The Call

cancer crab

Damn!, I hate these calls…

Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections — it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use — but it is not, strictly speaking, a cancer test. It is noisy — often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection — often markedly so — and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not — and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases — always alarming on first exam, with very high PSA values — and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis — after all, cancer doesn’t get better on antibiotics — but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimism that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage — although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score — a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult — if not impossible — to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this — without robbing hope — will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard — surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted — were there some bottled genie passing out such favors — is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course — not of days or years, details or circumstances — but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion — yet it is not hard to imagine — and sometimes to sense — the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise — but almost never on the initial call. On rare occasion, there is a casual indifference to the news — prompting reflection on what strength of spirit — or dense denial — such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted — an unworthy child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned — though poorly so — with His own.

But the call of death — so confidently faced from the comfortable vantage of good health and cheap grace — will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know – -by the tutor of past and bitter experience — that faith will sustain me and mine through it all. But one cannot know what that day will be like — nor should we wish to ever know.

But for Charlie, the battle will now be enjoined — the weapons and wherewithal of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality — it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion.

May it be also for me.

CAT Scams

cat scan cartoonThe Wall Street Journal reports on a recent New England Journal of Medicine study which concludes that doctors are over-utilizing CT scans, exposing their patients to excessive, and potentially harmful, radiation doses:

Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers.

The researchers, writing in this week’s New England Journal of Medicine, conclude that in the coming decades up to 2% of all cancers in the United States may be caused by radiation from computed tomography scans performed now. Children face the most danger, they said.

In ordering CT scans, doctors are underestimating the radiation danger … In many cases, the researchers say, older technologies like X-rays and ultrasound that expose patients to lower radiation doses or no radiation at all would work just as well.

Since CT scans were introduced in the 1970s, their use has grown to an estimated 62 million annually. An estimated four million to five million scans are ordered for children, Mr. Brenner said. Adults receive scans for diseases of the stomach, colon, breast and other areas. Children most often are scanned for appendicitis. It has become a favored technology because it provides detailed information about patients’ bodies, is noninvasive and typically is covered by health insurance.

While the scans save lives, the authors say, doctors are leaning on them over safer diagnostic tools because they underestimate the levels of radiation people receive from the scans.

The authors measured typical levels of radiation that CT scans emit. They found levels they say were comparable to that received by some people miles from the epicenters of the 1945 atomic blasts over Hiroshima and Nagasaki, Japan.

There can be little doubt that CAT scans, as well as other expensive medical imaging studies, are overutilized in medicine today. There is also no doubt that the overutilization of CAT scans in particular, with their ionizing radiation, does expose patients to significantly more radiation. It may be worthwhile to pause and think about why so many CAT scans are being performed.

Hint: It’s not because doctors don’t know that CAT scans deliver more radiation.
Continue reading “CAT Scams”

Little Pay for No Performance

If you’ve been following some of my previous posts on the insanity of the U.S. health care system, such as the Maze series, you will recall the looming ogre in payment “reform” called pay for performance. Medicare, and the me-too sycophants in the insurance industry, have been promoting and implementing a payment system which nominally will pay more for care which meets certain quality standards. This concept is based on a host of unproven assumptions — the most egregious of which are the unspoken assumptions that much care delivered is substandard, and that trivial increases in reimbursement will correct shortcomings in quality (which are vastly more likely to be due to system complexity than individual error or incompetence). Nevertheless, this lumbering freight train is rumbling down the rails toward our health heroine Nell, lashed to the tracks by Snidely Whiplash, your dastardly federal and private insurance bureaucrat.

Today’s Wall Street Journal (subscription required) reports on a JAMA study of just how well this system works. In a pilot project funded by Medicare, the stunning results are in: it doesn’t. Color me shocked:

Researchers at Duke University, examining heart-attack treatment at 500 hospitals, found that hospitals that received financial incentives to follow treatment guidelines didn’t improve their practices significantly more than hospitals that got no financial benefit.

The federal Centers for Medicare and Medicaid Services launched the pay-for-performance pilot in 2003. Participating hospitals provided the CMS with performance information for five conditions, including heart attack. Hospitals in the two highest performance levels for a condition received a bonus.

In the Duke study, published in this week’s Journal of the American Medical Association, 54 of the hospitals were participants in the CMS pilot and received the financial incentives. The other 446 “control” hospitals didn’t get such payments.

The findings showed that “the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction,” or heart attack, Duke cardiologist Eric D. Peterson and colleagues wrote in the journal article.

Of course, the usual special pleading is immediately evident: perhaps the carrots weren’t juicy enough (like that will ever happen, in a system which is economically hemorrhaging), or the sticks weren’t nasty enough (now you’re talkin’! Keep beating that dead horse, and surely it will run faster):

It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.

“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.

Now that the data is in, you can be sure that our bureaucrats will rethink their foolish ways — or not:

Still, the findings raise the question of what the Medicare system will do next. A Medicare spokesman said the agency hadn’t seen the study and so couldn’t comment on it.

Nice. Medicare, who funded the study, hasn’t seen the results. Never let the facts get in the way of a bureaucrat on a mission — it just confuses them.

Franchise Opportunity–Going Fast!

Rarely a day goes by when I do not receive, from my friendly Post-person, some promotional material. Much of it is trivial (pens emblazoned with drug logos), most of it banal (copies of stupid marketing materials which insult the intelligence, like this), all of it unsolicited.

But there are rare occasions when something truly transformational arrives at your door, unexpected and unannounced.

Yesterday was such a day.

The box seemed like so many others, UPS-tan, no distinguishing labels. Upon opening it I was greeted with what appeared to be a black t-shirt, in a clear plastic wrapper. Underneath, a curious plastic sheet with fluid-filled domes, not terribly unlike mutant bubble wrap on steroids.

My curiosity piqued, I read the enclosed letter.

I would like to introduce you to Vaso-Ware … The garment is designed to be worn for several days after vasectomy or vasectomy reversal … Each Vaso-Ware combines practical design and functionality … from its interior shelf for support to its oversized front pocket to hold ice … Vaso-Ware: we have your support.

Vaso-Ware?? What the …??

A closer look at the “t-shirt” reveals a smartly-designed pair of black Jockey briefs — sans the customary peep hole. In its stead: a pouch. I check inside: no baby wallabies. The weird bebubbled sheet fits neatly into the pouch, turning the briefs into a lumpy yet luxurious instrument for hi-tech genital hypothermia.


Suddenly, the light goes on; marching bands begin to play; my ship has come in at last!

This is a great franchise opportunity! And I’m giving you, my faithful readers, an opportunity to get in on the ground floor.

Now I know what you’re thinking: “Dr Bob, I love your writing, and I trust you implicitly. But are you trying to get me to invest in a business which sells a single product, which someone will purchase to use just once in their lives? What sort of fool do you take me for?”

Oh ye of little faith: ever heard of a bridal shop?

(Yes, I know that marriage is a growth industry; almost everyone nowadays seems to get caught up in more than one. But you get the point …)

So hear me out: this thing is big — really big.

The problem is, you’re thinking inside the box (or the pouch, if you will). Granted you’ve got the perfect apparel for making those ‘nads nippy in the dreadful days after the ol’ “snip-snip,” or the hopeful re-hook to keep the new wife happy. But what’s to keep ’em coming back for more, rather than tossing the bepouched panties into the dustbin of bad memories, never to purchase again?

Re-purposing, my child — re-purposing. Expand those horizons. Multiply those possibilities. Visualize success.

The key is to see the potential in this product — it’s almost limitless. Just to demonstrate — here’s a small sample of our new Vaso-Ware™ product line:

 ♦ iPants™: Plug in your buds, slip the ‘Pod in your duds! iPants™ come in a rainbow of colors to match your iPod. Great for the gym, where folks’ll think your scratchin’ yo’self when you’re just changing playlists. Bump the base, turn up the Ludacris, you’ll have a workout without breaking a sweat!

 ♦ Vaso-Ware Executive™: You’re an important person — and you know it! Your cell phone never stops ringing. Keep it close to home, and set the ring to vibrate for those you love. No more lying when you tell ’em to “call again soon.”

 ♦ Vaso-Ware Endowment™: If you’re more gifted than the rest, blessed by genetics, touched by Eutykhia — or are an aficionado of spam e-mails — life is good. But you know the headaches it can cause: enraged feminists casting icy glares at your glory; beautiful women “accidentally” bumping into you; pretty boys grabbing the adjacent stool (and other things) at the bar. It’s endless, embarrassing, and it’s time to put an stop to it. With Vaso-Ware Endowment™ you can pack your pachyderm in arctic coolness, guaranteeing the shrinkage which will put you back in the middle of the pack.¹

 ♦ Vaso-Ware Wannabes™: If you’re one of those poor fellows at the opposite end of the spectrum — whose bell clappers are high chimes rather than cathedral bells — Vaso-Ware™ has the answer for you, too! Stud-muffinry at its finest. Custom-fit bulges to enhance your image in all the right places. Available in Large, Extra-Large, and World Cup.

 ♦ Vaso-Ware Heat™: The world’s a dangerous place. You never know when some crazed Korean commando’s gonna shoot up the joint — and who wants to be his next victim? But you’ll be ready if you’re packin’ heat! With Vaso-Ware Heat™ you’ll be ready for action! Accepts all common handgun sizes. Shotgun and AK-47 adapters coming soon!²

 ♦ Junk-in-the-Trunks™: We don’t want to forget you ladies out there! Tired of that boring flat bum? Longing for that bodacious booty, but dreading painful plastic surgery? Then Junk-in-the-Trunks™ is just what the doctor ordered! Designed with a broad pouch in the rear, with perfectly-formed implants to make yo’ girlfriends green with envy! Comes in three sizes: Sportscar™, Wagon™, and Rumbleseat™³.

So you can see the enormous potential in this product. Why work the ol’ 9-to-5 when you can retire in luxury as a Vaso-Ware™ reseller? We’re also exploring foreign sales, and test-marketing specialized products, such as 72-Virgin-Ware™ for Middle East markets.

So don’t tarry — call 1-800-MyPouch for your information packet on investing in Vaso-Ware™ now. Our operators will be waiting.

1. Excessive exposure may cause frostbite. Discuss with your doctor before extended use.
2. Some restrictions apply. May not be sold to felons. Concealed weapons permit required. Safety lock recommended. Not available in every state.
3. Pilot car and wide load warnings may be required in some states.

My Favorite Medical Myths

A recent post over at the Advice Goddess regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the liberal side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part:

I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. …

One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician…

Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.

Now, my intent is not to beat up the poor fellow; he is, after all, a liberal, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.

So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error.
Continue reading “My Favorite Medical Myths”

Price, Value & Grace

One of my areas of professional expertise is infertility surgery, specifically reversal of vasectomy. Vasectomy is a very common form of permanent birth control, with an estimated 500,000 to 700,00 procedures performed a year in the U.S. It is a procedure which is devilishly simple to perform, while maddeningly difficult to repair. The vas deferens is a small, thick-walled muscular tube (2.5 mm = 1/10 of an inch in diameter) which transports sperm from the testes to the prostate and seminal vesicals. Its division to achieve sterility is a simple office procedure — but the extremely small diameter of its central channel (0.2 mm), and the tendency to form secondary obstructions after vasectomy in an extremely delicate structure called the epididymis, make successful restoration a daunting challenge, requiring that the repair of the duct system reliably be performed under high magnification, using a technique called microsurgery.

While increasing number of urologists are trained to do this specialized surgery, consistently successful outcomes require many hundreds of cases and many years of experience, a factor which few recently-trained urologists bring to the table. I have had the good fortune to have this kind of experience, going back nearly 30 years, and as a result have one of the largest experiences in this procedure in the country, and have performed reversal surgery on patients from all over the U.S. and a number of foreign countries.

Reversal of vasectomy is rarely covered by health insurance, and the procedure is expensive: costing $15-20,000 and up in some large referral centers. I have over the years, built and sustained a large surgical experience by pricing my services well below much of the competition, creating a win-win situation: higher volume (and therefore greater experience and surgical expertise) while providing a substantial cost benefit to my patients.

But the procedure is still very expensive. Too expensive for many.

I receive quite a few e-mails from my web site, most requesting additional information or expressing an interest in scheduling surgery.

So yesterday’s e-mail came as a bit of a jolt:
Continue reading “Price, Value & Grace”

Boutique & Box Store

Home DepotA recent article in the Wall Street Journal (subscription required) addressed an interesting new phenomenon in medical practice: the micro-practice. Physicians, weary of being forced to see large volumes of patients because of HMO requirements or financial pressures, coupled with high practice overhead and burgeoning paperwork, are striking out in a very different direction. Some physicians — especially in primary care — are opening small offices without office staff, seeing far fewer patients with much lower overhead, using technology to bridge the gap. As of now, these practices are quite rare, and represent a significant risk to the physician, generally resulting in substantial reduction in income. Nevertheless, it allows these physicians to practice a simpler form of medicine, spending far greater time with patients, having more free time for themselves, and returning to some of the priorities which brought them into medicine in the first place.

Now, I am skeptical that this particular model for medicine will gain wide acceptance. Nevertheless, I believe it represents a trend toward alternative practice models outside the standard framework of large-volume, federal and third-party insurance-driven enterprises. Another similar trend, also small in numbers, is the so-called boutique practice, where patients pay cash, often subscribing on an annual basis to a practice which then provides full services, including appointments on demand, greater access to the physician by phone, routine preventive care, longer appointment times, and other amenities.

I expect to see an increasing divergence in healthcare along similar lines. One analogy would be the box-store versus the boutique. The box store is large, has everything you might need at low prices, provides little in the way of services or amenities — think, Costco or Home Depot-healthcare. For those unwilling to partake of such Wal-Mart style health care, and who have the means to seek alternatives, there will be health care services provided with excellent service and benefits not available in the box store, such as plenty of time with the physician and short waits in the waiting room.

When talking about the social economics of providing health care, it is useful to think of it as a triangle: at one point is quality, and a second point, affordability, and a third point, access. There’s only one problem with this unlovely triangle: one can only have two of the three points at one time. Hence, if you have widespread access to health care which is very high quality, it will not be affordable; if you have broad access and affordability, quality — perhaps not necessarily medical quality, but service quality and access to more expensive or optional medical services — must be constrained. We are currently seeing in large measure the third side of the triangle: we are providing very high quality healthcare, which while expensive, is still relatively affordable — but the cost we are paying is limited access. There is simply no way to have all three points of the triangle.

There is a huge and growing access problem in American health care today, with tens of millions of Americans without insurance, and many more — especially those at or below the poverty level on Medicaid — who cannot find access to physicians because of their own limited financial resources, or the inability of physicians to accept reimbursement from federal programs which pay below the costs to provide the services. The pressure to resolve this dilemma at the political level is very large, and some form of universal coverage seems inevitable in the relatively near future.

In order to provide such broad-based coverage, however, the necessary limit on financial resources — whether federally financed, or paid for through employer-funded or personal-based insurance — must by nature result in a reduction in quality. This is not to say that substandard medicine will be practiced, although there is an increased risk of this; more importantly, there will be significant restrictions in access to optional, high cost technology, and an inevitable decline in service. Universal health care coverage, while critically important, will invariably lead to long waits for an appointment, very little time with the physician, seeing a different doctor at each visit, and having to wade through many levels of support staff to communicate with your doctor. This is already becoming far too common even under our current system due to intense cost-cutting pressures.

While such a universal coverage arrangement may prove very functional from the standpoint of providing basic care for large numbers of people, it will not prove satisfactory to many Americans who have become accustomed to a far more personal and consumer-driven model of health care delivery. There will, therefore, be strong financial incentives to provide alternatives to box-store medicine — and in fact, we are already beginning to see this.

The best contemporary examples of this alternative system of boutique medical care can be seen today in plastic surgery clinics, LASIK eye centers, and the growing trend toward high-end specialty hospitals catering only to orthopedics or other subspecialty care. While social engineers tend to decry such two-tiered healthcare systems, in fact, these alternatives respond far better to true market forces then does the lumbering dinosaur of federally-funded or third-party insurance-controlled health care. Plastic surgery clinics compete on price, service, and quality for a facelift, tummy-tucks, or a breast augmentation; high-end clinics charging more must be a higher standard of quality as well as provide extraordinary service. Consider the dramatic decrease in cost for elective corrective eye surgery with LASIK: prices have dropped dramatically over the past few years as high-volume LASIK clinics compete for patients. Hospitals, faced with a drain of better-paying patients toward specialty hospitals which provide a higher quality of service and a more satisfying patient experience must now re-examine their own quality issues, and are pressured to provide nicer facilities, better food, more nurses per patient, and other service-oriented improvements.

Beware of those — especially of the political persuasion — who promise unlimited, high-quality health care which is affordable. It does not, and cannot exist. We clearly need to address coverage for those in need of health care who cannot currently afford it, for health care, while not a right, is most certainly a very large part of our quality of life and well-being. The boutique model of health care service will not address this problem, in spite of the pipe dreams of libertarians who believe that free market solutions can solve all problems. This two-pronged approach may well provide a uniquely American solution to the worldwide dilemma of providing high-quality care, excellent service and access, and affordability Virtually all countries providing socialized, government-funded health care are struggling with the box-store problem. Poor service, long waits for care and “elective” surgery (like heart bypass and cancer surgery), and spiraling costs are the rule. But we in America have become accustomed to the highest quality of health care in the world, delivered quickly — for those who can afford it.

Perhaps it is time we abandon a utopian vision for health care, and settle on something, though imperfect, which may end up working quite well in the American healthcare system. It may well come from the ground up rather than from the top down.

More Embryonic Stem Cell Info

I’ve recently referenced an excellent article on the huge gap between hype and reality with embryonic stem cell research (as opposed to the real and growing applications of adult stem cells), and Michael Fumento again points out the huge gap between myth and reality here (HT: Instapundit). Maybe the word is starting to get out — although I’m not holding my breath.

On a separate note, I’ve been quite busy lately, with several personnel changes in the office in the works, but have a few essays near completion on the Faith series (part 1 and part 2 here), Moving the Ancient Boundaries, as well as updates on the Narrows Bridge construction — so stay tuned.

God bless, back soon.