May 28, 2015

Looking Back and Forward

'Tis the season. For reunions -- I'm attending my 50th Yale Medical School reunion this weekend. I would gladly go to medical school there again. It was where I developed a strong foundation for a medical and neuroscience career that included curiosity, a thirst for reading and writing, and a respect for listening, especially to patients. 

And what other medical school would have allowed me to play rehearsals and concerts several nights every week for four years? Bach cantatas and chamber music at the Yale School of Music and orchestral music in the New Haven Symphony and several other nearby regional orchestras, some conducted by Leonard Bernstein's conducting fellows with soloists like Arthur Rubinstein, Benny Goodman, and Mstislav Rostropovich.

At the time I couldn't avoid anxiety over being distracted from my medical studies. Now I am convinced it was exactly what I should have done--for my sanity then and for my life afterwards. I hope music protected me from the dehumanization that medical schools (Yale excepted) are so good at instilling in students. Nowhere else could I have had a better medical education. Now retired from medicine, I can still play music.

'Tis the season also for Commencement speeches. A brilliant one at Washington University by the film maker, Ken Burns, is my favorite so far this year. "Wash U" is where cynicism set in after the Army and the Vietnam War interrupted my happy University if Virginia postgraduate education. Burns explains that feeling -- I still feel it -- and offers good therapy, such as replacing cynicism by its "old fashioned antidote, skepticism."

Excerpts from Burns' finale don't capture the full essence of the address:
Remember: Black lives matter. All lives matter. 
Reject fundamentalism wherever it raises its ugly head. It's not civilized. Choose to live in the Bedford Falls of "It's a Wonderful Life," not its oppressive opposite, Pottersville... 
Don't confuse monetary success with excellence. The poet Robert Penn Warren once warned me that "careerism is death"... 
Listen to jazz. A lot. It is our music. 
Read. The book is still the greatest manmade machine of all -- not the car, not the TV, not the computer or the smartphone. 
Do not allow our social media to segregate us into ever smaller tribes and clans, fiercely and sometimes appropriately loyal to our group, but also capable of metastasizing into profound distrust of the other... 
Convince your government that the real threat, as Lincoln knew, comes from within. Governments always forget that, too. Do not let your government outsource honesty, transparency or candor. Do not let your government outsource democracy... 
Insist that we support science and the arts, especially the arts. They have nothing to do with the actual defense of the country -- they just make the country worth defending...


May 12, 2015

ON THE MOVE by Oliver Sacks

by Carl Ellenberger, MD

Who else would write this?
"It is the function of medication, or surgery, or appropriate physiological procedures, to rectify mechanism--the mechanism, the mechanisms, which are so deranged in these patients. It is the function of scientific medicine to rectify the 'It.' It is the function of art, of living contact, of existential medicine, to call upon the latent will, the agent, the 'I,' to call out its commanding and coordinating powers, so that it may regain its hegemony and rule once again--for the final rule, the ruler, is not a measuring rod or clock, but the rule and measure of the personal 'I.' These two forms of medicine must be joined, must co-inhere, as body and soul."   
...from Awakenings

Like medical care, medical writing usually focuses on diseases: incidence, causes, manifestations -- "the mechanisms" -- and treatment. Oliver Sacks focuses instead on the stories of the victims of neurologic disease, on finding the "personal 'I.'" A pill or a shot or surgery may be necessary but rarely can totally heal. None of those methods can cure, for example, patients with MS, Alzheimer's, or Parkinson's, so knowing who they are can be important in helping them improve their time on earth. Alas, in my view, medicine has been heading mostly in the opposite direction during Dr. Sacks' and my careers, a reality that becomes evident soon after On The Move begins.

I admire Oliver Sacks, author of Awakenings, The Man Who Mistook his Wife for a Hat, Migraine, other books and articles in The New York Review of Books, Granta, The New Yorker, and The New York Times, where his recent Op-Ed (Feb 19) revealed his current battle with a lethal melanoma. 

Throughout his career some of his colleagues, probably mostly those who practice, teach, or 'investigate' in conventional ways, have dismissed Dr. Sacks' voluminous, detailed, and often inspired descriptions of his selected patients (or other "subjects" (including himself in disguise), gathered over many hours of intense and repeated observation, as little more than material for his many writings, well-crafted as they are, but don't offer much to his patients. Sacks has, however, more than anyone, revealed to the public what Neurologists do, or at least should do, in addition to adjusting 'the mechanism' by ordering MRI's and EEG's, and prescribing medication.

Sacks is an avid musician and probably plays Beethoven sonatas on the grand piano in his apartment. He's also a biker, lifter, hiker, swimmer, surfer, albeit a clumsy participant at best in most of these endeavors, according to his account. And he does't hesitate to reveal his own demons.

Here's one of his music-related stories:

A producer was filming, in their hospital, the patients with post-encephalitic Parkinsonism (an excerpt), the characters in Awakenings. (The book was also made into a longer film starring Robert Di Niro). He asked, "Where is Kitty?" the music therapist.
"It was quite unusual in those days to have a music therapist--the effects of music, if any, were considered no more than marginal--but Kitty...knew that patients of all sorts could respond strongly to music and that even the postencephalitics, although often incapable of initiating movements voluntarily, could respond to a beat involuntarily, as we all do." 
David Leventhal of the Mark Morris Dance Company has taken that phenomenon to a new level; his efforts displayed in a new film, Capturing Grace, will soon be released. Then, in a footnote, Sacks relates: 
"By 1978, Kitty had decided to retire; we thought she had reached the usual retirement age of sixty-five, but she was, we learned, in her nineties, though astonishingly youthful and vivacious (could music have kept her young?)"
Little 'hard' evidence could be mustered to answer that question, Dr. Sacks' neurology colleagues would hasten to assert. But they don't get it. In On the Move, an amazing story teller reveals his own amazing life. 
   

March 24, 2015

Only Listen...

Super Bowl XLVIII is history and the world has seen and heard what some might say exemplifies the best of American arts and culture, evolved over centuries. Ditto for the recent Grammy's.

Did the half-time spectacle with instant wardrobe changes and dancing sharks  represent 'music' to several generations? 

You bet!

Will most Americans remain for their lifetimes unaware of the long rich tradition of Western music or assume that was outmoded in their lifetime? 

Sure.

Modern technology brings 'music' to more Americans than ever. Music is all around us. We no longer must make it ourselves (or go to church) to hear it, and are freed from the necessity to pay for sitting quietly through a long "recital" by a pianist or violinist, or even a single symphony. 

And we are now blessed with 'visuals' to combat boredom from having only one sensory system activated: fireworks, smoke, provocative costumes, frenetic movement, small dramas. We are unrestricted by stiff concert decorum and can join the musicians in dancing, shouting, arm waving with others -- or walk out to buy a beer and a hotdog. Alternatively, we can do other 'useful' activities at home alone while portable music is delivered into our ears.

The few remaining stalwarts who still assemble to listen to Bach and Mozart may be urged to keep up with the times. Classical music 'providers' (Is Gretna Music a "provider" of music like doctors who provide healthcare?) are urged to be more creative (as if Schubert or Stravinsky weren't creative enough). 

But, indeed, we should heed both urges. There is an enormous amount of 'new' music (and musicians) worth hearing. That has always been so. If we don't hear them, we may miss the Schubert and Stravinsky of our generation. 

We can choose to listen to the kind of music that speaks to us (usually resembling what we discovered as teenagers, see "My Music" 8/11/2014), but should ever seek to broaden our personal canon. Sometimes that happens in small steps over a lifetime; though it can happen with an unexpected revelatory bang: I can remember the first time I heard Mahler, Jordi Savall, Cleo Laine, and Pink Martini.  Sometimes the 'new' music we discover is newly written; other times it is a discovery of music written centuries ago. The classical canon is vast, and few of us have heard more than a fraction of it. Musical paleontology discloses that our ancestors could make very good music that will never be outmoded by audio technology, though now it can be distributed by it.

One of my guiding principles is to listen to musicians who have invested their '10,000 hours of practice' to acquire the ability to connect with me. An honest and sincere musician who has sacrificed and studied to perfect his/her talent and 'plays well with others' or alone, speaks to me far more than a narcissistic loud and flashy celebrity-of-the-month through megawatts of audio-visual accessories and backed by a studio full of 'producers.' 

And let Gretna Music be a guide. We have "good musical ears" to choose artists and compose programs. More than 1000 musicians have played on our stage.

The moral of this silly story is perhaps: "Only Listen. . ." Listen widely, not to just a narrow range of what you know or your friends think is cool and hip, but sample the vast new and unknown too. 

Despite the fascination of each new generation for the pop stars of their teenage years, an increasing number of children around the globe every day discover their fascination with a violin, a piano, or a trumpet. I'm with the late Charles Rosen who saw in their passion and large numbers a strong future for classical music. The good news is that very few people will in the future lack the opportunity to hear ANY music whenever and wherever s/he chooses.

The fulfillment of high talent, the just exercise of power, the celebration of human diversity: nothing so redeems these things as the recognition that what seem like personal triumphs are in fact the achievements of our common humanity. .. They flow from E.M. Forster's injunction in Howard's End: "Only connect..."
--William Cronnon

February 20, 2015

Quarterback or Concertmaster (revisited)

"An experiment: place a football fan’s brain in an MRI scanner during a game. I would bet that most of the moments of peak activity in the nucleus accumbens—the pleasure center—would correlate with the most violent collisions: a quarterback sacked from his blind side, a running back breaking through a tackle, a receiver laid out by a vicious open-field hit." (reference 1 below)


Football encourages, they say, team spirit, character, and self-confidence, but also starts a process that can lead to chronic traumatic encephalopathy ("CTE" will soon become a household acronym) and joint replacements. 

An orchestra or band can also foster those same qualities while respecting the brain and developing all its capabilities when it is most receptive (and at the same time most vulnerable to trauma). Listening to music is another way to activate the pleasure center of the brain.




1.  Nathaniel Rich: The Super Bowl; the horror and the glory The New York Review of Books, March 5, 2015
". . . nearly every current NFL player can expect to suffer from chronic traumatic encephalopathy, a degenerative disease that leads to memory loss, impaired judgment, depression, and dementia. 
Football players are also four times more likely both to die from ALS . . .  and to develop Alzheimer’s disease. An NFL player can expect to live twenty years less than the average American male. The average NFL career lasts 3.3 years. By that measure, each season costs an NFL player about six years of his life. Football fans, in other words, must ignore the fact that we are watching men kill themselves."

The opening quote is speculation. Here are references to some of the science:

"Consistent with earlier reports of boxers, our findings suggest that there may be 2 different clinical presentations of CTE, with one initially exhibiting behavioral or mood changes, and the other initially exhibiting cognitive impairment. The behavior/mood group demonstrated symptoms at a significantly younger age than the cognition group.... almost all subjects in the behavior/mood group demonstrated cognitive impairments at some point…." Stern, RA, et al, NEUROLOGY, Aug 21, 2013:

New research suggests a relationship between head impact exposure, white matter integrity, and cognition over the course of a single football season, even in the absence of concussion, in a cohort of college athletes. Neurology 2014;82: 63-69.

In a preliminary study comparing the brains of 50 college football players and 25 matched controls, researchers found that playing football was associated with reduced hippocampal volume on magnetic resonance imaging. (The hippocampus is where memory lives.--ed) Singh R, Meier TB, Kuplicki R, et al. Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. JAMA. 2014; 311:(18):1883–1888.

It's more than just occasional concussions. See Frontline's League of Denial here.

"...[football's] real advantage is that it’s louder, faster and more violent [than baseball] — which is to say, better in tune with our cultural moment. 'We are a shouting culture now….'" 
--New York Times, Sept 29, 2013

January 26, 2015

Music As Instinct

Rapture, a "joy excessive and sweet," as Spain's great mystic Saint Teresa of Avila, described it in her 1563-65 diary, can be achieved variously by music, religion--and hallucinogenic drugs such as the Amazonian religion-enhancer ayahuasca. Neurobiologists have tracked at least some of the peak experience of music to at least one cause, the release of the transmitter molecule dopamine within the striatum of the brain. The same biochemical reward system also mediates pleasure in food and sex. Because music began in paleolithic times. . . and because it remains universal in hunter-gatherer societies around the world, it is reasonable to conclude that our loving devotion to it has been hardwired by evolution in the human brain. 
In almost all living societies, from hunter-gatherer to civilized-urban, there exists an intimate relation between music and religion. Are there genes for religiosity that prescribe a neural and biochemical mediation similar to that of music? Yes, says evidence from the relatively young discipline of the neuroscience of religion.
--from E.O. Wilson's The Meaning of Human Existence

I suppose that applies to rock and hip hop too. Eventually we may learn whether Franz Schubert and Justin Timberlake generate different chemical brews within the striatum of the brain. As for Jay Z, I can only wonder.

January 3, 2015

Take This To Your Doctor

Carl Ellenberger, MD

For fifty years, I have read the prestigious New England Journal of Medicine, full of rigorously peer-reviewed and authoritative scientific articles with big words like "Imatinib, Peginterferon Alfa-2a," and sophisticated statistics I may not fully comprehend. During my career, the understanding of human disease, diagnostic precision, and treatment have greatly advanced while the "practice of medicine" in the US, transformed into the colossal industry of "Healthcare," has made some people healthier and others -- especially corporate executives and investors -- wealthier. 

Lately I have started reading non-scientific articles in the NEJM like The Virtues of IrrelevanceNarrative and Medicineand Rethinking the Social History, reminding me that, despite all these new developments, the doctor-patient bond remains the most important step in the process of care, just as it had to be for Hippocrates in 400 B.C.E. 

The Virtues of Irrelevance makes the simple case for a doctor to begin a conversation before probing the medical problems: 
"I like your necklace [shoes, pin, etc] ...." 
showing interest in the person as well as the illness. I have also seen that strategy turn strangers in restaurants into friends. 

Narrative medicine seeks each patient's story, as would doctors William Carlos Williams, Oliver Sacks, Abraham Verghese, and Atul Gawande. (see * below)
"... not only is diagnosis encoded in the narratives patients tell of symptoms, but deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness." 
See how hard it is to read medical articles? That excerpt is 'medicalese' for, "Our stories reveal who and how we are." You can't, for example, adequately understand most chronic pain, headache or backache without hearing the stories of those who have it.

Rethinking the Social History is a manifesto for "social medicine" (not "socialized medicine," a political term deriding Medicare) that
"…elucidates how patients' environments influence their attitudes and behaviors and how patients' agency -- the ability to act in accordance with their free choice -- is constrained by challenging social environments.
Translation: how and where we live affects our health. Your doctor needs to know.

As a consumer of healthcare (formerly called a patient), I can't dismiss the reality that doctors work on a tight schedule dictated by their payers (insurance companies or employers) who can financially penalize (or fire) them if their 'clinical volume' falls short. 

Seated in the exam room in a paper gown I answer opening questions like, "What are your concerns?" as the doctor examines and enters data on a screen, checks boxes, and periodically looks in my direction. He may send me for tests or up the chain of specialists. Later his office may call with results and instructions, sometimes the sole "product" of the services I hope my insurance will pay for.

Some physicians seem to avoid personal questions fearing they might run the conversation into overtime. I may remain silent for the same reason, even when my physician is a former colleague. That's unfortunate because more problems than you might think can be addressed by reaching a better understanding than by pills or injections.

When I do encounter a physician who wants to connect (most recently a podiatrist), I wonder if that behavior comes from his or her character rather than from medical education. As  conservatories may not teach musicians how to behave on stage, medical schools may not teach doctors how to listen to patients. Such skills certainly don't come though incentives from payers. I hope that when my failing parts can no longer be repaired or replaced my doctor will be one of the more human ones. (see Gawande's Being Mortal)

In my childhood doctors were thought to be the best educated and wise members in a community. Maybe that's why I admire those with non-medical interests, such as the writers mentioned above. I wonder whether their broader perspective of the human condition makes them better doctors, especially if it extends beyond playing golf, collecting wine, or watching football. When I once suggested to one of my mentors that that medical trainees read more widely, novels or poetry perhaps, he answered, "No evidence for that...."

Has making music made me a better doctor? That's difficult to measure. It helped me pay for (and survive) medical school, enlarged my network of friends and colleagues, and helped me understand the problems musicians have brought to me like dystonia (July 21, 2013), but I have no way of measuring outcomes in those cases or in others. Some may have assumed that music distracted me from medical work. Indeed, I never was a "high-performance" practitioner like an an ophthalmologist I worked with who saw 100 patients a day! But in my view quality trumps quantity, though the latter is easier to measure and reward.

I do not believe that advances in medical science require educators to stuff ever more information ("the material") into student doctors' heads. In fact, the reverse may be true; now information is in very accessible clouds. The mind is freed to connect with patients and 'apply the material.' And maybe acquire wisdom.

 "...wisdom, which is almost always another name for humility, lies in accepting one's own inevitable share in human fallibility." (Marilynne Robinson: When I Was a Child I Read Books)


*Doctor/writers mentioned above

Oliver Sacks: The Man Who Mistook His Wife For A Hat: And Other Clinical Tales, Awakenings
Abraham Verghese: Cutting for Stone, My Own Country: A Doctor's Story, etc
Atul Gawande: Complications, Being Mortal, etc
William Carlos Williams: The Doctor Stories and any edition of Collected Poems

December 24, 2014

An die Musik

Not much to do this Christmas Eve, laid up with a cold watching the rain fall from gray skies outside. So I thought of sending this message from Franz Schubert for the holidays:


O blessed art, how often in dark hours,
when the savage ring of life tightens around me,
have you kindled warm love in my heart,
and borne me to a better world!

Often a sigh, escaping from your harp,
a sweet, celestial chord
has revealed to me a heaven of happier times,
O blessed art, I thank you for that!

Bryn Terfel and Malcolm Martineau...




By Miles Hoffman...


Schubert’s song may well be the most beautiful thank-you note anyone has ever written, but it’s also something else. It’s a credo, a statement of faith in the wondrous powers of music, and by its very nature an affirmation of those powers. We may view it as a statement of expectations as well. The poet thanks Music for what it has done for him, but there is nothing in his words that would make us think that Music’s powers are exhausted, and indeed the noble, exalted character of Schubert’s music would lead us to believe that Music’s powers are, if anything, eternal, and eternally dependable.

But just how does our gracious Art exercise these powers? How does it comfort us, charm us, kindle our hearts? We might start our search for answers by positing two fundamentals: a fundamental pain and a fundamental quest. A fundamental pain of our human condition is loneliness. No surprise here: We’re born alone, we’re alone in our consciousness, we die alone, and, when loved ones die, we’re left alone. And pain itself, including physical pain, isolates us and makes us feel still more alone, completing a vicious circle. Our fundamental quest—by no means unrelated to our aloneness and our loneliness—is the quest for meaning, the quest to make sense of our time on earth, to make sense of time itself.







November 25, 2014

Watch Your Back

by Carl Ellenberger, MD

Although this post has little to do with music, the odds are good that some musical readers will find it useful. 

Chronic low back pain is the most common cause of disability and the largest category of medical expenditure in the US healthcare system. The system's response to it is a good example of what is wrong with the system. 

Treatment consumes about $100 billion a year in the US, 9% of total health care costs, not counting the cost of lost work. The fact that more than 200 cures are currently promoted amply shows that only a few can be proven slightly better than no treatment at all -- and only in selected cases.

Most back pain (80-90%) in otherwise healthy people occurs in episodes naturally limited to less than a few weeks that don't need medical attention regardless of severity. When pain remains for more than 3 months, it is called "chronic." That's what we are talking about here. 

If you have had cancer, tuberculosis, HIV, or certain other chronic diseases this doesn't necessarily apply to you. 

In an earlier post I wrote, "...more health problems than you might think can be solved by better understanding than by pills, injections, or surgery." Back pain is one.

So if your back pain is chronic, before having another injection or operation read Watch Your Back by Richard A. Deyo, MD, Professor of Evidence-Based Medicine at Oregon Health and Sciences University who writes with the authority of broad clinical and research experience. Importantly, Deyo does not promote any particular procedure. He writes in a lively style for the general public. 

You may need to revise your thinking about this problem; doing so may change your thinking about other medical problems. Some conventional rules don't apply. For example, when you have pain, you should continue, without fear of harm, the activity that makes it happen, not try to avoid pain by resting. 

A cause in the spine may not be found even by MRI, though if you are an adult, MRI may show more than one abnormality related to normal wear, such as a bulging disk. Know that if you submit to an MRI, you are twice as likely to submit to surgery. If you submit to surgery you are ten times more likely to have more surgery within ten years. Eighty percent of post-operative patients continue to need pain killers, including opioids (aka narcotics), indefinitely.

Deyo argues persuasively that the responsibility for treating low back pain is yours, done by you, not to you, guided by 'providers' who are not invested in what they provide. A typical spinal fusion operation, a current fad done for pain with increasing frequency, distributes its reimbursement of >$100,000 to many "providers" and manufacturers (think $500 screws) but cannot be proved more effective for pain than no treatment at all. Fusion may be necessary to stabilize your spine after an injury. 

Effective treatment involves a long and difficult life-style change but is your best chance of avoiding a lifetime of disability, depression, and reliance on opioids. This treatment changes the "pain module" of the brain, not anatomy of the spine, by means of cognitive-behavioral and exercise therapy. The concept is consistent with new thinking about the brain and its plasticity--the same plasticity that enables learning of a Beethoven sonata and causes dystonia in rare instances.

I hear you saying, "That's easy for you to say, but you haven't experienced the terrible pain that I have every day. It can't be "all in my head." There must be something terribly wrong where it hurts." You're the doctor. Do something! Deyo reminds us that acute pain is a protective sensation to call attention to the location of an injury. When pain becomes chronic, that simple relationship dissolves, the brain continues to falsely signal pain even after the original injury has healed, and the treatment becomes different. It becomes useless to keep trying to repair the original stimulus that created the pain. (That's like changing golf clubs after you have hit a bad shot.) Therapeutic efforts must turn to ways to change networks in the brain, as they must to treat chronic headache or chronic pain anywhere.

So it is not unreasonable to suspect that the epidemic of low back pain in the US has in one sense been created, at least in part, by the health care system. After all, $100,000+ for a back operation provides work and profits for many people, usually excepting the victim of the pain.


Deyo writes:

"...every system is perfectly designed to get the results that it gets. If our health care system generates high costs, promotes ineffective care, and creates avoidable complications, it's because we've inadvertently designed the system to get exactly those results.

In care for back pain, we do this by performing tests when they're unlikely to help and responding to alarming but meaningless results. We do it by prescribing medications and procedures with proven risks but unproven benefits. We do it by by expecting a quick fix from a probe, a pill, or a procedure when real benefits require harder lifestyle changes. We do it with unrealistic expectations of a pain-free life. We do it by responding to financial incentives for more rather than better care. And we do it by ignoring and underfunding the treatments that appear to be most helpful.

For back pain, here are the results: steadily increasing use of imaging tests, opioids, injections, and surgery. Costs that are rising faster than the rest of medical care. And at a population level, worsening patient function and work disability. We've perfectly designed our health care system to produce these results.

It's easier to understand this situation if you remember that the back business is indeed a business. This is the story of too much medical care today. In a for-profit health care system, the first concern is the bottom line rather than the patient's welfare. And too often it follows a business ethos: caveat emptor -- buyer beware."

Full disclosure: I wrote the guideline for use of MRI in low back pain for the American Academy of Neurology in 1994. It recommends limiting MRI to patients who have had pain for over 7 weeks. By then pain has gone in almost 90% of cases. But for some of them knowing for the rest of their lives they have a degenerated, bulging, or herniated disk may not make their lives better. A herniated ("slipped") disk is not like an inguinal hernia. You don't have to repair it.

November 2, 2014

ReJoyce! Singers in the back row stopped texting.

Memorable experience last Sunday afternoon in Carnegie Hall: Alcina. A breathtaking performance of Handel's last (of dozens) opera by The English Concert conducted by Harry Bicket. (Do you remember? That's the same group who attracted an audience of ~200 in Elizabethtown when we had to paper the house a few years ago.) 

Sunday was one of the series Joyce DiDonato curated for this season in Carnegie. Joyce as Alcina and a small cast of others whose names you might not recognize (see Tony Tommasini's review) delivered some of the best singing I have ever heard. 

Alas, most human beings have the misfortune to live entire lives without hearing a Handel opera. 

Alex Ross wrote a wonderful profile of Joyce last year. 

She sang the National Anthem at the last World Series game. More Kansans were familiar with the singer from "Staind" who forgot the words (maybe his first waltz?) before game 5. 

Do Joyce and Stained represent the bipolar state of music in America?

Did I mention DiDonato's Juilliard commencement address?






October 6, 2014

Flute Flamingo and Gretna Semiotics

You have heard stories about patients in hard times paying doctors with a chicken or a head of cabbage. In my view that's a better system than the Byzantine one in the US under which we spend part of our fee to justify it to the insurance company and the insurer tries to find reasons not to pay.

In Gretna, however, we bring humor and sophistication to the exchange, not just farm produce, and cut the insurers out of the transaction. Here, for example, is payment for a comprehensive neurologic "Evaluation and Management Service," E & M 99206.xxxxx. (Don't bother with 12 pages detailing what the service entails. If any of its required parts, say "one fact each about past, family and social history," are not properly documented, the hapless doctor can go to jail.)


Flute (piccolo) Flamingo, parts contributed by other instruments

The artist is my neighbor, Max Hunsicker, a drummer and musician who has has introduced generations of school children to the joys of music and Broadway plays and shows. One of Max's many talents is fashioning a flamingo for any occasion: to advertise the annual homeowners meeting, the beginning of the school year, or to mock the "Shitauqua," a sewage pumping station that sprouted last Spring to greet drivers as they emerge in our Shangri-La out of the long tunnel of trees on route 117. 

Any resident may awaken to find a pink flamingo nailed to a tree in his yard. Ours is a pair, one playing a piano, the other a flute. When I broke my leg, a flamingo appeared on a pair of crutches. The practice has gone on for over 20 years, but the flamingos have only recently achieved three-dimensional form.

We presented another member of the musical flamingo family to Susan, another neighbor, to reward her for her fine service as our board president.