Redline Doc

Cultural Insensitivity

I’m glad my culture of 5700 years has been reduced to ‘good moneymaking’.  After all, I’m sure the Moses, as he descended from the mount had a marketing plan to sell little Torahs all over, because he was culturally attuned.

I can hear  the clang of symbols as my ancestors fled Egypt making sure they stowed the gold on their way out of the country.

Throughout the centuries Jews have been derided for their attentiveness to money and things money, often imbued with powers never given them to control monies.  Shylock, that most derided of Shakesperian characters is but one of many.

Mr Romney, do you not hear the hoofbeats of history?    When you suggest that the Jewish people culturally are attuned to moneymaking did you disconnect from our recent history?  The images of Jews and money and world domination flooded German newspapers, particularly de Sturmer.

I understand the rush for votes.  I also understand that history is less forgiving than we thought. Apparently we are slow to learn those lessons. “Those who cannot remember the past, are condemned to repeat it.” 

Scammed Again!

Recently I sought to upgrade from my DSL service which we’ve had since 1998 or thereabouts, finding that the current (supposedly) 6/728 was really 3/284 on a recent billing. Its not easy upgrading.  Since we took M aBell (you do remember the good old AT&T ?) and made it many pieces.  Its rather like the Iron Giant, who reassembles himself from the blown apart pieces. He, on the other had is for good.  This, more like the evil empire.

Adventurous and with some time, I call the service part of my current DSL provider only to be lost in an automated system that once in, is difficult to escape, or in my case, so insistent on one course that I could not re-enter the system.  Desperate, I decided to lie to the system and it immediately sent me to a human.

I fared not much better since the human could not understand why I wasn’t happy and didn’t want all the bells and whistles services they were offering . It’s rather like getting a car, you want wheels , doors and some amenities; they want to sell you upgraded chrome or something the size of a Abrams M1 tank.  Sometimes I feel like a train on a parallel track or parallel universe and no matter what, I can’t jump from one to the other; but, I digress.

Oh, the fourth human says you need U-verse service. Oh? I do?.  She explained to me how much faster all this would be.  She also thought this was FTTP (Fiber to the premises) when I asked several times.  My location is about 550 yards from the Central Office (CO) although she said that didn’t matter any more. I set an appointment, rubbing my hands anticipating 18/1 (or maybe better!!).

The technician arrived.  He said he had to do some testing and so would DISCONNECT the service which was currently running, and I might add never to reappear again.  He came back several minutes later, all the services phone and internet down, announcing they’d have to get another (different truck different division) out there, sometime.  I’m glad he didn’t use the word soon.  I had a family member at the house who also happens to be very technically able and works in the server maintenance field; not unknowledgeable.

Gone. Truck, driver, service and when I called they said the installation was ‘in progress’.

No. It wasn’t. They have an 1830 call rollover in this division. Next day.

I call. They still insist this is being fixed and they have to wait for the incoming ticket.  How, by the way do I like my service.  ????  Ok.  I can take a joke.  I wait a few hours. Each of the meat shields the company has put in my way of getting to a person of knowledge says “I’m really sorry your’re having this trouble” but has no helpful actions available.

Tick tock. We’re coming up on a weekend when nothing will get done.  I call in vain hope that a human may be able to hook something up.   The phones are back on line mysteriously.   The human who finally helps says they’re really sorry and they’ll put it all together on Saturday Morning.  The set up guys are really nice, telling us to call support for the IP addresses and ranges for the static IP’s which we’ve had these last 14 years.

I’m on and off the phone.  The support line tells me that they don’t have that I need to call ATT ConnectTech.   I call.  The scam begins.  You can sign up for one time 5 day service for 149$ or 15$/month 12 month minimum billed to a credit card.  Sorry, we’re not part of that phone company.

News to me!  I pony up, figuring I’ll be able to access my system.  No. No. No. Not at all. The Level 2 tech, who is very nice gives me a netmask for a Category C netblock (wow, category C, I don’t think that IBM has a cat C netmask) .. but wow, ok.  I might add, not only is it wrong, but it also, of course, doesn’t work. The IP and netmask addresses, close but not right either.

I’m tired, angry, frustrated and feel very much taken. AT&T has made my life hellish without much work on their part.   I try, again the U-verse support. This time I get a Level 1 support who says, oh .. you need Level 2.

The information is supplied. Dawn breaks over the computer.  I’ve been scammed by AT&T yet again.

Sin Service

I’m astounded at what passes for service. I probably shouldn’t be.

Recently I went to a BestBuy.  They employ college grads, young folk, with slicked hair and ‘tude.  I’m usually in there, an older guy, tie, shirt looking about for what I need. At first I thought “bad clothing” or “bad BO” but that’s not it.  You can be systematically ignored in the store.  Asking a tech question may or may not get you a human to help, but for me it has worked to the extreme opposite, sent to some corner of the store so that when I get back, that person is gone and another in his/her place.

I have some news for BestBuy and their ilk. Of the monies we spent on tech this past year, and we spent a fair amount, we spent less than 5% at BestBuy, maybe less this year. These guys are circling to be the next CompUSA. The CompUSA  dudes had it down though.  Customer and service never made it on the same line with them.

As I watch the no-eye-contact cashiers, the smiles from the managers as they pull the goods through the turnstiles but neglect the customers paying for them,  they fail to understand that it is not employers who pay the wages, they only handle the money. It is the customer who pays the wages (Henry Ford).  They too are doomed, dinosaurs of a different age.

I wonder how in this economic race to the bottom, rather than increase the service, turn on the warmth, bring the people in the doors, the assumption that build-it-they-will-come still prevails. I am fortunate but have become much more picky about disbursing my funds, preferring service and knowledge over glitz and push.

Its a lesson the car industry has yet to learn as well.  Chrysler, famed for its CEO statement of yore “well we don’t make that model anymore” as an apologia for lousy engineering and a corporate culture of not caring. Bellied up to the National Soup Kitchen they took the money to renew themselves but if “bring back the Dart” is any measure of what that means, we’re in for more of failed engineering (the PT Cruiser), harum-scarum tactics (most of the SUV’s), and less attention to the consumer.

Sure advertisement can push the consumer into believing that more pollution is better,  that higher standards (be cautious of that word) would make the industry unprofitable and that what we need is a return to the over-sized, overpriced, under-engineered cars of the 90′s or 70′s.

Service at its worst is at the front lines of restaurants. Somehow, the ‘tip’  has become part of the expected payment, even for non-existent service.  I mean, how much service or even humanity do you get at the local donut parlor?  Mindless avatars push out coffee and what passes for food without ever making eye contact.  And there it is, the tip mug. It doesn’t say ‘por service’ anymore, heaven forfend, just TIP MUG.   I’d rather tip the machine at Horn and Hardart!

Out for breakfast recently we waited as other’s were menu’d, coffee’d then served then left!  I thought wow, we much be invisible. I snagged one of the waitstaff who said, oh excuse me then disappeared, forever. Another came over with coffee offering to get out check. We almost left the restaurant. I demurred and said we’d had neither coffee nor menus nor food yet!  Oh my gosh. And she too disappeared. The third came over without eye contact, without ‘gee I’m sorry’ and took the order.  Coffee appeared similarly. The food was delivered but without a rehash or recall. Who knew we wanted a bit of a warm up. Customarily I’m a very good tipper but rose to this occasion to tell the person at the register, quietly, what had happened.

“We get a lot of that around here”, she  said ruefully.  Dinosaurs. I can hear them falling all over the place.

Pish Tosh

Ahh my faith in the society of robber barons is renewed! On the news: A fine of 156 million is levied for stealing. No jail. No restrictions just the fine at 1% of last years net.  Wow! The cost of doing business.

I’m not dismayed anymore. I’m sad. I’m sure I’m not alone. The weasels are in the hen house and have eaten all the chickens and wonder why there are no eggs.

More interesting than the fine is the underlying lie. The company, and apparently the big five are all involved, took money from investors, short sold the investment (this means they bet AGAINST the investor making money), told them how wonderful the packaged securities were and then laughed at them for their folly.

Ho Humm. Business lying as usual. Whats the news here?  We’ve suspected for some time that the SEC (Securities and Exchange Commission) was bought and paid for, but now having raped the American economy and managing to blame the poor outcome on the suckers who bought into their racetrack scheme, the government fails to even slow down this juggernaut.

I agree with comedian Lewis Black who said “You should expect of your leaders what you expect of an experienced canoe guide.  We’re going down that fork in the river and not the other because down there there’s a *#$(* waterfall!!”  What we have are disneyesque leaders pushing us off the cliff like lemmings, to make a ‘good show’.  We should preserve the banks because they’re our salvation. HAH.

I watch, from the poorest census district in the United States, not 40 miles from nearly the richest, with the realization that we have always blamed the poor for our outcomes. They’re the ones who did this. They created the financial collapse, not the liars at the banks, not the conniving realtors who sold properties they knew would never be repaid, nor the investment banks which rolled all this compost into securities, laughing at the unicorns and morons that would buy such stuff that they themselves had bet against! Imagine that.  An so they have left a trail of devastation and destruction that will take years, if ever to recover from. The folks, trusting their employers to look after them had very low social security payouts but good supplemental income from investments made by their employers – now all vanished at the racetracks of the banking world.

“It was the best of times, it was the worst of times; it ws the age of wisdom, it was the age of foolishness; it was the epoch of belief, it was the epoch of incredulity; it was the season of Light, it was the season of Darkness; it was the spring of hope, it was the winter of despair; we had everything before us, we had nothing before us; we were all going directly to Heaven, we were all going the other way.” I’d hope there would be some public outcry, anger at the blood in the streets. How Dickensian this has all become.

 

Sucking the Marrow

I work in a Community Health Center and as such we see the folks at the bottom of the health ladder, well more like health string these days.  It must be that time for the HMO’s to come suck the marrow out of the bones of the state insured patients.

How so, you ask?  We, the physicians, are flooded with requests to change medications. Change? Well yes.  We need to use cheaper, not necessarily better for the patient, drugs for the patient to keep up our end of the deal.

Deal?  Well yes.  It would be inconceivable that we, the physicians, would not wish to enhance the fortunes of the struggling pharma boys (and girls – to be PC).    By ‘re aligning’ these medications, we can save, well a fortune (not for you buddy !!) for the struggling and underdog HMO’s.

Each year its the same, although the names change to keep the corporate profits spread like marmalade across companies. We get letters to inform (me) that some poor schlep of a patient has been provided with a transitional supply of prescription X while I go to look up a cheaper chicken.  The instructions are voluminous and there is room for exception.  Exceptions of course need be filed with the proper authority no doubt in some basement with missing stairs kept in the file cabinet guarded by a jaguar, though they’d like us to think that this process is made for ‘helping’ the patient.

There is an implication within all this, a copy which has, of course, been forwarded to the patient, that the profligate doctor (that would be me) has wantonly wasted the monies of the HMO.

Nowhere does it say that this is being done to save monies for some of the richest greediest corporations on earth.  Nowhere does it imply that these monies saved will go to their bottom lines.   In many ways this IS the koan of capitalism: make the little guy work so the big guy gets bigger and maybe some of this goodness, probably not money, will rain down on you.

So much for the marrow. What will they suck next.

 

REAL Health Care – in the Trenches.

I read Paul Romer’s The effect of Health Care Reform on others, a play on the vagaries of our dysfunctional healthcare system and putative illnesses of Mother Goose characters.  I admit it (a guilty pleasure) I laughed. Then I reflected on the daily life in our Community Health Center, in Connecticut, located in poorest city of its size in the nation. The irony is just too much. We (nutmegers) are the wealthiest per captita state in the nation!

But- I digress.

A patient appears at our primary care clinic on Friday. Classic signs of cholecystitis (gall bladder attack).  We hustle her by transport to the emergency room. Monday morning she’s BACK!  At the emergency room, the nice physician gave her the name of several surgeons she could call to have her gall bladder fixed. None take her insurance.

An 82 year old lady lives in her car. Bernie (this is too good) Madeoff with the retirement funding. She can’t afford the taxes. She lives in her car.

A patient comes for diabetic medication, gets a glucometer (to measure the sugar), strips (to use in the machine) but the company doesn’t pay for the lancets to draw the blood from the finger. Urmmmmmm.

A patient drops a heavy object on her foot. She goes (of course) to the emergency room, diagnosed with a fracture but referred to the clinic so that she can have a cast put on.  She is uninsured.   I might add this over a five day period.

A patient comes with a kidney infection. No problem. Antibiotics. Oh – we don’t cover THAT antibiotic.

A patient, finally stabilized on psychiatric medication shows up for a refill. UhOh. You need a prior authorization. What? This patient has  been taking this for a year. No matter. We need to consider the forms (they say) to make sure the patient is getting the best medication. Insurance oversight.

A letter arrived the other day from one of the major drug companies letting us know that they are going to be direct advertising to consumers for certain drugs so that they (the consumers) will know what best to ask for.

A young boy comes having (as children are wont to do) leaped off a picnic table and stepped on some glass. The local ER (no problem) sees the child, recognizes that there is glass ‘somewhere’ in the wound, sews up the wound, and sends the parents off in search of a surgeon who will see them on state insurance. Two days later. They arrive at our clinic looking for guidance. We are fortunate to have some favors to call in. He gets care.

Lest you think out there that is is a factor of my particular city, its not. As I speak with colleagues around the country, this is the rule not the exception. As insurers tighten the profit noose, looking to their bottom lines not yours, this is a frightening and every more common occurrence. As hospital emergency room expenses rise the quest to slide more care out to the community increases. Its shoddy. Its terrible. Its not good medicine, hell its not good care in the third world. It is however our current system.

Healthcare reform may change some of this but we are only at a beginning. I praise Paul for bringing a bit of humour to what is, for me, a very black, dark sad subject.

It Couldn’t Hurt .. Or Could It

I’ve been watching with interest the current Republican party dance around repeal of the Healthcare insurance legislation just passed.  Its a sad bit of badly made political salad with very little for those who need health insurance, a guaranteed business for the insurance companies (universal sign up), guaranteed pharma profits (no pharma negotiation) and extension of the market for about 40% of those who are still uncovered or uninsured.

State legislatures, not to be overlooked are trying their best to carve themselves in our out of the new Heatlhcare bill by blocking advances or by shouting states rights.  With hard economic times, its easy to get voters to hear the shouting but miss the salient points.

We’ve missed the boat, again. Smoke and mirrors and distraction reign supreme. The emperor, or his bill, have no clothes. This does not cover a majority of the uninsured. I’m waiting to see how those who are unemployed, now some approaching the 2 year mark, will pay for this bit of fluff.  The state’s assistance systems were already at a foundering point and shoving the burden to physicians and hospitals for the under and uninsured will only exacerbate the problem.

There’s a bit of shuck and drag going on here. We’re told that we need to work to pass this. We’re told it will bankrupt us. We’re told this is socialism at its worst.  Socialism?

Today one of the walking wounded comes to the clinic. She works 40-50 hours a week, full time  she’s told, at one of the local hospitals. To expedite services the hospital contracts out its housekeeping. The firm, to keep profits ripe,  they don’t pay insurance.  Hmm. Ok. We took what was a paid in-house position, took away the benefits, hired the same folks to do the same job so that the profits would stay as high as maybe ….

I digress. Here’s a full time working person with no insurance.  How is a public option for her, socialism?  From where I sit, we pay into the medicare system.  We pay it in wages and taxes and reap a long term benefit devoid of the need for stockholders to benefit. Although an inconstant fiduciary, generally governments have handled trust funds much better than banks or insurance companies, always looking to the next gaming table, ripening the profits.

If we allow the loud shouts to take back the minimal advances, and I agree its far from perfect, we’ll end up with still more uninsured.  The hidden cost of the ‘uninsured’ long patched over by draining high end payments from private insurers into the unbalanced pot is at an end. The insurance blokes, have cut off that avenue. The uninsured now go to emergency rooms, expensive care, and not much of it.

Emphasis from the Healthcare Plan was on primary care, extending to patients the ability to see and to find competent expert medical care. If we persist at deconstructing the fragile imperfect house, we’ll have but a very expensive house of cards fallen loosely and very expensively apart.  Threats of Medicare cuts are more thunder than substance. We do need government to help us. Watch carefully.

A View From Xela. Implementing FreeMED in Guatemala.

Jeff and I undertook implementation of FreeMED an Open Source Electronic Medical Record and practice management system for the Pop-Wuj Clinic, a primary care, non-profit, free and open clinic in Quezeltenango, Guatemala. 

The clinic, founded by members of Pop-Wuj Spanish School, (http://www.pop-wuj.org/)  a non-profit school for teaching Spanish language, and Dr. Jonathan St. George, an emergency department physician at Weill Cornell Medical Center . Dr St. George began with a space and a concept and has with coordination with the Timmy Foundation staffed a regular clinic with a full time physician and assistants, recruited a part time dentist and a part time community physician to work in the clinic.

Students of medicine or allied fields attending Pop-Wuj Spanish Language school assist with chores and triage at the clinic in the morning and then attend their language classes in the afternoon.

It is planned for the clinic to be self sustaining.  To derive funds, we will offer continuing medical education courses in Travel and International Medicine. the staff, all volunteer, will make the courses available, and the fees used to fund the clinic and operations.  We plan to use Open Source Training tools as a basis for online and study courses both for Pop-Wuj school and for Access Medicine, the teaching wing.  We hope to prove this funding model within three years.

The installation of FreeMED was not without its problems. Servers donated by SGI/Rackable Systems complemented laptops donated by Jeff’s employer helped get us off the ground. Immediate problems with infrastructure, the system wasn’t at all grounded coupled with a need for stable power, necessitated the purchase of a UPS to protect the servers.  Difficulty with the structures which are of concrete and re-bar hindered good WIFI transmissions within the building. We capitulated and wired the building for CAT5 (ish). I say “ish”, because the local wire is probably CAT3 maybe. We didn’t have any interference problems that we could pick up.

Once hooked up, we split the system for registration, triage, physicians and pharmacy. Registration has been by hand and is transiting well to the electronic system. The intake person has good aptitude with computers and was a quick study with some help. Triage, which is really vital signs and complaint are done by visiting medical students. An immediate difficulty is that the person in this position changes sometimes several times during clinic hours. There is very little regularity and registering each of these people will create some problems. At the moment, we’re continuing to register each person in the system and privilege them as such. The suggestion, by some, that we create a group without name, is problematic from several standpoints.

Physician training was minimal because of initial delays in deploying the system. However, I spent time with the physicians and we have enabled remote secure access so that they can use and manoeuvre through the system. For the most part, physicians are not the stumbling block.

There is a large pharmacy and much of the medication for patients is dispensed from this bank of medications. We did not pre-enter the medications and are still working ways to get some handle on the bulk of and entry of these medications.

The dental portion of FreeMED will be implemented once the medical is stable and in use. FreeMED continues to evolve. There were some specific changes made to accommodate the needs of this clinic and its staff. We hope to have some hard statistics from the program by mid year with full integration of the old (paper) medical records. The Fujitsu corporation has donated scanners which will enable us to port paper records into the system.

Once we have fully implemented FreeMED in the clinic, we hope to add Android capability to the Xela system, allowing for remote access as well as telemedicine conferencing.  The Android capability, already built into FreeMED permits recording and transcribing of teleconferences directly to the medical record. Other Android features are planned. FreeMED does work seamlessly to provide access by Android to appointment and other portions of the system including the internal messaging system.  There are other anticipated donations of medical equipment including monitors to the clinic. Those too are planned to be integrated using the SHIM portion of FreeMED.

FreeMED is an opensource GPL-licensed product, in use worldwide. FreeMED recently announced the release of the 0.9.0 beta version. More information is available through the FreeMED website.

If you are interested in helping with the clinic either by donation of time, energy,  equipment or monies, please contact donations at popwujclinic dot org    Another trip to the clinic is planned for May. If you have an interest in international or travel medicine and wish to contribute by taking the offered courses and /or contribute expertise contact.

Xela and More on the 19th

Hola!

We have arrived.  The medical brigade to Pop-Wuj has landed. We arrived on different flights but managed to coordinate being in the same part of the air terminal.  Customs went very smoothly although one of the bags with the primary server didn’t make it; it will be found an delivered soon (probably a mix up at Miami-Dade airport).

Out goal. Set up FreeMED for use in the Pop-Wuj Clinic.  The crew this week is here to work the medical clinic, assist Dr. Meg Sullivan, the clinic director and install and fire test FreeMED as well as transfer as much of the medical records as possible.

Our bus met us at the airport and quickly loaded the crew and luggage. Its a four plus hour trip from Guatemala City to Quetzeltenango, more often referred to by its K’iche’  or Quiche name, Xela.

Many of you may have read of mudslides in the Guatemalan Highlands The roads show evidence of the slides with many washouts of the roadway.   There were active drops with the busdriver, doing his usual Monte Carlo style driving weaving in and out of one way and two way highway areas on CA1-WEST.

We stopped to eat lunch along the way at a small restaurant nestled in the highlands. There I have my first coordinated pictures of the the team, minus me at this point. The lunch was a variety of foods common in the region, a bit more that we would normally have done for an interim meal, but satisfying.  Back on the bus for the last 2 ½  hours into Xela we arrived about 6pm local time.  Most of us are at Casa Manen, a local bed and breakfast.  Shelley chose, as I will next week, to live with a Spanish family.  We dropped Shelley at Pop-Wuj and will rejoin with her in the morning.

Because of the two hour time shift to Guatemalan time, although we’re all a bit wasted from the trip and the planes and leaving New York at 4AM its only 8 local time.  The crew goes to a local restaurant over looking the Plaza for some sit down and group building.   We’re all pretty revved about the morning and the week to come.

Bed time, well room time about 10pm in Xela.  These blogs will be about 1 day off because of the local time changes, but I hope to have more pictures and more local interest shortly.

Shelley Runs Demi Marathon

I don´t have pictures yet but Shelley ran with John Sullivan in a (billed as 26 km) race through the streets of Xela.

The race began a bit late and Dr. Sullivan and I were watching on street corners for the racers.  Its 2600 meteres up here so the air is thin.  Things done Guatemaltecan style are often without much preparation. There were no crossing guards, no blockoff´s to run interference for the Chicken Bus population and the cars seemed relatively oblivous of the racers.

The hills were daunting. The traffic next to the runners spewed dark deisel fumes as the racers coughed and ran.  Motorcycles, always taking the smaller parts of the road roared by .

We were able to watch the race from four vantage points – the last so close to the finish line that  I didn´t get to photograph Shelley at the finish.  She insists that the race was only a 15k but she finished and she and John were sore but happy.

Pictures I hope later and a short video as well.

Signing off for a bit until I can get to pictures and uploads.   Do check out my Flickr page.

Hola