Saturday, April 28, 2012

Giddy-up Dallas - Yee Haw! 2


The Gossips
Breakfast began at 0630. My dietary preferences were requested upon registration. My preference? Low salt, vegetarian. The menu for the conference was provided at check-in. “We want to make sure you have what you need.” I was bowled over by their service and thanked them profusely and thoroughly.
The meals were buffet-style with a plethora of vegan / vegetarian choices: several salads, hot and cold vegetables, whole grain and pasta entrees. It was by far the most truly, healthy buffet I’d seen outside a specialty establishment.
Breakfast backslid and contained all the usual suspects: scrambled eggs and bacon, oatmeal, fresh fruit, yogurt, pastries, bagels, and granola. I served up a plate of fresh fruit and coffee and longed, not for the first time, for bacon. I miss eating bacon, its scent is irresistible - still. AUGH!
As an interesting aside, our badges were bar-coded. Entrance into all conference events, including meals, were scanned. That’s a first.
I found Linda in the crowd of 300 - whew! The opening presentation covered the state of healthcare in the US. 
“Eight thousand dollars per person per year. Did you get that kind of value? We have the most expensive care, not the best care. Could we do better by the money we spend? It will take a shift from pay-for-performance (pay for procedures) to pay-for-results.” To that end, the remaining lecture addressed population management - moving the nation’s population toward health. How do we do that?
“For starters, one must understand the scope of the problem.” 
Visit: http://www.countyhealthrankings.org/ to view health outcomes by US county. This site provides the state of the state as measured by adult smoking, adult obesity, physical inactivity, excessive drinking, premature death, and death by motor vehicle crash.
Here’s an interesting statistic against which you can measure yourself: what percentage of Americans exercise 20-minutes three times per week, do not smoke, eat five servings of fruits and vegetables each day, wear seat belts, and have a normal BMI (body mass index = a ratio of body muscle:fat = gross indicator of body fat and health)? I guessed 20%. Survey says: only 3%. My mouth gaped and I gasped in disbelief.
How does one personally make use of such data? Compare yourself to the measure and start working toward towing the line. Why? Because your body is THE vehicle in which you travel through this life. If you honor it, it will serve you long and well. Life is easier in a body that works and moves pain-free. Really? Really.
“Next,” the lecturer moved on, “Provide basic health coverage for all.” So people can receive health maintenance in a doctor’s office instead of crisis intervention in an Emergency Department. 
Why should we pay for their healthcare, you ask? When people seek primary care in an Emergency Department (ED); who do you think pays for that? When they seek care in free, community, outreach clinics; who do you think pays for that? When they commit petty theft to get prenatal care in jail; who do you think pays for that? When they birth crack-babies that need detox and special schools; who do you think pays for that? When they are in and out of jail because they are unable to function without routine psychiatric medications; who do you think pays for that? When they come into the ED in hypertensive crisis because, due to job loss, they could not afford their blood pressure medicine; who do you think pays for that? When the blister on their toe turns into an ulcer and amputation because they had to choose between groceries or diabetes medication; who do you think pays for that? 
You think the poor, working poor, jobless, and disenfranchised don’t get medical care? Wrong - they get it late in the game and at the highest price - in the ED. Who pays for that?
WE do, our tax dollars pay for that. And who pays the highest effective tax rate in America? The middle class - that’s us my friends. So like the speaker, my feeling is - if we are paying for it anyway - let’s make it infinitely more efficient and cost effective by providing universal coverage. 
Kaiser’s CEO says initially, as we bring 32-million uninsured into the fold, costs will increase but ultimately drop as the cost burden  is shared across a larger pool and we move primary care visits from the ED. There are many parallels to car insurance.
CNN’s Fareed Zakaria (love this guy) did a series on healthcare. He says as other nations create healthcare systems for their citizens, our infamous model is the one to avoid unless expensive and inadequate is the goal. Ouch! There is no shortage of opinion on the topic. Some Christians argue for universal coverage from a place of compassion. Not surprisingly, the Christian Right is vehemently opposed. WWJD?
I know some of you will disagree and I am open to all conversations on this subject. But start your argument thoroughly grounded in reality: we have the highest cost of healthcare in the world, far from penetrating coverage, and a population in health crisis. All solutions welcome!
As healthcare reimbursement dollars shift to successful outcome measures (good BP, BMI, A1c, LDL, etc.) versus pay-for-performance (procedures), there will be increasing pressures and focus to have patients meet the health indicator measures like those in the aforementioned website. How, as healthcare professionals, do we motivate, cajole, enroll, and move people toward healthier lifestyles?
Ah - that’s the billions and billions (adieu Carl Sagan) of dollars question. 
The lecturer continued with requisite items needed for such a system of care and accountability: an electronic health record - check, an integrated delivery system enabling integrated care (translated: the Cardiologist knows the plan outlined by Nephrology) - check, a plan for addressing key medical issues more frequently - (we call it Every Patient, Every Time) - check.
Kaiser Permanente implemented a population management model at least four years ago. I work in a department focused on population management. It is a daunting, unending, ever-changing dilemma ...  and we are lightyears ahead of the country. 
As a people, we are living longer and living longer with chronic disease. How do we live well with chronic disease? If medical reimbursement is tied to “healthy outcomes”; how does my doctor get paid when my chronic disease is out of control? How does my doctor get my chronic disease controlled without my buy-in or participation? In short: how do we incentivize and monetize health?
The tension in the room was palpable as practitioners realized the scope of the task ahead - to which our paychecks are tied. And I - not for the first time - was thankful to work for Kaiser Permanente with its visionary leadership, workflows, and (albeit sometimes painful) expectations.
Lastly, the speaker proposed that if the personal mandate is struck down by the supreme court, expect an expansion of Medicaid and Medicare and an increased tax burden on the middle class. I’ve heard this from multiple sources and either way, there is a silver lining for me. As 32-million Americans enroll for health coverage, the demand for mid-level providers like myself, will explode.
This opening lecture was worth the price of admission against which the remaining conference paled. Hence, I’ll spare you the details of insulins, and incretins, and endocrine blah, blah, blah.
Linda and I hailed a cab to West Village in Uptown, a swanky collection of outdoor eateries an boutiques just north of downtown Dallas and bordering Highland Park. I had a friend in Alaska who hailed from Highland Park. She joked the soil was black with oil and her middle fingers were crooked for the weight of her silver spoons. Magnolia was an outrageous, bodacious, boozin’, schmoozin’, smokin’ gal who lived life large in every way... until la vida loca disrupted the endothelial function of her coronary arteries and her come-to-Jesus arrived prematurely. I hadn’t thought of her in years until I stomped through her old stomping grounds.
The sign said: Cowboy Cool. “This will be an urban cowboy store,” I said, pulling the door open. Swanky? Oh honey, you ain’t seen nothin’ yet! Custom made boots with pricing upon request. These weren’t boots, they were hand-tooled, seamed in braided leather, works of art priced at no less than four-figures. Beautiful? OMG!
We walked the mile from West Village to Javier’s Gourmet Mexicano Restaurante and arrived with the help. The outdoor patio, the cigar bar, and the brass wrapped beverage bar were open until they began seating the dining room. We ordered margaritas. 
Our bartender Jorge’ provided some backfill. Javier’s serves the cuisine of Mexico City in a realistic setting: a masculine jumble of mounted game, large paintings in gilded frames, and hanging plants. Their chips were unsalted, super thin, and made on-site daily.  
Remember Chris? You should know if their food is good from the beginning - by the crispiness of their chips and snappiness of the salsa. They came with ramekins of salsa and whipped butter. Yes - whipped butter into which one could dip their chips if one was so inclined. I dipped one, er - no thanks - I thought, remembering Magnolia’s early come-to-Christos. I did eat an excellent salad of spicy, grilled shrimp, avocados, and cilantro dressing.
As another aside, Dallas is home of the first frozen and blended margarita. As a young restauranteur, Mariano Martinez put tequila and the slushie adult beverage on the map in Dallas at Mariano’s Hacienda back in the 70’s. Let us raise our voices in praise.
Still marching to PST, I was not ready for sleep. I sat against the Hilton’s infinity pond, to the trickle of water, and watched Nebula. Nebula is a tangle of, what appears to be amber glass beads but are, in fact, bicycle wheel reflectors, and cabling - an eight-story, kinetic sculpture that appears to tumble endlessly in the atrium of Anatole's middle tower. In daylight, the clockwork gears overhead are visible and if one tracks a single bead, one discovers that Nebula does not tumble but undulates. Backlit at night, I found its slow somersault overhead not unlike the curl of waves breaking upon the sand, mesmerizing and calming.  See Nebula on YouTube: go to minute-14 of the website below.
You artisans may enjoy the 4-part series recounting the fabrication of Nebula at http://www.youtube.com/watch?v=mSCM-CJlrIg&feature=relmfu
I had no knowledge of this sculpture before my arrival or any concept of what it took to assemble but its presence was undeniable and grand. At night, it brought a touch of magic and silent movement to the overhead cavity, which I enjoyed immensely.
Stay tuned for unlikely assassins and the grassy knoll. (I know I said this before but it is really next.)

Sunday, April 22, 2012

Giddy-up Dallas - Yee Haw!


“I'm wondering about wearing my cowboy boots,” I said, extending and wiggling a booted foot. “But traveling with something this bulky...” my voice trailed off. 
“Buy boots there,” Maria said, “You'll find boots there you won't find anywhere.”
“Really?” That never occurred to me.
“And a cowboy hat,” Bev offered with enthusiasm, “Ya gotta have a cowboy hat.”
“I actually bought a Stetson when I visited Jackson Hole. It even has stampede straps so it's pretty stylin'. But again, traveling with something like that...”
“Yeah, for sure someone will set their laptop on your Stetson,” she agreed.
My journey to Dallas began very early at Sacramento International Airport’s Terminal-B. I shuttled in from long-term parking and stood just inside the doorway, gazing up. Morning seeped in from the east, bringing pale light into the cavernous terminal. The red rabbit, suspended in a perpetual state of scurry, hung overhead. The bus growled as it pulled away from the curb. Voices disappeared, dissolved in space, vaporized like breath in winter, and the terminal was terminally quiet indeed.
I looked left, to the twin escalators that dropped uninterrupted from the third floor. There have to be more escalators! I have time, I thought, glancing at my watch. I started toward the escalators, rolling my carry-on behind.
My gaze followed the escalators to the third floor and confirmed again that they both flowed down, uninterrupted from the All-Gates-on-three. I looked further left and saw people queuing for another set of escalators going up. Aha! I picked up speed and clamored aboard for Ticketing-on-two, to collect my boarding pass. Why doesn't the bus drop us off in front of these escalators? Perhaps in time it will, when the old Terminal-B is demolished and the road re-routed.
I watched a family of four shuffle through security. Their lanky teen wore a cowgirl hat. Her father was tall, sporting a week’s worth of stubble on his scalp and goatee. His jeans tightly corralled fleshy thighs. Her mother was tall with bottle-enhanced, auburn hair that touched her shoulders.  Stature implies age though not when one is of lanky lineage. Her brother acted six but was tall as ten. Aboard, they occupied the row ahead of me and during take off he reached across the aisle to grasp his wife's hand. “I love you,” he said with a squeeze. Sah-weeet! 
As an aside, we’ve been told that takeoff and landing are the most dangerous phases of flight. I wondered if that was truth or urban myth. A Google search pointed me to PlaneCrashInfo.com. They report accidents and fatalities by phase of flight: takeoff and initial climb= 20%, final approach and landing = 36%. Guess it’s true. Interestingly, crash survival rates steadily climbed during the previous seven decades then dropped precipitously in the new millennia. I suspect 9/11, with high volume flights and 100% mortality crashed the stats with the planes. But I digress.
With a bird's eye view, I couldn't help myself, I studied him. Had he failed to shave cheeks and neck, his head would be a fuzz-ball. I looked for further evidence of his linkage and lineage to furry clansmen. My eyes rested on tufted knuckles. The backs of his hands and ankles were coated. It's likely, I quickly concluded, that beneath those jeans and two shirts Daddy was quite... Never mind. I opened my book.
He stood to retrieve something from the overhead bin and I got a whiff of mothballs. Mothballs? It's a distinctive odor. Who uses mothballs anymore? Daddy does!
On approach into Dallas, the day was hazy-gray with a forecast for warm thundershowers. The trees were fully leafed - in Dallas spring had sprung. A red horse galloped atop a white water tower perched over an outdoor stadium. College football? This is Texas Dorothy, could be high school.
I connected through Dallas when traveling to Chicago last year and remembered DFW as a cramped and outdated facility, ill suited for today’s large jets. Nothing had changed but the date - DFW's concourse was congested with passengers overflowing from painfully inadequate gate seating areas. 
At baggage claim I passed a man holding a single sheet of paper printed with the NovoNordisk bull, obviously collecting people for a NovoNordisk conference. A large, large man suited in black leaned against the wall and held an electronic tablet displaying the logo and name of the conference I planned to attend. Chris lead the way, lumbering to the Cadillac Escalade in thick-soled shoes made to withstand the gravity of his 350+ pound frame. 
“Where you from?” he asked politely. Chris was Texas born and bred but spent the intervening years in Sacramento. 
“I was a river rat,” he said, “Lured back to Texas to make something of myself at nineteen” by his Daddy's promise of a new 240Z. It worked, he is married with kids and has never left.
We exited the DFW airport complex due south, headed for the Tom Landry Hwy. Directional signs pointed toward the LBJ Freeway and the George Bush Tollway, roads that circle concentric about Dallas. Clearly, Dallas is presidential country and cowboy country - and Dallas Cowboy country. 
Chris made a food recommendation: Javier’s. “It’s a little pricey,” he said, “But it’s worth it.”
What do I know? I know Taco Bell and Chevy’s.
“You should know if their food is good from the beginning - by the crispiness of their chips and snappiness of the salsa.” I figured he knew a lot more about it than I and put Javier’s on my list.
“Do you like history?” After answering in the affirmative Chris mentioned the Sixth Floor (Book Depository) Museum and the Grassy Knoll. It was already on my list. If I’ve read one book about that fateful day in Dallas, I’ve read four. A Warren Commission cynic and skeptic, I was anxious to examine the physical evidence preserved on Elm Street.
We pulled into the Hilton Anatole, consisting of three, reddish-brown, brick towers. I disembarked into a bevy of bellhops and thanked Chris for a pleasant ride. According to their brochure, the word “Anatole” hails from Greece meaning “where the sun rises.” The Hilton Anatole covers 45-acres wedged between the freeway and industrial zone, three miles northwest of downtown Dallas. It is a convention resort housing 1600 guest rooms, 79 meeting rooms, and over 600,000 SF of flexible meeting/event space. Larger than life, “18th century, bronze, Chinese Fu Dogs guard the lobby entry-way with ferocious glances to scare off evil spirits,” just as they did for their home or origin, an ancient Buddhist temple.
I swear registration clerks must assess our ability to walk as we queue for their service. I rode the glass elevator to the eleventh floor. The rooms were organized around a large atrium beneath a glass ceiling where Buddha, carved in white, Vietnamese marble, sat contemplative. I threw open the drapes of my room next to the corner suite, farthest from the elevator, and took in a view of downtown Dallas. I was suddenly struck that the last three rooms at my last three conferences were corner rooms with commanding vistas. Yippie ki-yay! Hurray for a body that “ambulates independently without use of assistive devices.” (My charting jargon for a body that moves unaided.) I thank God every day for mind and body that work.
With four-hours to burn, I wanted to move a bit. Pinks Western World, a wholesale-to-the-public, cowboy outfitter was nearby. Chris pointed to it as we drove by. 
“There’s Pinks. You can walk to it along the frontage road.” In keeping with Maria’s suggestion, I walked along Anatole's carved, relief walls and the half-mile to Pinks, to look at cowboy boots in Dallas.
Four generations of Pinks greeted me from their stations around the showroom floor. An ancient man with bushy brows beneath a cowboy hat nodded from his prop against a round of cowgirl shirts, just inside the front door.  I wore a Honolulu Marathon cap and carried a backpack. 
“Are you here for a conference?” Customers from the conference center must be common.
“Yes, a diabetes conference next door.”
“Are you an Endocrinologist?” That’s an unusual question.
“No, I’m a nurse practitioner.” 
To make a long story short, Bushy-brow’s great-grandson was diagnosed with Type-1 diabetes in 2011. He is a junior in high school, continues to play varsity football, and uses the new OmniPod insulin pump when not suited for football. They were happy with his care at Children’s Hospital but the whole event had scared and corralled them. They learned as a family and now enjoy his football games all the more.
I browsed and chatted while Grandpa and Daddy trailed me through the store. After a very pleasant visit, I thanked them and they wished me well before I ventured again into the hot, humid day.
I re-entered the Hilton Anatole through its western lobby and was welcomed by a breathtaking, nine-foot Quan Yin carved from a single block of white, Vietnamese marble. 
Quan Yin is the shortened form of a name meaning One Who Sees and Hears the Cry from the Human World.  In Sanskrit, her name is Padma-p├óni, or "Born of the Lotus." She is one of the San Ta Shih, the Three Great Beings, a Holy Trinity, and is often compared to the Virgin Mary.
Quan Yin, alone among Buddhist gods, is loved rather than feared and is the model of Chinese beauty. Eastern religion claims Quan Yin earned the right to enter Nirvana through great love and sacrifice during life. However, while standing before the gates of Paradise, heard a cry of anguish from earth below. Turning back, she renounced her reward of bliss eternal and in its place found immortality in the hearts of the suffering.
      The parallels of the great religions never fail to provoke questions in me: a Hindu Holy Trinity, a gated Heaven or Nirvana up there, the universal message of doing unto others and earning one's place, etc. Is it just me?
A matched set of gigantic vases lined the opposite wall. The Hilton Anatole, as it turns out, displays the largest, private collection of Asian antiquities ever assembled for an American hotel, a fragment of the Crow Collection of Asian Art. I wandered through the hotel - appreciative of each piece and its placard.
With Sacramento gripped in late winter storms, I intended to enjoy the weather. I grabbed my bikini and book, and made my way through Anatole’s Sculpture Park to the outdoor pool. Temperature and humidity in the 70’s - ahhh. You can take the woman out of Hawai’i but you no can take Hawai’i outta da wahine. The warmth and humidity felt wonderful on my skin - which was not so pale, pasty, and sickly as those visiting from more northerly destinations.
I watched a crow scavenge for scraps. Alert and energetic, it hopped from lounges and fluttered to tables, pecking at points of interest. Unlike the full-bodied, foot-long, Poe-esque ravens of Yellowstone, Dallas' crows are two-thirds tail - all plumage and glitz - sooo apropos for a Dallas show.
I was gripped and glued to the pages of The Girl with the Dragon Tattoo. A group of friends in their 20’s moved in nearby. They chatted in-between texting and surfing on their phones. 
“I can’t imagine a world without facebook and twitter,” he exclaimed. That seems like such a girly thing to say. He was tall and lean and heretofore, seemed quite intelligent - my interest was piqued. “If we had social media for the last 40-years,” he continued, “The world would be in a better place. We would not be facing the same problems.” They spoke of the Arab spring and our ever-growing sense of one world - one people. He has a point.
After an hour, I gathered my belongings and retreated to my room to shower and ready for the opening program. I expected to reconnect with a few western-states acquaintances. I dined with a pharmacist from Napa and diabetes nurse from Billings, MT. Linda’s stories of diabetes in-reach into Montana’s Indian reservations were inspiring. I greeted Sugar Nancy, a bodacious, outrageous endocrinologist from San Francisco. I chatted with Nazly, a multi-ethnic, enchanting, exotic, shapely mother/doctor from L.A.
The conference began at 0730 the following morning - 0530 PST. I returned to my room and a brightly lit Dallas skyline but try as I might, sleep did not easily come.


Stay tuned for conferences and Cowboy Cool.