West of the Rotunda

Now that we are relaxed about the Covid pandemic, should we grade ourselves on our response? Or do we just want to go “whew!”, wipe our brows and put our noses back to the grindstones?

Well, you’re going to do what you want to do, and I’m going to do what I want to do. Maybe that’s the lesson we have learned from this.

I read a mind-numbing column proudly published in a reputable North Idaho newspaper where the board certified ophthalmologist still argues for Ivermectin. Some docs are going to do what they are going to do. I didn’t learn that during the pandemic. I’ve known that from my first days in medical school. Heath care is not a monolith, just as We the People are not.

And it might just be that trait that I like about people. I respect cowboys. Indeed, I’m a bit of one. I have always bucked the big pharma-driven trends on prescribing medications. But I’m not asking Cowboy Bob for public health advice. And I don’t recommend you look there either.

So, it’s hard to be too critical about Idaho’s response to Covid. Our Covid death rate was near the national average, as was our infection rate and immunization rate. That means about 5000 people died in Idaho from Covid. Keep in mind, Covid started out, when nobody was immunized, before the Omicron variant, with a death rate that killed 1 out of a thousand infected.

So, let’s pat ourselves on the back. Average is good, isn’t it? One thing we have clearly learned is the public is not very good at assessing and responding to risks.

Some of us are. And the data on that is now in. A British Medical Journal study looked at the many counties in the lower 48. (Why do Brits get to grade us Americans?). They compared the Covid death and infection rate to the immunization rates. Counties with high immunization rates reduced their Covid deaths by 81% when compared to counties with low immunization rates. Maybe the immunizations were a good idea. But I’m sure you have your own opinion about that.

One of the reasons to grade our response to a “bad cold” pandemic that killed about a million Americans is because the next one might be a bit rougher.

Have you priced eggs recently? Have you heard of the H5N1 Bird Flu?

Remember that Covid only killed 1/1000? H5N1 rarely infects humans, so far. But when it does, the mortality rate is 56%. That comes to 560 dead of the 1000 infected. That’s 560 times a fatal as Covid.

But we are safe so far from the bird flu, right? It is rapidly transmitted between birds. It is even infecting migratory wild birds now. Penned flocks die like, well, chickens. But they are just birds.

Some animals that prey on or scavenge bird carcasses have become infected. We lost a skunk to it here in Idaho. So, mind your roadkill harvesting.

In the last few months there have been outbreaks in mammals. A mink farm in Spain reported an outbreak. It has not been confirmed but it is suspected the virus spread amongst the animals.

And that’s where the leap occurs. When a virus mutates to infect the upper and lower respiratory tract cells in humans, as Covid did, then we sneeze, we cough, we spread it. And, if the damage the virus does to our bodies stays as virulent as the current H5N1, we will die at a much faster rate than the “bad cold” Covid pandemic.

When you pack the world with as many humans as we have, something is going to get us. And even getting an “A” on your pandemic response report card won’t stop all the deaths. That doesn’t mean we shouldn’t try to do our best.

Governor Little proudly proclaimed he had “cut red tape” right after his first inauguration four years ago when he restructured the state entity overlooking all the professions. Maybe he cut more than red tape.

You need to understand this system a bit before I get into a full-blown rant.

There are MANY professions in this state that get their sanction to perform their services from state statute. In my short time in the legislature, it seemed like every year another profession wanted to be “licensed”. The health care professions sector alone includes nurses, doctors, physical therapists, and indeed, ten more. For some reason, midwives and genetic counsellors aren’t included in the “health professions”, but instead with the “occupational licenses”, along with another dozen professions, including Outfitters and Guides. This reorganization was supposed to streamline the licensing process.

You might find yourself questioning why the state even gets involved in this licensing process. I know the Freedom Foundation does. Libertarians think any restriction on “free trade” just drives up costs. Does a license somehow ensure the professional you engage provides quality services? We have all followed how a licensed physician, trained to do laboratory tests provided telehealth primary care during the pandemic. And we’ve seen how the Idaho Board of Medicine dismissed complaints against this physician, seemingly without investigating them. So, don’t let my $200 annual Medical license fee convince you of the quality of my care.

Maybe Idaho could just go all cowboy and let the public beware. There’d sure be less red tape.

But cutting red tape might also mean there’s less folks to answer the phones when there’s a problem.

Let’s look at a problem. The clinic I work in has tried to hire nurses. Let me tell you, nurses are getting hard to come by. Moreover, the interview process can be long, the background checks take time, but here’s the final delay. Idaho licensure requires nurses to submit fingerprints.

I remember having to submit fingerprints when I got an Idaho medical license. I had to wipe off the embedded grease from cranking my Model T. For some reason back then I didn’t question the need for such a hoop to jump through. Maybe I was numbed by all the premed hoops (physics, organic chem) and medical school hoops (short white coats and board exams) and residency hoops (no sleep).

National nursing organizations support the requirement for fingerprints. Only six states don’t require them. A lot of people seem to think, including Idaho, I guess, it makes sense. Along with the requirement is an FBI background check for past crimes. I’m sure you are comforted that the nurse putting in your urinary catheter has no armed robbery convictions. Maybe not.

Here’s my gripe. Thanks for waiting this long. Both the nurses my clinic hired have had to postpone their start dates a month waiting for their fingerprints to be approved. They have had to submit multiple samples, all at added cost, and always a delay.

I tried to call the Idaho Board of Nursing to ask what the problem was. I got two phone numbers. Both went to voicemail. Neither called me back.

There, you’ve listened to my rant. I apologize. Maybe it got you thinking if we really need this whole licensure thing. I have very strongly mixed feelings about it. If Idaho government is going to give a profession the ability to restrict practice in the marketplace, citizens deserve some confidence in the quality of that state sanctioned profession.

And if the state is going to continue expecting professionals to jump through these licensure hoops, they should be timely. I’m not asking for more red tape. Just someone to answer the phone.

When it’s hard to give praise, it should be worth more. This is going to be very hard for me to offer. It shouldn’t be. When ideas are the subject, not behavior or intentions, we should look squarely at the ideas and consider praise or rejection. That’s not hard, is it?

So, I want to praise a bill in the Idaho legislature offered up by Representative Heather Scott. I don’t want to praise Heather when she wraps herself in the Stars and Bars or her disruptive tendencies in the Idaho House. I just want to offer my support to a simple bill she has introduced.

House Bill 20 adds a misdemeanor criminal penalty to bad faith reporting of child abuse, neglect, or abandonment.

Why is such a penalty needed? Shouldn’t we protect anybody who is trying to prevent or report child abuse? Here’s where we get into the real world. The laws we write should have a clear awareness of the real world.

We see so many ideas floated in the swirling pot of the Idaho legislature that are just dog whistle attempts to protect us from the boogey man. I could list them, but I’m sure we would not agree on the real-world threats we face. Your fear of Sharia Law might be as great as my concern about ground water.

But I digress. I must move forward with the real-world reason this law makes sense.

For many years I served on my county Multidisciplinary Task Force for the Prevention of Child Abuse. Every county in the state is supposed to have one. I got chosen to participate because the law that established these groups called for a member of the healthcare community to serve. At the time, I was the county coroner. I was also a practicing family physician. So, I went to these monthly meetings on my lunch hour. They agreed to meet at that time so I wouldn’t have to miss clinic time. Every other person on this task force was a state, county, or city employee, not a private businessman. Doctors are businessmen. Time out of clinic is lost income.

We would start each meeting by reviewing the month’s list of Child Protective Services referrals. We, as a task force were charged to make sure proper handling of these cases was being done.

There were usually twenty or thirty, maybe up to forty referrals in our little county. They were graded by risk to the child, high to low. Each month there would be just one or two high risk situations. The vast majority of the referrals were found to be either low risk, unfounded, or even false.

It was not uncommon for there to be disputed custody, an acrimonious divorce and custody battle going on. One parent might make an allegation against the other and, through investigation CPS could determine the allegation was sometimes false, sometimes unfounded, and sometimes offered in bad faith to try to influence the court.

False claims take up time and effort. Bad faith claims are an attempt to use the power of the state for malicious purposes. It is quite fair that there should be consequences for such bad behavior. Thank you to Representative Scott for putting this forward.

I wish all people behaved with integrity. I want to believe most people do. But I live in the real world, so I know this is not always true. I take cash when I sell on Craigslist. I count the bills before the buyer leaves. And I give cash when I buy.

It is only fair that the laws we write express such expectation of integrity. And it is only fair that bad faith actions have consequences.

Our founders thought some freedoms should be in our Constitution. They couldn’t agree on all of them, so they became the first ten amendments. amendments. The Bill of Rights was passed after the Constitution was ratified. These first ten amendments had the effect of limiting how government could impose itself on a citizen.

The Idaho legislature has worked hard for many years to define freedoms for “the unborn”, so now we have a real mess of conflicting laws saying abortion is illegal. I doubt they will get to work cleaning up any of these conflicts this session, but I wonder, given the recent events in my town, whether any legislator would consider protecting us against unwarranted searches.

By the way, if you didn’t know, I live in Moscow, Idaho. Yeah, we’ve been in the news a bit lately.

The Fourth Amendment protects us from “unreasonable search” and specifies that warrants for searches shall specify probable cause. The courts describe the details, and they are being redefined as the world changes.

No founder knew about DNA. But we have a case in our town that just might pivot on such evidence.

Some states have decided to weigh in on their interpretation of this freedom. Idaho should too. Clarity for the investigating agencies helps convictions stick when the rules are followed. Otherwise, convictions can become lake house payments for appellant lawyers.

Defining this freedom for modern times would take some careful consideration and study. DNA databases are often proprietary. And these private companies can and do develop their own rules for how their information can be used. But they can also be bought and sold. And with these transactions, their assets, their DNA databases, are transferred.

Think about it. You sign on to get some genealogical information. Maybe you read the long legal document before you give them your credit card info. You don’t plan on committing any major crimes soon, so you figure it’s just for the lawyers to argue about.

But your information can also tell an investigator about your relatives. The DNA they got from a crime scene might suggest some relation of yours. That relative didn’t give permission. You may not know your crazy uncle really was crazy, maybe homicidal. But you just fingered him. Maybe you’re alright with that use of that information. Uncle Charlie might not be. And if he has good lawyers we’re now on shifting sands.

I would challenge the Idaho legislature to consider this work. Indeed, given their embrace of freedom, I would hope the Idaho Freedom Foundation would get on board. Maybe they have, I don’t know.

I have no idea if any legislators are considering this. Given their track records, I bet they are just waiting for some “model legislation” from ALEC. That’s too bad. I believe we here in Idaho have some thinking and some work to do.

We want crimes solved. We want to feel safe in our communities. Given the crowds down at the pool hall last week, I’d say the students have returned here to our college town from their Christmas break and feel pretty safe. But there is a long road ahead for trial and conviction. Maybe just seeing a suspect in orange coveralls makes people feel safe.

Defining the legal limits of DNA database searches will help law enforcement know how to search. Further, it should protect us from unwarranted searches by our government. Balancing this is the work our legislators should be doing.  I want our system of justice to serve us all.

Since Joe Biden finally visited the southern border, I want to know when Brad Little is going to close Idaho’s borders. Who are all these people?

For the sixth year in a row, we are in the top tier of fastest growing states. We had a minor slip this year to the second spot, after coming in first for the previous five. Estimates have us a little north of 1.9 million. The state has more than doubled since I moved here to hunt mastodons in my youth.

No wonder the legislature sits on a budget surplus. I guess all these newcomers buy things and pay taxes. Those elderly legislators have reserved parking there in the Capitol garage, so they don’t see the crowds swarming in. And they go home when the legislature adjourns to their 500-acre gated ranches where the ag designation protects them from property taxes. I doubt many have a mortgage. Maybe some.

But they for sure have health insurance. Even if they are on Medicare, they can still get taxpayer paid health insurance as a state employee, even though they are part-time. Maybe they consider themselves full time now that we said they can call a session whenever they get a few colleagues to sign on. That health insurance benefit is quite a perk. Right up there with the reserved parking.

And now they are talking about how much it costs them to fund Medicaid expansion. They are still butt-hurt about that initiative that passed back in 2018.

I understand the worry about Medicaid funding. I watched the costs go up for years. Though I am proud to say, the 4 years I did the DHW budgets on JFAC, the cost increase was comparable to inflation. What we had no control over back then was the Catastrophic Health Care Fund for the uninsured. That cost doubled in ten years.

So here I am whining about all these folks moving in, but I don’t think we should be going back to “the good old days”. I saw a case of “the good old days” in the clinic a few weeks back. Fifty-year-old working guy made $200 bucks a month more than made him eligible for Medicaid. He didn’t go on the exchange, took his chances. His shortness of breath finally took him to the ER. They gave him an antibiotic and sent him home. When he couldn’t breathe the next day, he went back. This time they found the pulmonary emboli and the 10-centimeter mass in his chest. Who should pay for this?

He’s not going to be back at work for a while. The bill for the two ER visits would probably take his home and tools. Or they could go unpaid, and the hospital could cut a couple nurses from their staff. I wonder just what the Idaho legislature sees as a solution for this. I expect we’ll hear some proposals.

I am greatly disappointed that we haven’t made much investment to look at how we pay what we pay in the Medicaid program. A recent legislative study suggested Medicaid payment rates hadn’t been evaluated for many years. If you want to pay less, and I do, it seems worth evaluating just exactly what you are paying for and whether it is worth what you are getting. So, the Idaho legislature will gavel into session this week, the Governor has been inaugurated and the interns have been hired, trained, and warned. The bars in Boise have stocked their shelves, the reserved parking spaces are swept free of the pigeon droppings and our elected leaders will gather to serve our common good. All is well.

Just as Speaker Mike Moyle has established, partisan power has its benefits. As his doubtful idol, Barack Obama said, “Elections have consequences.” Speaker Mike decided to reduce the number of House seats for the minority party on the Budget Committee, JFAC. Why should he stop there?

Idaho law gives the Governor power to appoint members of boards and commissions that are empowered to direct state agencies. This is a process that is supposed to enfranchise the public in the government they elect.

The Idaho Constitution limits the number of departments to twenty. And Idaho law defines just who can serve on these boards. Back in the 1960-70’s, when Idaho had a Democratic governor, but the legislature was mainly Republican (a bit less so than now), the legislature enacted laws requiring the partisan membership of these boards and commissions be somewhat balanced. For instance, the Public Utilities Commission, the folks who regulate the power company this state was named after, Idaho Power, has three members. It may not have more than two members of the same political party. Why? I guess back when we had a more balance state, the need for balance on these governing bodies was thought to be valuable.

Maybe Speaker Mike has other ideas. He needs to start drafting a lot of bills.

This was floated by Representative Brent Crane a few years or so back about the Redistricting Commission. His point was, we are a republican state, why do we need balance on that Commission? He quieted down when he realized redistricting appointments were mandated to be balanced in the Idaho Constitution. But boards for Education, Transportation, Commerce, Corrections, etc. are in statute. Statute is the legislatures sandbox. They can make the game however they choose. Start drafting.

To be honest, I’m not sure why this matters. Maybe at some time it did. Maybe being a commissioner was a steppingstone to higher office. I know that has been the case for some legislators. No Idaho Democrats that I can think of, but quite a few Republicans. It should be a place to learn about governance and serving the public good. And then to move from there to legislating for the public good makes good sense.

So maybe the balance our current laws require on these Idaho Boards and Commissions will change. Maybe Speaker Mike and the Idaho legislature Republican supermajority will see the folly of such partisan affiliation and decide to strike such requirements from our laws. After all, most statewide votes are 60/40 republican/democrat. Why should we even be considering a commissioner’s partisan affiliation? Shouldn’t we just be considering their fitness to serve? To the victor the spoils, right?

I guess it gets back to just how you see this government serving us. Many see government as a vending machine. You put in your money, and you should get back what you want without having to kick it or shake it too much. Republicans think you should get Coke, Democrats, Pepsi. So, if Democrats win the election, all you can get is Pepsi, no Coke in the machine. And the versa if Republicans win.

What a dismal picture of the common good.

I don’t see government as a vending machine. Government serves us all. But if you want beer in the vending machine, that will need some review by a commission or a board and maybe some reference to the laws and maybe the Constitution.

Serving us all is a tough job. Serving all our constituents is indeed very tough, I can say as an unelected legislative representative. I must not have been doing a good enough job. The voters told me so.

But did they know my work? Or were they just responding to the partisan label? Maybe that partisan label has little value. It sure has power.

Have you wrapped all the presents? Have you looked under the tree? Are the stockings hung with the hope of St. Nick? I hope so. Idaho rural hospitals will be offered a stocking stuffer this year from our federal government that might leave them asking, “Where’s the pony?”

This policy shift comes in last years budget bill. That’s where most things happen in Washington DC nowadays. No committee hearings on boring budget items or policy decisions. It seems the only public hearings and debates are about things that have plenty of partisan opportunities for sound bites and teeth gnashing. Small town hospitals? Yawn. Unless you live or work there.

This gift is pony droppings.

There has been no doubt some small town hospitals are stressed. A study found over 600 are at risk of closing in the next ten years. Over 180 have closed in the last 17. So, the budget proposal offers a “fix”.

If a rural hospital promises to not keep patients longer than a day, they will get $3.2M in federal dollars annually. You shift your small hospital from providing inpatient care to being an urgent care facility with a helipad, you get a boost. What are they thinking?

Is inpatient care cheaper at big city hospitals? Is it better? We don’t know the answer to these questions, but we really do know what happens to small towns where the hospitals close. One in 12 jobs in small towns are supported by their small hospitals. After hospitals close small-town populations shrink.

What does the landscape look like here in Idaho? Honestly, not as bad as in many states. If you look at the maps for closures and at-risk rural hospitals, you might as well overlay the map for states that have not expanded Medicaid coverage. We did that. But it took the Idaho voters, not the governor or the legislature to get that done.

Idaho currently has 30 rural hospitals. None had closed in the last 20 years and only two are considered at risk. That is the lowest rate of any state with a substantial rural population. What makes Idaho special? I would argue, good local governance.

If our federal delegation wanted to do something that would substantively help our rural communities instead of gelding their hospital services, there are many choices, many solutions. Private insurance companies pay less to rural providers than urban ones for the same services. And rural hospitals have a higher percentage of private insurance patients than urban hospitals do. You can blame Medicare and Medicaid all you want, but there’s good evidence that changing the way rural hospitals are compensated mainly by private insurers, would avoid this problem.

This choking out of rural healthcare has been a long time coming. When the pandemic hit and DC sloshed cash outwards, the rural hospitals got some boost. That dries up on New Years Eve. This “solution” is supposed to forestall some closures by making the local hospitals walk-in urgent care clinics.

I don’t envy the small hospital board members considering this. Should they accept the “gift” their congressmen have offered and close their facility to inpatients? That would mean grandpa’s pneumonia gets him a helicopter ride to the big city. And Billie Jean won’t be having her baby where she was born. No, you can’t make sure babies come out in less than 24 hours.

I see this “solution” as just another example of how we Americans don’t want to face our problems. I’m glad we have these volunteer hospital board members in our communities who understand and want to serve their neighbors. Congress is offering them money to stab their neighbors in the back.

Thank your local hospital board member and wish them a Merry Christmas. They deserve it.

There’s gotta be a joke that fits this occasion, but I can’t come up with it. Maybe I will.

The Idaho Republican Legislature is not a punch line. It’s a simple fact. Nobody’s laughing. But we voters keep returning these jokers to the statehouse. Maybe us voters are the joke.

Six years ago, when the proposal came before the Idaho legislature to cap the homeowner exemption, there was good testimony that predicted where property taxes would be right now. A retired expert on taxes made some good graphs and analysis of the proposed law. He told the lawmakers that homeowners property taxes would start to climb, and commercial property taxpayers’ taxes would level off. And his analysis didn’t include dramatically rising home values. It just included a steady increase. So even if things had stayed the same, the local property tax burden was going to shift to homeowners. Well, home values did climb. In some places they have doubled in this short six years. Now, it seems, Idaho Republican legislators have decided there is a problem with property taxes. And they can’t seem to find the right solution.

Every Idaho Democratic legislator voted against this proposal six years ago. Less than a dozen Republican legislators joined them. I remember the Assistant Senate Majority Leader (now the Senate Pro Tem) even acknowledging in his debate there might be “some shift” in the coming years. But he argued this change was good for “business”. I guess not your or my business. Somebody got a break on this shenanigan, and it wasn’t Joe Homeowner. But Joe Homeowner probably votes Republican.

So now, with many suggestions brought up to fix these skyrocketing property taxes, the Idaho Republican legislature can’t seem to find the solution. It’s not hidden. Why can’t they see it? It’s pretty obvious.

Okay, here’s the joke. I walk out to my old bicycle outside the Capitol to pedal home in the dark. Billy Republican is wandering around looking at the ground. “Can I help you?” I asked.

“I dropped my keys, and I can’t find them.” Billy says.

“Let me help” I say.  After some minutes I can’t find anything either and I ask him. “Where did you drop them?”

“Over there”, he gestures to a darkened sidewalk.

“Why are we looking here?” I’m perplexed.

“The light is better over here.” Billy admits.

It’s hard to admit you made a mistake. It can seem very dark and foreboding to fess up. I have always found it a learning experience, not something to be avoided. I’ve made lots of mistakes in my life, in my votes, in my diagnoses, in my relationships. Admitting mistakes is a sign of character, not weakness. Even in a politician, though all the experts tell politicians to never make such a confession. They think we want to vote for infallible representatives. There is no such thing.

The Idaho Republican legislature made a mistake six years ago and we, the voters, have been paying the burden ever since. Property taxes have driven some fixed income elderly from their homes.

It’s past time when the Idaho Republican legislature should have fixed this. So now they are wringing their hands and scratching their heads about a solution. Solutions have been brought up for the past three years. They don’t get a hearing. I guess the Idaho Republican legislative leadership just wants to look in the comfort of a well-lit hallway and not really find the keys they say they lost.

In this case, Idaho Republican legislators did not lose anything. They voted for this mess. Now they need to admit they made a mistake and man up to choose the simple solution. It’s in plain sight.

You’ve probably never heard of this federal law: The Indian Child Welfare Act. The main reason I know about it was I had a sister who helped craft and defend it. She is long dead, but I remember the lessons she taught me.

The law has come before our now conservative activist court. It will most likely be struck down, given how that body has been manipulated by our US Senate. But you need to know about the law.

ICWA was passed by congress in 1978. At that time about a third of native children in state custody were adopted into non-native families. Tribes and many others argued the cultural existence of our Native Americans was being decimated by such practice. The law said that the priority for states to consider for the placement of native children should be with native family or tribal members.

I won’t burden you now with residential schools and the policy our county has had with regards to the people we stole this land from. But taking children from one family and placing them in another has worked for millennia to dissolve defeated cultures and strengthen the victors. ICWA was an attempt by congress to preserve the cultures of our native populations.

But I was a medical resident working in the pediatric ICU. We had an abused native child, beaten by someone on the reservation, here for his third stay with repeated brain damage. I said to my Indian law lawyer sister Sande, “Why can’t he just go to a good home? Why does he have to go back there?”

She heard my racist undertone, my ignorance, my bias. And she quietly shook her head and responded in her moderate and measured way, “You just don’t understand.”

And I didn’t then. I do now. I wish she was alive to hear me say this.

A few times on the Idaho Senate floor obscure laws would come up for consideration, and it would be telling when the Majority Leader would carry them and explain them to us. Senator Bart Davis did this occasionally. I remember a couple that had to do with the Health and Welfare provisions about foster care or adoption. He always made a point of saying these changes to Idaho Code we were considering were consistent with ICWA. I wondered about that.

Back in 1978 when ICWA was before congress, one of the opposing factions was the LDS church. They had a program in place at that time that took native children from their homes and placed them in LDS homes. This practice conformed to their church ideology. I have never discussed this with Bart. But I sensed he thought the Federal law should be respected and upheld.

As we face the dismantlement of many comfortably held ideas that prior Supreme Courts have found in our Constitution, it will be up to the states to consider whether we wish to enshrine these ideas in our state statutes or constitutions. The list will become long if the pace of this activist court is sustained. Are we Idahoans up to the task?

Senator Davis is a devout Latter Day Saint. He has profound knowledge of the law, his church, and the history of the native peoples in our state. Does he think the principles of ICWA should be in our statutes? Do you?

Is the preservation of the cultures we have displaced worth our effort? I doubt any newly elected Idaho legislator has this issue on their to do list. It is worth our consideration. I wish Sande could be here to guide me. I think I know what she would say.

I keep seeing patients and trying my best. I sometimes wonder if it’s the right thing to keep doing. I’m sure there are younger, smarter, more agile providers out there who could be doing this work. But whenever our clinic tries to hire someone, it can be 6-12 months before we get a bite and sometimes, we don’t land them.

I enjoy seeing the patients. I know they sometimes don’t enjoy seeing me. That makes the work a bit harder. But I have never thought my job was to provide customer service. That’s a big part of the job, but it’s not the whole job. I had some very long and arduous training that instilled in me the sense of a higher purpose. I was trained to serve health, not to just give the customer whatever they wanted. Prescribing antibiotics to every child with a cold might make the worried mother feel better, like she was doing her best so she could then go off to work, leave the kid at daycare, she’d done her best, might make the customer happy. But it did not serve the child, the community.

When I first started practicing primary care in 1989, the most common prescription in the United States was Amoxicillin. It was commonly prescribed for children with colds. Many children with colds have the yellow snot draining out of their noses back up into their middle ears. Ah, an ear infection! We can treat that!

Amox 250/5ml I tsp tid for 10 days.

The kid gets better, and we glorious physicians get credit. But I had read the study that showed ¾ of middle ear infections get better in 2 weeks whether they are prescribed antibiotics or not. But then, we get no credit, do we? And it takes a while to convince the working mom her kid just needs some care, not drugs. And I need to see 25 patients a day to make my exorbitant salary. I can see why Amoxicillin was popular.

Ten years later the most popular drug was Oxycontin. You know how that turned out.

So, I work at this clinic a few days a week and I try to teach my fellow providers and the patients I see how to be healthy in the lives we live and the work we do. Two weeks back I came out to my frosty pickup and found a parking ticket. I had not gone home for lunch. I had brought a sandwich, thinking the noon drive home was wasteful. But the $25 ticket hurt.

I get to the clinic at 7AM and leave at 6PM. My lunch is from 1-2. We have a three-hour parking limit downtown. I guess the drive home made the parking enforcement people happy. The ticket irked me.

I tried another spot last week. Under the snow I scraped off in the dark was another ticket. This week I have decided to walk to work. It’s only about a mile.

My new knee is fine but the old left hip hurts. I don’t want to fall on the ice and snow. Send me your prayers.

If we want good healthcare in this country, we need to be thinking about just what that means. Do we want whatever we want whenever we want it? A patient’s partner last week called me an ignorant old man because I wouldn’t order all the wasteful blood tests his partner requested. “You need to get with it old man!” he glared at me. The ticket felt worse.

I know medicine. I do my best to practice that way. I can’t say I know the body politic. I wish we would have this discussion.