit of “health” and prolongation of life seem to be more in line with personal challenges and a game to be played, the chance of honor for a great discovery, rather than the sympathetic concern for the whole person, body and soul. Purpose and meaning in life are oriented around maximizing pleasure and minimizing pain and suffering. Healthcare is the agent responsible for restoring maximal pleasure, either to the individual or to the community, when things go mentally or physically wrong. The greatest creed of healthcare, the Hippocratic Oath, provided the framework for practicing our profession. Without either a framework or a direction, we flounder. Healthcare, rather than being a true profession, becomes the utility of the state to maintain function and order, rather than the pursuit of a higher good. We have lost our soul in medicine. I am leaving medicine because my profession no longer is a profession of Hippocratic orientation. I have no interest in being a duped servant of an evil state.

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