Funny Toes: A Physician Viewpoint

Webbed Toes

It probably took me twenty years to notice that, unlike most people, I had an incomplete separation of my second and third toes. I thought my toes were like everybody else's, but once you start peeking, you see that webbed toes are not normal, although they are not really rare, either. After another thirty years, it became apparent that most of my numerous descendants had the same kind of toe; it was obviously an inherited condition. When the family clan gathered at the beach, it was a source of mild amusement, possibly even a little pride. A few weeks ago, I happened to mention the matter at a party, whereupon another doctor promptly pulled off his shoes and socks, and revealed fused or webbed toes of a much more striking sort than mine; obviously, he was proud of it, too. He is of an old, old Philadelphia family that owns one of the oldest, if not the oldest, house in Germantown. His family, too, is stigmatized in the same way only more so. In Philadelphia, when you are proud of your family, you are really, really, proud of it.

Ainhum

Which brings me back to my days as an intern in the accident room of the Pennsylvania Hospital. When there is a sudden crowd of people in an emergency department, the nurses get everybody undressed, put in a hospital gown, and instructed to wait for the doctor behind a curtain that doesn't quite reach the floor. For some reason, as a medical student I had been particularly struck by a photograph in a textbook of an inherited disorder said to have been first noted on a slave ship; the disease in native language, was named Ainhum. For reasons obscure, a tight little band appears at the base of the fifth, or little, toe. It gets slowly tighter over a period of months, and eventually the little toe falls off. That's all there is to Aihnum, and all that was known about it. So, imagine my surprise and delight to walk past a row of naked feet sticking out below curtains -- and there was my first and last case of Aihnum.

I summoned my colleagues, and the visiting medical students from both Jefferson and Penn who at that time shared training in our accident room. I raced off to my room to get a camera to record this momentous event. An elderly staff physician, either Tom McMillan or Charles Hatfield, wandered past and was invited to share the excitement. Well, he says, I saw one of those forty years ago, it looked just like that; old Doctor Norris showed it to me when I was an intern. Much murmuring ensued but abruptly stopped when the patient himself rose up and started putting on his clothes. He was going home, but why? "Well," he growled, "I came here because my back hurts, and all you people do is look at my toes!" He said he was going over to the Jefferson Hospital to get proper treatment, and I guess he did.

Morton's Toe

And finally, there is Morton's Toe. Or perhaps more properly, Mortons' Toes. There were in fact two Doctor Mortons, one of them at Columbia College of Physicians and Surgeons where I went to school, and the other at the Pennsylvania Hospital where I interned. In New York, Morton's Toe refers to a painful callous, or neuroma, that forms on the bottom of the victim's big toe. In Philadelphia, such an answer would get a failing grade, because the Philadelphia Morton had noticed that some people have a big toe that is shorter than the other toes, instead of being bigger as the term would suggest was proper. The tricky thing about this relatively harmless variant is that the big toe is actually not short at all. The foot bone, or metatarsal, is short, so the toe of normal length sits back farther on the foot and just looks shorter. The main significance is for shoe salesmen, since the shoe needs to be long enough to avoid crushing the other toes.

So now, you readers who were not lucky enough to go to medical school can get a feeling for what it seems like to be a doctor. The other significant shared bond within the fraternity, is a sense of outrage at the way health insurance companies drag their feet paying doctors, but that's not limited to feet..

http://www.philadelphia-reflections.com/blog/1506.htm

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Hospitals Shift Costs Three Ways

Safeway Store

The CEO of Safeway Stores recently offered his own company's preventive approaches as an example of what the nation can do to reduce health costs. He's undoubtedly sincere, but he's wrong; he just shifted costs to Medicare. This is only one of three ways, major ways, cost-shifting is misleading us.

Medicare

Average life expectancy is increasing at more than two years per decade, but people always eventually die. Since health care costs are heaviest in the last year or two of life, extending life will soon push nearly all those heavy terminal costs from employer based insurance -- into Medicare. To die at age 64 costs Blue Cross a lot; but to die at 65 just costs Medicare a lot, it doesn't save Society any money. From Safeway's point of view, this effect has the happy outcome that Safeway's health costs are diminished. From the point of view of society, however, lifetime health costs are the same or even greater, because they have been shifted to Medicare. Let's put it another way: dying at age 64 costs the employer and the employees; but dying at 65 costs the taxpayers. Safeway's CEO has definitely improved health care, and accomplished a wonderful result for his employees. But his claim that reduction in his company's premiums reflects a saving of money is at best unproven, and in theory probably incorrect. Increasing longevity is constantly pushing more costs from employers to Medicare, and not just in Safeway; the prospect is that soon substantially all major sickness costs will be assigned to Medicare. (To explain the failure of most employer insurance costs to fall comparably in response to this shift, one must look elsewhere).

But instead of going down that trail, let's look at a second form of cost-shifting. Government payers and monopolists are able to pay hospitals less than actual costs, and get away with it. The worst offenders are state governors administering Medicaid, where the underpayment is roughly 30%, in spite of federal reimbursement to the states for most of it at full price. The resulting profit is used for various state purposes, mainly nursing home reimbursement. For the most part, such diverted funds are used for purposes not easily eliminated, so it is unlikely there will be much cost reduction for government if the scam is acknowledged and eliminated. To avoid bankruptcy, hospitals raise the rates for other health insurance plans -- and the uninsured. Employers are paying for most of it, so they stand to gain from reform, only to face higher state taxes as matters readjust. We have yet to learn where these costs will shift if the federal government takes over the costs of the uninsured. To a major degree, the federal government and its taxpayers are already paying for a lot of this uninsured cost, through the Medicaid shift. So its present dilemma is whether to pay for it twice.

Blue Cross Blue Shield

There's still a third cost-shift. In 1983, Medicare stopped reimbursing hospitals fee-for-service (itemized patient bills are still prepared but are meaningless fictions) and for thirty years has paid by the diagnosis, not the service. Consequently, per beneficiary inpatient costs have only risen 18% in five years, while outpatient costs have risen 47%. Skilled nursing and home care costs are rising even faster.

Not only do these shifts provoke inpatient nursing shortages, they start a war for patients between hospitals and office-based physicians. The difference between a hospital which makes money and one which loses money is based on whether there is enough out-patient revenue to compensate for the hidden tax which the state effectively imposes on hospitals in order to pay for nursing homes. These splashes send off ripples in all directions, enough to fill volumes of commentary.

Just notice, for example, that neither Medicare nor private health insurance pays below costs, if you look at total national balances. Private insurers are paying hospitals 32% more than actual inpatient costs, while Medicare is paying 6% more than national cost. And yet 58% of hospitals are losing money. It could fairly be said we are just looking at a maldistribution of the uninsured, as a cost, and a maldistribution of non-inpatient revenues, as a profit, among the nation's hospitals. To what extent such maldistribution reflects uneven quality, as the losers claim, or inefficiency, as the winners would say, -- merely starts a diversion of attention which could last twenty years while we examine it.

And disruptions enough to take decades to fix. Anyone who believes that ham-fisted reform next month will save money in a situation like this, is dangerous to have around.

http://www.philadelphia-reflections.com/blog/1696.htm

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Cataracts

Cataract Surgery

At a social gathering of older Americans, if someone excitedly announces he has just had successful cataract surgery, the chances are good that every other person in the group will reply they have had it, too. Those who have had two eyes operated have slightly more social clout than those who have had only one, but in general soft lens implants are what everybody has. It's pretty common to meet someone for lunch who had a cataract operation that morning. What a contrast from the olde days. Until about 1970, having a cataract removed was a matter of spending two weeks in a darkened room in the hospital, with your head held in sandbags to keep you from moving. And the result, while better than nothing, was the need to wear glasses so thick they resembled the bottom of cocoa-cola bottles, and narrowed the visual field to the end of a tunnel. Those who had cataract surgery forty years ago had to be blind before the risk was justified.

Everybody gets cataracts, and almost everybody is cured.

There was a reason for this, relating to a blinding eye condition known as sympathetic ophthalmitis. The most harrowing of dangers associated with eye surgery was the tendency for an injured eye to become allergic to itself, and hence also allergic to the opposite eye, soon leading to total blindness in both eyes. Eye surgery was nothing to fool with, and it was particularly dangerous to have a foreign body like a piece of flying glass enter the eyeball. And then, came the Battle of Britain, where so many owe so much to so few.

Spitfire

The British pilots were flying Spitfires, a type of airplane with a large plexiglass canopy over the pilot, allowing him to look in all directions for the enemy. The German Messerschmidt pilots would swoop down on the Spitfires, machine guns blazing. The Spitfires were not necessarily shot down when they were hit, but many of them had shattered chards of plexiglass sprayed into the cockpit, and many of the splinters went into the British pilot's eyes. If they managed to land the planes, the British doctors administered emergency first aid, stopped major bleeding, fixed major broken bones. In the heat of the emergency, no one noticed that bits of plexiglass were being left in the eyeballs.

Eventually, these survivors were being treated for scars and injuries in clinics, long after the war. One British opthalmologist suddenly had a striking insight. These eyes, with buried foreign bodies in them, were working just fine. No sympathetic ophthalmitis; that wasn't supposed to happen. Ultimately, the realization spread that plexiglass could be used as a lens implant, and many patients were successfully treated with a so-called hard lens.

The next advance was the soft lens. Someone realized that soft plastic, like a soft rubber ball, has a memory. Squeeze it out of shape, and it will soon return to its original shape. So, in effect, a soft lens of the proper size and shape can be squeezed into a toothpaste tube, injected into the right place in an eye, and it will pop back into shape. Before this can be done, of course, the rotten old lens has to be removed in any of several ways; pluck it out with eyebrow tweezers, or buzz it into liquid by lasers or other means, suck out the juice, and squeeze the squashed-up soft plastic lens into place. With practice, the whole thing can be done in ten minutes. That's modern cataract surgery, and it's pretty slick, especially if you know what the struggles were, before the Spitfires.

But don't let me overstate matters. This operation still has its risks. The retina behind the lens may turn out to have been defective, so a new lens hardly helps very much. Or there can be a slip, which amounts to one drop of blood getting where it doesn't belong, and the eye or both eyes are ruined. When I had my eye fixed, I seemed to be lying on the stretcher for a lot longer than necessary. Suddenly, I heard operating room doors banging open, and several older physicians in street clothes came in, huddled around, talked with each other for a long time, walked slowly back out into the corridor. I knew exactly what that was all about, and it didn't improve my serenity. Eventually, a nurse asked if I was ready, and I said, Yes, I guess so.

http://www.philadelphia-reflections.com/blog/1697.htm

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Inside the Big House

Peter Binnion, M.D.

The Right Angle Club was highly honored recently to be addressed by Peter Binnion, MD, the former Chief of Cardiology at the Pennsylvania Hospital, distinguished librarian of the Shakspere Society, and well-known former Main Line physician. Peter is now, hard to believe, Associate Director of a state prison medical program. One of the members of the audience asked him straight out, "Why are you there?"

At a time when prison medicine is widely, and correctly, regarded as a generally deplorable system, it is hard for the public to understand the sense of duty which impels at least a few of the profession to try to improve matters. And it is particularly difficult for the lay public to understand the attraction for a well-trained academic physician to work in an environment of severely ill patients. In a sense, it's like the old days.

And Peter slyly pointed out, it may be somewhat like the future, if we aren't careful. He artfully repeated the anti-medical care harangues which are now commonly issued by various liberal politicians, denouncing the extravagant care we are supposed to provide, and the uncaring attitude toward the uninsured sick. Having resonated with any left-leaning members of the audience, he proceeded to describe what things are like when government provides the care, and how it feels to observe the limitations of a real bureaucracy. Just for a start, he isn't allowed to call himself a doctor. He's a provider of care. And to go on, not only are the prisoners three to a room designed for two, but one quarter of those without cells, sleep on the bare floor,

Delaware State Prison Patch

Over ninety percent of the prisoners are taking illicit drugs; their ingenuity in smuggling simply passes belief. What's called drug detoxification among new inmates gets briskly to the goal. Our speaker delicately avoided the disagreeable notion that study after study has shown that illicit drugs in prison are almost invariably smuggled in and sold by the guards. For them, it's just a source of supplemental income, justified in their minds by low pay for unpleasant work. Lots of the prisoners have HIV infection, although not as many as depicted in rumor. Unless a disease is life-threatening, treatment is not encouraged. Hernias are not repaired, for example. And so a physician working in this environment is intended to spend all of his time with life-threatening conditions. Most physicians would shame-facedly have to admit this makes for an exhilarating professional experience, and it is indeed the sort of environment in which post-graduate medical training once took place, almost everywhere. Up until now, Peter had never seen a case of Hepatitis C. In the past two years, he has treated six cases. Diabetes is almost always out of control, because it is absolutely forbidden to allow the prisoners to have the needles to give themselves insulin. Sharps, you see, are prohibited.

It's a little disconcerting to be given lectures on how to behave if you are being held hostage, but the fact is that the prisoners universally treat the doctor with great courtesy. You know they are always looking for drugs, and you know they regard the medical system as a soft spot in the security system so it's a good place to launch an escape attempt. But regardless of the motivation, Peter observes at least as much civility in these patients as in the Main Line office. The doctor really doesn't want to know the reasons for imprisonment, and the prisoner certainly doesn't volunteer it, so the topic just doesn't come up.

Three goals are maintained, above all others, by the prison authorities. The suicide rate is regarded as a measure of the prison system, so extreme measures are taken to prevent it, or to prevent suicide from being successful when attempted. There is a very high rate of schizophrenia among the inmates, which probably reflects the deplorable state of psychiatric hospitals following the 1983 Budget Reconciliation Act. The second over riding goal is to protect the guards ("officers") from attack, so that scissors, hypodermics, and things which could remotely be described as a "sharp" are scrupulously sought out and eliminated remorselessly. The final goal, of course, is to prevent escapes, which have become the public measure of whether or not it's a good jail. The precautions taken to prevent, thwart and punish escape attempts hang heavy in the air.

All legislatures hate prisons; they cost too much. Since budget restraints lead to many of the nastiest features of prison life, budget restraints enhance the punishment. How much these two ideas reinforce each other is hard to say, but one thing is clear. Individually, people are pretty decent; collectively, Society is a bum.

http://www.philadelphia-reflections.com/blog/1708.htm

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Reforming Health Reform (2009)

Congressman Robert Andrews

A single e-mail to constituents, and no other communication visible to the general public, announced a town hall meeting with our Congressman, Bob Andrews, on the campus of Rowan University, from 6 to 8 PM, August 24, 2009. The subject was to be Health Care Reform Legislation. On arrival, it was hard to find the auditorium in the square mile of new college campus, and only a small sign entitled "Event" indicated the place to park. Lots of cars.

By counting seats in a row and multiplying by the number of rows, the University Auditorium held 3000 people, but at 6PM it was difficult to find a vacant seat. The doors were almost blocked by two lines of people standing to speak at microphones in the center of the hall, snaking all the way out past the television cameras and then out the door. These people were strangely silent, preoccupied but not rude, apparently rehearsing their speeches. In the lobby outside the doors, several workers were distributing posters showing "Thank You!", checking people off on lists of some sort. Many of those who got posters were wearing red T-shirts emblazoned with something or other.

Rowan University

When I finally got a seat inside, it was behind a whole row of such T-shirted poster-holders, mostly but not entirely of the black race. The Congressman was giving a little speech to the effect that he was one of the committee members who wrote the bill, so of course he had to support it. Strange, that as a member of Commerce and Labor he was working on a bill which traditionally is the province of the subcommittee on Health, of the Ways and Means Committee. In any event, that gave him the ability to explain some of the language which was a little too hard to understand. Several in the audience shouted out something unintelligible at that point, but mostly the audience sat in silence, waiting for the questions. He soon opened it up for questions, because he wanted to know what his constituents were thinking.

Although a few inevitably wandered off the point, questioners were confident, moderately deferential, remarkably effective. No matter how it was stated, and no matter how it began ("I have always voted for you, Congressman"), they were at the microphone to run a sword into him. To some extent, posting the entire bill on the Internet has changed politics. One old man, reading from his papers, said that page 343 says, etc; to which the harassed Congressmen blurted out, "That isn't true!" And the old man held his ground, "Oh, yes, and what else isn't true, that's written in the bill?"

Our congressman represents a working-class district, as clearly illustrated by his previously running for Congress without opposition. In searching for the reason this solidly Democrat audience was so antagonized, one gathers they generally have Unionized health benefits, and feel threatened that insuring the "illegals" will be paid for by impairing their own insurance. Somehow they feel that anyone who denies it is lying to them. ("It isn't what's in the bill, it's what will be in the bill ten years from now.") Except for college professors, they have the most luxurious health insurance coverage in America, and are accustomed to boasting of it. Somehow, this privileged position drowns out their envy of rich people. When told that only the top x% of the country would have its taxes raised, one man bore right in on the Congressman. "You never heard anyone asking a poor man to give him a job". (Yeah, right, right on, Yeah.)

Although the people in red shirts holding posters put up a fight for fifteen minutes or so, they soon subsided out of recognition of who owned the room, and the remaining three hours of "questions" were almost uniformly negative. After an hour, the television cameras left the room, and at that signal the people in front of me wearing red shirts, also left. After a succession of speakers praised physicians somewhat excessively, a couple of physicians got up and made a poor showing at the microphone. One of them, a fat woman, had the poor judgment to tell these folks that many diseases like diabetes were self-inflicted, but later heard that it would help if our President would himself stop smoking and leave the rest of us to mind our own business. Two women who proclaimed themselves single mothers were no better treated..

At 9:30, a meeting scheduled to end at 8PM still had a thousand people in the audience, and fifty at the microphones. But I had had enough. They made their point. All that remains is to see how fairly the television editors extract significant clips, and to find out how the rest of the nation feels.

http://www.philadelphia-reflections.com/blog/1714.htm

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Time To Care

Dr. Norman Makous

It sometimes seems as though Medicare has been a standard part of the scene for so long it now needs major reform, but when a doctor has practiced Medicine for sixty years he has seen a lot of contrasts between the old way and the new way, not all of them favorable to the new -- which we are now tired of, and trying to repair. That's particularly true if the doctor practiced at America's first and oldest hospital, because it sustained many traditions from two centuries before, and was among the last to yield to the imperatives of newcomers for the last forty years, their hands grasping for the purse strings. Dr. Norman Makous must either have a remarkable memory or a thick, detailed diary. He tells three hundred pages of fast-reading anecdotes about sixty years of his own medical practice, before summing up in fifty pages of reflection. One by one, he describes the innovations in his field of cardiology and how they affected him and his patients. Thiomerin, one of the first of many easy ways to pump out excess body fluid accumulation, transformed the treatment of congestive heart failure. Synthetic digitalis claimed to but probably did not much improve things over dried digitalis leaves; it certainly raised the cost. Cardiac catheterization, electro-shock resuscitation, ultra sound diagnostics, MRI and CAT scans, cardiac surgery using the heart-lung machine, and finally cardiac transplants -- all started out as headline-news spectaculars, evolved into cutting-edge advances, and then settled down into the Standard of Care that you obtained a plaintiff lawyer to sue about. All in one medical lifetime, supposedly prepared for by one Medical School course, followed by one residency apprenticeship, the specialty of Cardiology was completely transformed at least six times.

Time to Care

Meanwhile, the leadership of the medical profession was tenaciously resisted by those who supposedly followed its direction. Hospital administrators, either trying to reduce costs or to maximize institutional reimbursement, and sometimes just trying to glamorize their corporate vehicle; million-dollar-a-year salaries for administrators probably held out some perverse inducements, as well. Nurses, cut loose from hospital training programs to invent a new profession of nursing administration within university campuses remote from the scene of sickness. Health insurance executives, trained in the art of income maximization by Business Schools, driven by the need to lobby and the need to accommodate quirky laws lobbied by others, pressured by corporate human resources departments who were in turn pressured by unions and corporate managements -- and constantly bothered by expensive new technologies invented by doctors "who needed new toys". University administrations, placed in charge of numerous recalcitrant medical staff physicians, applying the principles of the German research systems upon an intransigent profession that persisted in preferring the care of sick people to the chase for research grants. And politicians, elected for two-year terms in which they felt pressure to accommodate a hundred conflicting interest groups.

Against all this and more, Dr. Makous describes how the practicing physicians especially those trained in the traditional way, found only one sympathetic, kindred interest group -- the patients. During a period when everybody else seemed determined to snitch a piece of the health insurance money pie, the patient wanted one major thing from the doctor. He wanted to be helped through his illness. The patients loved their doctor, in what was known as the patient doctor relationship. But a strange thing was also true. The doctors loved their patients, the only group in society who seemed to care what the doctor was trying to do.

http://www.philadelphia-reflections.com/blog/1725.htm

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Only Three Things Wrong With American Healthcare

Although Congress is offering several thousand pages of proposals for healthcare "reform", none of them even mentions the three main difficulties, to say nothing of fixing them. Let's be terse about this:

1. Health insurance is fine, but if you make it universal, there is no impartial way to determine fair prices. Somebody must haggle with the vendor in order to introduce the issue of what is the service worth? The customer doesn't care what it costs to make, or whether the vendors are being paid fairly. If everyone is insured, no one cares what it costs. Not only do all costs rise, but they rise without coordination, without a sense of what each component is worth, relative to alternatives.

2. Employer-based insurance is fine, but it ends when employment ends. You just can't stretch employment-based insurance because you can't stretch employment.

3. State Medicaid programs are fine, but just about all fifty states are going broke trying to pay for it. Extending it to more people by raising the income limits just makes things worse. Items 2. and 3. are related. Trying to do both -- expand Medicaid as employment shrinks -- during a recession is incomprehensible. Item 1. (price confusion) gets drawn into this because the States try to pay less than it costs, hoping to shift the deficiency through hospital cost-shifting, utterly confounding the information which prices provide. The doctors have no way to tell which is the cheapest approach to a problem, so they don't try. Without control over prices, we can only control volume.

That's really all there is to this mess. Not one word of the current legislation even mentions these problems, so of course the legislation blunders. Even a child can see that compulsory expansion of benefits to universal coverage will fail if you can't pay for what you already have. No one will make sacrifices for a new system if the sacrifices seem futile. They are futile, so leave me alone.

The current administration has been compared with bank robbers who see they are trapped, and decide to shoot their way out. Let's see them try to shoot their way past the first Tuesday after the first Monday in November.

http://www.philadelphia-reflections.com/blog/1754.htm

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Christmas Reflections

My father in law, a prominent obstetrician in Binghamton, New York, regularly took his family to New York City sometime between Thanksgiving and Christmas. The three-day junket was described as a visit to do Christmas shopping. Another relative made similar trips from home in Tyler, Texas. Several of my patients made such visits to Philadelphia from their homes in West Virginia, stopping by to make a medical visit to me during the same trip. From the seasonal crowds in Penn Station and in the shops on Chestnut Street, it was clear that an annual visit to the big city was a common custom in the upper crust of small to medium-sized cities, for whom the more expensive shops of the bigger city provided big ticket items bought infrequently, and the distinctive luxuries which made them stand out from the socially less-enlightened back home.

These shopping visits were not confined to purchasing, although that was the main focus. It was a time to go to the theater, orchestra and opera, maybe an occasional ballet and art exhibit. The choice of large city might be related to returning to the University, or other period of professional training for a drop-in visit, because these associations made it possible to observe the latest trends and innovations, a useful issue in the smaller towns. The ladies could observe the trends in fashions, and everyone would have a chance to dress up in the better hotels and restaurants. This recirculation between the small towns and the big one at the hub unified the region, establishing hierarchy rather widely. And it hardened traditions in the big city, since auslanders tend to return to the same hotel, restaurants and social gathering spots even more than the local residents do; there isn't time in a brief visit to shop for new venues, unless the trip itself reveals that times and places have somehow changed in an important way.

The pipe organ at Wannamakers

That's all changed, today. The pipe organ at Wannamakers, the cluster of department stores around Eighth and Market, the theater district, Caldwell's and Bailey Banks and Biddle upscale jewelers, the fancy women's clothing shops on Walnut and Chestnut Streets, and the bespoke men's tailor shops -- have disappeared in a slough of retail despond. The excited crowds of upscale shoppers have dwindled, at least in the center city shopping area. Students of sociology point to the decline of the department store as a central commotion in the center of this phenomenon, blaming that in turn on the spread of national brand names by television and more electronic forms of advertising. The department store did your comparison shopping for you, putting its brand name on the product and placing its reputation behind the choice. If Wannamaker could determine that a Japanese radio was of high quality, it became Wanamaker's radio. Today, Samsung and Sony do their own advertising, sell their products through outlets in the suburban malls. Philadelphia residents enjoy as much retail choice and pricing as ever, they just shop in the malls located along the Interstate circumferential highway, just outside what used to be the outermost suburbs. So the volume of retail shopping among Philadelphians probably hasn't changed a great deal; it has merely shifted to the malls where there is parking for your car to transport goods which the department stores used to deliver. It is the annual visits from the subordinate small cities at moderate distance that has disappeared. Small cities now have their own shopping malls, carrying national brand name merchandise. Losing this source of business, the associated entertainment industry has declined to a point below sustainability for most of them -- in the center city hub. Along with the disappearance of this regional recirculation, small cities have lost their sense of affiliation with a bigger one. The small-town professional class which was the biggest participant in this annual migration, is professionally more isolated but so are their clients. The upper crust of the small town now must constrain its horizon to the smaller town professionals, with their lesser claim to distinction. For a while, the disparity can be overcome by specialization, but ultimately the distinction of the big-city specialist rests on assembling a richer experience from a wider drawing power. In Medicine at least, the insistence of Medicare on paying the same fee for the same service lessens the economic incentive for self-repair of the system.

Wannamaker's Christmas Light Show

Meanwhile, nature of Christmas itself is becoming standardized. Fewer people make their own Christmas presents, whether through knitting or baking. If the process of commercial gifts goes the full distance, eventually the joy of searching for exactly the right gift will seem more like paying your taxes. These things already cost too much, are worth too little, and neither the process of giving a gift nor the process of receiving a welcome gift will retain much joy. Or significance. What was until recently a Christian religious celebration has become diversified into a generic "Happy Holiday", presumably in order to avoid offense to other religious groups who themselves likely persist in their old traditions of ritual greeting. The assault on Christmas is however not primarily cultural, but commercial. The silent ostentation of elaborate outdoor lighting and the secular versions of Christmas carols, endlessly replayed over loudspeakers in stores, probably have more destructive effect on the community winter solstice ceremony than any competition for religious adherence.

The coming next step in the modification of the Christmas season is dimly visible in the assault of pocket telephones on the suburban shopping mall. After enjoying only a few years of victory over the center city department store, malls must now confront shoppers with portable telephones containing a camera and GPS geographical locator. Seeing something he likes, the shopper of the future can photograph its bar code in the shop display, and be immediately told of all the neighboring stores which sell the same product for a lower price. Electronics are thus about to turn Christmas shopping into an electronic auction, no doubt making it eventually easier to do the shopping from home.

What Christmastime means to me is a recollection of what it once was like at the nation's oldest hospital, and not so terribly long ago, at that. Before 1965, the Pennsylvania hospital had been staffed for centuries with unpaid student nurses, working under the direction of unpaid doctors in training, supervised by volunteer attending physicians. Of the five hundred beds, only forty were filled with paying patients and the rest were housed in long communal halls. On Christmas morning at 7 AM, the drowsy patients were astonished to be awakened by a procession of very pretty student nurses, led by Miss McClellan the grim-looking Directress of nursing, and followed by a handful of internes and residents, all singing Christmas carols and carrying lighted candles in the dark. Miss McClellan herself was never heard to utter a note, but the student nurses had been trained in four-part harmony, and the interne doctors were enthusiastic followers. The faces of the poor old indigents in the beds were filled with pure delight as we traipsed past, chanting of the travels of Orient kings, the pregnancy of virgins, and other miracles of the occasion.

http://www.philadelphia-reflections.com/blog/1757.htm

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