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

211 Topics

Evolving Philadelphia
The city changes.

Suburban Philadelphia

Right Angle Club 2015
New topic 2015-01-22 22:20:28 description

Particular Sights to See:Center City
Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.

Decline and Fall of Philadelphia
In 1900, Philadelphia was described as the largest commercial (ie non-capital) city in the world. By 1929 it was flat on its back, and never recovered its former position. Why did this happen?

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Philadelphia Reflections is a history of the area around Philadelphia, PA ... William Penn's Quaker Colonies
plus medicine, economics and politics ... 1865 articles in all

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Exercise As Fun

{lifting weights}
Exercise Against Resistance

Almost every retirement community, cruise ship and large hotel has a "fitness center", so there really is no excuse for retired people to be as weak and flabby as they generally are. Arthritis is pretty common, but it is ordinarily so mild that taking a large aspirin or a small Ibuprofen tablet will cause you to forget about arthritis pain long enough to get some exercise. Stretching exercises will often get rid of what pain remains, and you should feel better as a consequence, not worse. All sorts of good things happen when older people start getting regular exercise; but if you are really crippled, the following is not written for you.

A friend who regularly "goes back" to Princeton reunions reports that about half of his class was still alive for the 60th reunion this year. Unfortunately, only eight members of the class were able to walk in the parade. The rest rode in golf carts. Speaking with the understandable bias of a Yale alumnus, I have to say this sort of thing is not necessary at all.

Almost everyone graduates from high school in pretty good condition, and the majority of college graduates are pretty fit at the time of graduation, too. Speaking from the vantage point of the 60th reunion, the fellows who were the athletic campus heros are generally the ones who have serious hip, knee and shoulder disabilities which become fairly troublesome by the time of their retirement from the work force. Either that, or they soon regale you with stories of their artificial joint replacements. Nevertheless, it is curious that these are the class members who keep up their exercise in some way, usually golf or tennis, sometimes sailing; it almost seems as though it should be mandatory to learn golf or tennis in college, so that by the time retirement comes along, exercise has become a lifetime habit. That even seems to be true of the ones in golf carts because of football injuries in the past, but scientific studies don't seem to have established whether vigorous football, baseball or polo as a youth make you pay too great a price in later life; it would be interesting to know the overall trade-off.

The majority of Americans have a different life pattern, and must be urged to change it. After they get married and have a steady job, they abandon exercise pretty completely. A few games on weekends, perhaps, and vigorous summer vacations for a few years in their 30s and 40s. After that, there is essentially no exercise at all, a steady gain of weight ("My, don't you look good,") and if they are lucky, no major illnesses until they retire. The fact is, most people don't much enjoy exercise, and arrive at retirement age with the bravado boast they haven't had much exercise for thirty years. Even the medical profession has abandoned them; doctors tell them that exercise is good for you, a most unwelcome scientific opinion.

Combatting Sarcopenia

Let's simplify some of the confusion which abounds among trainers and physiotherapists, about the various competing types of exercise. There are three types, and you need all three of them. First, you need to overcome the decades of disuse atrophy which come from endlessly sitting at a desk. The muscles get thin and withered, a condition which luxuriates in the descriptive term "sarcopoenia". Start out with about six weeks of the kind of exercise a lot of people say you shouldn't have, the weight-lifting variety, chin-ups and push-ups, possibly Charlie Atlas-type of pushing one hand up while pushing the other one down, or pushing one foot against another. That's sometimes called "Dynamic Tension". The purpose of all this is to build muscle size, or bulk. The professional athletes who look so grotesque with their shirts off tend in addition to resort to self-medication with a mixture of testosterone and growth hormone, but that's not advised for them or for you. It may be that thirty years of administering illicit muscle-building hormones will prove to be statistically harmless, but right now it doesn't seem exactly a wise or harmless thing to do. The professional athletes imagine they can make many millions if they just get a small edge on their competitors, and after that they can retire in luxury. Even if that dubious claim eventually proves to be true for them, it isn't true for most of the rest of us. If someone is as emaciated as a concentration-camp survivor, perhaps hormones are justified, but it is only wise to undertake it under a doctor's supervision, and only for a few months.

After the muscles have been bulked up for a month or two, perhaps longer if you are incorrigibly lazy, it is time to go to stretching and platform building. Some effort should be made to rotate muscles of the whole body, particularly if there is still an appreciable amount of muscle soreness for a day or two after each session. This is the time for a gym with a dozen different types of machines, each one aimed at a different muscle set. The magic number is five; stretch and pull each muscle group five times and then go to another; usually it's five times on each side of the body, or ten times per machine. Take an aspirin or ibuprofen before each session, and drink at least a glass of liquid afterward. Three times a week is often enough for a beginner to get started; but remember if you give yourself a month's vacation, it will take another month of hard work to get back to 80% of what you had only recently achieved.

After six months or so of this drill, start building endurance. A stationary bicycle, a treadmill, or swimming pool laps are useful for almost anyone. Running on a track is fine, but the majority of retirees have enough arthritis somewhere that they have to be careful about jogging. If pain appears while doing this, especially chest pain, stop immediately.

A word about shoes. People with ankle injuries, chronic flat feet, or arthritis in the feet and ankles may well find they can't get any endurance exercise because their feet hurt. Before rushing into bunion surgery or some other drastic response, try some foam rubber shoes. These were once special-ordered by a famous seven-foot professional basketball player, who wanted to be three inches closer to the basket when he threw the ball. So, three inches of foam rubber were glued to the sole of his running shoes. Well, you trip if the edges aren't trimmed at the heels and toes, so various other small modifications evolved. Eventually, a commercial version emerged in which the foot is essentially encased in foam rubber, and after walking on them for a couple of weeks, the rubber gets crushed down appropriately. The effect is a moulded shoe, just like moulded ski boots, with crushed foam rubber instead of fiber glass. Quite often, the effect is to push the bones back into ideal arrangements, with dramatic relief of the chronic pain. If your feet don't hurt, you walk more, maybe even start to jog. During the first few weeks, be careful, or you may stumble and fall on your nose. After a month, you'll forget you have them on, and maybe even forget your feet used to hurt. Progress can be measured by the ability (usually after six weeks or so) to put on regular shoes for a day. Without pain.

Public Misconceptions

(Healthcare for Citizen Lobbyists)

The White House and designated Congressional committees define the concepts behind a law, while actual legislative language is written by lawyers on the committee staff, sometime "assisted by" officials of involved departments. They supply meat on the bones, so to speak. In the technicalities of the topic getting little popular attention, lobbyists sometimes are asked to make suggestions. They may even go so far as to provide "suggested" language. Let's make some small suggestions. When a health package totals 18% of GDP, even small arguments become big ones.

{top quote}
Average Hospital Profit Margins: Inpatient 2%, Accident Room 15%, Satellite Clinics 30% {bottom quote}
Payment By Diagnosis

Outpatient is Not Necessarily Cheaper Than Inpatient For the Same Problem. Medicare provides half of hospital revenue; the other half often follows the same approach. The reimbursement mostly has nothing to do with the itemized bills they send, and may have little to do with production costs. The DRG (Diagnosis-Related Groups) system for reimbursing hospitals is thus not directly based on specific costs in the inpatient area. It is related to clustered diagnoses lumped into a DRG group, and then assumes overpayments will eventually balance underpayments within individual hospitals. That last point is questionable, and especially so in small hospitals. When two million diagnoses are condensed into 200 Diagnosis groups, group uniformity just has to be uneven. Reimbursement means repayment, but this interposed step often wanders from its definition. Someone in the past fifty years discovered the reimbursement step was an excellent choke point. Manipulating the reimbursement rates without changing the service is a handy place to choose winners and losers; it's largely out of sight of the people who would recognize it. Furthermore, for various DRG groups, or for all of them, it becomes possible to construct a fairly tight rationing system for inpatient costs. The degree to which actual production costs match a particular DRG reimbursement rate is blurred by inevitable imprecision in the DRG code construction. It is impossible to squash a couple of million diagnoses into two hundred code numbers without imprecision. It works both ways, of course. The coders back at the hospital will seek it out, experimentally. A grossly generalized code is placed in the hands of hospital employees, results in a system which suits both sides of the transaction, but is one which ought to be abolished, on both sides, by computerizing the process. The overall outcome with Medicare is an average 2% profit margin on inpatients during a 2% national inflation target of the Federal Reserve. This is far too tight to expect it to come out precisely right. And in fact, inflation has averaged 3% for a century.

For technical reasons, the same is not true of outpatient and emergency services. Emergency services are said to average 15% profit margins, and outpatient services, 30%. It is therefore difficult to believe anyone would start anywhere but the profit margin, and work backward. The consequence is the buyer has stolen the pricing process from the seller. Without the need to communicate one word, prices rise to the level of the available payment, and then stop there. But let's not be too specific in our suspicions. An incentive to direct patients to the emergency and outpatient areas must exist, and is acted upon. Any assumption by the public that outpatient care is cheaper than inpatient hospital care is likely to be quite wrong. Short of driving the hospital out of business, prices are whatever the buyer chooses to make them. There was a time when the buyer was Blue Cross, and behind them, big business. Nowadays, it is Medicare.

Let's test the reasoning by using different data. Because hospital inpatient care is reimbursed at roughly 106% of overall cost, while hospital outpatient care is reimbursed at roughly 150%, hospitals are impelled to favor outpatient care, no matter which type of care happens to have the cheapest production cost, the best medical outcomes, or enjoys the greatest comforts. Instead, the rates and ratios are ultimately determined by magazine articles and newspaper editorials. At some level within the government, a political system responds to what it thinks is public opinion, vox populi est vox dei. No matter what their personal feelings may be, hospital management encounters more resistance to wage increases in the inpatient area, less resistance in the outpatient and home care programs. So, true costs must actually rise in the outpatient area, sooner or later, following the financial incentives. Personnel shortages follow, as does friction between hospitals and office-based physicians. The process is circular, but the origin of favoring outpatient care over inpatient care was primarily driven by some accountant reading a magazine article. Everybody can guess what it costs to wash a couple of sheets and buy a couple of TV dinners. Nothing known about hotel prices justifies a 50% difference in price between inpatient and outpatient care, everything else being equal. The room price is mainly supporting overhead costs which are unrelated to direct patient care, so those fixed costs are like migratory birds, settling to roost where it's quiet. Remember, it isn't costs driving the system, it is profit margins.

The Return of a Discharged Hospital Patient Within 30 Days is not Necessarily a Sign of Bad Care. Early re-admission can of course be a sign of premature discharge or careless coordination with the home physician. But it can also mean a convalescent center is convenient to a hospital, making it reasonable to move the patient without much loss of continuity of care; and treating his return to the acute facility as a matter of small consequence. It is also a matter of cost accounting; when you claim a hundred dollar hotel cost to be worth thousands of dollars, many distortions are inevitable. If a hospital essentially shuts down on weekends, for example, there really might be better care available at home. Imposing a penalty for returns to the hospital post-discharge has certainly changed behavior, but it is far from clear which institutions are better as a result of it. Without a detailed study of longitudinal effects and costs, this rule is no more than an untested experiment. Without access to accounting practices, doctors assume the penalty for a high re-admission rate merely affirms that hospital insurance reimbursement by DRG is solely dependent on the discharge diagnosis, therefore bears little relation to the quality of care. Given a particular diagnosis, reimbursement is totally independent of any other cost. When all you have is a hammer, everything looks like a nail to the DRG.

The legitimate reasons for re-admission to the hospital are many and varied. Collectively they could well constitute a general attitude on the part of a particular hospital that it is reasonable to send many patients home a little early in order to achieve greater overall cost savings -- in spite of sustaining a few re-admissions. But this is somewhat beside the point. The insurance companies adopt the phraseology that favoring readmission is the only way a hospital can increase reimbursement under a DRG system. This is merely a debater's trick of shifting the blame. More or fewer tests, longer or shorter stays have no effect, but readmission can double reimbursement. Consequently, re-admission has been stigmatized as invariably signifying careless treatment, justifying a penalty reduction of the reimbursement. This is high-handed, indeed. It would require a research project to determine which of the alleged motives is actually predominant.

The Doughnut Hole: Deductibles versus Copayments. To understand why the doughnut hole is a good idea, you have to understand why copay is a flawed idea. In both cases, the purpose is to make the patient responsible for some of the cost in order to restrain abuse. As the expression goes, you want the patient to have some skin in the game. The question is how to do it; the doughnut has not been widely tried, but the copayment approach is very familiar: charge the patient 20% of the cost, in cash. This co-pay idea finds great favor with management and labor in negotiations, because the premium savings are immediately known. If the copayment is 10%, then employer cost will be decreased 10%; if it is 50%, the cost is reduced 50%. In midnight bargaining sessions, such simplicity is much appreciated. However, the doughnut hole was not devised to make negotiations simpler for group insurance, it was devised to inhibit reckless spending, theoretically released once the initial deductible has been satisfied.

Health insurance companies also like both co-pay and doughnuts. Both afford the opportunity to sell two insurance policies as two pieces of the same patient encounter, adding up to 100% coverage, but eliminating the patient's skin in the game. Doubling the marketing and administrative fees seems like an advantage only to an insurance intermediary, while it totally undermines the incentive of restraining patient overuse. In practice, having two insurances for every charge has led to mysterious delays in payment of the second one, even though they are often administered by the same company. Physicians and other providers hate the system, not only because it involves two insurance claims processes per claim, but because it often makes it impossible to calculate the residual after insurance, i.e., patient cash responsibility, until months after the service has been rendered. Patients often take this long silence to imply payment in full, and disputes with the provider are common. Long ago, older physicians warned the younger ones, "Always collect your fees while the tears are hot."

So, the idea of a doughnut hole was born, after empirical observation about what was owed on two levels, one for small common claims, and another for big ones. Formerly, the patient either paid cash in full or was insured in full, so arriving at the Paradise of full coverage was purchased in cash within the first deductible. Unfortunately, once that last threshold was crossed, the sky became the limit. Some way really had to be found to distinguish between extravagant over-use, and the use of highly expensive drugs, particularly those still under patent protection. The idea was generated that if the two levels of the doughnut hole were calculated from actual claims data, there often might be a clear separation of minor illnesses from major ones. Since the patient would ordinarily be uncertain how far he was from triggering the doughnut hole, the restraint of abuse might carry over, even into areas where the facts were not as feared. It is too early to judge the relative effectiveness of the two different patient-responsibility approaches, but it is not too early to watch politicians pander to confusion caused by an innovative but unfamiliar approach, while the insurance administrators simplify their own task by applying a general rule, instead of tailoring it to the service or drug. And by the way, the patients who complain so bitterly about a novel insurance innovation, are deprived by the donut hole of a way to maintain "first-dollar" coverage, which is a major cause of the cost inflations they also complain so much about. Some people think they can fix any problem just by loudly complaining about it. Perhaps, in a politicized situation, it works; but it doesn't fool anyone.

Is Preventive Medicine Always and Everywhere Less Expensive? As heads nod vigorously in support of prevention, please notice in general usage it suggests several different things. The overall implication is that small interventions for everyone are less expensive to society; less expensive, that is, than large expenses for the few who get the disease. That is clearly not invariably true, and unfortunately in a compulsory insurance world, it may seldom be true.

Take for example a tetanus toxoid booster, which ten years ago cost less than a dollar for the material. Recently in preparation for a vacation trip, I was charged by my corner drugstore $85 dollars, just for the material. If you do the math, I feel it is rather likely that $85.00 times millions of Americans is a far greater sum than the present aggregate cost of Americans actually contracting tetanus, especially after multiplying by ten for the conventional advice to have a booster shot every ten years. This becomes more certain if one adds in the cost of administration. The vaccine is quite effective, we had almost no cases in the Far Eastern Theater in World War II. The British who did not vaccinate routinely, had large numbers of often fatal cases. Furthermore, even if the tetanus patient survives, the disease is hideously painful. Is it better to immunize routinely? Yes, it is. Is it cheaper? I'm not entirely sure, because I have no access to production costs of tetanus toxoid. But it certainly seems possible it isn't cheaper. Malpractice costs, which are a different issue entirely, complicate this opinion.

Something, probably malpractice liability, has transformed an undeniably effective preventive procedure from clearly cost effective to -- probably not cheaper for a nation which no longer has horses on the streets, but still has horses on farms and ranches. This is presently mostly a malpractice liability problem for the vaccine maker, not a preventive care issue. Take another well-known example. In the case of smallpox vaccination, it is now clearly more expensive to vaccinate everyone in the world than to treat the few actual cases. The waffle currently being employed is to limit vaccination to countries where there are still a few cases, hoping thereby to eradicate the disease from the planet. Over and over, examination of individual vaccinations shows the answer to be: better, yes, cheaper, no; with the ultimate answer depending on accounting tricks in the calculation of cost, cost inflation because of third-party payment, and related perplexities. To be measured about it, the profitability of preventive measures could act as a deterrent for finally calling off prevention, by taking on a briefly more expensive campaign to achieve final eradication. Somewhere in this issue is the whisper that "natural" gene diversity of any sort must not be totally eliminated, a viewpoint which even the philosopher William James never openly extended to include virulent diseases.

Routine cervical pap tests, routine annual physical examinations, routine colonoscopies and a host of other routines are in general open to questioning as to cost effectiveness. The issue is likely to increase rather than go away. Much of the current denunciation of "Cadillac" health insurance plans focuses on the elaborate prevention programs enjoyed by Wall Street executives, college professors, industrial unions, and other privileged health insurance classes. A more useful approach to a borderline issue might focus on removing such items from health insurance benefit packages, particularly those whose cost is subsidized, either directly or by income tax deductions. Those preventive measures which demonstrate cost effectiveness can have their subsidy restored, or placed together in a category which must compete for eligible access to limited funds. The inference is strong that unrestrained substitution of community prevention for patient treatment escalates costs rather considerably, and certainly needs to demonstrate more cost effectiveness before subsidy is approved. While self-interest is a possibility if only physicians are consulted, total reliance on bean-counters could eliminate benevolent judgment entirely. Community cost effectiveness is a ratio, and both sides must be fairly argued.

In the final analysis, without some form of patient participation in the cost, this issue may be unsolvable. To launch a host of double-blind clinical trials to find out the truth will lead to answers of some sort, which will quickly be undermined by price/cost confusion, leading to increasingly futile regulation. Including preventive costs in the deductible at least allows public participation in the decisions and true balance to begin; which is to say, even universal preventive care admiration cannot be adequately assessed except in the presence of a substantial open market for the product. Much "preventive" care is really "early detection" or "early management". When the goal changes so subtly, it is often not possible to judge what is worthwhile, except by placing some price on pain and suffering. The abuse by the trial bar of the monetization of pain and suffering in the malpractice field, ought to be a gentle reminder of that. Preventive colonoscopy has clearly caused a decline in deaths from colon cancer; that's a medical judgment. Whether the cost of catching those cancers early was cost effective is largely a matter of colonoscopy cost, and on digging into it, will be found to be as much an anesthesia issue as a colonoscopist one. In any event, it is not one where the opinion of insurance reviewers should be decisive. In summary, if the litigation industry moves to make omission of prevention a new source of action, it will surely be past time to caution the public about the direction of things.

Plan Design. The insurance industry, particularly the actuaries working in that area, have long and sophisticated experience with the considerations leading to upper and lower limits, exclusions and exceptions. Legislative committees would be wise to solicit advice on these matters, which ordinarily have little political content. However, the advisers from the insurance world have an eye to bidding on later contracts to advise and administer these plans. They are not immune to the temptation to advise inclusion of provisions which invisibly slant the contract toward a particular bidder, and failing that, they look for ways to make things easier, or more profitable, for whichever insurance company does get the contract. The doughnut hole is a recent example of these incentives in action; no member of any congressional committee was able to explain the doughnut for a television audience, so it was ridiculed. The outcome has been a race between politicians to see who could most quickly figure out a way to reduce the size of the hole. The idea that the size of the hole was intended to be an automatic adjustment to experience, seems to have been totally lost in the shuffle. Asking industry experts for advice is fine, but it would be well to ask for such advice from several other sources, too.

Fee-for-Service Billing. In recent years, a number of my colleagues have taken up the idea that fee-for-service billing is a bad thing, possibly the root of all evil. Just about every one who says this is working for a salary, and I suspect it is a pre-fabricated argument to justify that method of payment. The obvious retort is that if you do more work, you ought to be paid more. The pre-fabricated Q and A goes on to reply, this is how doctors "game" the system, by embroidering a little. I suppose that is occasionally the case, but the conversation seems so stereotyped, I take it to be a soft-spoken way of accusing me of being a crook, so I usually explode with some ill-considered counter-attack. My basic position is that the patient has considerable responsibility to act protectively, which is often undermined by excessive or poorly-designed health insurance. Nobody washes a rental car, because that's considered to be the responsibility of the car rental agency. A more serious flaw in the argument that we should eliminate fee for service, was taught me in Canada.

When Canada adopted socialized medicine, I was designated to go there by the AMA, to see what it was all about. That put me in conversation with a number of Canadian hospital administrators, and the conversation skipped around among common topics. Since I was interested in cost-accounting as the source of much of our problems, I asked how they managed. Well, as soon as paying for hospital care became a provincial responsibility, they stopped preparing itemized bills. Consequently, it immediately became impossible to tell how much anything cost. The administrator knew what he bought, and he paid the bills for the hospital. But how much was spent on gall bladder surgery or obstetrics, he wouldn't be in a position to know. So I took up the same subject with the Canadian doctors, who reported the same problem in a different form. Given a choice of a surgical treatment or a medical one for the same condition, they simply did not know which one was cheaper. After a while, the hospital charges were abandoned as a method of telling what cost more, and eventually no effort was made to determine comparative prices at all. There's no sense in an American getting smug about this, because manipulation of the DRG soon divorced hospital billing charges from having any relation to underlying costs, and American doctors soon gave up any effort to use the billing as a guide to treatment choices. We organize task forces to generate "typical" bills from time to time, but these standardized cost analyses are a crude and expensive approximation of the immediacy of a particular patient's bill.

My friends in the Legal Profession make a sort of similar complaint. The advent of cheap computers created the concept of "billable hours", in which some fictional average price is fixed to a two-minute phone consultation. In the old days, my friends tell me, they always would have a conference with the client, just before sending a bill. The client was always asked how much he thought the services were worth to him, and usually the figure was higher than the actual bill. In the cases where the conjectured price was lower, the attorney had an opportunity to explain the cleverness of his maneuvers, or the time-consuming effort required to develop the evidence. A senior attorney told me that never in his life did he send a bill for more than the client agreed to pay, and he was a happier man for it. Naturally, the bills were higher when the attorney won the case than when he lost it, which is definitely not the case when a hospital is unsuccessful in a cancer cure. Similarly, you might think bills would be higher if the patient lived than if he died, but income maximization always takes the higher choice.

Frank Furness (2) Rittenhouse Square

{1804 Rittenhouse Sq}
1804 Rittenhouse Sq

George Washington had two hundred slaves, Benjamin Chew had five hundred. It wasn't lack of wealth that restrained the size and opulence of their mansions, particularly the ones in the center of town. The lack of central heating forced even the richest of them to keep the windows small, the fireplaces drafty and numerous, the ceilings low. Small windows in a big room make it a dark cave, even with a lot of candles; a low ceiling in a big room is oppressive. Sweeping staircases are grand, but a lot of heat goes up that opening; sweeping staircases are for Natchez and Atlanta perhaps, but up north around here they aren't terribly practical. Building a stone house near a quarry has always been practical, but if there is insufficient local stone, you need railroads to transport the rocks.

Early Victorian

So to a certain extent, the advent of central heating, large plates of window glass, and transportation for heavy stone and girders amounted to an emancipation from the cramped little houses of the Founding Fathers. Lead paint, now much scorned for its effect on premature babies, emancipated the color schemes of the Victorian house. Many of the war profiteers of the Civil War were indeed tasteless parvenu, but it is a narrow view of the Victorian middle class to assume that the overdone features of Victorian architecture can be mainly attributed to the personalities of the Robber Barons. This is not the first nor the only generation to believe that a big house is better than a small one. The architects were at work here, too. It was their job to learn of new building techniques and materials, and they were richly rewarded for showing the public what was newly possible. Frank Furness was as flamboyant as they come, a winner of the Congressional Medal of Honor for heroism, a man who wore a revolver in Victorian Philadelphia and took pot-shots at stuffed animal heads in his office. He affected the manners of a genius, and his later decline in public esteem was not so much disillusion with him as with the cost of heating (later air-conditioning), cleaning, and maintenance which soon exceeded provable utility. The simultaneous arrival of the 1929 financial crash and inexpensive automobile commuting to the suburbs stranded square miles of these overbuilt structures. It was the custom to build a big house on Locust, Spruce or Pine Streets, with a small servant's house on the back alley. During the Depression of the 1930s there were many families who sold the big house and moved into the small one. Real estate values declined faster than property taxes and maintenance costs; incomes declined even faster.

{Delancey Street}
Delancey Street

It thus comes about that large numbers of very large houses have been sold for very modest prices, and the urban pioneers have gentrified them. You can buy a lot of house for comparatively little, if you are willing or able to restore the building. We thus come back to Frank Furness, who was the idolized architect of the Rittenhouse Square area, in addition to the massive banks and museums for which he is perhaps better known. Unfortunately, most of the Furness mansions on the square have been replaced by apartment buildings, but one outstanding example remains. It's sort of dwarfed by the neighboring high-rises, but it was originally the home of a railroad magnate, a few houses west of the Barclay Hotel, and it holds its own, defiantly. Inside, Furness made clever use of floor-to-ceiling mirrors to diffuse interior light and make the corridors seem wider. Although electric lighting made these windowless row houses bearable, modern lighting dispels what must have been originally a dark cave-like interior on several floors, held up by poured concrete floors. Furness liked to put in steel beams, heavy woodwork and stonework, in the battleship school of architecture. If you were thinking of tearing down one of his buildings, you had to pause and consider the cost of demolition before you went ahead.

Frank Furness Window

There are several others of his buildings around the corner on the way to Delancey Street, one of them set back from the street with a garden in front. That's what you expect in the suburbs, but land is too expensive in center city for very many of them; this is the last one Furness built before rising real estate costs drove even him back to the row-house concept. On Delancey Street there is a house which he improved upon by adding an 18-inch bay window in front. The uproar it caused among the neighbors is still remembered.

{Dr.s Home (?)}
Doctor Home and Office

A block away on the part of 19th Street facing down the street, Furness buit another reddish brownstone house to glare back at the neighbors. The facings of the front suggest three row houses, and it was indeed the home of a physician who had his offices on one side, entrance in the middle, and living room on the right. The resulting staircase in the middle is used to good effect by opening a balcony on the landing overlooking the parlor below. As befits the Furness style, the wall are thick, the wooden beams heavy. And, in a gesture to the lady of the house, the room adjoining the living parlor is a modern modern kitchen, so the kids can play while mama cooks, or guests can wander by as she gets dinner ready. Times have changed, the servants quarters once were plain and undecorated. The lady of the house never set foot in the kitchen, so she could care less what it looked like.

{Window View In}
Window View In

As a matter of fact, that's the remaining problem for these places, the rate-limiting factor as chemists say. Automatic washers, microwaves, electric sweepers, spray-on cleaning fluids and similar advances are the new industrial revolution which makes these hulking mansions almost practical. What's still lacking is the social structure of Upstairs and Downstairs, the servant community overseen by the lady of the house, who once was sort of the Mayor of a town. The lady of the house is now a partner in a big law firm, or similar.It simply is not wise to leave a big expensive place unattended by someone constantly supervising the domestic help. It is never entirely safe to leave the financial affairs of the household in the hands of someone who is not a central member of the owning family. Perhaps the father of the family can be brow-beaten into spending some quality time with the children once in a while.

{Window View Out}
Window View Out

Perhaps an accountant can for a fee be trusted with the finances; perhaps a butler can be found who will whack the staff when they get out of line. But the plain fact is these monster houses were built around the assumption that the lady of the house would run them, and the old style of manorial life cannot return unless the house is completely redesigned for it. Some day, perhaps a genius of the Frank Furness sort will make an appearance, change everything, and make everybody want to have it. But it is asking for something else when you insist on this happening in an old stone fortress that was designed to house a different style of life.

Beware the Middle-man: Common Stock Index Fund Earnings are Not the Same as Investor Returns.

There's quite a lot to passive investing, if you mean running an Index fund. The rewards of this hired complexity can nevertheless be lost by carelessness in choosing an expensive middle-man. Or even by having a reliable agent who works for an organization, remorselessly devoted to its own income maximization -- in the middle. Or having a small reliable agency bought out by a corporate raider with entirely different goals from the ones you thought you selected. But if your long-term common stock index results approach 10% total return, at least you have passed the first test. As my mother repeatedly told her granddaughters: Don't marry the first man who asks you.

Asset Allocation Managing the funds of a Health Savings Account has important similarity to managing a pension or endowment fund. An important distinction: healthcare imposes random cash requirements on an HSA, compared with the steady, predictable cash requirements of an endowment fund. After the Health Savings Account has matured to a steady state, its fund balance becomes predictable, just as cash balances in a big bank eventually do. Nevertheless, the HSA is probably destined to require larger cash reserves while maturing, and a second period of volatility after age fifty, when more serious illnesses get more frequent. On top of that, when a securities crash comes along, it may take as long as two years for the market average to stop falling, and as long as three years to recover. That's by contrast with normal ripples in the markets, where 90% of important gains or losses are made in 10% of time periods. The rest of the time the market dawdles.

If most "dips" are followed by recoveries, why not just wait it out? Here, almost all organizations have the same problem of "meeting the payroll". The uproar of being late with a payroll must be experienced to be believed. While most employees will quietly accept a short, reasonable delay, the few who are stretched by a brief interruption for any reason, can be very vocal. The financial management of any fund faces the same issue, and is very reluctant to repeat it. All of them face the possibility of some sudden decline in the value of the portfolio, when at first it would be general opinion it is wiser to avoid selling from the portfolio and wait for a quick recovery. Reserve portfolios are set aside for sudden cash requirements, of course, but human nature induces most people to wait and hope for better times. In more tangible terms, it is generally the business of the investment manager to cope with a lot of small waves, but only the Board of Directors can decide to liquidate the whole reserve. In for-profit situations, there is also a question of paying taxes.

Conventional advice is to maintain a portfolio of 60% stocks, 40% bonds, with the cash flow from the bonds intended to bridge the gaps. Since bonds pay less than stocks, overall portfolio yield is lowered. If interest rates are unusually low, it may be the bond component which is itself the risk, but at least in theory, mixed assets "balance the risk." As a consequence, an 8% steady yield from an endowment or pension fund is the best performance many professionals expect, with most funds even happy to achieve 7.5%. But happiness is relative. We have just demonstrated the first step in how a 10% total return can turn into 4%. You're already down to 7.5%.

Frank Furness (1):PAFA

{Pennsylvania Academy of the Fine Arts}
Pennsylvania Academy of the Fine Arts

The Pennsylvania Academy of Fine Art is notable for its place in Art history, for its faculty over the centuries, and for its influential student graduates. It is therefore not to slight the institution's remarkable place in the world of art, if we pause to notice that the building itself, the place that houses all this, is itself an outstanding work of art. Whenever mention is made of Frank Furness, its colorful and influential architect, the first stop on the list is the building he built to house a school and display its glories. Perhaps the best way to illustrate the achievement is to compare it with the Barnes Museum, which also was built to house a school. It also has an outstanding permanent collection, perhaps a greater one than PAFA. But the Barnes building scarcely gets a mention, and is about to be abandoned for a preferable location. The Furness building however is a massive pile of solid rock, immovable throughout massive changes in its neighborhood. To move that building out to the Parkway has never even been suggested. You can move if you like; we were here first.

{Student Workroom}
Student Workroom

The exhibition rooms are interesting, even clever, but the hand and mind of the architect are best seen in the school, the Academy. Seldom seen by the public, the entrance to the school is underneath the front staircase which sweeps the public visitors off to see the exhibition. Up the stairs, admire the carved walls, the massive supports and the iron railings and out into rooms with scarlet and gold walls, and a blue ceiling with stars. When the it leaves, the public sweeps back down the inside stairs and out the tunnel-like entrance, then down the outside stairs. Where was the school?

{PAFA Marker}
PAFA Marker

It's underneath the exhibition area, reached by a door under the stairs, unnoticed unless you ask for it. There you will find a darkened lecture hall and corridors lined with plaster casts for teaching purposes. But an artist's studio must have diffused northern light, and lots of it; the problem for the architect was to provide a huge slanted northern skylight over a basement. This trick was accomplished by pushing the walls of the first floor out to the street and installing a slanted skylight in the "ceiling" of the overhang. When the overall effect is that of a fortress meant to defend against a barbarian invader, built with massive walls and roof -- hiding a glass skylight is quite an achievement. Furness was a showman; it was not beyond him to place an architectural tour de force right in front of generations of students looking for something to portray.

{Welcome, Conventioneers}
Welcome, Conventioneers

We are told the building was five years in construction, designed and re-designed as it rose. The resulting effect is achieved by building around its interior as it evolves from bottom to top. Quite a difference from buildings laid out in advance, forcing the interior contents to conform to the initial design without regard to cramming down its contents. There is an overall design at work here; it's evocative of a Norman church with side extensions, but you have to look for that rather than have the architect thrust it in your face.

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 "" - 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 "" - 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 [] and noticed a ton of great resources. I recently had the honor of becoming a part of a new non promotional project on 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
Posted by: SUSAN WILSON   |   Aug 12, 2012 12:49 AM

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