"A Good Death"

Shelli Feder

What does compassionate care look like at the end of life? What does it mean to have a “good death” today?

Yale School of Nursing (YSN) Associate Professor Shelli Feder:

What we think is a good death has changed over the decades. There is no single good way of dying. It’s really about what matters most to that person and how they want to die and where they want to die and what they want to do before they die. Part of providing good hospice care is trying our best to make sure that that happens.

One of the most beautiful things about hospice is about reframing end of life and living with a critical or a life-limiting illness. Oftentimes by the time patients get to hospice, which too often is too late, they’re tired. They have been in and out of the hospital; they’ve been stuck a gazillion times for IVs; they’ve undergone tests; and they’re tired of all that intervention and invasiveness. Hospice is an opportunity to sit down and talk about what matters most to you right now. We can’t change the fact that you’re dying. But what we can change is how you’re feeling in this moment. That’s the definition of dying well.

I have come to realize that dying is about letting go, which sounds trite because what is dying but letting go of life? But prior to that final act one has to let go of dreams unfulfilled, wishes for one's children, legacies that won't be completed. Once one releases oneself from those burdens, the feeling can be liberating. Then, perhaps, you are ready to go.

A Condition That Was Caught in Time

Pulmonary embolism (Cavallini/Science Source/WSJ)

I had been feeling pretty chipper until the beginning of September. As the month proceeded, my asthma got worse, and I could no longer take 30-45 minute walks in the morning. Last Monday I showed for a scheduled doctor's appointment; the nurse took my vitals and immediately called for oxygen.

The doctor strongly suggested that an ambulance transport me to emergency. Of course, my wife could have driven, but the ambulance had the necessary equipment and personnel if the situation worsened.

Over the next two days I was poked and prodded at Stanford General. There were ultrasounds, chest X-rays, CT scans, echocardiograms, and dozens of blood draws. The good news was that most of the tests were negative. I was short of breath because the asthma had been exacerbated by a blood clot that had formed in the right lung. I will have to take the blood thinner Eliquis indefinitely. I was discharged Wednesday, and my condition wasn't serious enough to warrant being on oxygen at home.

Considering the possible outcomes, I was pretty lucky:

About 900,000 people are diagnosed with blood clots—deep vein thrombosis or pulmonary embolism—in the U.S. each year, according to the American Lung Association. For many, the first symptom is sudden death.

“I call it the people’s disease. It doesn’t spare anyone—rich, poor, male, female,” says Dr. Parth Rali, director of the pulmonary embolism response team at Temple University Health System in Philadelphia... “You could be the healthiest person in the world and unfortunately it can still happen to you.”

Some lifestyle factors increase your risk of blood clots, such as obesity and smoking....Dehydration can thicken the blood. And taking hormonal contraceptives... also raises the risk.

Then there’s movement, or lack thereof. When your legs stay still for too long, the blood may begin to form clots, which can then travel through the heart and into the lungs.

Yes, more things to worry about, but better than the alternative.

The Cure is There if you Look for It

(Photo from crosswalk)

Today's Old Testament lesson includes the verse: "Is there no balm in Gilead? Is there no physician there?"--Jeremiah 8:22

Gilead was a mountainous region that was known for its agricultural products, particularly for its healing medicines.

The land of Gilead was known for its balm, a liquid rosin that flowed or dripped from certain trees such as pine, cedar, cypress, or terebinth. Gilead was most noted for the Balsamodendron Gileadense, a rosin-producing tree native to that area. Because of easy access to medicinal ingredients, many physicians made their homes in Gilead.

The Book of Jeremiah laments both the spiritual waywardness of the Israelites and the impending threat of Babylon, which later did destroy the Temple in Jerusalem. (King Nebuchadnezzar expelled the Israelites from the region during the Babylonian Exile that occurred in the 6th century BCE.)

There would be no material balm that would cure Israel's idolatry (the worship of something other than God). Many Christians believe that Christ is the balm that Jeremiah is seeking.

Note: Foster City's Gilead Sciences is its largest public company, currently valued by the stock market at $142 billion. Founder Michael Riordan originally named the business Oligogen in 1987 but changed it to Gilead Sciences when he heard the biblical passage. He could have done worse.

The Science Helps You Get Settled

(Photo by Sergiy Barchuk/WSJ)

In our there's-a-pill-for-everything culture there are worse medications than propranolol:

Approved by the Food and Drug Administration in 1967 to treat symptoms of cardiovascular disease, propranolol has become the go-to pill for dealing with all sorts of stressful situations, from public speaking to first dates. Prescriptions are on the rise, up 28 percent from 2020, according to the most recent data from IQVIA, making propranolol—a generic drug that is relatively inexpensive—the fastest-growing pill in the category. By slowing down heart rate and lowering blood pressure, the drug can reduce the physical symptoms of anxiety, though it has not been approved by the FDA to treat the condition. Most people take it situationally; musicians and actors, for instance, have long relied on beta blockers like propranolol before performing (“I took a beta blocker, so this is going to be a breeze,” the actor Robert Downey Jr. said during his 2024 Golden Globes acceptance speech). Now a new generation of stars is spreading the gospel.

I have never taken the drug but can't be too judgmental: if my livelihood depended on being cool in stressful situations I may well be using propranolol all the time.

Where other beta blockers focus on specific parts of the body, propranolol “affects beta receptors in the heart and everywhere else in the body, including the brain,” according to Dr. Nassir Ghaemi, an academic psychiatrist and professor of psychiatry at Tufts University School of Medicine.

“The effects on the brain are the effects that cause the decrease of anxiety,” Ghaemi says.

Compared to benzodiazepines, such as Xanax or Valium, propranolol is considered nonaddictive and is among the “mildest variety of anti-anxiety medication,” he says, but it is not without risk. Because propranolol works to reduce blood pressure and heart rate, if you reduce it too much, the person could faint.

The Mayo Clinic lists the "more common" side effects:

Chest tightness

cough producing mucus

difficulty with breathing

Anxiety

dry mouth

hyperventilation

irritability

restlessness

shaking

sleepiness or unusual drowsiness

trouble sleeping

unusual dreams

None of the above side effects appear particularly dangerous, so users are probably not gambling with their long-term health by taking propranolol or other beta blockers. Speaking as a baby boomer who witnessed some work colleagues taking prescriptions and illegal drugs (cocaine, marijuana) 40 to 50 years ago without apparent ill effect into their golden years, the rewards outweigh the risks, so you won't hear tsk-tsks from me.

If You Have to Ask, You Can't Afford It

(Photo from charity buzz)

From 2009 to 2016 I was a regular viewer of Royal Pains, USA channel's romantic dramedy about a startup concierge medical practice in the Hamptons. The show had the difficult-to-diagnose conditions that doctor shows usually have and multi-season story arcs. The millionaire inhabitants of the Hamptons were sometimes gently mocked, but there were no pure villains. When the series wrapped, the practice had become successful, and all the major characters had resolved their conflicts.

Now there are several concierge doctors in the Hamptons, and one even attributes the founding of his business to the TV show.

Along with other areas with surging centimillionaire and billionaire populations such as South Florida, the Bay Area, New York City and Los Angeles, the East End of Long Island is teeming with concierge doctors who treat patients swiftly (usually), discreetly (hopefully) and expensively (always). These doctors charge a membership fee anywhere from a few thousand dollars to six figures a year, with one-off house calls on top of that often starting around $1,000. These doctors do not typically accept insurance.

“Money is not an obstacle,” Rashid said. “Not only can concierge medicine provide fast service, it also provides advanced medicine.” Rashid, a family physician who trained in Miami and New York and has worked in the Hamptons for 15 years, opened a branch of her company in Palm Beach, Fla., in 2021 for their snowbird clients.

The Hamptons concierge-medicine boom started in 2020, when doctors saw an opportunity to test and treat the affluent community working remotely from their beach houses. Nationwide chain Sollis Health, which focuses on emergency medicine, started a center among the tony horse farms of Water Mill in 2021. Other options include Casa Health, White Glove Medicine and individual practitioners including Dr. Magdalena Swierczewski, M.D., and Dr. James Giugliano, D.O.

Dr. Golberg treats a couple aboard their yacht

Many of these doctors bill themselves as one-stop shops for all family medicine needs. Some do cosmetic services, several specialize in increasingly popular antiaging and integrative-health services, while others rush over to White Parties in the wee hours when things go awry. All of them know their way around Lyme disease and addiction issues.

[Dr. Alexander] Golberg had the idea to begin practicing concierge medicine in the Hamptons after watching “Royal Pains,” a television show that ran from 2009 to 2016 about a doctor who does just that. An entrepreneurial type, Golberg immigrated from Russia in 1989 and worked at his cousin-in-law’s cubic zirconia business after medical school. He has an M.D. from St. Petersburg Medical Academy and a D.O. from the New York College of Osteopathic Medicine, and is board-certified in family, osteopathic, antiaging and regenerative medicine.

Patients get instant, personalized service in exchange for paying annual six-figure fees, and their clients are happy to pay it,

Inflammaging

Almost every death of a person I know in my age cohort is attributable to cancer.

The following hypothesis has previously made sense: medicine has advanced to such an extent that fewer people are dying of heart attacks, strokes, or sudden trauma; chronic diseases are far more difficult to treat, hence there are more deaths from cancer. However, the aforementioned is only a partial explanation; researchers have discovered that aging immune systems are less able to fight off cancer. [bold added]

(Image from Science Direct)

...studies of individual immune cells in human lung tumors, as well as in old mice, have revealed how chronic, or pathogenic, inflammation in older people—dubbed inflammaging—interferes with the immune system and fuels cancer growth...

Inflammation is the immune system’s reaction to a threat. Immune cells circulate in the body, attacking invaders such as viruses and cancer and calling for backup—more immune cells—when necessary. Working correctly, they can beat back Covid-19 or heal a cut on the finger. But the immune system can also overreact, fueling inflammation that gets in the way of healing or leads to disease. It misfires like this more as people age....

Often the assumption is that older people get sick more easily because their immune systems weaken, says Dr. Thomas Marron, a thoracic medical oncologist who heads the early-phase trials unit at Mount Sinai’s Tisch Cancer Institute. That does happen, he says, but at the same time, “we really are seeing this sort of hyperactivation.”

“The body is just basically like a flower bed primed to grow cancer as you get older,” he says.

As a person ages, the immune system has to work harder to kill infections or mutations, like cancer. But the immune system itself is aging and produces fewer of the type of immune cell that targets and kills cancer cells. At the same time, it makes more of a type of immune cell that responds initially to infections. Known as myeloid cells, with aging they become more inclined to overreact and create inflammaging. These inflammatory cells may provide a “hit” necessary for older cells with mutations to turn cancerous, says [Dr. Miriam] Merad of Mount Sinai.

Combatting defective immunity systems is only of several approaches that are being explored in the race to cure cancer. 54 years after Richard Nixon announced a War on Cancer the path to an eventual victory no longer appears to be impossible.

Stanford Medicine

Charging stations can be found in every building

Since the beginning of 2024 family members have often used the medical facilities at Stanford. We have availed ourselves of the services in neurology, gastroenterology, ophthalmology, dermatology, oncology, radiology, and early drug development, as well as the laboratories and emergency rooms.

The personnel, equipment, and buildings are uniformly excellent. If we must be critical, we have experienced an occasional slip-up in scheduling, probably due to growing pains from Stanford Health's multi-billion-dollar expansion program.

But the greatest drawback, IMHO, is something that Stanford can't do much about, namely the difficulty getting to its facilities quickly. The tony Peninsula towns Palo Alto and Menlo Park have blocked traffic improvements, so cars must traverse the same local streets as they have since World War II. Getting from the freeways to Stanford can be heavy going, especially when one considers the growth in the Silicon Valley economy.

Nevertheless, we'll live with the inconveniences. Both Stanford and UCSF have world-class medical facilities, and we know people who fly here for treatment. The quality of medical care is one benefit of living in the Bay Area that we don't often hear mentioned.

A Small Step for Science

(Image from Cleveland Clinic)

Your humble blogger volunteered to be part of a medical study. However, in order to qualify I had to submit to a series of tests, not only to establish a baseline for future comparison but also to see if I met certain minimum health requirements.

Earlier this week I had difficulty passing the electrocardiogram (ECG). The "QT interval" was stuck between 475 and 480 when it had to be under 470. No matter what the technician and I tried, i.e., relaxing and slowing breathing, raising or lowering my back, removing the iPhone and Apple Watch, nothing worked. (On the previous day the reading was 494, and they gave me an injection of potassium and magnesium in order to remedy a shortage that can raise the QT interval.)

The Mayo Clinic: [bold added]

On an ECG, there are five waves. They use the letters P, Q, R, S and T.

Waves Q through T show the heart signaling in the heart's lower chambers.

The time between the start of the Q wave and the end of the T wave is called the QT interval. This is how long it takes for the heart to squeeze and refill with blood before it beats again. If the interval takes longer than usual to happen, it's called a prolonged QT interval.

(GE image)

GE Healthcare:

Just as there are many ways to correct the QT for heart rate, there have been numerous attempts to establish the upper limit of "normal" for a corrected QT interval.

Women have a slightly longer QT interval than men. This figure shows the 99% upper limit of normal of the QTc for men (470 msec) and women (480 msec).

Speaking of prolonging, this story has gone on long enough. Just as we were ready to concede defeat, I thought of my hearing aids, which were too small for the technician to notice and which, in any case, were not on her checklist of forbidden ECG items.

Upon their removal the QT interval fell all the way down to 446, well below the cutoff. Even before the study has begun, I'm already contributing to the advancement of science.

Great American Success Story

(Photo: NASA/Zuma Press/WSJ)

41-year-old Jonny Kim is the epitome of the Great American success story. Born in Los Angeles to South Korean immigrants, he has been embraced by Asian-Americans, who also dread comparisons with him by their parents. [bold added]

In half a lifetime, Jonny Kim has achieved the American dream three times over. He was a Navy SEAL. Then he graduated from Harvard Medical School. And on Tuesday, he blasted off as part of his latest act: astronaut.

When novelist Wesley Chu first learned about Kim, a 41-year-old father of three who is also a Navy pilot, his first reaction was awe.

His second: “Thank God my mom is not friends with his mom.”

After word of his feats spread, Kim became a global source of inspiration. And yet, to many of the same people who glance at his résumé and can’t help but compare it to theirs, he has also conjured up a bit of another feeling.

Dismay.

This has been especially true in the Asian-American community, where Kim, the son of South Korean immigrants, has been simultaneously lauded as a hero—and feared, only half-jokingly, as “every Asian kid’s worst nightmare.”

The worry: No matter what they achieve, their high-demanding immigrant parents will say Jonny Kim already did that—only better. “We accomplished all this stuff, but really, it’s what he did that matters,” Chu said.

Kim became an internet meme among Asian Americans, who frequently take to social media to express gratitude that he’s not a relative. NASA’s social-media posts about Kim are flooded with comments expressing similar sentiments. “As a fellow Asian, I hope my parents do not get to read this. But, safe journey my man,” one wrote.

His childhood was marked by tragedy:

It all started with trauma during his childhood in Los Angeles. Kim said he witnessed his father, who he described as alcoholic and abusive, pull a gun on their family. Police shot his father dead in their attic.

His desire to physically protect his mother and brother led him to become a Navy SEAL. But an Ultimate Frisbee ankle injury delayed his plan to join the Navy as an operations specialist. When he recovered, a recruiter steered him toward becoming a medic.

In 2005, Kim joined SEAL Team Three, serving as a medic and sniper, among other roles. He earned a Silver Star and a Bronze Star for treating wounded comrades during two tours in Iraq, an experience that motivated him to attend medical school.

No matter how successful, we eventually meet someone who is better than we are in our field of endeavor. (My revelation occurred in college.) Jonny Kim has yet to meet that person.

Hospital Chaplaincy

Spiritual care volunteers and staff at Stanford Hospital Chapel

Before an Episcopal priest can be ordained, he or she must complete several months of Clinical Pastoral Education (CPE). In CPE the students minister to non-Christians as well as Christians, much as priests do in the real world.

Clergy that I have spoken to have said that their most intense and rewarding experiences have occurred while they did their CPE as hospital chaplains. [bold added]

Hospitalized patients and their families often struggle with religious and spiritual quandaries but can’t attend their houses of worship or don’t have one. Chaplains thus fill crucial gaps. As the religious makeup of the U.S. has changed in recent years, their profession has begun to do so too. Board-certified chaplains are now increasingly trained to help patients of diverse beliefs. To learn about their vocations, I [note: Columbia prof. of psychiatry Robert Klitzman] recently conducted an in-depth study, speaking with 50 chaplains from across the country and from different faiths.

While chaplains aid countless patients, they are in many cases marginalized and underfunded. The Centers for Medicare and Medicaid Services allows for direct reimbursement for spiritual services only within the Veterans Affairs system. Offering spiritual care for hospice patients enrolled in Medicare is mandatory but not directly billable. As a consequence, many hospitals have no chaplains; some rely on local volunteer clergy, who know only their own faith, or on other healthcare professionals to fill in for spiritual care...

Chaplains are often the only staff with time to talk to patients, whom they can therefore get to know well. I learned of one patient who phoned the on-call nurse every day at 2 a.m., complaining of pain. The staff tried altering his medicine without success. Finally, a chaplain spoke to the patient, who turned out to be carrying significant guilt from his mother’s suicide when he was 18. When the chaplain arranged for the man’s elder siblings to talk about it, they were “aghast,” the chaplain told me. “They reminded him that their mother had mental-health issues: ‘Don’t you remember?’ It was like a 50-pound weight had been lifted. After that, he never again called the nurses at night.”

Chaplains also serve as critical mediators in conflicts among patients, families and physicians. At another hospital, a teenager who was dying wanted to donate his organs. Soon he was brain dead and on life support, which surgeons planned to remove in the operating room. The boy’s family wanted to be present when he died, but the surgeons refused for fear that they’d disrupt the procedure.

Presented with an impasse, a chaplain negotiated a solution: The family would dress in sterile gowns and stay in the theater for three minutes. The family and physicians sang “Amazing Grace,” the boy’s favorite song. When he died, the mother said to the chaplain: “Thank you for that gift. . . . We got to sing my son into heaven.”

In my research it wasn’t uncommon to learn of medical professionals wary of spiritual care, which they saw as having no medical benefit. Yet spiritual counseling can help patients choose palliative care when the treatments available are both futile and painful.

In facing serious disease, millions of patients find themselves pondering the eternal. Most of us will die in hospitals, far from any religious institution, and might benefit from chaplains’ care. Our healthcare systems would do well to recognize and value them more.

Spending one or two nights in a hospital changes a person. Although WiFi is now commonplace, the hospital environment is not conducive to endless Internet surfing or scrolling through social media. The patient confronts thoughts he may not be accustomed to having, especially if he is non-religious.

In his hour of need, there may not be family members the patient is comfortable talking with, and he can't bother medical personnel, whose focus is usually confined to the health of our physical bodies.

That leaves the hospital chaplain, whose job has expanded to being ready to converse with those who are members of different faiths-or no faith at all. In an increasingly irreligious society the irony is that the need for chaplaincy services has never been greater.

Dr. Bryant Lin

Bryant Lin teaching a class on Oct. 23 (Merc photo)

A member of our family has been seeing Dr. Bryant Lin at Stanford Health for years. Lately Dr. Lin has been unavailable. Now we know why; he has been battling lung cancer.

“If you look at the survival curves, you would give up. But you may be one of the lucky ones. You need to have optimism, tinged with reality,” said Lin, a beloved clinical professor and 50-year-old nonsmoker with two teenage sons who was diagnosed with advanced metastatic lung cancer earlier this year.

...Lin initially dismissed an annoying cough that started last spring. But it continued to worsen, causing him to wheeze.

“I’ve never had a puff of smoke of anything in my life,” he said.

In one week, he got stunning news. What he assumed was just a normal spring allergy was diagnosed as stage IV non-small cell cancer, which had already progressed to his bones and liver, with 50 lesions in his brain.

The diagnosis, about a month before his 50th birthday, “was so drastically different than what I was expecting,” he said. He was quickly hospitalized...

Lung cancer causes more deaths than any other cancer, with survival rates decreasing as the severity increases. While smokers make up the majority of those cases, 15% to 20% of people with lung cancer are non-smoking, like Lin. There is new evidence of an increase in the incidence of lung cancer in nonsmokers, although no one knows why. It is largely a silent disease that goes undetected for a dangerously long period.

The gene mutation that causes the cancer disproportionately affects those of Asian descent.

While not cured, Lin’s scans are strikingly improved after an innovative medicine called osimertinib, which targets his specific mutation. It blocks proteins that control cell growth and division. His cough is gone, and he is almost symptom-free...

With roles reversed, Lin says he is learning both how to be a patient and how to more fully be a doctor.

He urges doctors to not focus just on “medical science things” but the emotional and practical challenges of their patients. He urges patients to build tight community of support and deepen their relationship with their doctor, who can act as an advocate when things go wrong.

He’s not sure how much time he has left. “One year? Two years? Five years?” The class, he said, “is to give back to my community as I go through this.”

After receiving his terminal diagnosis, Dr. Bryant Lin continues not only to fight the disease but teaches classes at Stanford Hospital, including his own life experience in the content. None of us know with certainty how we might react to such news; character reveals itself in such moments.

Sneezing: Letting It All Out

(BBC photo)

I've had some bad hay fever days, but nothing like this:

Florida man sneezes his intestines out of his body at restaurant

A Florida man eating in a diner with his wife recently sneezed so forcefully it caused parts of his intestines to exit his body through a surgical wound, according to researchers.

Details are found at the above link, and your humble blogger has mercifully omitted them from this post. Paramedics and doctors put things back where they belong, and the patient is expected to recover fully.

Despite the sensational nature of this incident, it does have some scientific value: [bold added]

The journal notes that the case is an important one because it fills in gaps in the literature about dehisence, the bursting of wounds.

"While wound dehiscence is a well-known complication, this case is important because evisceration through the abdominal surgical site after cystectomy is poorly described in the medical literature,” the article concludes.

If I ever have surgery during allergy season, I'm pumping myself full of antihistamines.

Toughing It Out

I've used 3 out of the 30 tablets

Over the years I've had a few outpatient procedures that resulted in residual pain. The doctors have prescribed oxycodone to be taken as needed, just in case ibuprofen or acetaminophen aren't sufficient to reduce the discomfort to tolerable levels.

The danger of addiction to opioids like oxycodone has been publicized for years, and it's prudent to stop taking it as soon as one can. Now there's another reason to set the bottles aside:

Hidden Dangers of Opioid Epidemic: Study Links Prescribed Opioids to Cardiovascular Disease

They focused on approximately 50,000 patients, 30% of whom had received prescribed opioids, over a three-year period. Those who had received prescribed opioids were significantly more likely to later develop cardiovascular disease (CVD), the researchers found. The researchers also found that higher doses were associated with a higher risk of CVD.

Although the exact mechanism by which opioids cause cardiovascular disease isn't established, it is known that long-term opioid use is correlated with higher concentrations of triglycerides and low-density lipoproteins (LDL), as well as a higher incidence of atrial fibrillation (Afib).

Doctors prescribe medications because they believe that the benefits exceed the cost to a patient's health, but patients should not be reticent in asking about the side effects. In the case of pain relief and opioids, sometimes it is preferable to tough it out.

San Francisco Doesn't Look So Bad

...compared to Oakland. Headline:

Oakland crime surge: This major employer is telling workers to eat lunch on site [bold added]

Kaiser Permanente, the city’s largest employer, sent out a memo last month asking employees to stay in their buildings for lunch and throughout the workday, according to a report from KTVU. The memo also directed workers from out of town not to hold meetings in downtown Oakland...

The new precautions come as Oakland residents reel from a 21% increase in violent crime last year over 2022. Robberies climbed 38%, and burglaries increased 23%. For the second consecutive year, the city logged 120 homicides.

Kaiser Center, where I spent many an evening safely 1975-78.

During the mid-1970's I worked more than half the time in Oakland as a junior auditor for a CPA firm. One of its major clients was the Kaiser family of companies, the most notable at the time being Kaiser Permanente, Kaiser Steel, Kaiser Industries, and Kaiser Engineers. All were headquartered in Oakland.

(Digression: it's impossible to overstate the importance of Henry J. Kaiser to the post-war development of Hawaii, to the shaping of health care in California, and even to the nation's history, when his mass production of Liberty ships helped win the War.)

Because of its large Oakland footprint, not to mention its origins in the East Bay, Kaiser is unlikely to depart that benighted city. Nevertheless, if employee safety continues to be a major concern, Kaiser has to be looking at alternatives.

One wonders if Blue Shield is having regrets about its move to Oakland:

A representative of Blue Shield, the health insurance provider that moved its corporate headquarters from San Francisco to Oakland in 2019, said Friday that the company would offer “various options” to keep employees safe when they come to the office. Among them: ride-hail services, secure parking and security guards.

Blue Shield asks most employees to come to the office at least twice a month, and for executives to show up once a week.

Within the past decade the Raiders, Warriors, and Athletics have abandoned Oakland. As businesses and workers flee, Gertrude Stein's famous 1937 quote is truer than ever.

Annual Check-up

I checked off a couple of items on last year's list, but the doctor added some to take their place.

The #1 goal, lose 10 pounds, is an old friend. I blame the post-COVID bounce in socializing and trips to Hawaii.

Monitoring blood pressure is a new addition. The readings have been climbing over the years, and weekly home measurements will help him decide whether to put me on medication when I come back in three months.

One health worry that's no longer on the list: last month's colonoscopy removed five non-cancerous polyps. I won't have to schedule another one until 2027.

It could have been worse, so I'll take it.

Just Maintaining the Status Quo is Hard

Whatever one's views on abortion, there's no question that its reduced availability has made it riskier to be an obstetrician gynecologist who has to worry about running afoul of the law, even if he or she strives to be compliant.

Surveying the legal landscape, medical students may decide that being an OB/GYN is too tough because of regulatory requirements. The coming decline in the number of doctors who provide pregnancy, childbirth, and women's health services (not abortion) is probably not what pro-life lawmakers intended.

Now comes another blow: Hospitals Shutter Maternity Wards Amid Falling Birthrates

The closures are broadening a swath of America without maternity units, commonly communities that are sparsely populated or aging. The trend threatens to worsen infant health and maternal death rates that have hit the highest level in decades.

Hospitals that are closing maternity units said they can’t recruit enough staff to safely operate. Hospitals with fewer births are less attractive to doctors and nurses, executives said. Births at OSF HealthCare St. James-John W. Albrecht Medical Center in Illinois declined to 120 last year from 184 in 2019.

It's a sad state of affairs in 21st century America that, whether a woman wants to see through or terminate her pregnancy, she has to travel a greater distance to ensure a healthy outcome for herself.

Patient in my Circumstances

In a wheelchair this ride would have been perfect.

My outpatient procedure was scheduled from 6 a.m. to 8 a.m., and, because general anesthesia would be used, the clinic would not allow me to drive home. Coincidentally, for the first time ever, I couldn't hitch a ride with anyone because of various calendar conflicts.

No problem, I told them, I'll just take a cab or Uber or Lyft. That won't do, they said, you will have to use a licensed medical transportation company.

And so it was that I Uber'ed to the appointment at a cost of $18 plus tip and hired a medical van to take me back for $100. The vehicle was equipped for wheelchair passengers and was overkill for a patient in my circumstances.

I could work myself into a lather about liability insurance, government regulations, and one-size-fits-all safety requirements. Cultivating an attitude of gratitude is better: I have the means to pay the bill, and the procedure was quick. Besides, anger often hurts the person expressing it as well as its object.

The driver made sure I got to the front door okay. There's a reason there are a dozen businesses like his in the area, and some day I may genuinely need his services.

I Got the Jab Anyway

Three years after the government locked down everything, fear of the coronavirus has largely dissipated. Outside of hospitals and doctors' offices few people wear masks.

While mRNA vaccines appear to provide some benefit, their protection against COVID-19 isn't foolproof. Also, scientists and government officials now confirm that there can be side effects, including myocarditis and pericarditis.

Despite the apparent lessening of the COVID-19 danger, and the now-documented potential side effects of the vaccine, I got the jab anyway.

We'll be traveling next month to visit family in Hawaii, and I don't want it on my conscience should an elderly person get sick.

And yes, I'll wear a mask, too.

Pictures on the Wall

A family member had an appointment with an opthalmologist, and so it was that we were at the Stanford eye clinic, three miles east of the university's main campus.

Rather than look at my phone I prowled the halls and gazed at the collection of '60's pop art. There were Andy Warhols and Roy Lichtensteins (pictured above) on both floors, along with less well-known artists like Allen Jones, Mel Ramos, and Guy Dill.

The screens will always be there, and when you're in a new place, even as nondescript as a doctor's office, you can be pleasantly surprised by getting up and looking around.

They'd Rather Curse the Darkness

Church-state frictions manifest across many cultural touchpoints, but this is a new one:

The sanctuary candle: dangerous to the hospital (CNA)

Feds tell Catholic hospital to blow out sanctuary candle or face penalties

The federal government recently told a Catholic hospital in Oklahoma to either blow out a small candle or stop serving elderly, disabled, and low-income patients...

Saint Francis Health System is a premiere health system with five hospitals in Eastern Oklahoma. The health system cares for nearly 400,000 patients each year, has given away more than $650 million dollars in free medical care in the past five years, and employs more than 11,000 Oklahomans...

Since Saint Francis opened its doors in 1960, the health system has had a sanctuary candle with a living flame as an act of worship. The flame, far removed from medical equipment and patients, is shielded by two glass holders, sits on a brass basin, is affixed to a wall and has a brass top covering it, with many sprinkler heads above it...The federal government now threatens to tell all patients who rely on Medicare, Medicaid, and CHIP that they can no longer receive care at Saint Francis—all over a candle.

After the hospital's lawyer responded, the government retreated:

The hospital was informed that it will receive a waiver, provided it posts signs warning about keeping oxygen equipment away from the tabernacle candle, which is already enclosed and on a wall six feet off the ground.

IMHO, government employees could not possibly have believed that a single candle posed a danger to thousands of Medicare, Medicaid, and CHIP (Children's Health Insurance Program) patients. This was a demonstration of power that showed that even minor disputes with the government can be costly. And no, Catholics, you're just imagining that this is retribution for your stances on abortion and same-sex marriage.

One thing is certain: Florence Nightingale, aka "the Lady with the Lamp" and founder of modern nursing, would have been persona non grata on battlefield hospitals if these bureaucrats had been around in 1854.