Vol. 78 November 15, 2012 The TWO Oldest Professions

November 16, 2012

A recent visit to Greek/Roman ruins ringing the Eastern Mediterranean Sea reminded me again about how much has changed, and how nothing has changed.

Every guide in Pompei takes their group to see the brothel. On its walls are the best preserved and most colorfully restored frescoes in this Roman town buried under 30 feet of Mt. Vesuvius’s volcano ash in 79 AD. Since most Pompei residents, and certainly the visiting sailors and merchants, could not read nor write, the services offered were depicted by pictures. The picture of each sexual position was marked with its relative price; one, two, or three hash marks. The route to the brothel in this city of crisscrossing streets was clearly marked by a street stone carved with  a graphic phallus and scrotum and a left-pointing arrow showing the way.

At Ephesus, a Roman city in Turkey that rivaled the size of Rome in 100 AD, there are no restored brothel walls. Its most striking restoration is the facade of the Celsus Library, one of the largest if not the largest library of its era. Every guide there gleefully points out the secret tunnel that led from the library to the brothel.  A stone block carved with a single serpent entwined around a winged staff, the sign of a physician(1), rests on the approach to the Celsus Library facade. (That’s a traveling bag from the Duffy Health Center for the Homeless perched on top of the stone.)

In both Pompei and Ephesus one of the temples was used as the gathering place for ill people to be ministered to by special priests. The “admitting process” to these “hospitals” started with an examination of the patient to determine how near death he or she might be. The priests were quite protective of their hospital’s reputation and did not want it to be known as “the place to go to die.” If a patient was considered near death or even with a questionable chance for cure, the patient was instructed to go back home, pray to the Gods for relief, and return in a few days.

This triage process is strikingly similar to the one described to us by the guide at the temple of Amenhotep, Egypt, which we visited on a previous trip. Hippocrates (the “father of medicine”) and later Galen studied at the temple of Amenhotep, and acknowledged the contribution of ancient Egyptian medicine to Greek medicine. The earliest known surgery was performed in Egypt around 2750 BC. The wall hieroglyphics there documented all kinds of easily recognized forceps, cutting tools, clamps, and other surgical instruments.The floor carvings and pictographs in this temple were less formal, but still understandable, and are thought to be the work of “patients” waiting in the gallery to be admitted or to be sent home after “triage” by their priests.

So, generals still fall because of beautiful women, hospitals still worry about their mortality rates, and “how best to die” is still a public issue for discussion, BUT now-a-days the hieroglyphics are electronic (2).

1. The caduceus with TWO serpents entwined around a winged staff, now considered the physicians’ sign,  was actually the sign for merchants, commerce, and the god Mercury.
2. The Telegraph (UK) reported that the FBI had 20,000 – 30,000 pages of communication, mostly emails, between General Allen and Ms. Kelly.

Vol. 72 August 1, 2012 Obamacare and the Olympics

August 1, 2012

The Olympics, like Presidential elections in the U.S., occur every four years. Cities, like candidates, compete fiercely and spend lots of money to be the  winner of the “host” contest. No one really knows how much the hosting, or the Presidential term will cost, and no one is ever sure how it wil be paid for. Both always end up costing more than anticipated. The Olympic games, like our Presidential elections, often reflect the state of our world at the time.

The British opened their Olympic Games with a stupendous show that included a celebration of their National Heath Service! It must have been a Socialist conspiracy, something we would expect from China. Can you imagine that ever happening in America!? Medicare is almost as old  as the NHS (born in 1965 rather than 1948), is a great comfort to those over 65, and politicians attack its benefits at their own peril, BUT a celebration of Medicare during the Super Bowl halftime? I don’t think so! Maybe in twenty years.

America does have the best medical care in the world for most people, but I think that we are so busy explaining why it is so expensive and why not everyone has access to it that we never get around to celebrating it. Now that the constitutional fight over ACA has been resolved by the Supreme Court maybe we can begin to celebrate some of its positive aspects.

The extension of coverage on family policies to children up to the age of 26 proved to be so popular that most insurance companies announced that they would provide that coverage even if the court struck down the act. Likewise, providing coverage for pre-existing conditions.

Whether the penalty for not obtaining insurance coverage is a tax or not is still a political football, but the tax (according to the Supreme Court) will amount to about $95 a year in 2014. 26 cents a day seems to be a ridiculously small price to pay for counting on other tax payers to cover your medical bills if you lose life or limb.

Micheal Phelps did not win his record-breaking gold medal in the solo medley event, but did so in the four man relay. His solo event fourth-place finish should remind us all that despite supreme conditioning, a dedicated will, and a stellar record, the body does age and performance decreases. We will all be eligible for Medicare some day. Why not sooner than later if current Medicare subscribers think it so great?. Phelp’s team win reaffirms how performance can improve with the help of trained colleagues. The ACA incentivizes the formation of “Medical Homes” of primary care physicians, nurse practitioners, physician assistants, social workers, and others organized together to deliver patient-centered care. We will need such organizations of physicians and physician extenders.  A significant “unintended consequence” of the ACA, now just being discussed, will be the shortage of primary care physicians to provide the care for the newly insured under ACA.

What about that 5 foot weight-lifter 123 pound that no one ever heard of stepping up and lifting over three times his own weight?! Not much has been said about the Center for Effectiveness Research established by the ACA. It is no five-footer, but is one of those “sleepers” in the Act that could profoundly effect our health care by system by evaluating and publicising the benefits ( and costs) of new technology. Another “small item” in the ACA which may eventually become perceived as a giant is insurance coverage for mental health services, a first.

The Queen’s granddaughter’s equine competition has at least knocked the stories about Romney’s Dressage horse off the TV. Maybe Obama’s grandchildren will compete  in a future Olympics (women’s basketball?). Better yet, the opening show, like this year’s scene of the Queen greeting Mr. Bond, could feature the then-President turning in his chair and greeting his visitor with, “Welcome back, Dr. Berwick”.

By then we may know if Olympic athletes are genetically superior to us mere mortals. I am sure that we will be screening them for “gene therapy”. As Dr. David Jones states in his NEJM article on the medical history of the Olympics, “What’s the limit of human performance? We still don’t know”.

I say ditto for the ACA.

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