Month: November 2018

New Giordano’s Pizza opens on Denver’s 16th Street Mall – read all about it here.

 

The first Giordano’s pizzeria opened on Chicago’s south side in 1974.  I first arrived in the Windy City two years later.  My UofC friends and I soon made it a regular weekend study break stop, along with nearby Gertie’s Ice Cream at 59th & Kedzie – since closed, but once home of the “Tummy Buster” which was free if you (and only you) could finish it all in one sitting.

New La Crosta Pizza opens in West Sac on 3rd Street – read all about it here.

 

Tastes in pizza certainly have changed over the past 40 years. But one thing that remains constant is the nearby ice cream place: Two doors down from La Crosta is Devil May Care Ice Cream and Frozen Treats, home to some seriously wacky flavors like “coffee and donuts” and “lavender honey & bee pollen.” Yes, you heard that right… bee pollen.  Hmmm, maybe ice cream tastes have changed over the last 40 years too?

 

 

We spent the day before I turn 60 mostly downtown (Denver). Our first stop was St. John’s Cathedral, then over to the 16th Street Mall for lunch at The Cheesecake Factory.  From there it’s only a 2-block hop on the mall shuttle to Christkindl Market, an annual pilgrimage for us. This is a great place for schlocky German crafts and fashion, polka music, gooey confections, and – my personal favorite – Glühwein (don’t ask).  We got home just in time to watch on TV as the Broncos beat the Steelers in a thriller at Mile High. In so doing, we avoided not only the crowds and traffic downtown, but also the potential shame of the home town team falling to 4-7.

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I found a recent DP review online for one of those “100 Things To Do In Denver Before You Die” guide-books.  While I haven’t done all of them, I did find it mildly entertaining. I also gleaned the following tidbits, shared with you here free of charge while I’m still a 50-something. After tomorrow, though, the price goes up. Way up. You been warned.

Excerpts from “100 Things to Do in Denver Before You Die”

The first building in Denver in 1858 was a saloon. There are 90 breweries, bars, saloons and rooftop cafes in the downtown area alone. (My favorite is Gov. Hickenlooper’s own Wynkoop Brewery, right across from Union Station.)

Stranahan’s Distillery makes some of the finest American single-malt whiskey this side of the Mississippi. Its tasting room (open noon-5 p.m., at 200 S. Kalamath St.) and distillery tours are something to write home about. If you’re really into your whiskey, consider camping out on the sidewalk outside the distillery with your fellow “Stranafans” on Dec. 1 for a taste of its special Snowflake whiskey blend.  (How can I never have been here? This goes on the bucket list!)

Denver Performing Arts Complex: There are 11 venues that seat 10,000 people for theater, symphony, opera and dance, making it the largest performing arts center under one roof in America. (We saw Book of Mormon here recently – hilarious.)

Denver Art Museum: The two buildings were designed by Gio Ponti of Milan, Italy, and Daniel Libeskind (his first building in the U.S.). They contain an impressive collection of Native American arts, plus other important art from around the world. Special exhibits have highlighted the works of everyone from Degas and Monet to Yves St. Laurent and Cartier.  (Anne’s a member and goes all the time.  Me, not as much.)

Denver Museum of Nature & Science: This is the fourth largest museum in the nation with one of the world’s best exhibits of dinosaur bones, many of which were discovered in Colorado. It holds a digital planetarium, IMAX theatre and hands-on scientific exhibits. (I’m a sucker for science, but even if you’re not, this is still a great place to visit with kids.)

Denver Botanic Gardens: Specializes in high altitude plants that can only be found in Colorado in the high tundra of North America, as well as a wide variety of other gardens, from tranquil Japanese gardens to classic English gardens. (I was last here when the Chihuly glass exhibit first came to town a few years back, but still a favorite.)

History Center Colorado: This new $100 million museum has interactive experiences to showcase the state’s history. Go down a simulated ski jump, descend into a coal mine, or learn about the importance of water to the dry and arid Southwest America. (Never been there. If you go, write me a review, please.)

 

 

A couple of geology and climatology stories today.

Earth science rocks!

Greenland’s newly discovered ice crater, here. Who knew?

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Unlucky dinosaurs, here. My own theory is that the dinosaurs were wiped out not by post-Chicxulub-impact soot, but by the well-documented health hazards of cigarette smoke. But that’s just me – and Gary Larson, I guess.

 

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California’s recent fires and air quality, here. I can tell you that the air around Sacramento has been so bad of late that you can’t even see to the end of Midstream Lane – pictured here in happier times of clearer air.

 

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Last but not least – bear with me now, folks – cosmogenic nuclide dating of glaciation, here.

Especially cool is the video from the American Museum of Natural History’s Science Bulletins, here, which follows geologists on a rock-harvest expedition much like the one I went on a few years back with a geologist friend from Colorado College. Our trip was to the Snowy Mountains of southern Wyoming. The one in the video was in New Zealand. But the underlying scientific principles and procedures are the same. What will they think of next?

Interesting to note, sample analysis post-harvest can take literally years due to the big backlog on high-tech equipment needed to determine nuclide levels. One would almost say, the pace of publishing research findings in this field is, well, positively glacial.

 

 

 

EMR – Electronic Medical Records – is a topic of special interest to me because it sits at the intersection of three streams of modern life which are near and dear to my heart: Medicine, Computers, and Writing.

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Atul Gawande is a surgeon who is also a writer. He has written a long long LONG piece about EMR  in the most recent  issue of the New Yorker.  It’s called “Why Doctors Hate Their Computers.” If you have the time and inclination, you can read all about it here.  Or, you can read on…  if you dare.

My brother-in-law is a former respiratory therapist. He now jets around the country helping hospitals implement an EMR package called “Epic.” He is well compensated for his time.  And he has seen the EMR debate from both sides.

When Gawande describes his initial encounter with his Epic “trainer” – this is how he sets the scene:

The surgeons at the training session ranged in age from thirty to seventy. I estimated about sixty per cent male, and one hundred per cent irritated at having to be there instead of seeing patients. Our trainer looked younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut, a blue button-down shirt, and chinos. Gazing out at his sullen audience, he seemed unperturbed. I learned during the next few sessions that each instructor had developed his or her own way of dealing with the hostile rabble. One was encouraging and parental. Another was unsmiling and efficient. Justin Bieber took the driver’s-ed approach: You don’t want to be here. I don’t want to be here.  Let’s just make the best of it.

My brother-in-law looks nothing like Justin Bieber.  He’s a long long LONG way out of college.  But I am guessing – to his credit – he takes the driver’s-ed approach.

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The debate over EMR boils down to a couple of key issues, each of which is viewed differently from the patient’s perspective, from the doctor’s perspective, and from the perspective of the computer guys sitting in the middle. I’ll address each of the issues in turn.

Control.

 

Back in the old days, meaning back when medicine operated under the “Arrowsmith” model (you can read about Sinclair Lewis’ novel  of a callow young doctor’s coming of age early in the 20th century here), the doctor-patient relationship was sacrosanct. House calls were not uncommon. And medical record-keeping was, well, mostly an after-thought. This gave the doctor a tremendous amount of control over literally everything. It gave the patient a close personal relationship with his or her caregiver, but not much else.  The relationship was highly asymmetrical.  That’s just the way things are – take it or leave it. (And computer guys didn’t even exist yet – more on this later.)

Many docs of my generation got into medicine with the “Arrowsmith” model lodged in the back of their brains. Is it any wonder then that, in an age of Epic and EMR, a lot of them would seriously contemplate early retirement than give up the total control which they see as a birth-right of their profession?

Communication.

 

From the patient side of things, Epic’s easy access to lab results and ease of communication with caregivers via the Patient Portal are undisputed pluses. Theoretically, access to historical information about a patient’s prior care should be a boon to physicians as well. And sometimes it is. But there are some unintended side effects of this model that tend to drive docs crazy. One of these is the sheer number of notifications and prompts spewing out of the system . These have to be continuously sorted though, prioritized, and attended to. Which ones are significant, or even relevant, in a particular case? Under the weight of this information deluge – and related time crunch – the doc’s temptation to ignore/delete becomes almost irresistible.

A more insidious, and I would say pernicious, side-effect of the computerization of medical record-keeping is what’s known as “the screen effect.” Consider the difference between the following two scenarios:

A patient sits on an exam table. The doc arrives and sits on a stool. In the old days, the doc talks to the patient looking him or her straight in the eye, elicits what’s known as a History of Present Illness and – if it’s an initial visit – a Family History and a General Review of Systems as well. Then the doc examines the patient from top to bottom, again giving the patient full attention. Afterward, once the patient is dressed and gone, the doc either writes or dictates notes of findings and impressions.

In an age of Epic/EMR, however, there’s a big shift after the doc comes in and sits down. Now, instead of looking exclusively and directly at the patient, the doc is looking primarily at a computer screen. (S)He’s inputting data as (s)he goes, responding to prompts, and – maybe, occasionally – glancing up at the patient. Set aside all the things potentially missed in terms of physical diagnosis.  It’s the social implications that are most profound. The “system” is now what’s driving the interaction. And, smart as that “system” may be, the trade-off between “record-keeping” and “relationship” has been undeniably altered.

Economics and Time

 

I mentioned the time crunch before. While there’s an initial promise of time-saving from EMR, the results where rubber meets road are a bit more complicated.

Unlike in the Arrowsmith days of solo primary care, modern medicine is big business first and foremost. The vast majority of physicians  nowadays are either part of a group practice or even a vast medical conglomerate that cares as much or more about profit as about patient care. (Those Big Corporations are the ones that can best afford the price tag of EMR packages like Epic, after all.) Talk to docs individually, or examine the statistics, you will find the same thing: The pressure to produce profits, measured as patient-visits-plus-treatments divided by time, is not just the bottom line. In fact, it ultimately drives both EMR lines of code as well as docs’ minute-by-minute decision-making. Do I even need to say, this is not necessarily a good thing?

Not for patients, of course – but especially not for docs. Job dissatisfaction leading to burnout or early retirement. Taking shortcuts – like ignoring those incessant Epic prompts/emails. And of course, facing toward a screen instead of toward a human being in an exam room. That last is perhaps the biggest of all bugs in a system still under construction, a system which is currently being beta tested on the American medical consumer.

Conclusion

 

So, in the face of all that, what’s an Epic consultant like my brother-in-law to do? Keeping an even keel during training (the driver’s-ed approach) certainly can’t hurt. Beyond that, understanding and attending to the parameters of frustration on each side seems key. To the extent that system customization can cut down on irrelevant and/or unnecessary information-flow to harried medical providers (more than just physicians, btw), by all means:  Do it!  To the extent that employing medical scribes, for instance, as the effective EMR interface-users – thus freeing up docs to face patients again in the exam room – Yes, Hallelujah, and Amen!

As for the underlying economic forces re-shaping the landscape of Big Medicine these days, I am less sanguine. Just as Henry Ford’s assembly line – and later, computerized robotics – transformed the auto industry, so too with medical care delivery. Given the seemingly astronomical price tag health care carries these days, I’d be more surprised if it didn’t.

As to whether becoming a doc retains its allure in an age long past the extinction of Arrowsmith? Well, that remains very much an open question. Might be better to trade in the white coat for a blue button-down and chinos, become an Epic consultant.

Oh, and don’t forget the early Justin Bieber wave-cut.  Details here.