PHILADELPHIA REFLECTIONS
The musings of a Philadelphia Physician who has served the community for six decades

241 Topics

Medical Economics
Some Philadelphia physicians are contributors to current national debates on the financing of medical care.

HIDDEN ECONOMICS OF HEALTHCARE
Here are a few of the reasons Healthcare Reform still isn't going anywhere.

Terse Verse: Thomas C. Howes (1)
Poetry is a form of literature that uses imaginative and creative words in a compressed form to express idea

George Washington in Philadelphia
Philadelphia remains slightly miffed that Washington was so enthusiastic about moving the nation's capital next to his home on the Potomac. The fact remains that the era of Washington's eminence was Philadelphia's era; for thirty years Washington and Philadelphia dominated affairs.

Philadelphia Before the English Settlement
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Sometimes, Even the Supreme Court Looks Negligent

If the United States Supreme Court itself makes a mistake, it remains pretty much a mistake in residence, until the Court itself re-examines the matter. It would be indelicate for anyone else to cite a list of examples for this observation, so they are usually taken up, one at a time. The example with the greatest application to Healthcare is the 1982 decision in State of Arizona v. Maricopa County Medical Society.

Maricopa County is where Phoenix is located in Arizona, and its County Medical Society was one of the pioneers in what were then called Foundations for Medical Care. These were organizations in which local physicians took the lead in organizing and managing health insurance for the local community, by organizing and owning a local health insurance company. The rules and policies of the Foundations were conceived and implemented by physicians, who felt abused by the defects of health financing they saw in daily practice. It is also true, these physicians were impatient with both the government and the health insurance companies, who seemed to resist helping the sick poor by implying that agreements to lower prices for the poor must violate some overly broad per se technicality intended for business corporations. Surely it can be agreed that lowering prices for the poor might occasionally be anti-competitive, without asserting it is so invariably anti-competitive that sweeping judicial decisions can be justified without presenting evidence. An agreement among competitors not to raise prices for the poor, is after all not exactly the same anti-competitive behavior which Adam Smith described as a "contrivance to raise prices". Furthermore, on the topic of regulating business corporations, it is not an enumerated Constitutional power for the federal government to amend the Constitution's "Equal Justice" clause, to regard two opposites as essentially identical.

At the same time, "Foundation" physicians believed they could see opportunities for reducing waste in the local hospitals which might only be exploited if physicians were in charge, because physicians could judge the cost/benefit more readily. Having recently returned from Korean War, these doctors knew medical care could be excellent without any health insurance, and indeed even while hospitals were only a collection of tents. Perhaps a few of them were overly influenced by the TV serial, "MASH", whose central theme is that if doctors take the lead and do the right thing, much can be forgiven. That's a sort of Hollywood referral to the latitude of ancient Courts of Equity, intended to cover a situation where obvious harm exists, but no law exactly addresses it.

The Maricopa Medical Society

Accordingly, the "better sort" of doctor in Arizona perceived the respectable ones would readily consent to care for the poor at lower rates, whereas the shirkers in their midst might ruin things for everybody by refusing to perform a fair share of pro bono work. When the only penalty was exclusion from membership in the county medical society, this approach was not excessively coercive, and essentially put a label on the participants. Like labor unions, the doctors do resent the free rider phenomenon. The idea of a two-class system of medical care was equally abhorrent to them, however. If there wasn't enough money to spread around, a "good" doctor would just agree to lower his fees unilaterally. This moral quarrel often conflicts American business, which characteristically takes the view that it doesn't really matter what costs or taxes or burdens are imposed by government. What matters is that competitors should generally agree to operate under the same handicaps. When handicaps are roughly equal, the difference between success and failure is -- talent. To a considerable degree, talent rising to the top summarizes the aspirations of the anti-trust statutes, where it becomes both a simultaneous source of cost escalation and price suppression. Physicians are ultimately expected, not least by their colleagues, to find their highest duty is fiducial to the patients' best interest, particularly when the main conflict is only a financial one. In the anti-trust arena, particularly the per se violations, the difference between a business corporation and a medical society is sufficiently wide to justify some professional latitude. As it is not wide, in the case of insurers, and as it only partly remains, in the case of hospitals. The Maricopa Medical Society perhaps responded with excessive intensity to the challenges of making local sense out of the price-fixing dilemma, but it was never given an opportunity to make its case.

At one time, local healthcare costs were held down by imposing competition on the hospitals, treating insurance administrators as clerks to pay bills, rather than as big business's cup-bearer of fairness in a naughty world. Needless to say, the hospitals and health insurers had long chafed at the ability of physicians to shift hospitals, and the patients to shift insurers, whereas Arizona's Attorney General seemed to suspect a return to Robin Hood notions of a special right to defy the law. Somehow disappeared was the much better-defined concept of peer review. In certain parts of the country, big business was already reconsidering its financial control of hospitals and insurers, acting as agents in both assuring good medical care, and restraining its cost. With the defeat of physicians by the Maricopa decision, plus the approaching withdrawal of big business, the way was soon opened for hospitals and insurance companies to assert monopoly control of their own finances -- peer review, indeed. Thirty years later, hospitals and insurers are now universally merging, applying monopoly controls to admit favored employee physicians as their personal judge and jury. The Affordable Care Act is a mechanism by which government could assert control over the victors, thus converting government itself into the only battlefield. It's a far distant cry from leaving medical decisions in the hands of physicians and their patients, to choose the treatments, and to agree on the price. The approach looms for something called "justice" to replace what was once regarded as "fiduciary."

Sen. John Sherman

The Attorney General of Arizona, himself a colorful character, soon brought suit for anti-trust violation, since price-fixing had been declared a per se violation, or confession of the absence of competition. These were additions made to the Sherman Anti Trust Act by earlier Supreme Courts, who found an Act allegedly written on the back of an envelope was difficult to administer. Further strictures were imposed by the Clayton Anti-Trust Act, but these might be remedied by subsequent Congresses. The important consequence was that the District Court of Arizona found it quite unnecessary to hold a trial or hear the evidence. The Court found against the doctors entirely on the basis of a motion for summary judgment. The matter passed through the Court of Appeals to the Supreme Court, which on the theory that price fixing is price fixing, by a vote of 4 to 3, upheld the Arizona suit. All the way from a writ of summary judgment in a district court, to the United States Supreme Court, without formal examination of the facts.

Perhaps, strictly on lawyerisms, that was safely correct. But in terms of the effect on medical care, it won the war for control of hospitals and the insurance companies. Instead of settling down, prices continued to escalate. Somehow it was interpreted to mean that a hospital or an insurance company might do a great number of things which were forbidden to organizations run by physicians, and the proliferation of red tape is enormous. The consequence is that Foundations run by physicians were under constant threat of what might happen to them if they did what HMOs could be seen to be doing every day. The whole Clinton health plan evolved from this particular case and its implications. From the physician point of view, if you had medical training, you were disqualified from running an HMO, because a change of leadership shifted the antitrust issue to a different level for two identical organizations. And that was true even if the physician had been trained for the role, while the administrator had not.

What was particularly galling was to be tarred with the same brush of antitrust whereas others would describe their identical behavior as self-disciplined in the public interest. Self-imposed financial restraint was taunted and abused by aspirants for the same job with the same temptations, with multi-million dollar incomes but without adherence to the same code of ethics. The joke is that after all the Clinton Healthcare Plan's uproar, the public decided they disliked HMO's intensely, mainly because they couldn't choose their own doctor. And the doctor was being hampered in doing what seemed professionally best for the patient. None of these legal issues had arisen for physician-run HMOs. While of course that might happen, such disputes would be settled by physicians, using medical arguments, followed by a change in management if the medical community widely disagreed with the decision. The only substantial difference was that doctors were running one, but subservient in the other, and the Courts had found that when doctors were in charge it amounted to price-fixing between competitors. As matters eventually turned out, the hospitals solved this issue by converting nearly all physicians into their employees, and the war has shifted to who will control hospitals.

It now remains for some case to be found and carried to the Supreme Court which would allow an examination of the facts of this matter, perhaps remanding the case back to the District Court to hold a trial. That would seem a bare minimum after thirty years, and now it might no longer get precisely to the central issue, somehow getting lost in narrow legal issues. Somehow, a new way must be found to examine which of two rather extreme theories of the early 19th Century needs to be muzzled. Either we must establish that experts are so likely to be right, they should usually be in charge. Or else whether decisions should be left to the "noble savage", usually quite young and untainted by self-interest, whose mind is unsullied by complexity, having no choice but resort to "fairness" as a standard. Both of these are early Victorian ideas -- of the Enlightenment, and of the Romantic era. They have both had a long run, and both have demonstrated flaws. But at least in the case of a scientific pursuit like healthcare, it would seem the default ought to be to the expert, and the appeal ought to be to the noble savage. Just how to arrange that, we must leave to the lawyers.

While on the subject of mixing business practices with professional standards, we might as well direct judicial attention to the unfair and probably unconstitutional (equal justice) tax preference for employers who purchase health insurance for their employees, and make a profit for doing so. An unnecessary grievance is thus created for millions of self-employed and unemployed people. Now seventy years old, this grievance has dubious evasions as its historical origin, has resisted multiple efforts for repeal, and benefits only one large group: big business. Henry Kaiser claimed he had difficulty attracting employees to his war industries because of wartime wage and price controls. Persuading the War Production Board to look the other way, he cloaked inducements to employees as something other than employee compensation. The fringe-benefits circumvention has since grown entirely out of control, but is fiercely defended by business and union interests. As it grows, however, the inequity for the self-employed and unemployed to remain excluded from it also grows. Instead of addressing this problem directly, it might well be conjectured that regulatory attempts at forcing individual policies into group policy eligibility might be a way of exacting a price for cooperation, and for lobbying silence after eighty years of undue benefit.

Summary of the Maricopa Case

From a legal standpoint, the uncomfortable feature of the case of the Maricopa Medical Society is that it went all the way to the Supreme Court without any trial of the facts or real opportunity for the defendants to present their case. That is, the whole HMO movement was effectively removed from the hands of physicians by a motion for summary judgment, on a Supreme Court decision, 4 to 3.

To hold a trial of the facts by remanding the case for trial, would seem to be one way to introduce the defense the doctors would have made. It is improper to suggest to their lawyers what the defense should be, but certain facts are now public knowledge. The Medicaid Act was passed in 1965, requiring state consent for a joint program. By 1972, Arizona was the only remaining state not to have agreed to Medicaid, which by then was widely recognized as the worst run and most underfunded medical program in America. In 1982, Arizona adopted a small portion of Medicaid, and it was only in 1988 that it fully adopted the program. In 2001, Arizona's governor was offered 7.9 billion dollars over four years, as matching money for the insurance exchange feature of the Affordable Care Act. The governor recommended to the Legislature that they accept the offer, because at least it was "better than Medicaid". There can be little doubt the Legislature of Arizona was adamant on the issue.

What were the doctors expected to do with the sick poor people? No doubt, there was a wide divergence of opinion, but it was made to seem likely only a handful of saintly volunteers would come forward, and none of them would be able to afford to pay hospitals what it cost. They felt that only by bullying a substantial majority to take the cases would it work, and the only weapon they had was to make it a condition for membership in the medical society.

Under these contentious circumstances, surely the Supreme Court could find some words to create a better outcome. Price fixing is a per se violation of the act, and there is little doubt, all HMOs fix prices. Only a physician-run HMO could be accused of fixing prices for competitive reasons, although it is arguable how strongly they would compete to obtain indigent patients. The Supreme Court may be reluctant to overrule the price fixing part, and the Arizona politics of this case are surely thorny. But at least the Court could find some clarifying language about physician-run HMOs as obiter dicta . The opportunistic response of the non-physician-run HMOs was to exploit the opportunity to eliminate the competition of physician-run groups. In the meantime, the public has found HMOs run by non-physicians have become contentious in the extreme, whereas the earlier physician-run ones were tolerated by most physicians, and embraced by quite a few. The matter is one of the important threads in the Obamacare controversy, so the Supreme Court has an opportunity to improve quite a few situations by writing a clarifying paragraph or two. As John Marshall discovered, when the Chief Justice, speaking for the majority, makes a side-bar comment without the force of law, it is a brave lawyer indeed who will bring a suit challenging it.


Terse Verse -- Introduction

INTRODUCTION

Poetry is a form of literature using imaginative and creative words in a compressed form to express ideas.

There are two basic forms of poetry. One form is blank verse while the other follows a fixed or standard format. Two examples of the latter are Haiku and Limericks. Haiku are three lined unrhymed poems while limericks are five lined rhymed poems of a humorous nature. Terse Verse poems follow a standard 16 lines of one syllable, also in a humorous style.

Themes of Terse Verse are observations of everyday life and comments on American lifestyles and behavior. Terse Verse uses puns and word play to give readers a different viewpoint of familiar situations. It is difficult to group these poems into specific categories since there are a wide variety of topics. Each poem must be read and enjoyed on its own merits.

In brief, Terse Verse is a form of poetry which reduces ideas to the fewest words to deliver different points of view and bring a smile to the reader.

--Tom Howes

Introduction to Terse Verse

Let's be Brief

We live in an ocean of words and information that demands our attention and often threatens to drown us. To combat this we must sort out the news and knowledge to determine what is important and what should be discarded.

One way of fighting this on slaughter is to be more selective of what we hear and what we read. It is difficult if not impossible to read every word or every article in a newspaper. Instead we usually scan the headlines and then choose. In business, executives pick the summaries and skip over the details. In reading a book, the plot is better remembered, as the characters and descriptions fade into the background.

In literature poetry presents ideas in a more compact form, fitting the thoughts in an appropriate format. Sometimes those thoughts can appear complex like a code that must be cracked. Other times the poem is much more simple and is more quickly understood. Rhymed or unrhymed, whether Haiku, sonnet,or blank verse, poems must be able to establish a connection between the writer and the reader to communicate ideas.

In Terse Verse the format boils down to presenting ideas and observation on human behavior and American culture using idioms, puns, and wordplay that can be easily read and enjoyed. The key to effectiveness is simplicity and the key to simplicity is brevity. And that is what Terse Verse is about in a nutshell>./p>

Index

Buisness Brief

Car Senses

Culture Shocks

Family Manners

Food for Thoughts

Good Sports

L-O-V-E

Modern Times

Money Matters

Mortal Fears

Personal Problems

Pet Projects

Politics as Usual

Shopping Talk

Social Scenes

Stage Frights

Vanity Fares

Wordly Ways

Write or Wrong

Last Laughs


Terse Verse: Down Beat

"Dow"n Beat

Prize seat
Wall Street
Watch wheels
Spin deals
Bears bulls
Push pulls
News rocks
Bonds stocks

Tune starts
Check charts
Buy sell
Till bell
Note gong
Ends song
Floor roars
Counts scores


The Doc Fix

Unless a Congressman's name is attached by the media, it generally isn't easy to know who was the originator of a disagreeable law. In the case of Medicare, moreover, the program is technically an amendment to the Social Security Act, so amendments must originate in the House of Representatives, Committee on Ways and Means, Subcommittee on Health. The problem is easily fixed by the Senate making an amendment to some unrelated House bill such as housing relief in Kansas. At any rate, a law was passed by both Houses to the effect that doctors' reimbursement would be held down if general Medicare costs had risen more than a certain amount. The theory was of course that doctors are in control of medical costs, and should be punished if they rose. The real purpose was to keep the doctors docile and quiet, since at the last moment, each and every year, an exception to the punishment was made, just for one more year. This went on for eighteen years, until Republicans finally achieved a majority in both Houses of Congress, and the law was promptly repealed. It was now possible to be pretty sure who had been behind the law. To reinforce this identification, the Senate Majority leader, Mitch McConnell (R, Ky.) executed a flashy last-minute parliamentary maneuver to rescue the repeal from its unidentified enemies. The "doc fix" was finally fixed.

In the course of this wrangle, it was revealed that physicians received 12% of Medicare expenditures. It reminded me that I had published a graph in The Hospital That Ate Chicago , showing that physicians received 20% in 1980. That would suggest their reimbursement had fallen by 8%, and perhaps that is true. However, reimbursements to other providers have risen, so the net change in physician reimbursement might be different from 8%. However, a different factor probably played an important part in this shift. During that period, a majority of physicians changed from solo private practice to working on a salary provided by a hospital group practice. The reimbursement effect of this was to shift physician overhead out of the costs, but not out of the reimbursement, which now goes to the hospital. Since almost every physician in practice spends 50% of his gross revenue on office overhead, there is plenty of room for shifts which do not appear in the totals. Yes, physicians protected their net income by this maneuver, but the hospitals acquired an expense they did not necessarily intend to maintain. Squeeze the hospitals with DRG or other means, and they had a piggy bank they could always pilfer.


Hospital Cost-Shifting Reacts to the DRG

Medicare's payment-by-diagnosis system requires a diagnosis code for its computers to specify the payment. Codes are the way doctors can conduct their activities on a medical level, while identifying to the billing department what the activity is worth. The billing department knows well enough that these values will be later smudged and bloated, so why make work for yourself being accurate? Careful, fellows, your foot is on a slippery path.

High-handed Codes. The government could have chosen a coding system called SnoMed (Standard Nomenclature of Medicine), which specifies several million diagnoses in detail. Or it could have specified ICDA (International Classification of Diseases), which in its various iterations can identify several thousand. What it did choose was DRG, or Diagnosis-related Groups, specifying about two hundred. With various adjustments and offsets, this translates: there are only two hundred different payment amounts to choose between, two hundred price buttons to push -- for millions of diagnoses. The theory is that some cases will cost more, some will cost less, but in the long run it all comes out just exactly right. Saves work for the billing clerks, that way. Careful, fellows, you have stepped over the line of what is allowable latitude. Buried in your computer cubicles, hidden behind green eyeshades, you have convinced yourselves the world will tolerate anything you do for your own convenience. Try talking to one of them some time -- you will surely find the door is locked, or the boss is out to lunch, or it isn't company policy to allow accountants to talk to outsiders. If you have credentials, you may talk to a spokesman who seems to keep repeating himself. It does not seem to have occurred to anyone that the public wants to know if the charges are fair, and has a right to know if they are accurate. How can they be either fair or accurate, if millions of activities are reduced to two hundred price choices?

I remember well, sitting in the Congressional hearing room when this proposal was first made. I giggled that Congress would let someone even utter such nonsense, let alone pass a law to go ahead with using it. But now I have to listen to reports this system has been in place for twenty years, and it works just wonderfully fine. A friend of mine was a graduate student at Yale, helping to develop the DRG system in its original form. He, too, is appalled that such an unexpected usage could even be considered, for what had an entirely different purpose. The DRG was part of a coding system devised to assist the Professional Standards Review Organizations monitor insurance claims for errors and fraud. The behavior of each diagnosis group was studied for its general outline, and general patterns were identified. If a case fell outside the norms, it was tagged for investigation. Just how well DRG's worked out for that particular purpose, I have no idea. But to extend it for actual payment of particular claims, simply boggled the mind, and still does.

Children Playing With Matches. When you let people do things like that, some pretty unexpected things happen. In the first place, you need at least one extra system for paying for patients who don't have Medicare. However, Medicare accounts for about half of average hospital revenue, so there is pressure on everybody to conform to the system of the big cajuna. An elaborate system called Chargemaster was devised for itemized services to be listed on an itemized bill, which now runs to dozens of pages for each patient. Since nobody much was going to use anything but DRG, the reasoning went that constant revision of thousands of itemized charges would be a big and useless task. Since you had to do it, you set the charges so high you wouldn't have to come back and revise them. Countless reporters have asked dozens of hospital administrators to explain the itemized bills which emerge, and almost every administrator admits he doesn't understand Chargemaster, and never looks at it. The billing clerks of the hospital look at it, however, and the patients look, and reporters look. Itemized bills totalling tens of thousands of dollars are sent, first to the patients, and then to the bill collectors. Stephen Brill's America's Bitter Pill is filled with "Tom and Mary of Tuscon" anecdotes, so let me add a couple of personal ones. For example, I received a bill for Eight thousand dollars from my own hospital accident room for twenty minutes treatment for a sprained wrist; the hospital clerk had joined in such a welcoming reunion for old times' sake, he forgot to collect my insurance numbers. After several strikingly threatening letters, communication eventually stopped. In another case, I discovered that another of my hospitals sends its bills when tests are ordered, not when they are performed. Consequently, a patient I discharged from the accident room without having the tests the interne had ordered, received an astonishing bill for the services, anyway. Since he was vice-president of the insurance company which covered him, there were some gratifying repercussions. On a later occasion, my oldest son received a bill for $13,000 for a colonoscopy from a famous Boston Hospital, and asked me what I thought was fair. I said it was worth a couple hundred dollars, so he called his insurance company, following which the revised bill was one thousand dollars. He fell all over himself writing a check, for what I still say was a gross overcharge. Notice one theme running through all of these true stories. They all involved outpatient services.

You see, the hospitals were all shifting to a chargemaster system for outpatients, because the inpatient charges (often for the same services) were frozen by the DRG. In fact, it is widely quoted that inpatient profit margins were 2%, accident room profit margins were 15%, and the outpatient area made a profit of 30%. If anything approaching that is true, well, what would you do in their place? The next time you go past your local hospital, try to notice if a construction crane is working on a new building. The chances are excellent you will find it's a new outpatient building.

After all, with the Federal Reserve promoting the zero interest bound, mortgages are pretty cheap. Right now is an excellent time to build a building, if you ever think you might need one. So, some of these buildings might be designed to house group practices. If a hospital plans to go into the outpatient business, it needs a lot of doctors. A shrinking minority of physicians are still in private practice, so it's getting hard to find a doctor. Hospital-salaried physicians are easy to hire, but hard to get on the telephone, and even harder to find on nights and weekends. If you put physicians on salaries, you will get an almost instant forty-hour week. As the husband, father, and nephew of female physicians, it is a little unbecoming of me to observe that a majority of medical students are women these days, and of course it delights the feminists. But it's also true that women physicians have a biologic need for regular hours, retire earlier, and seek out specialties which accommodate them. Women like to be in groups, because there are fewer times to be on call for holidays and weekends which you can share more widely. You will need more women physicians to do the same job that men do, so the public can eventually expect higher costs for the same service. By the way, with three women physicians in my immediate family, I never once heard a complaint from them about male discrimination.

Hospitals are busy buying up physician practices because of the indirect effect of the DRG. Furthermore, the prices are high and the government is paying the bill through the hospital reimbursement system. My old friends smile and wink they will go back into practice if the hospital reimbursement declines. That long-term cost has to be factored in, although I doubt it will happen as they age. But if it does, the cost of reconciling a physician surplus might have to be included in the eventual reckoning of what the DRG did or did not save.

When you get down to it, the DRG is an excellent rationing tool, and rationing invariably creates shortages. Robert Morris learned that lesson the hard way during the Revolutionary War. He didn't say much during the Constitutional Convention in 1789, but he was utterly determined that we not construct a command economy -- which is rationing on a much grander scale. He kept his attention on his own business, but his protege Alexander Hamilton did the talking, and his best friend George Washington did the listening. How is the DRG a rationing tool? The government makes the rules, sets the prices, and monitors the outcome. However you choose to achieve a 2% profit margin, its effect can be judged from operating within a 2% inflation rate, achieved by a 2% inflation target of the Federal Reserve.


I'm overwhelmed. I'm thinking of a one-line poem by William Blake: "Enough or too much" " stragglers who live from 85 to 91." Sorry to be a burden, but soon to be 91 I can still go a couple of rounds without huffing and puffing. You remind me of Dr. Melvin Konner.... professor.... anthropologist..... physician.
Posted by: Martin   |   Sep 27, 2014 5:16 AM
I want to thank you for this wonderful resource. I find it fascinating. May I offer one correction? In the section "Rittenhouse Square Area" there is reference to the Van Rensselaer home at 18th and Walnut Streets and its having a brief fling as a club. I believe in 1942 to about 1974/5 the Penn Athletic Club was located in the mansion. The Penn AC was a good club, a good neighbor and a very good steward of the building - especially the interior. It's my understanding that very unfortunately later occupants gutted much of the very well-preserved original, or close to original, interiors. I suppose by today's standards the Van Rensselaer-Penn Athletic Club relationship could be described as a fairly long marriage. The City of Philadelphia played a large role in my life and that of my family, and your splendid website brings back many happy memories. For me and many others, however, there is also deep sadness concerning the decline of so much of the once great city and the loss of most of its once innumerable commercial institutions. Please keep-up your fine work. Your's is a first-class work.
Posted by: John D. Mealmaker   |   Aug 14, 2014 2:24 AM
Dr. Fisher, The name Philadelphia University was adopted in 1999, as you write, but the institution dates to 1884 and has been on School House Lane since the 1940s. It acquired the former properties of the Lankenau School and Ravenhill Academy, but it did not "merge" with either of them. I hope this helps when you update your site.
Posted by: David Breiner   |   Jun 11, 2014 10:05 PM
Hello Dr. Fisher, I was looking for an e-mail address and this is what I could find. I must tell you my Mother who you treated for years passed away last May. She was so ill with so many problems. I am sure you remember Peggy Marchesani. We often spoke of you and how much we missed you as our Dr. You also treated my daughter Michele who will be 40. I am living in the Doylestown area and have been seeing the Dr's there.. I just had my thyroid removed do to cancer. I have my fingers crossed they get the medicine right. I am not happy with my Endochronologist she refuses to give me Amour. I spoke with my Family Dr who said he will take care of it. I also discovered I have Hemachromatosisand two genetic components. I have a good Hematologist who is monitoring me closely. I must say you would find all of this challenging. Take care and I just wanted to convey this to you . You were way ahead of your time. Thank you, Joyce Gross
Posted by: Joyce Gross   |   Apr 4, 2014 2:06 AM
I come upon these articles from time to time and I always love them. Is the author still alive and available to talk with high school students? Larry Lawrence F. Filippone History Dept. The Lawrenceville School
Posted by: Lawrence Filippone   |   Mar 18, 2014 6:33 PM
Thank you for your articles, with a utilitarian interest, honestly, in your writing on the Wagner Free Institute of Science [partly at "...blog/1588.htm" - with being happy to post that url but the software here not allowing for the full address:)!] I am researching the Institute, partly for an upcoming (and non-paid) presentation and wanted to ask if I might use your article's reproduction for the Thomas Sully portrait of William Wagner, with full credit. Thanks very much for any assistance you can offer here. Josh Silver Philadelphia
Posted by: Josh Silver   |   Jun 2, 2013 1:39 PM
Thank you for your articles, with a utilitarian interest, honestly, in your writing on the Wagner Free Institute of Science [partly at "...blog/1588.htm" - with being happy to post that url but the software here not allowing for the full address:)!] I am researching the Institute, partly for an upcoming (and non-paid) presentation and wanted to ask if I might use your article's reproduction for the Thomas Sully portrait of William Wagner, with full credit. Thanks very much for any assistance you can offer here. Josh Silver Philadelphia
Posted by: Josh Silver   |   Jun 2, 2013 1:39 PM
George, Mary Laney passed away last November. I was one of her pall bearers. She had a bad last year. However, I am glad that you remembered her and her great work. I will post your report at St Christopher's and pass this along to her husband Earl. Best wishes Peter Hunt
Posted by: Peter Hunt   |   Mar 28, 2013 7:12 PM
Hello, my name is Martin. I came across [http://www.philadelphia-reflections.com/blog/1705.htm] and noticed a ton of great resources. I recently had the honor of becoming a part of a new non promotional project on AlcoholicCirrhosis.com. We decided to put together a brief guide about cirrhosis, and the dangers of drinking. We have received a lot of positive feedback and I wanted to suggest that we get listed on the above mentioned page under The National Institutes of Health. Let me know what you think and if you have any further requirements or suggestions.
Posted by: Martin   |   Jan 1, 2013 8:51 AM
I FIND THIS VERY INTERESTING, INDEED. I AM HOWEVER, SEARCHING FOR THE ANCESTOR WE HAVE BEEN TOLD WAS JOSEPH M. WILSON OF JORDAN TOWNSHIP IN WHITESIDE CO. IL USA. MY HUSBAND WAS ORPHANED AND WITH LITTLE CONTACT WITH HIS FATHERS SIDE OF THE FAMILY THE 9TH OF 10 SURVIVING CHILDREN SINCE ALL ARE DECEASED BUT, ONE). I HAVE HOPED TO FIND HIS CONNECTION AS TO THE STORIES RELATED BY SEVERAL OF HIS DECEASED RELATIVES THAT WE ARE CONNECTED TO THE WILSON MILL FAMILY HISTORY. OF JOSEPH AND FRANCES. MY HUSBAND WAS ALSO, FAMILY TO: GRANDFATHER RANSOM (ISABELLA)WILSON & HIS BROTHER WILLIAM; OF ELKHORN GROVE CARROLL CO. IL USA AND HIS SON JOSEPH WILSON(NANCY). I?WE( MY SONS AND NEPHEWS NEICES AND GRANDDAUGHTERS IN COLLEGE... WERE HOPING THAT NOW THAT I AM ON THE COMPUTER AND WITH YOUR HELP THRU THE GENELOGICAL SOCIETY TO YOUR ADDRESS WE MAY FIND THE FAMILY WE SEEK. MY LATE HUSBAND AND I DROVE PAST THE SITE OF THE FIELD WHERE JOSEPH AND FAANCES ARE BURIED , THE CEDARS ARE GONE AND IT IS NOW FIELD. I HAVE BEEN HOPING TO FIND THE LINK FOR OVER 30 FAMILY TO PAY TRIBUTE TO THOSE WHO HAVE GONE BEFORE AND PERSEVERED TO BRING US THE LIFE WHICH WE ENJOY AND SERVE, TODAY. I RECEIVED ONLY THIS WEEK BY A FLUKE AN EMAIL WITH PHOTOS FROM A 3RD COUSIN THAT FOUND MY EMAIL ON A COUSINS EMAIL ADDRESS AFTER INQUIRING AND INTRODUCING HIMSLEF: AND HE TOOK THE TIME TO SEND MANY PHOTOS AND HISTORY OF GRANDPARENTS AND FAMILY AS WE HAVE HAD NONE. WE STILL DON'T HAVE A PHOTO OF HIS MOTHER AND FATHER. WHAT I HAVE OF THE TREE, I AM ANXIOUS TO SHARE WITH FAMILY THAT IS SEEKING HISTORY, AS I STILL AM HOPEFUL TO FIND IT IN TIME FOR THE DEADLINE AUG. 30 TYPED AND DELIVERED TO MY MARTIN HOUSE MUSEUM WHERE I AM A MEMBER. MY HUSBAND WAS A MASTER MASON WHILE IN LODGE WITH THE COUPLE THAT DONATED THE HOUSE TO BE A MUSEUM. THANK YOU FOR YOUR TIME AND THE GRAT WORK YOU HAVE ALL DONE ON THIS HISTORY. WE WERE LIFE MEMBERS OF THE LUTHERAN CHURCH BUT , THERE IS NOT ONE IN OUR TOWN, SO I FOUND THE REFORMED CHURCH,OF WHICH, I AM VERY HAPPY TO BE A PART. THANK YOU .
Posted by: SUSAN WILSON   |   Aug 12, 2012 12:49 AM

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