Health Care - Only when it's me!

   When I first started writing a medical blog I thought I'd have so many readers, writing so many comments, that I mightn't be able to  keep up with it.  After all, I'd been practicing medicine for fifty five years and on virtually every social and other occasions, no  matter how hard I tried to steer the conversation away from medicine, there seemed to be no escape.  None of the people I was interacting with were my patients but they all  assumed that I would have an overwhelming desire to  listen to their health stories and those of their families, every one of them unique, from their mother's gallstones (the biggest the doctor had ever seen!) to their grandfather's prostate.  Many of them wanted to point out the inadequacies of the health care system and particularly of the physicians and nurses they had to deal with.  I must add, a few, a very few, wanted to tell me about the excellent care and consideration they had received but they were few and far between.  Some, seemed to feel that not only was the whole profession incompetent and uncaring, but that I  personally was responsible.
   I listened endlessly to complaints, some subtle and some resentful, about the vast amount of money doctors made, from folks with a thirty-five hour work week, benefits and fat pension, when I was working twice as  many hours with no benefits and no pension (until I was smart enough to become an academic and working for he University, which is, of course a civil service job).  When I pointed out some of these facts, they would point out  to me, sometimes rather aggressively, that it was I who decided to go into medicine and I knew what that implied before I made the choice.  I didn't bother to point out to them, that no young person, inspired by idealism and excitement and glamour of  a medical career really has any idea of what it is going to cost them.  It costs them their youth and many of the joyful and carefree experiences that most young persons enjoy.  It exposes them to all of the tragedies and catastrophes and suffering that is the human burden, that most people of their age can't even imagine.  That has a high price tag.
   One of the most irritating aspects of the chats encountered in the social milieu was from the folks with no medical or scientific background, who were determined to inflict me with crackpot alternate medical treatment for various conditions. They usually were not so  much interested in discussing the possible scientific merits of whatever they were advocating, as in receiving an endorsement of whatever they were proposing.  When they didn't get that, they were in no doubt that it was because of the vested interests of the medical profession, who were really only condemning it, because doctors would lose money if they let people find out that almost any condition could be cured by a gluten free diet or coffee ground enemas that they could get in  Mexico for only a few thousand dollars.  No one ever seemed to grow tired of medical tales, especially when they were telling them.
   So when I started my medical blog,  I thought folks would be thrilled to have a forum in which they could discuss any and all issues related to health care, personal, community, practical or theoretical.  Interesting and unusual stories, serious and not so serious, amusing and funny incidents.
   Two years later, after blogging twice a week with a variety of articles and anecdotes, I found that there was no discussion, few comments, no raising of interesting issues other than those I raised myself. Not even any complaints. 
   Then the light turned on and it dawned on me!   People are only interested in medicine when it effects them personally.  If one is currently not involved with the health care system it really doesn't matter very much.  It seems to be there, was once admired and even now isn't that bad, although some people seem to be complaining.  That's why Canadian health care is now near the bottom of the list in the developed world.
   And that's why I'm cutting down on the frequency of medicalmanes.com so I can turn my attention to a completely different type of blog!  I will appear here from time to time, but not on a bi-weekly basis as in the past.
   Your comments if you have any, will as always, be welcome.

The Stethoscope. Is auscultation obsolete?

   On the occasion of the 200th anniversary of the invention of the stethoscope, one of our National newspapers featured a piece debating whether the stethoscope is, or soon will be obsolete.  Now that we have ultrasound, CT scans and MRIs should we be throwing away the stethoscope?   That's like saying now that we have calculators and computers should we stop learning 'times tables'.  Some would say yes, and that has been a part of  our decline.  I think  the same about the art of auscultation, a vital tool in the understanding and diagnosis of what is going on in various parts of the human body.  

Invention of the stethoscope

René Laennec wrote the classic treatise De l'Auscultation Médiate, published in August 1819.^[2] The preface reads:

In 1816, I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [direct auscultation]  (i.e. putting the ear directly on the patient's chest) being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, ... the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.

 Here's a picture of Laennec's stethoscope:

 

 Here's a picture of my stethoscopes:










So they have changed a bit with the passage of time!

 When I read some of the comments made by many of my modern colleagues I have the uncomfortable feeling that they are not physicians st all.  Admirable technicians and scientists, yes, and much more capable than I at interpreting computer data aimed at many complex diagnostic problems.  On the 200th anniversary of the invention of the stethoscope some doctors have already written it off an obsolete diagnostic instrument.  Many of us who have used the stethoscope over a lifetime found it to be a valuable diagnostic instrument that is portable, inexpensive, noninvasive and capable of giving much information to those who have learned to use it efficiently.   Many doctors and nurses can pull out their stethoscope at any time of the day or night and get an immediate answer to the pressing question they need the answer to right at that moment and not just in auscultation of the chest, but of the bowel and other locations.   No waiting around to find the right piece of equipment and sometimes the right technical expert to interpret what it may mean. 
  Another and perhaps tenuous relationship is the real-time connection between between the doctor and the patient, the conduit between the physician's brain and the patient's body, during which the doctor can modify and localize the examination in accordance with his findings.  It is only after a careful clinical examination that  high tech instruments should be introduced in an appropriately directed manner, bearing in mind that inappropriate use is not only expensive but can be dangerous in unleashing the medical cascade that has cost more than one patient his life.
   Let me finalize my feelings for the humble stethoscope with an ode I composed a couple of years ago on the occasion of hanging up mine:

     Ode to a Stethoscope

I lay you, faithful stethoscope to rest,
Against how many hearts have you been pressed?
 The secrets of the airways all laid bare,
As you measured sounds of heart and air,
No MRI or CAT scan will astound,
The way you did, just listening to the sound.

Oh mighty stethoscope you told me so much,
And confidence exuded from your touch.
Now relegated to a lowly role.
I still think that you head the Honour Roll!

                

Health Care Waste..and waste...

  In 2009 the Auditor General of Ontario released the report of his investigation into the scandalous waste of the eHealth Agency in Ontario, the body charged with implementing electronic health records in the province.  The bill was over a billion dollars!  God knows how much by now, 2016, for a system that is barely limping along.  The Board of Directors stated that it felt it had little power over the CEO, thereby revealing their total incompetence to serve as a board.  There was more than a little skulldugery and CEO Sarah Kramer walked away with a generous severance and a bonus to boot.  We're still spending a fortune on trying to implement a comprehensive system.  Now the former president of the TD group, a banker, who advised the premier to sell off 60 % Hydro One (the electric company) is being asked how to 'maximize the value' of the province's Digital Health System (i.e. the electronic medical  record ).  eHealth Ontario is a government owned private agency responsible for organizing and storing your medical data.  You may wonder what 'maximize the value means'.  Sounds to me like the precursor to trying to cut some sort of a deal that would remove the monkey from the backs of the Premier and her administridiots and place it elsewhere.
   Let me wind up with a little illustrative fable.

A fable

 

Once  upon a time ...

 

The  king called on the royal weather forecaster and inquired as to the weather  forecast for the next few hours.  The royal weatherman assured him  that there was no chance of rain for at least 4 days.
 
So  the king went fishing with his wife, the queen. On the way he met a farmer  on his donkey. Upon seeing the king the farmer said, "Your Majesty, you  should return to the palace!  In just a short time I expect a huge  amount of rain to fall in this area." 
 
The  king was polite and considerate, he replied: "Thanks for your concern, but  don't worry. It's not going to rain today. I hold the palace meteorologist  in high regard. He is an  extensively educated and experienced  professional. And besides, I pay him very high wages. He gave me a very  different forecast. I trust him." 
 
So  the king continued on his way.  However, a short time later a  torrential rain fell from the sky. The King and Queen were totally soaked  and their entourage chuckled upon seeing them in such a shameful  condition.
 
Furious,  the king returned to the palace and gave the order to fire the  professional. Then he summoned the farmer and offered him the prestigious  and high paying role of royal forecaster.
 
The  farmer said, "Your Majesty, I do not know anything about forecasting. I  obtained the information about rain today from my donkey. If I see my  donkey's ears drooping, it means  with certainty that it will rain  very soon."  So the king hired the donkey instead.
 
And  thus began the practice of hiring dumb asses to work in the government and  occupy its highest and most influential positions.
   
The  practice is unbroken to this day...

 

(My apologies to all of the donkeys I know.)

Cannabinoid Hyperemesis Syndrome / Oh Canada, O Cannabis.

  Cannabinoid Hyperemesis Syndrome.

   What is it?  It is a syndrome characterized by recurrent nausea, vomiting and abdominal pain associated with chronic marijuana use.  It was first described in 2004 and found to occur in cyclic patterns.  It resolves with cessation of cannabis use.  Gastro-intestinal  system testing is characteristically negative. These folks often think they are treating their symptoms by increasing their use of pot.  When they present themselves at the emergency room this relatively recent diagnosis is usually not considered. They often end up having an extensive GI workup which shows nothing, but does cost a lot of money.  Apart from its immediate effects, marijuana also effects brain development and may effect thinking, memory and learning functions on a long term or even permanent basis.  Smoking pot seems to have most of the same problems associated with it that tobacco does. It also increases heart rate for up to an hour after smoking it so may put persons with cardiac problems at increased risk. Many more side effects may well emerge in the future. 
   In Colorado, since legalization of pot, emergency room visits related to marijuana have increased by thirty percent.  Hospitalizations related to pot are up from 803 per 100,000 to 2413 per 100,000 between Jan 2014 and June 2015.  A national survey suggests there has been a significant increase in the use of pot by the 18-25 year old group of Coloradans.
  Canadians are about to leap into the Pot pot.  This decision will cost us a lot of money in a health care system that ranks 10th of 11 in health care in the developed world.  More people will wait even longer for health care that they urgently need.  More people will be maimed or killed on the roads. Pot shops will proliferate and pot will be available to underage kids.
  The politicians and their adminstridiots are not concerned about this.  It will be a politically popular move, keep the folks happy and be a lucrative source of taxes, so why should they care.  Even more surprising is the fact that a considerable number of physicians seem to support this move and regard it as an easy source of money.
  The decline continues.
     

Family Medicine Tales - The last argument.

 "Is there a physician aboard the aircraft?" The Captain's voice rang out over the intercom system of the 747.
 

    I lingered in my seat for a moment, as long my conscience would allow me to, hoping there was another physician on board who would come forward before I did.  This was the first holiday we had managed in two and a half years and our first trip to Hawaii. I  knew I'd been too preoccupied with work for too long, and hoped this holiday would restore us.  I pushed myself wearily out of my seat, and identified myself to the stewardess.

      "We have him up in first class, doctor, there's more room there. He's having a fit," She said.

      I rapidly moved up to the front of the aircraft, beyond the curtained partition, into the comfortable, spacious, first class area.  A disheveled, heavy-set man was convulsing on the floor.  A stewardess knelt beside him, trying to push a wooden tongue depressor between his teeth. White foam escaped from his mouth as amidst the seizing, he attempted to turn his head away.

      "What sort of medications do you have on board?" I asked the stewardess as I knelt down beside the patient, and taking the tongue depressor in one hand, I  firmly grasped the man's chin with the other, forcing his jaws apart sufficiently to insert the wooden stick between his teeth.

      "I'll get the medications bag," the stewardess said, moving quickly into the storage area in the front of the cabin.

      I  loosened the man's collar and tie, and then took the black medications bag that was handed to me.  I quickly rooted through it's untidy contents, then emptied it on the seat beside me.   I found a small cardboard container with some ampoules of phenobarbital, and a syringe and sucked up the contents of two of them into the syringe. 

      "Need any help?" one of the few passengers who had been watching apprehensively, asked. 

      "If you can give us a hand to get his jacket off, I'll be able to inject this right into the vein and get this seizuring stopped," I said.

      With the help of the man, and the stewardess we got the patient's jacket off and  managed with difficulty to get the needle into the vein and inject the phenobarbital.  A few minutes later the seizures had diminished, and the man slipped  into an uneasy sleep. 

      "Has this man anyone with him?" I asked the stewardess.

      "No," said the stewardess, "he's on his own."

      "I think he'll be okay now, but he should be checked over by the airport physician when we land.  We'll need to find out about his previous history, and if he's on any medications, to decide what needs to be done next. How long will it be before we land?"

      "About two hours, we'll radio ahead to make sure the airport physician is available to look after things".

      "Well, I'll go back and join my wife, you can come and get me if you need me," I said.

      "Would you give us your name and address, doctor, so we can account for the drugs we have used?"

      I gave them my name and address, and went back to join my wife.

      "No rest for the wicked," I said. "The least they might have done is moved us up to first class for the rest of the flight," 

      About three months after the Hawaiian holiday I had to attend a meeting in Toronto. The professional association to which I belonged and served on the executive, met several times annually, usually in Toronto.

     
    Earlier in the day, the chairman, Don Watson had suggested that after the meeting the group go out to dinner in a nearby restaurant that had recently opened.

      "Great," said Rick, "I hear this place is really good, although I haven't actually eaten there yet."

      "It's excellent," Don said, "Will I make reservations for about seven?"

      Everyone agreed that this would be a good idea, and a few minutes after seven o'clock, when I walked into the Magnolia Grill, everyone else was already working on their first drink.  Several members of the party spotted me enter the restaurant and waved to me.

      "I'm with the Watson party over there," I indicated to the hostess who greeted me.

      She waved me on, and I made my way through the noisy restaurant over to the group of seven physicians sitting in an alcove that slightly muffled the ambient sounds. I took the empty seat next to Joelle Levesque, one of the two women in the group.  Joelle was a lively attractive thirty two year old physician from Quebec.

      "Half the department heads in family medicine are so busy with their administrative work that they only see patients one or two half days a week.  No one can maintain either their credibility or competence with that limited amount of practice," Ian Hamilton was saying, "Hi Stan." he added as I sat down.

      "I hope you guys aren't going to talk shop all night. Haven't you had enough all day?"

      "Dr. Smith wants some scintillating conversation," Joelle Levesque said sarcastically."

      "Well, I wouldn't actually expect that from this group," said I facetiously.  At the same time I thought to myself,that no one seemed to think that was funny!

      "I just had an interesting experience on my way back from Moscow," Don Watson's timely interjection defused the developing tension.  "I got the Moscow - London fight, and we were barely in the air, when the Captain wanted to know  whether there was a doctor on board.  Well, I sat for a moment, hoping some eager young physician would rush forward and leave me sipping my scotch, but of course no one did, and I reported for duty to the stewardess.

      'just up there in first class, Doctor' she said'

      I went upstairs into a very fancy looking lounge, and found a perfectly healthy looking young woman, who had some pain in her left shoulder and had read somewhere that this can be the first sign of a heart attack, which very obviously it wasn't.  So I gave her the appropriate reassurance and was heading back to our rather modest seats in the back of the aircraft, when the stewardess said, 'we'd like you and your wife to enjoy the first-class facilities for the rest of the trip, Doctor.'  So Ann and I came forward and go the royal treatment for the rest of the trip."

      A chorus of "lucky so and so " went around the table.

      Then I said, "I guess that wasn't Air Canada, then.  Let me tell you what happened to me," and I recounted my story of a few months earlier, finishing with, "and I didn't even get a thank you note."

      "What you want, they kiss your ass?" Joelle said rudely, her French Canadian accent coming to the fore.

      "No," said I, a little taken aback at the strength of her reaction,and the obvious resentment in her voice, "all I wanted was a little common courtesy."

      Joelle pulled a cigarette out of the packet sitting on the table beside her, put it in her mouth and lit it herself, and then rummaged around her bag, finally pulling out a pen. (We all smoked like troopers in  those days, especially when we were drinking!) She then fixed her angry gaze on me.

      "What flight was this supposed to be on?" she quizzed me.

      "It was January 17th. Air Canada. I don't remember the number, but how many flights can there be from Toronto to Honolulu in any given time."

      "Yes, we can find that out" Joelle replied, noting the date that I had given her.

      "Why are you so interested in this?"I asked .

      "Because my husband is the Head of public relations for Air Canada."

    I couldn't suppress a chuckle."I see," I said.

      She scribbled furiously on the back of her cigarette package, her crescendoing anger becoming increasingly evident.

      "Air Canada routinely sends out a letter of appreciation all passengers who come to the aid of others." Implying I didn't mention I had received one.

      "I certainly didn't get one."

      "If you didn't, we'll check it out and send you one."

      "Thanks"

      She continued scribbling on the back of her cigarette package.

      "I will give this information to my husband and you will hear from him, if you didn't get a letter." she said sourly.

      "Don't worry about it," said I casually.

      The evening wound down uneasily, and at about 11.30pm the group stood  up and started their goodbyes.

      "See you in the morning," said Don Watson, "We should have our business completed by noon, so those of you with early flights should have no problem."

      The gathering broke up, with those with cars making sure that everyone had a ride back to their hotels.  

      Following the meeting I took a limousine out to the airport to catch the mid afternoon flight back to Saskatchewan.  I was glad to get back at a reasonable hour for a change and have a little time to spend with the kids before bedtime, and a pleasant long evening at home.

      Eight O'clock Monday morning, I was at Family Medicine Rounds.  The rounds, usually over by nine am dragged on until nine thirty.  As soon as they were over I slipped away to the office to check my mail as I had been away for several days.  It was the usual rubbish, advertising literature which had slipped past my secretary, usually not much did, some teaching activities from other departments that I wasn't much interested in, a complimentary copy of a book in which I'd written a chapter and some notifications of upcoming events.  A pretty boring assortment,all in all.  I was getting ready to go over to  the clinic, when the phone began to ring insistently.

     
 "Hello," .

      
 "Hi Stan," said Peter, executive director of the Association of Family Physicians, "I'm afraid I have some very bad news for you.  Joelle Levesque was pulling out of the parking lot, leaving the hospital this morning, when she slumped unconscious over the wheel of her car.  By the time they got her to the emergency department she was dead from a brain hemorrhage."

      "Oh my God," said I,wondering for a moment whether I had played some part in causing her death.

      "We are going to send regrets from the executive, and suggest that we would like to establish a scholarship in her name  As an executive member would you be supportive of setting up such a fund?" asked Peter.

      "Definitely," said I, for some insane reason feeling as though I had contributed to her demise.

     

     

     

     

Stress, stress and more stress.

   I often hear people complain about how much  more stressful life is today than in the past.  I don't think that is true, but I do think that people are losing the ability to handle stress and to deal with situations that previous generations had to overcome using their own resources.  It was a swim or sink situation and most people learned to deal with stressful situations and by so doing became more resourceful and more competent at dealing with it, thus equipping themselves for the vicissitudes of daily life.  Of course, we all know that all  men are not created equal and there are men and women who deal with stress very well and there are those who do not do so well.  In any case, even in those who do deal with stress very successfully, the burden can sometimes become overwhelming.  Appropriate help is of course, a very good thing and can save suffering and lives.  Nevertheless, too aggressive and too early intervention stunts the ability of  the individual to develop the necessary skills and results in a population that is overly dependent on others and cannot cope with even mild stress.  In 2015, half of Americans starting university reported being stressed all or most of the time. This seems to be particularly prevalent in our institutions and our universities, where healthy energetic young adults seem to be constantly whining about 'microagressions' and 'safe spaces'  (Give me a break!)  Mild amounts of stress are beneficial and teach people to deal with adversity.  It encourages thought, creativity and activity and the successful thrive on it.  On the other hand, high level stress or persisting stress have enduring effects that are detrimental to the individual and do require intervention.  
Hans Selye, the great Hungarian, McGill endocrinologist, described the body's reaction to stress as the General Adaptation Syndrome.   In his words:
"I call this general because it is produced only by agents which have a general effect upon large portions of the body .  I call it adaptive because it stimulates defense.   I call it a syndrome because its individual manifestations are coordinated and even partly dependent on each  other."
   He described three stages of response to stress.
The first is the Alarm Stage, in which the body activates its flight or fight response and releases stress hormones into the blood stream.  These hormones enable activities above and beyond what one is normally capable of that might be instrumental in saving your life, such as getting out of the way of a hungry lion.  In modern life, if this generated energy is repeatedly not used it can becme harmful.  The adrenaline surge elevates blood pressure and can, over an extended period of time damage blood vessels and even the heart.  
Adaptation or resistance stage.
   Cortisol also has many damaging effects when released over an extended period.  When the stress is dealt with, or partially dealt with hormone levels tend to gradually  reduce towards normal.  If the stress in prolonged or repetitive and its resources are exhausted permanent damage may result. 
   Stage 3 may result in either recovery or exhaustion of the of those resources. 
Recovery occurs when the the compensatory mechanisms overcome (or adapt to) the stressor effect or the source of the stress is removed.  Alternatively, if the stress is great or prolonged the mechanism's ability to deal with it breaks down and the individual is unable to function normally.  The autonomic nervous system becomes hyperactive, resulting in rapid pulse, palpitations, sweating and anxiety.  Hormone levels remain elevated and can effect long-lasting or permanent damage to the gastro-intestinal, cardio-vascular and immune systems.
   So, to sum up, a little bit of stress is good for you.  Teaches you how to evaluate potentially dangerous situations and to do something about them.  This is probably one of the most important skills you can acquire and like most things in life improves with practice.  When the stress is great or persistent or your attempt to deal with it fails, then you need help.
Comment if you'd like to discuss stress.

More Sabbitical Wanderings Israel. Pt 5.

Tue 20 Feb 1996
 
Kibbutz Katura

       We woke up at the crack of dawn to the sounds of the birds - and the trucks.  we grabbed a quick bite of breakfast, suspiciously reminiscent of the previous nights dinner, and headed out to a nearby kibbutz, where Jeff carries on a clinic. Irene went for a walk while Jeff and I saw patients at the clinic. The chair of the department had asked me to make observations and recommendations regarding the many rural clinics I visited and comment about how they compared with Canadian rural practices. There was a considerable cross-section of clinical disorders, ranging from the minor to the major.  It was of interest to me that the Kibbutz employs a number Thai workers, mainly as fruit-pickers.  Jeff thought the official figures were 30,000 Thai workers.  Probably there were more, he thought. We saw a couple of them at the clinic.  It was very difficult as they spoke  only Thai.  The technique was to phone an interpreter, and once on the line the patient would relate the problems to the interpreter, who would then relay it to the doctor.  Then the phone would be passed back and forth, and the story relayed.  Time consuming and sometimes the translators skills were not the  best, but it's the best that was available.

       After the clinic was over we drove to Eilat.  Following along the awesome Jordanian Mountains, the border a mere few hundred meters to our left, we arrived at the Red Sea and Eilat in a short while. We spent a while on the glorious beach, then walked along the promenade.  One could have been in an exotic resort anywhere in  the world.  We spent a  little time looking into various shops, some very high-end, others not so much. then ambled  back to our car.  We drove back up the Eilat Road back to Beer Sheva by the Dead Sea route.  Took us about two and a half hours to get home.

Wed 21 Feb.

       Went to work this am and picked up a bunch of mail that was dispatched express from home. It took 11 days to get here. In the mail was a sad note informing me of the death of my old school friend, Bernard Green.  The note was from his wife, with no return address.  I must try to get her address so I can send a note. Bernie and I were the closest of friends during our formative years, and were in and out of many scrapes.

Thur 22 Feb.

       Went to work again!

       This evening we went over to Betty and Arye (we knew her from Dublin) for a light supper before going to see "Fiddler on the Roof," by the Beer Sheva opera soc.  Arye's home made Cherry Brandy was good - I'd get the recipe if I thought I'd ever get around to making it.  The production was good and enjoyable, if not professional.  It was in Hebrew, of course,with English titles.

February 23, 1996

       Sat around the yard and did a bit of planning for a trip up north.

       This evening we went over to Lisa and Nachum Portugese for supper.  I met Lisa at the clinic.  Argentine immigrants to Israel, they are both physicians, she a Family Doc, he some sort of Shrink.  She dark and chubby, with an animated manner and a face that was as expressive as her voice.  He, quiet, reserved, blond hair and blue eyes belying his Sephardic origins.  Lisa told me that his family moved from Spain at the time of the inquisition, to Portugal.  Eventually the family moved to Argentina, where the name 'Portugal' was bestowed upon them.

       Lisa talked non-stop, telling us about all the hoops they were forced to jump through to get licensed in Israel, she being non Hebrew-speaking and knowing just a little English, he speaking some Hebrew.  Finally they did get to write their exams in Spanish, and both of them did well.Lisa also regaled us with some stories of demanding patients, and believe me, there was no shortage of them in Israel.

        Talked a little politics.  I asked him what he thought of Peres.  Nachum said he had voted for Rabin, but thought Peres was a little too left and a little too soft.  He was for peace, of course, but would rather negotiate from a position of strength.  I brought up 'BB' Netanyahu, saying that he seemed to enjoy more popularity in America than he does in Israel. He agreed, but thought that the elections could go any way. (This was 1996 remember).

       They have a delightful little  girl who is learning English and seemed delighted to have us to  try it out.  Before we realized it, it was almost midnight, and we took our leave.  It was a very pleasant evening.

February 24, 1996. Sat.

       This social life is going to kill me!  Got up in time to head out to brunch at Carmi Margolis'  Carmi is assistant dean, and is very interested and active in the areas of Clinical Practice Guidelines and Clinical Decision Making.  He is an American,who after his stint in the US Army, came to settle in Israel. A tall, nice looking man in his fifties, he wears a small kipa on the back of his head.  He told me that after his discharge from the US army he contiued to do his reserve duty, and some years served in both the US and Israeli armies.

       Present at the lunch as well as the Margolis' and three of their five children, was a young Cuban couple who had recently emigrated to Israel from Cuba.  He is some sort of Aviation Engineer, she a mid-wife.  Neither of them have found work in their chosen fields, and he is currently working in some sort of factory.  She is trying to get licensed as a mid-wife, but has the additional difficulties associated with not speaking Hebrew or English very well. Mrs Margolis is a dance teacher, and also American.  We discusssed dance, music, Cuba, medicine and politics.  Sang a few shabbat songs as is their family tradition, had a nice lunch and sang grace.  The Margolis' are vegetarian, and served some interesting dishes, including 'vegiballs', which if nobody had told me I would have taken for meatballs.  Left at about 3.30pm and had a drive around the old city, then home.