A Capitalist Went To Cuba...

Mrs. Dalai and I continue to travel to weird and wonderful places, and with me being officially retired, we hope to do so even more often. Cuba has always intrigued me, and I had even strongly considered joining a religious mission trip here some years ago. Yes, there is a very small, but very vibrant Jewish community in Cuba. We never did make that trip, but we are now circumnavigating the island nation on a very nice cruise ship. While other ships have made the run, this is the first visit for our particular liner, and I feel a bit like a pioneer. Our first stop was in Santiago, very near Guantanamo, then to Cienfuegos with a side trip to Trinidad, and we end the journey in Havana.

I am very taken with this place. The land itself is spectacular, mountainous with pristine beaches almost ringing the island. The three cities on the itinerary all have incredible natural bays around which they grew. Someday, this will be a paradise, but I'm glad to have seen it before there is a Starbucks on every corner. And I promise that will happen.  Such beauty only a stone's throw away from Key West, Florida, will not go unnoticed for long.

Yes, Havana is only 90 miles (well, 93 to be precise) from the United States. Ninety miles and about 50 years away. Much of what you've heard about this place is accurate. It is Socialist, and it is poor. Very poor.  Many, if not most buildings are in need of repair, there is trash in the streets (perhaps less than in other big cities, but still...) and there are any number of beggars. We are told there is no crime to speak of, and I hope we don't find out otherwise.

You can look up Cuba's bloody past yourself, but suffice it so say that the citizens have never had an easy time. Its early history contains savage native tribes, and being owned by one colonial power and then another. In the mid-portion of the last century, Batista, the pre-Revolutionary tyrant, supported by the US until near the end of his reign, tortured the people and set the stage for Fidel Castro's Revolucione. Of course, the subsequent regime has not had a stellar human rights record, either. Since I'm here in country, let's not get into that right now. It's all out there on the internet.

We have only had close contact with our tour guides, who work for the government-owned tour company. Most everything here IS government-owned, although there are many tiny private businesses. Many rent out rooms, or operate small restaurants out of their homes. But if a business becomes wildly successful, the government will nationalize it. The standing philosophy suggests that a business should not become so wealthy as to have the means to influence the government. Right.

Our guides were honest with us to the extent that they were allowed, or so it seemed, anyway. To a man (or woman) they all admitted that their society is not perfect. This is pretty obvious. They did tout the fact that there is universal health care (but did not comment on its quality) and all mentioned the safety-net of a monthly ration card that would provide rather less than a month's requirements. Our guides did not tell us how much they made, but did say that a teacher might make $20 US/month, and a high-production torcedor (cigar-roller) in one of the state-owned factories might make up to $200/month. I can only imagine what the Cubans think of us spending what is for them over a years' salary on a box of Cohibas. (Yes, I did! You can't go to Cuba and NOT buy cigars...perfectly legal to bring them home!)

We did visit a cigar factory in Cienfuegos. They make cigars sold under a number of brands, and I haven't a clue which were being rolled that day. We weren't allowed to take photos, sadly, and there was a factory "guide" (handler would be a better term) who followed our group to enforce that. Even so, one of the torcedors (who are mostly ladies, by the way) handed me a freshly-rolled beauty and suggested I put it in my pocket. Mrs. Dalai suggested otherwise, and I sadly gave it back. I hope I did not offend...the ladies are on production, and she was giving me a gift from her own pocket. But with the handler watching, I figured it might get her in trouble.

As a group from a cruise ship, I think we were monitored minimally, if at all, by the Cuban government, although I'm told by friends in Florida that people travelling as individuals, technically no longer possible, are closely watched. I wandered around Old Havana looking for the best cigar deals with no obvious tail. In fact, I really got the feeling that the Cubans couldn't care less about a bunch of elderly Americans (average age on our cruise was mummified) unleashed on their nation. I had some illusion that the US government might be more interested in our travel to this once-forbidden destination, but upon arrival back at the cruise terminal in Miami, our encounter with Customs consisted of a brief glance at our passports, and a "Welcome home!" So much for pretending to be a smuggler.

Of all the things told to us by our guides, here is what I found most poignant:

I am telling you this as Jose' (not his real name) the man, not Jose the guide. We were amazed and thrilled when Mr. Obama came here. We didn't believe it would happen until we saw it ourselves. We are sad that Mr. Trump has reversed some of what had changed, but we hope he, too, will come here and see that we want to be your friends.

Some of you have asked me how I like living under Communism. I would LOVE to live under Communism, where everything would belong to everybody. You could drive a car and park it when you are finished, and then I would get in and drive it somewhere else. That would be perfect. But what we have in Cuba is NOT Communism, it is Socialism. And it doesn't work. 

While I don't agree with his assessment of Communism, he appears to be quite correct about Socialism.

I do have some sad observations about my fellow American travellers. As I mentioned, they were mainly older, some quite a bit older. We were definitely in the youngest quintile, and probably the youngest decile of passengers. And we are not spring chickens anymore. I've railed before about waiting to take that trip of a lifetime until the end of your lifetime, and there were a few of those on board. Still, most of the rest of us were able-bodied, not that Cuba requires any great vigor to visit.

You've heard about the entitled Millennials and their horrid behavior. Well, they had to learn it somewhere, and I think I've discovered the source. I have never been as embarrassed by the behavior of my fellow Americans as I was on this trip. While the majority were gracious, courteous, or at least civil, a good number of the old folks were cranky, whiny, pushy, and downright unpleasant to be around. I thought for a time I might be in a bad remake of Snow White and the Seven Dwarves, in this case, "Snowflakes and the Seven Statins". Frankly, I saw a level of anger and even contempt among this bunch which I don't recall seeing before. Perhaps as I get older myself, I find this stuff more obvious and less tolerable. These folks would cut in lines (not nice when you are waiting for a tender in 95-degree heat to take you back to the ship) and grouse about everything. Get between them and someplace they want to be, even if it means they would only have to take an extra step to go around, and you'll be the recipient of a very loud and very irate "EXCUSE ME!!!!!" I refrained from responding, 'you're excused". I don't know if these people have chronic pain syndromes, or they are just rich and spoiled, and expect the world to kowtow to them. One would think touring a poor nation like Cuba would bring home the message of just how lucky we all are to have what we have and to be able to go back to it. Or not.

Compounding the joy, there was a custom among some from a certain part of the U.S. to (loudly) describe in great detail everything going on around them in real time to their companions, as if the latter were not seeing the same things at the same time, peppered of course with appropriate color commentary. Maybe the rest of us would rather experience the experience for ourselves? That's too bad.

Be that as it may.

I do urge you to visit Cuba should the opportunity arise. You won't regret it. Bring me back a Trinidad if you wouldn't mind...

"Ramblings On Radiology And The Job Market"

Image courtesy HoustonMethodist.com

Dalai's note: Daniel Corbett is a Radiology business consultant who has posted incredibly useful information on Aunt Minnie as long as I've been there. This opinion piece should be mandatory reading for all in the field.

There has been much posted lately about the robust job market for radiologists. There has been wide ranging discussion about the quality of the jobs available with regards to corporate practices and teleradiology. The potential to join a group without knowing about "discussions" the group may be having with other entities is very real. As for private practice jobs I think most would agree many if not all practices are facing the same difficulties with short staffing due to increasing volume, retirements and partners leaving for greener pastures. All this adds up to an increasingly risky job market with potential for "jumping from the frying pan into the fire" for experienced radiologists or just plain getting screwed by a fellow looking for their first job. For you 2020 fellows this can be disconcerting as there are many jobs to choose from and recruiting tactics have become aggressive. Loan repayment, signing bonuses, super short partnership tracks all tell of the desperation of groups down one or more FTE's and desperately need the help.

In my 30 years in radiology I have been through several swings in the job market. The radiologist shortage of the early 2000's was deep but technology leaps and radiology increased efficiency lessening the impact of short staffing. It was bad and many groups fell apart but as a specialty we got through it. This new shortage seems more intense and desperate as efficiency through technology has maxed out. We all felt safe for the last 10 years and even complained that there were too many radiologists turning radiology into a commodity. I never believed that for a second. Radiology is THE anchor specialty and cornerstone on which all healthcare relies on. There was never a question in my mind that volumes would continue to grow along with the demands on radiologists.

In my mind the whole corporate radiology model is nothing more than a Wall Street attempted takeover of the most lucrative healthcare specialty. It changes nothing in the dynamic of traditional relationship between the radiologist, the medical staff referrer and the patient. Corporate radiology is an invasion of suits and greedy radiologists selling out their specialty for a cut of the pie which has been steadily declining. These corporate entities have invaded our specialty by taking advantage of the market forces which are beyond anyone's control. With a large percentage of radiologists at or near retirement age, many of which were in controlling position within their groups, it was easy for them to lure "exit strategy" radiologists with large amounts of PE money. Over the past ten years the delayed retirement of many senior radiologists created the short term surplus of radiologists which helped these entities take hold due to a ready supply of radiologists looking for work. Another aspect is the marketing power they wield with large amounts of money. The corporate groups have unlimited funds in which to hire people to call your hospitals to get an audience. They bring high powered radiologists and business people to pitch their product of efficiency, quality, technology and 24/7 sub-specialty reads to dreamy eyed administrators who are tired of hearing complaints about their private practice radiologists. The corporate groups have moved from purchasing the fat cat groups to hostile takeovers. The gloves are off and they will steal your contract from under your nose and the next thing you know you will be offered to become an employee or leave. I know this is true because I am seeing it happen in real time with several groups. It is a train wreck in slow motion.

I believe no group is safe as the stated goal of these entities is total market domination. The total corporatization of radiology would be a disaster for radiologists, hospitals and patients. These corporations must be fought at every level to keep radiologists as autonomous clinical and business entities. Radiologists should refuse to work for them even if it is for excellent pay in the perfect location. As an employee you have no control and never will. Do not trust their "partnership" sales pitch. Only in a corporate practice as an employee are you truly a commodity to be used and replaced. Only in a private practice do you truly have a say in your business and your future.

The deepening shortage of radiologists is our best weapon in the fight against corporate radiology. As long as there are good private practice options the the corporate groups will struggle for staffing. Being unable to fulfill their lofty promises will be their demise. Their whole business model is dependent on properly staffing their contracts while taking a cut for investors. They throw a lot of money up front but the ROI depends on maintaining the status quo over time. I believe once the time limits for the buyouts expire those radiologists will leave causing the house of cards to collapse. Private practices must also do their part in the fight. Dishonest and dysfunctional practices must strive to be better. To remain relevant and secure private practices must do away with unfairly long partnership tracks, tiered partnerships and shady outpatient and billing schemes. Strive to be democratic and provide good professional management at all levels. Work had to promote fair practices so partners and soon to be partners feel they are treated properly and are invested in their practices. If you don't lose people you never have to recruit new people. Only by being the best option for new radiologists will private practice win over corporate radiology. Strive to improve and maintain the best relationship with your contracted hospitals. Meet regularly, immediately address issues, constantly promote your practice within the medical staff. If there are no cracks in the armor the enemy can't get in!

Finally I want to advise the 2020 fellows on a few things. So far I have encountered an astonishing number of 2020 fellows who have already committed to a practice, before even starting their fellowship. I know this is because of the huge number of opportunities out there. If you get an offer with the top group in the community of your choice and you know in your heart this is THE job for you then by all means sign. But know over the next 15 months there will be plenty of other opportunities open to you. Don't be tempted to continue to interview after making a commitment. This past year I know of several fellows who reneged on groups they signed contracts with to take another job they found later. This is not how you want to start your career. When you interview you must expect the practice to put pressure on you to sign. This is normal and expected but trust me you will rarely lose an opportunity by delaying. If you interview early tell practices up front you will not make a decision until you have completed your interview process no matter how long that takes. If they chose to not interview you then you know what they are about. Do not succumb to the pressure to get a job while the market is hot. You have all the time you need. Traditional timing of interviewing after starting your fellowship and committing before the end of year or later will work out well for you. I foresee groups hiring 2020 fellows very early then continuing to recruit for an experienced candidate. If they find one they may renege on you!

Radiology is experiencing rapid change again. There are some bad things to be wary of but there is also great opportunity. Knowledge is your best tool so do your homework before making changes. Seek advice from trusted sources whether your a radiologist looking to make a job change or a group looking to improve your operations and processes. Hopefully private practice will win the day and we will see a new radiology paradigm evolve over the next decade.

ADDENDUM...More from Mr. Corbett:

Private practices contracted to a hospital is the purest form in hospital based specialties. The volume generated by the hospital department will generates X in pro fees. This is the book of business available. This will vary by location and payor mix. The rads read and bill for the exams and get reimbursed creating the "pie" of net revenue. From the net revenue you need to pay the bills/expenses which usually include billing fees, accounting, legal and all the other miscellaneous costs to run the business. In some groups this can include employees and all the expenses that come with them including rent, equipment and supplies. What is left is physician compensation. Included in physician compensation are benefits and tax deductible business expenses like CME, Phones, Med mal, health, etc. What is left is W-2 which is your taxable income.
  
These expenses vary greatly by group based on size and how they choose to run the business. Some practices have high overhead due to many employees, imaging centers, own billing companies, etc. I have seen overhead percentage run up to almost 30% of collected revenue. I have also seen lean, self managed groups run as low as 9-10%. Considering a primary care practice averages 40-50% overhead, radiology is not such a bad gig. I believe the average overhead percentage for a well run private practice with no imaging centers to be around 12% which includes billing and management (legal, accounting, infrastructure).
  
Now consider a hospital employed practice. The hospital provides all the infrastructure including the billing, management and benefits. They pay the radiologists a salary and benefit package to provide service. This can be a simple model and appear to be a good deal for some radiologists as long as they are getting paid a fair market rate for a fair market volume of work. The problems with employed models is hospitals don't do well managing radiologists and the expenses get away from them. They also don't understand fair market value and its relationship to the amount of work. They often get wrapped up in silly unrealistic RVU productivity models which cause more damage than good. Also most radiologists (doctors in general) who are employed default to the lowest productivity needed to keep their job. Why work harder if you don't get paid more? This requires hospital employed models to be overstaffed which lead to higher costs (overall) to get the work done so the hospital ends up subsidizing the professional component out of the technical revenue. Some hospitals are fine with this if it is control they crave but eventually the constant turnover and internal dysfunction can cause them to fail.
  
So the original question is how can a corporate sell their model to hospitals? The answer is NEVER if there is a lean, well run private practice in place. Almost every single corporate take over happens because there is weakness with the current provider. Lack of service, poor quality or most common group dysfunction is the culprit in a private practice contract loss. Every Single Time! The corporates always sell the hospital on making their radiology provider woes go away. They are NEVER a cheaper option. They sell the hospitals on quality, technology, infrastructure, management and especially service. Also the lure of 24/7 sub specialty reads is like crack to a hospital administrator, especially dealing with a troublesome group.
  
Let me be clear about this again. The idea of skim jobs and back door financial deals between hospitals and corporate radiology are pure fantasy. Sure sometimes there are some shady deals that get them in the door but for the most part the deal must stand alone on the service provided for the revenue generated. As we all know you can only streamline, increase efficiency and cut costs so much. After that it comes down to what the radiologist gets paid. The main cost modifier for these corporate groups is through the leveraging of teleradiology but this has a hard limit. You need critical mass onsite to make any hospital run optimally. When the market was fat with radiologists they could pay less. Now that there is a shortage they must be competitive which dips into their profits. As I have been saying all along, staffing will be their downfall. If they can't afford market rate labor and maintain staffing they will fail. Once the profits decrease and losses accrue Wall Street is gone! Unfortunately when this eventually pans out there will be a large hungry black hole which will need to be addressed but that is for another post at another time.
  
Again in reality is nothing can compete with a competent well run private practice surviving on the professional component. Hospitals desire high quality reads with superb service and not providing a subsidy. In the past hospitals provided their well respected groups financial help with the supply and demand of radiologists turned. No hospital wanted their long term (functional) providers to self destruct. Usually these subsidies where tied to real data showing where the group needed help to remain competitive. When the market changed the subsidies were removed or renegotiated. The key is always fair market value and the ability to properly staff. All hospitals really desire are well led and managed groups where the radiologists are involved at all levels. If they have this they have no need to consider other options.
  
In a perfect world this should be easily attainable but too many groups are dysfunctional. Poor leadership, lack of proper infrastructure, disruptive radiologists, poor practice management, shady partnerships and billing practices, you name it, it's out there. You may think your business is yours and not known by the hospital and medical staff but you would be wrong. All your dirty laundry is out there. You know it because you know all the other physicians dirty laundry. What still amazes me is how a multi-million dollar business like a radiology practice can be properly managed by the radiologists who have no formal training in business. I know of many multi-million dollar radiology groups who are managed by former techs and some with no formal healthcare business education. Not to say some of these people are not good at what they do and are not dedicated. I have worked with some amazing practice managers but how can one person, even one with a BA or MBA in business know all there is to know about a highly complicated business like radiology? They just can't be experts at everything. It still boggles my mind how many groups have little to zero oversight of their billing companies or operations. When was the last time your group audited your billing company? We have found hundreds of thousands of dollars being lost over many years. BTW this is another area where the corporates will have an advantage. They know where EVERY dollar is generated, collected, and spent.
  
I am always hesitant to sound like I'm marketing but I was asked how organizations like RP and Envision get their noses under the proverbial tent. My answer is and will always be the lack of organization, leadership, governance, finance and overall management of private practices. For the sake of security and protecting itself from any potential invasion, every private practice should do a top down, comprehensive, in the weeds evaluation of the way they structure, govern, lead, operate and manage their practice.
  
Healthcare is rapidly changing. We are being told to do more with less. The cost of this amazing care we have in our country can't be afforded by the majority of the population. The insurance industry is broken. They way healthcare is delivered is broken. Change is inevitable and change is where Wall Street invests heavily. Wall Street and PE money are capitalizing on the greed, dysfunction and lack of cohesion between radiologists. After all they can run your business way better than you. They will buy some and steal others. The only way to stop them is compete and be better. But the first step to recovery is learning you have a problem. I hear it all the time...our practice is great, everything runs well, we all get along, everyone loves us....just before the bus runs you over - BAM!

Senior Discounts

On January 1, 2019, I officially retired from the position I held for 28.5 years. Let the new era begin!

In the interest of transparency, I have to tell you that this was not entirely by choice, and I am assured that there was no problem whatsoever with my work. But be that as it may, my life's schedule is now pushed up just a bit. The metamorphosis from practicing physician to private citizen (and eventually, I suppose, to patient) is a process I had started a few years ago, when I cut back to working 26, and then 22 weeks per year, dumping call in the process. There were those who couldn't understand my action at that time, those who said I was not a "team-player" and that I was "gaming the system". I strongly disagreed then, and I still do. If anything, at part-time rates, I was a bargain for the niche expertise I provided, but the attitude betrays a level of pain, both self-inflicted and externally-sourced, that many physicians experience, but won't discuss.

I'm not totally out of business, however, which is one of several reasons why I demurred on the retirement party the group wanted to give me. (They remind me too much of wakes anyway.) Our med-mal carrier allows us to work up to 60 days per year without additional tail coverage, and so I'll be able to keep my hand in the till, I mean the practice, for a while longer, and so I'm not quite gone from the old place just yet. This little reprieve gives me, at age 60, a bit longer to reinvent myself. I love travel, and had planned on doing more in retirement, but the abrupt loss of revenue (not to mention having to pay $37,000 out of pocket for health insurance and deductible) will limit that. There will be no 'round the world cruises for the foreseeable future.

Some have asked: "Is it wrong to retire early from a medical career?" Some, including me, have answered, "No." "Wrong" implies that we retirees are pilfering something by going about our merry way, which is certainly not the case. As with everything else in life, this transition represents a balance; retirement obviously stops the emotional hemorrhage, the drain on our psyches and our souls inherent in this business, but we are then deprived of the many joys of healing as well. It's a tough choice...maybe I'm lucky I didn't have to make it all on my own.

Retirement brings seismic changes in my personal finances, and so I've had to make some adjustments. Obviously, it's hard to know how much cash you need until you know how much you spend. To that end, I created the Google Form illustrated below, which allows the entry and subsequent monitoring of every single expenditure. Every single dollar. Every last cent. EVERY. LAST. BLOODY. CENT. I am going to have an absolute and complete handle on this if it kills me, and it just might.

There are any number of fairly painless ways to save a buck. The home thermostat, for example, is now set to a reasonable 68 degrees, instead of the more comfortable 72. Should have done that years ago. I suppose when summer hits down here in the Deep South (usually sometime in late February), I'll jack it up to, oh, maybe 75? I'm already wilting at the thought.

Reaching age 60 will facilitate some savings, although I had a minor intestinal disturbance when the kid at the grocery check-out announced, "And since today is Wednesday, you get the Senior Discount!" I used to think the average age of those taking advantage of Senior Day was dead. But hey, I'm getting pretty good at value shopping. I can tell you which neighborhood grocery has the best deal on Veuve Clicquot. What?! I may be un(der)employed, but I haven't yet reached the level of eating dog food. Or the dogs. Yet.

Everyone now wants to know about the next chapter. The short answer is that the book is far from finished, and I'm just starting to type the first word or two of the first line of that next chapter. I mentioned above that I will continue to work for the old practice for a while. Of the 60 days I'm allowed this year, I have 29 booked so far, and that will at least help with health insurance. In addition, I've been asked to give a talk to our state Nuclear Medicine Society meeting in a few months, and I've found that the best way to keep my skills sharp is to share them.

In the meantime, there is quite a bit to do around the house. My two little dogs alone can keep me quite busy; their favorite activity is requesting to go outside so they can come back in again. The laundry basket magically fills itself up at least every other day, which must be addressed. In case you wondered, I haven't ruined anything in years. No, I don't wash it all in hot water.

There are drawers that need dumping, their contents sorted and reloaded, stuff to be taken to Goodwill, and things to be moved from one shelf to another. Like the gym ad, I find myself picking things up and putting them down again, although the objects do end up in other places, thank you. And the yard always needs something done to it. I do have a service, but they don't weed, and they have a very bad habit of blowing leaves into the bushes, thinking I won't notice. I've been known to use a Shop-Vac to literally vacuum out the azaleas; the last time I did that I accumulated a pile of leaves about 3 feet high, which the yard guys charged extra to haul away, even though it was all their fault to begin with. And I seem to have discovered magic weeds (no, not those!) that happily ingest and thrive on Round-Up. All that exposure to a potential carcinogen for nothing.

My main achievement in retirement so far has been the establishment of the "For Better Or Worse But Not For Lunch" club:

"Club" is perhaps too fancy a word for a gathering of a bunch of retired guys who need to get out of the house once in a while, but call it what you will, we had a great time at the first lunch meeting. The plan is to reconvene on the second and fourth Tuesdays of the month. Assuming I make them all, that leaves only 331 more days to fill...

And fill them I shall. There are still a few trips I've had on the books since before the Lessened Event, and you'll eventually see pics here from some far-flung places. (Teaser...several destinations are islands, one is in a desert, and one will involve Star-struck photos with Famous People!)

The elephant in the room is, of course, what I will REALLY do when I grow up, since there doesn't seem to be a way to avoid adulting at this late date. Honestly, nothing seems to fit perfectly. I've tried writing, but obviously I haven't been quite as motivated as I once was. Maybe that will change. And while I enjoyed my mission trips, I found they are more for the young and strong, and those who think well on their feet, even after multiple sleepless nights. I don't want to do locums, and the VA here needs to fill several full-time spots before I could even be considered for a part-time NM position. I've sent out some feelers to various PACS and equipment vendors, but surprisingly, they are not yet squabbling with each other to be the first to have Doctor Dalai on the payroll.

No doubt the real answer is something else I haven't considered or even thought of as yet.

So, for the moment, I'm going to wallow in my (mostly) retired status. I'll sleep late on occasion, and be the best house-husband I can be. I've been advised by other retired docs to just relax and enjoy it for a while. The proper path will become obvious. Eventually.

But for now, you must excuse me...the clothes dryer just buzzed...

The Abscopal Effect

In the waning years of my career as a Nuclear Radiologist, I have become somewhat more jaded than I was as a younger doc. When you see cancer and other diseases fifty times a day, sometimes getting better, sometimes getting worse, that's bound to happen. Of course, I far prefer reporting improvement, but relapses are also part of this job. The oncologists wander into the reading room every few minutes, or so it seems, anyway, to look at their patients' scans (the gantry is generally still warm). If the news is bad, I will tell them in all honesty that I admire the strength it will take to deliver the bad news. On those occasions I'm quite content to sit in the dark and stare at my 8 monitors.

One day last week, one of the Med Onc's came in to the reading room with a rather odd look on his face. "You didn't read this scan, but I want you to look at it," he said, which immediately set my mind at ease. (The four most dreaded words in this business are: "You read a scan...") 

He had me look first at a PET/CT from earlier in the year on this elderly patient:

You don't need me to interpret this for you, which is a bad sign. We see several lesions in the liver, presumably metastatic spread of cancer. There is a small focus in the upper thoracic spine, and a much larger coalescence of several lesions involving the lower thoracic spine. There are other lesions, and there is (benign) calcification around the mitral valve of the heart. 

OK...now, here is the most recent study:

Just about all the bad stuff is gone. Most everything we see is physiologic. (The hotspot in left upper abdomen is in the stomach, and the CT didn't show anything there, but we'll still watch it.)

This isn't a particularly unusual scenario following therapy, and I complimented my friend on another successful administration of his potions and poisons. At this point, he shifted uncomfortably from foot to foot. He finally looked up and said, "But we only treated the lower spine lesion with radiotherapy. We didn't treat the other areas!" We called in the treating Rad Onc, who was equally surprised. "Wow. This would have to be an abscopal effect. I've never seen one before. There might be 20 or so reports out there..."

What in the world is the "Abscopal Effect"?

From the Wikipedia:

The abscopal effect is a phenomenon in the treatment of metastatic cancer where localized treatment of a tumor causes not only a shrinking of the treated tumor, but also a shrinking of tumors outside the scope of the localized treatment. R.H. Mole proposed the term “abscopal” (‘ab’ - away from, ‘scopus’ - target) in 1953 to refer to effects of ionizing radiation “at a distance from the irradiated volume but within the same organism.”

Initially associated with single-tumor, localized radiation therapy, the term “abscopal effect” has also come to encompass other types of localized treatments such as electroporation and intra-tumoral injection of therapeutics. However, the term should only be used when truly local treatments result in systemic effects. For instance, chemotherapeutics commonly circulate through the blood stream and therefore exclude the possibility of any abscopal response.

The mediators of the abscopal effect of radiotherapy were unknown for decades. In 2004, it was postulated for the first time that the immune system might be responsible for these “off-target” anti-tumor effects. Various studies in animal models of melanoma, mammary, and colorectal tumors have substantiated this hypothesis. Furthermore, immune-mediated abscopal effects were also described in patients with metastatic cancer. Whereas these reports were extremely rare throughout the 20th century, the clinical use of immune checkpoint blocking antibodies such as ipilimumab or pembrolizumab has greatly increased the number of abscopally responding patients in selected groups of patients such as those with metastatic melanoma.

Visually (also from the Wiki):

"Proposed mechanism of the abscopal effect, mediated by the immune system. Here, local radiation causes tumor cell death, which is followed by adaptive immune system recognition, not unlike a vaccine.'

So, this rare phenomenon probably has a scientific explanation. I'm used to seeing various cancers and other diseases cured, or at least kept at bay, including things we were taught not that long ago were "incurable". I see what was once impossible happen pretty much every day. And that's amazing enough when you think about it. 

Arthur C. Clarke once said, "Any sufficiently advanced technology is indistinguishable from magic." While there is science behind the Abscopal effect, it is still unusual enough that I have no problem calling it a miracle. As a rare perk in my end of health-care, I had the great opportunity to show the scans to the patient herself. She and her husband and daughter took it all in with quiet faith and dignity, enough to make you cry. How many times in a career does the opportunity come along to tell someone their prayers have been answered? 

A miracle? Maybe. After all, we did have all the bases covered. The MedOnc is Muslim, I'm Jewish, and the patient is Christian. I wonder if that sort of coming-together would work in other venues...

A Cold-Call Email From A Headhunter

I HATE SPAM. HATE IT. With a passion. Almost as much as I hate robocalling telemarketers. I REALLY hate them. It would be nice if the Feds would send just one little bitty teeny-tiny cruise missile into a Bangalore call center or two. I do believe that would solve the problem.

But back to email SPAM.

In among the various advertisements for incredible products (that don't exist), emails from Russian women (written by burly gentlemen who probably aren't in Russia), and offers from Nigerian princes (who probably are Nigerian but are unlikely to be royalty), I often find messages from radiological headhunters, middle-men trying to either get me to hire someone or to put me on their list for similar cattle-calls. Now, before you get upset, I will certainly acknowledge the existence of legitimate, high-level employment agencies, who provide a service to the best candidates and groups or employers. However, any agency that acquires slots to fill and people to fill them via cold calling, and unsolicited emails, is NOT an agency I want to deal with on any side of the equation.

Note: I am NOT looking for a job. I'm working 22 weeks per year, a sustainable pace, and I'm hoping to continue to do so. It is quite clear that the headhunters are fishing for anyone with a medical license and a pulse. Otherwise, why reach out to an old guy like me? I guess the fees are not age-based.

My latest bemusement stems from the following communication. The company involved will remain nameless, unless someone gives me a reason to mention it...

Subject: Re: Primary Care Providers - Can you recommend a colleague?

If you aren't interested, please unsubscribe rather than marking as junk.

Good Afternoon Dr. Dalai,

I wanted to follow up on the email I sent last week regarding primary care locums in your town. Do you have any time in your schedule to help? Experience with addiction desirable, but not required. Details below:

(My Hometown)
Mon-Fri 8:30a – 5p
No afterhours, no weekend call
20-30 patients per day
Treating substance withdrawal

Please let me know if you have any interest or know of a colleague to refer. I look forward to hearing from you!

Thanks,

RB - Primary Care Recruiting Specialist

Houston, we have some problems already. First, I'm NOT a Primary Care Provider! And marking these emails as junk is what most people correctly do with them. And.... TREATING SUBSTANCE WITHDRAWAL? Is addiction a job requirement? Or would the successful candidate have to participate in treating others? Inquiring minds want to know. Unfortunately for RB, I didn't. This response went out immediately:

Hey RB....THIS IS SPAM and you have been reported to the FTC and your ISP. STOP USING BOTTOM FEEDER spamming. It will NOT work.

This got the attention of someone higher up in the company food-chain:

Please allow me to apologize for any inconvenience this email may have caused you. I have performed a thorough search and found that this the only email we have ever sent to you. I am not sure specifically from where they obtained it, but your information was on a list we purchased through a major healthcare data supplier. I would posit that the message sent by RB was “Bulk” in nature rather than SPAM. We have a legitimate business offer, we didn’t send anonymously, we provided all of the necessary “Unsubscribe /Opt Out” requirements. Additionally, she did offer a referral should you know any colleagues. She did receive several positive responses and we have somebody placed already as a result of the campaign. Once again, I would like to apologize and let you know that you have been permanently removed and can expect no further communication from us

Respectfully, RM, USMC ret.

Vice President of Recruiting and Gov’t Ops.

That really made it all better. It was a legitimate business offer! Who knew!? And apparently RB lied when she said she was "following up" the earlier email that her boss RM says was never sent. I love it when someone attempts to plant false memories, don't you?

While I don't generally mess with Marines, RM's justification of the low-class approach was just too much. SPAMMING is no different to the recipient than Bulk email...the messages are NOT WANTED by the vast majority of the population. Even worse, they purchased my name from a sucker list! This was not to go without challenge, although I was still being relatively nice at that point:

Thank you. Please let me know the source of my email address so I can put a stop to this sort of thing.

The response came quickly:

That I can’t do with 100% accuracy. It would have either been Billian's HealthDATA or Definitive Healthcare. I believe the two are now merged, but when we originally obtained lists, they were two separate entities.

I was actually able to determine that it was Definitive. As mentioned, I have removed your email so that you won’t be on any bulk distribution lists. I would like to ask, though, if I should keep you in my database? I do occasionally have Locums Radiology work if you might be interested. If not, I certainly understand.

And here, I saw red. I've just made it clear that I don't want to be SPAMMED, and the gentleman keeps digging for business! I wasn't terribly nice at this point:

I would say it took incredible gall for you to even ask that question.

Please provide the name of the manager/owner of your company. I need to have a little talk with them, it seems.

I guess I hurt the Marine's feelings, which was not really what I wanted to do, but desperate times call for desperate measures. Here's his final communication:

Dr. Dalai,

I thought we had reached some amount of common ground after explaining my position based on one email sent to you. I aim at providing a valued service to any potential provider, hence my question relating to keeping you in the database but never sending you email. After what I thought had been worked out and we had engaged in a dialogue, it seemed normal to ask that question. There was no Impudence. I obviously now have the answer to my question. I will permanently remove any trace of you from our system and wish you all the best.

Respectfully, RM, USMC ret.
Vice President of Recruiting and Gov’t Ops.

No Impudence? Heck yes, there was Impudence! Keep me in the data base but never send me emails? Right.

I guess headhunting is a brutal business, requiring the participants to climb all over each other to get clients and job slots. That's all well and good, but DON'T use SPAMMING (or cold-calling) to fill your lists. It's low-class, it's annoying, and despite the claims otherwise, I suspect positions and candidates gathered in this manner might not be the best of the best of the best. No offense to anyone hired this way; I hope you are all happy with where you are.  But I PROMISE the headhunters: you are angering far more people than you are serving. Find a better way.

By the way, I did get in touch with Definitive Healthcare (sales@definitivehc.com) and requested that my information be removed from their system. They promised to do so. Unless you like to be SPAMMED, I would strongly recommend you do the same.

Until the next outrage...

"Despicable" GE Spins Off...Minion Healthcare?

I couldn't let an occasion as momentous as General Electric spinning off its Healthcare division go without mention. As yet, the new pure-play division has no name other than GE Healthcare, which is what it used to be called before being spun. Off, that is. So I guess it's up to me to name the new baby.

We all know that Siemens performed a similar excision of its Healthcare Division back in March of this year, although this was announced back in November, 2017. You may know that Siemens had a sponsoring relationship with Disney...

...until October of 2017, and I have to wonder if that had something to do with the unfortunate moniker "Healthineers" applied to the new Siemens offspring. Perhaps the folks in Erlangen don't realize how odd it sounds. No offense to Siemens or to Disney, but it just doesn't click. (A bit of trivia: Few will remember that GE  once touted a "Healthymagination Initiative" worthy of Figment himself.)

General Electric once owned NBC/Universal (which is now a Comcast property). Universal Studios produced the "Despicable Me" movies, starring the Minions. Thus, I propose the name "Minion Healthcare" for GE's new little prodigy. I'll take my fee in small bills, please.

The various articles about the new lil' baby GE imply that the rationale for the birth was similar to that of Siemens (and of Toshiba selling off its healthcare lines to Canon): Cash, or lack thereof. From AuntMinnie:

Despite its storied lineage, GE Healthcare got caught in the downdraft created when its parent company in 2017 announced a massive one-time charge to write off liabilities related to a long-term care insurance business that it has sold off. The cash crunch called into question the wisdom of GE's corporate structure as a large, diversified firm with multiple varied businesses. The cash woes and associated stock slump led to GE being removed from the Dow Jones Industrial Average earlier this month.

The company began jettisoning smaller units to raise cash, and speculation was that the healthcare division would be one of them. But Flannery's assurance that healthcare was a core business prompted many industry observers to believe that medical would remain within GE's fold.

Ironically, GE Healthcare has been one of the stronger performers in GE's corporate portfolio. The division posted 2017 revenues of $19.1 billion, up 5% compared with $18.3 billion in 2016. The business also grew its profit by 9% to $3.44 billion last year, compared with $3.16 billion in 2016.

Now, of course, Minion GE Healthcare puts a different spin on being spun:

Kieran Murphy, president and CEO of GE Healthcare, will continue to lead GE Healthcare as a standalone company, maintaining the GE brand.

“GE Healthcare’s vision is to drive more individualized, precise and effective patient outcomes. As an independent global healthcare business, we will have greater flexibility to pursue future growth opportunities, react quickly to changes in the industry and invest in innovation. We will build on strong customer demand for integrated precision health solutions and great technology with digital and analytics capabilities as we enter our next chapter,” said Murphy.

Flannery (GE CEO) added, “GE Healthcare is an industry leader with financial strength, global scale and cutting-edge technology. Our talented Healthcare team will continue delivering precision health solutions, building on our heritage of technology innovation that delivers patient outcomes.”

Whatever that means.

GE's "storied lineage" is the result of acquisition after acquisition after acquisition:

GE's roots date back to the 19th century, when a pair of inventors -- C.F. Samms and J.B. Wantz -- founded the Victor Electric Company in Chicago in 1893. They began making x-ray systems one year after Wilhelm Röntgen's discovery of x-rays in 1895.

A series of acquisitions and mergers followed over the next 25 years, until in 1920 when Victor Electric was acquired by GE, a manufacturer of x-ray tubes. The company grew rapidly over the coming decades, and after World War II moved its headquarters and manufacturing to the Milwaukee area.

Additional corporate milestones occurred in 1985 when GE bought Technicare from Johnson & Johnson, acquiring Technicare's large installed base of CT scanners; it bought ultrasound developer Diasonics Vingmed in 1998 and CT manufacturer Imatron in 2001. A major acquisition occurred in 2003 with a $9.5 billion purchase of U.K. life sciences and contrast media company Amersham, a move that brought GE into the pharmaceutical business.

GE Healthcare also accomplished a number of medical imaging product milestones over the years. The company was one of the first manufacturers of CT scanners, installing its first system in 1976. In the early 1980s, it launched its Signa line of MRI scanners, which went on to become one of the best-known product brands in radiology.

GE Healthcare's IT Division in particular has been the recipient of a lot of outside technology:

The list of companies assimilated into the GE collective includes Dynamic Imaging, as above, whose IntegradWeb PACS is the basis of the mostly-functional Centricity Universal Viewer, and Scanditronix, the predecessor to GE's PET division. Let's look at how these two product lines have progressed to get some idea of how Minion Healthcare might do in the years to come.

GE, as above, purchased Dynamic Imaging in 2007, for at least $200 Million (some say much more than that). As a user of the venerable old Centricity versions 2-5, I was thrilled for the possibility of a usable PACS, and DI's IntegradWeb was one of the few competitors to give the old AMICAS PACS a run for its money.

Alas, GE had tremendous problems in integrating Integrad. The plan was optimistic, and could not be fulfilled. I was told many years ago that the Web DX initiative, integrating PACS-IW, with new streaming engine, to Centricity PACS has yet to fulfill the promise that was told to the market upon the DI acquisition. GE also publicly showed, at tmultiple RSNAs, engineering efforts to integrate AW Server with Centricity PACS and PACS-IW. We tried it for several months as a PET/CT reading solution. The AW port itself worked, more or less, but the integration to PACS was so problematic that we had to abandon the effort. We now use Segami Oasis for this purpose. (I wanted MIM, but that's another story.)

The current incarnation of Universal Viewer does work adequately, but it took YEARS to get this done. PACS-IW was first announced in 2008, but the Universal Viewer, the functional version, was finally delivered to us in 2015. (Even then, there were so many problems we almost rolled it back to Centricity 5.x.) UV is a Frankensteinian stitching together of a number of different technologies that GE had acquired, developed and individually brought to market over the years. This jumbalaya of seven products was touted as the Universal Viewer, a "web-based" viewer with numerous capabilities. The components included:

• Centricity PACS (RA1000)
• Centricity PACS-IW (The immediate descendant of DI's IntegradWeb)
• AW Server
• IDI Breast Workstation 
• Web DX Streaming Engine
• Centricity Clinical Archive (formerly Centricity Enterprise Archive)
• Zero-footprint (ZFP) viewer for image review and mobile access. 

GE previously re-labeled a Calgary Scientific product for remote use. The newer ZFP viewer was/is different than the Universal Viewer itself (and it is significantly more streamlined, i.e. limited in its functionality).  Thus, GE continued down the same path of separate viewers for diagnostic and clinical access as with RA1000 and CentricityWeb. (I consider the latter one of the absolute worst pieces of PACS software ever made, and I once told a GE VP exactly that. He looked as if I had just called his dog ugly.)

It should be mentioned here that Merge managed a similar feat with its PACS, but did a better job of blending the pieces from the original AMICAS PACS, as well as those from Emageon, Merge, and eMed. And it did so after firing being unable to rehire the original PACS programmers, despite my sage advice.

Where does Minion Healthcare take GE PACS from here? Most of the cool kids, I mean cool PACS, have been bought up by other larGE companies, so there will have to be further innovation from within. I have to wonder if the economics of healthcare IT and such will dictate a reversal of the procurement trends. Might we someday see Minion PACS spun off again, to an EMR vendor perhaps?

Let's move from software to hardware.

We could have a very long discussion about scanners of all genres, CT, MRI, Ultrasound, Nuclear, PET, PET/CT, PET/MRI, and so on, but as this article is getting longer and longer, and I'm getting older and older, let's concentrate on PET/CT. I have some experience in this realm.

GE's PET business descends from Scanditronix's scanner division, purchased at the beginning of 1997 (for some reason, another source says this purchase occurred in 1986 and a third says 1990), along with rights to sell the latter's cyclotrons. Siemens had been working with CTI Molecular Imaging of Knoxville, TN since 1987, and purchased it outright in 2005.

You might recall my very famous (or infamous) row with GE over my 2005 blog-post, which I have just republished after suppressing it for many years:

http://doctordalai.blogspot.com/2005/07/theres-more-than-one-way-to-scan-pet.html


To make a long story short, I compared the PET/CT offerings from GE and Siemens, and found GE lacking as they were using the older and less efficient BGO crystals. Siemens used the article in its own sales pitches. GE became concerned that I was calling their machines non-diagnostic (I wasn't) and a big commotion followed. Much of the problem stemmed from our internal politics, but the controversy tapped into a yuuuggge pool of resentment aimed at GE, and they may well have lost some sales over the issue. I would far rather they lost sales over their equipment, that I felt at the time was inferior, but no matter. We are all best friends now. Sort of.

Rather than go through the painful discussion of how PET works, I will refer you to these two excellent reviews of the history of PET:

History and future technical innovation in positron emission tomography

and

PET--The History Behind the Technology

In brief, all you need to know about PET scintillator/detector crystals can be found in this graph:

From the first paper:

The widespread adoption of 3-D acquisitions challenged the limits of BGO (bismuth germinate), especially for whole-body imaging of large patients. The response was an ongoing search for a scintillator with better light output, faster rise and decay times, improved energy resolution, and reduced dead-time. . .The higher light output would also improve energy resolution leading to a more efficient rejection of scattered events.

The search led to the discovery of a new scintillator, lutetium oxyorthosilicate (LSO), that had originally been used for nuclear well logging but was found to have much superior light emission properties to BGO for PET imaging. The first commercial PET scanner incorporating LSO was the (Siemens/CTI) ECAT ACCEL that appeared around 1999. . .While some vendors have used a derivative of LSO that incorporates a small percentage of yttrium (LYSO), Philips Healthcare introduced a PET scanner (Allegro) with GSO as the scintillator. The technical advantages of these new scintillators resulted in better energy resolution leading to finer subdivisions in the detector blocks and lower scatter fractions and improved timing resolution leading to lower random coincidence rates. Overall, the new scintillators yielded considerably higher noise equivalent count rates, especially for whole-body imaging of large patients.

A major advantage of LSO, apart from the higher light output leading to better spatial and energy resolution, is the fast timing that leads to lower detector dead time and, above all, the capability to measure the time difference between the arrivals of the two annihilation photons in the detectors. This ability, termed time-of-flight (TOF), provides positioning information for the annihilation point that is not available without TOF. . .(I)t was not until LSO appeared that TOF made a resurgence with the launch of the Philips Gemini TF (TrueFlight) followed by the Siemens Biograph mCT.

I can vouch for the fact that the mCT has markedly better images than the (very) old GE Discovery with BGO crystals (which it replaced in our shop) and mildly better images than the newer LSO Siemens Biograph 16.

BUT...the old GE Healthcare started doing some major innovation in PET, advancing its PET/CT offerings and managing to produce a PET/MR as well. I think, well, I hope, it is safe to assume that this will continue under the new regime, although the pockets providing funding will necessarily be more shallow.

It is harder than it should be to determine which scanners have which components. Siemens doesn't talk so much about solid state detectors, and GE's literature keeps its crystal composition close to the vest. After getting frustrated, I Googled and Googled until I found an article that compared the offerings as of 2017. Here's the pertinent table:

Notice in particular that one of the GE's (Discovery IQ) still use BGO crystals, but tries to compensate with more rings of detectors, and that the Siemens mCT Flow uses PMT's (Photomultiplier Tubes) and not the newer solid-state silicon photomultipliers (SiPM's), found in the Discovery MI. Siemens does offer SiPM's in the Optiso UDR detector of their newest scanner, the Biograph Vision.

GE spent a lot of time and a LOT of money trying to convince the world that BGO crystals could overcome the laws of physics, and indeed they sold the darn things until recently. But the fact that GE finally got it, that their latest and greatest scanner line features LYSO detectors, their flavor of lutetium crystals, and solid state photodetection (nice description of the Lightburst Digital Detector here), tells us that Big GE planned to continue to be a Big player in this space. And I guess we can assume that the next Discovery ME (Minion Edition) will continue to avoid being particularly despicable.

So...

As a very minor GE stockholder, I'm awaiting my shares of Minion Healthcare. And IF I ever get the chance to purchase another PET/CT, I promise I'll give the Discovery's a look.

The Wedding Speech

Dalai's Note: My daughter "Dolly" got married last week to an incredible guy whom we'll call "Lama". Forgive the awkwardness of these false names in the following piece, but I did want to share my "Father of the Bride" speech with everyone. If you were wondering, this might have something to do with my lack of posting lately...

If I could have your attention for just a few moments…

I want to welcome all of you, our good friends, old and new, and family, old and new, to this celebration for Dolly and Lama! We are thrilled to have you here on this wonderful occasion! I can’t begin to tell you what it means to all of us that you have joined us here in the Rainy North! It’s nice to see that we have about as many doctors as lawyers! I promise to try hard not to make this sound like a closing argument, but maybe more short and sweet, like my Radiology reports: Normal, but clinical correlation required!

I really want to thank everyone who worked so hard to make this amazing evening possible. First of all, thank you Lama for asking Dolly to marry you, and thank you, Dolly, for agreeing! Obviously, there are quite a few moving pieces to an occasion like this, and Mrs. Dalai and Dolly, with help from our wedding planner, have done a great job of pulling it all together. We might not live up to the standards of that British wedding last week, you know, the one with Harry and Meghan, but I promise we’re going to have an equally good time.

A marriage unites two people, but it also unites two families. I think Mrs. Dalai and Dalai, Jr., and I are almost as happy as Dolly is about her new husband (I’ve got to get used to saying that!) and her new extended family. We, of course, were not part of the selection process, but I hope we would have done as well! Back in the old days, such decisions were made on the basis of who had the largest tracts of land...we’ve come a long way since then!

We knew Lama was a special guy from the moment we met him. In fact, on that first meeting, Dolly had been burning the candle at both ends and in the middle, for something new and different, (I think she had been on call the night before) and she managed to fall asleep in her chair over drinks. Of course, it doesn’t take too many drinks to knock her out anyway, but I’m sure Lama knows that by now. So, the three of us ignored her, and talked for several more hours, and we had a great time! That Dolly was relaxed enough around Lama to doze off and leave us to interrogate--I mean talk with him, well, that spoke volumes. By the way, Lama, you passed the interrogation with flying colors.

A couple should complement each other, and Dolly and Lama certainly do. Both of them are multi-faceted, and they each bring a huge list of talents and interests to the relationship. Dolly and Lama bike, sail and ski together and have introduced to each other to many more activities. Here’s one you might not know about her, Lama: Dolly as a child liked to roller-blade, but she had trouble with stopping when skating down the hill of our driveway, so she usually ended up diving into the bushes at the end of the run. Hopefully she doesn’t do that on the ski slopes!

While Dolly and Lama do have many common interests, they differ in many ways, like their chosen professions. The combination of a physician and an engineer is a bit unusual. I wear both hats, so I understand to some degree the traits and characteristics that have to coexist. Lama, as an engineer, has demonstrated an analytic approach to things, as well as common sense, at every turn, at least since we’ve had the pleasure of knowing him. Dolly, on the other hand, is an example of why we should be careful about what we wish for. Before Dolly was born, Mrs. Dalai prayed for Dolly to have her nose and my brains. Unfortunately, Mrs. Dalai forgot about my lack of common sense when she made that wish! I’m proud to say that Dolly is a fabulous physician, and has strong and caring instincts when it comes to her patients, but as for common sense, well.... Lama, it will be nice to finally have someone in the family who really does have that very uncommon quality. And good luck, by the way.

This wouldn’t be a proper Father of the Bride speech without me revealing an embarrassing Dolly story, so I’ll use my favorite to illustrate the common sense thing. Dolly, was named after her grandmother and her great-grandfather, but she has been known by a dozen nicknames over the years: Pookie, Big D, Spark Plug, Artzy Dolly, Sissy (courtesy of Dalai, Jr.) and probably some camp names we don’t know about. And when her mom and I needed to talk about her when she was in earshot, we referred to some little girl named Yllod, Dolly spelled backwards. I’m not sure when she caught on to that one, or if she ever did! Yes, Dolly, that was you we were talking about!

At the end of her Senior year of High School, she was out and about with her friends, on her way to help with the Senior Prank. This was to be nothing really bad, just filling the halls of her school with balloons. But the police were quite vigilant that night, and while no one was arrested, Dolly did get to have a nice little chat with one of the officers. Now, here’s the punch line: When they asked her name, Dolly, not using whatever common sense she was graced with, quite helpfully answered, “Do you want my real name or the name I go by?” Hopefully we have that problem solved as of tonight. You may know Dolly wasn’t sure what name to use after getting married. Since she has publications in the medical literature, her first thought was to still be “Dr. Dolly Dalai”. But ultimately, she decided to take Lama's name, and so she is now Dr. Dolly Lama. That has a nice ring to it, doesn’t it?

Along with the new name will come a new dimension in Dolly and Lama's relationship. Those who know me well are quite aware of my warped sense of humor, so forgive me when I declare that it goes without saying, or at least it should, that the marriage is much more important than the wedding. But the wedding is pretty important, too, and seeing the happiness in Dolly and Lama's eyes tonight is certainly the crowning joy of parenthood.

And so I lift my glass and ask you all to join me in wishing Dolly and Lama a lifetime of happiness and laughter, of joy and harmony. Listen carefully to each other, don’t take yourselves too seriously, but do take each other seriously. May you cherish each other, treasure your time together, and may the excitement of this evening continue throughout your lives together.

And with that I’ll say, Cheers!!! L’Chayim!

Driving "Miss Taxi"

As my second trip to Ghana winds down, I think of what I've seen and accomplished. The people I've met, the places I've visited. The mark I've left on this wonderful nation, and that it's left on me. One returns from a trip like this a better person, and that growth is enhanced by those who touch your life during the brief sojourn away from the known.

I have literally met royalty this trip (long story, won't talk about it for privacy reasons.) I've worked and played with some very fine physicians, IT people (yes they are!), technologists, and and so forth. Neither an abundance nor a lack of resources can dictate the someone's quality (or lack thereof). Suffice it to say, there are good, kind, capable, and amazing people anywhere and everywhere. You just have to find them.

I'm going to tell you about the most amazing person in Ghana, perhaps in Africa, and maybe beyond that. Her name is Esenam Nyador, but she is known throughout Ghana as "Miss Taxi". And she is KNOWN throughout Ghana. Everywhere we went, she was recognized and greeted as the celebrity she truly is.

My fellow volunteer discovered Esenam in the process of figuring out what to do over the weekends, when there is little activity at the hospitals. Any Google search involving "Ghana" and "guide" will yield listing after listing mentioning "Miss Taxi". And so, we had a tour like I've not experienced anywhere in the world, planned, executed, and delivered by someone who is very clearly proud of her nation. Her love for Ghana shines through at every point, and it is very, very infectious.

I could give you a travelogue, and drone on with descriptions of stop after stop. But I'm not going to do that this time. I'm not even going to put up more pictures. You need to come here and see this place for yourself, and you need to have Esenam show it to you. Trust me. I'm a doctor.

So what's the big deal with "Miss Taxi" you ask? It's all there in her nickname. Miss. Because Esenam has almost single-handedly broken into a formerly (and still, to a considerable degree) all-male field.

The odds were truly against her. Esenam was a single mother of two boys when she decided she was not going to let the world keep her down. Scraping by to make ends meet, she went to college, getting her first degree (Social Work major, Psychology minor...her SECOND degree is a Master's in Family Resource Management) from the beautiful University of Ghana. (I know it's beautiful because Esenam drove us through the campus, and we were able to see it through her eyes.) Having a rather strong entrepreneurial spirit, not to mention just a touch of rebelliousness and maybe just a bit of feminism, she chose the taxi business "because this is is a very non-traditional thing to do for a woman in Ghana, and I think of my decision as a gender statement. I didn’t mind stepping on a few toes to change the status quo."

In the United States, we might shrug and wonder why this is a problem, but in Ghana, it's a problem. A BIG problem. The male Taxi Unions would not let her participate in the business. Until, that is, she offered to take the riders they wouldn't transport. And from there, she built a thriving business.

People still stare, four years into this social experiment, if you will, at the "lady taxi driver". While there are a few more, this is still a male-dominated business. But there are clients, perhaps mainly female, who feel safer with a female driver. And many of those women have husbands. See how it goes?

Esenam has been featured on Ghanaian television, and has received worldwide praise and notoriety. She has TWO big ongoing projects, one that trains women to drive buses, and the other, trucks.  In fact, she's just back from Germany, where she received a rather important award. I'll let her tell you about that and her two ongoing projects:

The project that I work on is known as Women Moving The City Project. It seeks to training 60 women to drive intra-city commuter buses in Accra. The training is gradually grinding to its end and our ladies are awaiting the official agency to test them and grant them driving licences. The project is been funded largely by GIZ Ghana, Scania West Africa and West Africa Transport Academy. I actually started out as a volunteer for the project, right from the project campaign design stage as the ambassador. Months into the project, GIZ Ghana hired me as the Gender Consultant on contract and they are extending my contract till August to cater for the second project. It humbling to know that my volunteerism to help empower fellow women has not gone unnoticed! The project won a third position prize in the GIZ Global Gender Projects award in Germany on the 9th of March this year.

The second project has just been rolled out. It's dubed Women Moving Trucks. It's equally funded by the same team. Twenty women are to be trained for a logistics company for ready employment to transport goods on the western corridors of Ghana.

I could go on.

Kids, I'm not a feminist. I'm not a chauvinist. My daughter, Dr. Dolly, says I'm a humanist. If that translates to simply not caring about trivial differences, I'll accept the title. But seriously. I have always had a few innate beliefs, and Number One on my list is that everybody is equal, and should have the opportunities afforded to anyone else. I've just always felt that way. Can't tell you where I got it. Everyone has strength and nobility, and so on, and we need to celebrate that, and we need to let everyone on the planet evolve to their full potential. Keeping someone from doing so because of their gender or skin color or whatever is just plain stupid. I can't drive a truck or a bus, and I wouldn't last 39 seconds driving a car on the streets of Accra. But I have zero problem working with someone who DOES have those capabilities. Female? Why do I care? Get me there safely and comfortably please. Which is exactly what Miss Taxi does. 

Ghana is a poor nation, but its people are the most gracious I've met in a lifetime of world travel. Their hospitality is second only to their generosity. All they want in return is to know that they have pleased you. What they might lack in material wealth, the Ghanaians make up for with their honesty, and humility. And Esenam is the epitome of Ghanian grace.

Come to Ghana, to Accra. And let Miss Taxi show you the sights. You won't be sorry. Unless you ride with someone else!