Wednesday, March 22, 2017

"You made STONES?"

"Gallbladder's Last Day" comic by The Awkward Yeti, used with permission.
Who knew there were comics about the gallbladder??

Certainly not me, until half of my FB feed was filled with this cute little guy after folks found out that I had to have my gallbladder removed.

So, I had to banish the little fellow and his stones.

I'm now 48 hours after a bunch of exuberant surgeons, fellows, and residents spent the better part of 90 minutes mucking about in my insides.

I am no stranger to surgery - aside from a c-section and an emergency appendectomy, I've also had a ton of orthopedic procedures. Let me say, general anesthesia never gets easier to recuperate from. I have about a 2 hour window to do anything before I need to take a nap.

Which makes the dogs ecstatic.

It's amazing to me that human bodies heal after that kind of planned damage and that we can live well minus what seems like pretty essential components in our meat-suits.

So, there you have it. It's been several weeks of intermittent 'oh, G-d I want to die' kind of pain and now it's just a bit of a tugging sensation in my flank when I change positions. And that post-surgical pain will fade quickly.

My husband remarked that my color was better - my face is back to its usual rosy pink from the slightly gray tinge. I suspect I'd been dealing with a barely functioning gallbladder for some time before the stones got large enough to cause an acute problem.

I am grateful for surgical advances that let them do this operation laproscopically - making several small holes  and working with tiny cameras to guide the work rather than have to have a large abdominal procedure.

Now it's time for another dose of motrin and a nap.


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Tuesday, February 28, 2017

Health Care: A Dark Fairy Tale

Lost in the Woods

Okay. I am breaking from my usual blog topics to talk about health care.

"But you're a writer. A poet. Sometimes a potter," you say. "What do you know about health care?"

Actually? Quite a lot.

Once upon a time (in 1984) I earned my undergraduate degree from the University of Rochester in health policy/planning/history. I created my own concentration (my degree was specifically in Ethical Issue in Health Care) because at the time, there wasn't an established major in public health. Now there is.

I went on to graduate school at Columbia University in NYC and earned a masters degree in Physical Therapy in 1986. Immediately after that, I started working in the field and practiced as a physical therapist (PT) for almost 25 years before I left the field.

So I know a thing or two about health care in the US, from an historical perspective, from a policy perspective, and from working in the trenches during the years of run-away health care costs and our first institutional efforts to reign those in. I was there at the start of HMOs (Health Maintenance Organizations) which were touted as the answer and the future.

They were one answer, but given how complex our health care system is, it wasn't a surprise to any of us working in it that it didn't solve the problem.

But I'm getting ahead of myself. Let's go back a bit, shall we?

At the turn of the 20th century, medicine as we recognize it today didn't really exist. There was no standardization of medical education, research, or care. Most medical care was provided at the individual physician level, in a private office or in a patient's home.  Individuals had to pay for the care they received and in many cases, that care was paid for on the barter system, if the physician accepted it.

  • Insurance didn't exist as we know it now, though there were some mutual protection plans sponsored by Unions to help pay for lost work time due to injury or illness.
  • Hospitals were primitive places that essentially warehoused the mentally ill and the chronically sick.
  • Most people were born and died at home, and rarely under medical guidance
  • Physicians' training was scattershot and they often learned on the job.
  • The widespread use of surgical anesthesia (ether) was less than 50 years old!

Then along came a man named Abraham Flexner who was tasked with investigating and reporting on the state of medical education in the US and Canada. His report, published in 1910, was the blueprint for the standardization of medical school and a shift to the scientific method in medical research and treatment.

And we are still feeling the reverberations of his recommendations, over 100 years later.

While a lot of good (and our conception of modern medical care) emerged from the Flexner Report, so, too, did a lot of unintended consequences. In addition to the ones noted in the linked Yale report, were others that directly and indirectly contributed to the explosion of health care expenses that continue to rise today.

Some intended and unintended consequences of the Flexner Report.

First and foremost, it standardized medical school curriculum across the nation and based medical training on the scientific method. Thanks to Flexner, if you saw a doctor in NYC and one in Des Moines, IA, you could be sure they both had a similar skill set and knowledge base. There was a huge consolidation in medical education which included (unfortunately) the closure of many medical schools that trained African American physicians and women. However, it also ensured that quack schools were shut down.

Then came the Great Depression. Hospitals shut down. People couldn't afford to pay the doctor. There was a recognition that a community without medical care would quickly become a failed community and the first insurance companies that we would recognize as health insurance were formed. (A group of teachers in the Dallas area agreed to pay premiums in advance to the hospital in exchange for the promise of future care. This was the rise of Blue Cross.) [From this brief history of employer based medical insurance. A good read. It quotes one of my undergrad professors, Theodore M. Brown.]

So employer based health care insurance kept the industry afloat until after the depression.

Along with this new way to pay hospitals and doctors, came change in the structure and nature of hospitals in some dramatic ways. As the US population expanded and new cities arose, there was a need for new hospitals. Their construction was financed by the government, with many caveats, traceable to the recommendations in the Flexner Report. It included the dismantling of the old ward system, where patients were taken care of in multi-bed wards that could be supervised by a minimal amount of nursing staff.

When hospitals shifted to semi-private and private rooms, the costs of providing patient care skyrocketed as the number of employees needed to adequately supervise those patients increased.

And there are still more consequences of the Flexner Report: Along with the scientific method, came the rise of medical specialties, which also, unfortunately, brought with it a devaluation of general practice and primary care; problems we are still seeing today.

Along with the personnel costs, the technological and pharmaceutical advances brought about by WWII and continuing to the present day brought huge capital expenses to medical care.  Those costs were passed along to patients who increasingly couldn't afford to pay them. Especially if they were retired or indigent.

Our patchwork health insurance system

Still with me?

So we have employer-based insurance that covers some hospitalization and some physician's visits. And because of tax laws, those plans were advantageous to employers to provide.  But what if you weren't or couldn't be employed?

That's when Medicare and Medicaid came into being as hospitals and doctors could not longer absorb the costs of providing free care and we realized that having some public safety net to assure medical care was a public health need.

But there were still significant holes and while universal insurance has been floated by lawmakers periodically since the early 1900's, for one reason or another - primarily political will - it has never come to be.

And over the years, to the present day, health care costs continued to rise. For a while, employers absorbed the costs, until that became unsustainable. Researchers were looking at health care as a system and came to the conclusion that the fee for service method, where health care personnel and hospitals are paid for each service they provide, encouraged high usage of health care. Greed being what it is, and with the perception of the costs being paid elsewhere, many health care providers and hospitals simply fed off the system, knowing they would get paid for whatever they provided. Individuals didn't see the cost increases because their insurance was paying the bills. Insurance companies increased premiums to ensure their profits.

In the 1970s, different models were promoted, based on capitation: that is, doctors would be paid a small amount of money per patient they had on their lists, and had to manage their costs for that pool of patients. If a patient remained healthy, the doctor kept that money. If too many patients needed medical care, the doctor's pockets would be thin. The theory was that this would give the doctor incentive to provide only the most needed care and 'trim the fat.'

Capitation was one of the basic principles that became the first HMOs (Health Maintenance Organizations.) It was believed that this kind of financial shift would rein in medical costs.

But it didn't.

Primarily because we still had (and still have) a patchwork system of for-profit insurance, not-for-profit insurance, employer provided or sponsored insurance, and government insurance (medicare and medicaid) with no standardization among all the plans in terms of basic coverage and payment to the medical providers.

The plot thickens. . . 

And it gets more complicated, still, because of the pace of technological change, the way early adoption of tech is expensive, the expectations of individuals, the lack of a cohesive public health strategy, and the malpractice mess.

The more we tried to treat health like a business, the more byzantine the system got. Because here's the heart of the matter:

Health is not a commodity. 

It's not a widget that is produced, then bought and sold. Sure, there are pieces of the industry that are like manufacturing: medical equipment, pharmaceuticals, for example. But basic supply and demand and price pressures don't really work well in medicine.

Say you have a burst appendix. Trust me, you won't be shopping for the best price for your appendectomy. You will be writhing on the floor and if you're lucky, a friend or family member will be able to take you to the nearest ER for care. You will not be comparison shopping for surgeons: whoever is on call whenever you show up will be who you are operated on by. You will not be able to negotiate for what pain meds you are given, nor how long you will stay in the hospital.

When you are ill, you need care. When you are ill, there is only demand, not supply. Business models simply don't and won't work, EVEN IF YOU COULD GET PRICING INFORMATION. Which you really can't because it's not really available. 

Standard of care also makes the market forces issue moot. Here's another example. In the old days, if you sustained a knee injury, you would have an arthrogram - an xray with dye to see where the injury was. It was uncomfortable, exposed you to the risk of allergic reaction to the dye, and involved radiation. Then along came MRI technology. No radiation. No dye for the knee examination. But it was SIGNIFICANTLY more expensive.

There was a time when both were being done and which you received depended on your insurance, your doctor, and if the hospital had the MRI machine. Then standard of care shifted in favor of the MRI even though arthrograms were cheaper and were effective in diagnosing knee ligament tears. So the more expensive practice became the standard practice.

This happens in almost every sphere of medicine.

Then there's the whole system of malpractice. The issue isn't with malpractice suits, per se, it's with the equating of bad outcome with malpractice. Medical negligence SHOULD be punished. Bad outcome in the absence of negligence shouldn't be.

But it is. It's cheaper for insurance companies to pay out malpractice claims instead of going to court, even if they know the physician is not culpable. That increases the rates of malpractice insurance which increases the cost of providing care.

So, yeah, it's complicated

There was a push for universal health insurance during the Clinton presidency and we all know what happened to that.

Then a conservative think tank floated another idea. That idea turned into Romneycare in MA which turned into the ACA (AKA Obamacare) nationwide. It was the idea that we could somehow tie together the patchwork of all our myriad insurances by creating regional health care exchanges. Every citizen would be required to buy health insurance if they didn't already have it through employers, and insurance companies would be able to afford to provide care more widely because they'd have the larger risk pool. (Healthy folks' premiums would offset the cost to provide care for less healthy folks.)

Because most people have been shielded from the true cost of medical care and of health insurance, the sticker shock was huge. But the government, committed to keeping the patchwork system in place instead of committing to a single payor system, hoped to sweeten the pot by offering subsidies for individuals to pay for the premiums.

It worked in some states better than others: states willing to increase and expand medicaid were states where the ACA worked best and had the most success. In other states, where the mostly Republican administrations refused to expand Medicaid, the cost of insuring the sickest fell to private insurers who didn't want to offset their traditional profits by actually paying for care. So they cried poverty and pulled out of those exchanges. Leaving it harder and harder for individuals to obtain and pay for insurance in those places.

The vendetta against the ACA

The ACA is far from perfect. But in the absence of the will to move to a single payor system, it's the best we've got now.

(And if you're going to argue against a single payor system by making claims of Medicare fraud and the need to keep government out of your health care, you'd better come armed with facts because regardless of what some legislators would have you believe, Medicare works. It provides reliable care to a huge number of people with an exceptionally small amount of fraud and a lower percentage increase in costs as compared with the rest of our disorganized system.)

It's ironic in the extreme how the ACA had become the target of the conservatives since it was a conservative plan in the first place, INCLUDING the individual mandate.

And here's where I must leave our tale: Where we are now may not be the happily every after of health care, but if the ACA gets gutted without a viable replacement (of which there is none, because this stuff is hard and everyone knew that), far too many of us will end up wandering in the dark and terrifying forest with no way out.


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Wednesday, February 22, 2017

Social Anxiety, Imposter Syndrome, and Conventions

Looking thoughtful at the Doctor Who panel with John Chu and Don Pizarro
photo by David Marshall

Imposter Syndrome.

Yeah. It's something that all of the writers I know have struggled with at different times in their careers. For me, it seems to be the strongest at venues like cons, where I am thrown in with other writers. It's hard not to fall prey to the inevitable comparisons game: I'm an indie; Writer X is published by Tor. My books haven't won awards; Writer Y is a Hugo winner. I've published 6 novels; Writer Z just published their 30th. And has a new 3 book contract. And their panels are SRO. And. And. And.

I typically both look forward to and dread cons. I know I will exhaust myself being 'on' so I can make sure to present my best self during the event. And I will walk around feeling insecure and anxious, certain that I don't belong in the myriad of conversations happening all around me. Still, I force myself to interact, all the while believing the people I'm talking to just want me to shut up and leave.

That's my anxiety brain talking. My rational brain knows that's bunk: I'm not intrusive. I do respect boundaries and personal space. I don't monopolize conversations.

The biggest problem I have at cons is that anxiety brain doesn't typically listen to rational brain.

This past weekend, I was a guest at Boskone.

For the first time since I started attending cons, and certainly since I started to be invited to participate, I didn't feel limited by my anxiety brain.

I was scheduled for 4 panels (moderator for 2 of them), a reading, and a signing. For all of the events, I felt comfortable and prepared, without the sense of manic pressure that usually carries me through a con.

I moved in and out of conversations with a fluidity that was new to me. I met old friends, long time acquaintances, and made new friends.

I've been trying to figure out what changed for me this year. Many folks remarked, both during Boskone and afterwards, that this was the best Boskone they remember. It felt more inclusive, more welcoming, more relaxed. I'm sure some of that external energy helped me, but my ease was bigger than that.

After a number of years attending, I think I've finally reached critical mass where I recognize enough people and enough people recognize me that I don't feel like the eternal wallflower. And it's more than that, even.

I've finally reached a place where I'm comfortable with both who I am and where I am in my writing career. The dreaded Imposter Syndrome is intimately tied up with the unhealthy comparison issue. Those things have less power over you as soon as you understand and accept that there will always be writers with more success than you, more prestigious publishers, more awards, more reviews, more income, more fame. And NONE of that has anything to do with you. (By which I mean *me*.)

NONE of that has much bearing on you (me) as a person, your (my) writing, and your (my) publishing career.

Where I am in my writing and publishing has nothing to do with where someone else is.  

This is not a Reality TV show. No one gets voted off the island or disqualified in the lightning round. 

I think this was really hammered home for me in a conversation I took part in at 'bar con' (a random assortment of folks who happened to be at the same table after the formal part of the con was over. Some of us had drinks). There was a gentleman at the table with a "my first Boskone" ribbon on his badge and we asked him what had brought him to the con.

He was very reticent to tell us, but after some good-natured teasing, he admitted that a friend convinced him to come after reading some of his writing.

"Aha!" I said. "You're a writer."

He spent a good part of the evening denying it, even as we discovered (all hail the power of a smart phone!)  he'd written multiple novels and teaching guides to those novels, published, and had his work used in teen gang violence prevention programs.

Even through his full-on Imposter Syndrome, any of us at the table could see the truth: he had lit up when he talked about his writing. It was clear where his passion lay. And we all called him on it. (In a supportive way.) I hope he came away with a new appreciation for his creativity and an acceptance of himself as a writer.

Even as I was calling on him to accept himself without apology or caveat, I was simultaneously reminding myself of the same lessons.



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Thursday, February 16, 2017

Where to find me: Boskone edition

I'll be reading from Dreadnought and Shuttle, and maybe a bit from the forthcoming Parallax!

This weekend, I'll be participating in Boskone, the Boston area's longest running SF convention. It's a place for readers and authors to connect and have great conversations about all things geeky. There are some great panels every year and I'm on some fun ones, including:

Katniss, Furiosa, Elsa, and Rey: The New Woman in SF/F Film

They each made big impressions in big recent genre movies. What do these characters say about the current state of heroic female figures in our cinematic imaginings? What traditions do they uphold or subvert? What promise do they hold for our futures?

So You Wanna Be a Time Lord

The time for a new Time Lord is fast approaching. Peter Capaldi is on his third season, which means his stint as The Doctor is likely nearing an end. We've seen speculation about casting the next Doctor, but maybe Capaldi isn't ready to go, especially since his character is starting to gel. What are our hopes for the future? Do we want to keep Capaldi? Whom would we like next? Maybe we can even ask our panelists why they might make a good Time Lord....

From Maladies to Medicine

Panelists share tips and tricks on how to realistically injure and heal your characters. Learn what questions to ask when it comes to the effects of specific injuries. Hear how certain modern and ancient medical practices and medicines can help with healing. Find out how authors make their characters’ pain and recovery feel real and relatable.

When Is It a Gimmick?

Story gimmicks often seem like good ideas at the time — but instead of applause, they get eye-rolls. What is a gimmick, exactly? Are they all created equal? We'll discuss common gimmicks, identifying traits, and ways to transform them into truly fresh ideas.

I also have a solo reading and a signing scheduled. My books will be for sale in the dealers room at the Broad Universe table.

So if you're going to be in town this weekend, please come find me!



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