Random Thoughts from a Restless Mind

She was 89 years old, my last patient, sitting demurely in my exam chair. I think I’ve known her for about 10 years. If I’m remembering correctly we’ve been through two cataract surgeries together, and I’ve done a little bit of laser work for her left eye. In fact, she’s in the office for us to consider some laser for her right eye, but she doesn’t really have any problem with the right eye today. It’s her left eye that’s giving her a little bit of trouble.

“It’s hard to describe. It’s like I have a headache or toothache around my left eye. I don’t have any problem at all with my right eye. I’ve had some sinus problems on this left side. That headachy feeling goes away with a Tylenol and a little bit of warm water. What do you think I should do?”

I look at her chart. I’m starting to remember more about who this extraordinary  woman is. There’s no mention of a family doctor in the chart. “Oh no, all of my doctors have died! All of the department heads and bigwigs I used to see are long dead,” she chuckled. More of her personal history is starting to come to me. 89 years old and she still does the books for her family business. Does all the payroll — files all of the taxes. With the exception of the pain around her left eye the only problem she will admit to is running out of steam in the office earlier in the afternoon then she did a couple years ago.

I start to slip into “Dr. mode” because, well, that’s what I do! That’s what all doctors do. We are presented with a problem, a symptom or disease, and we seek a solution. One of the wonderful things about being ophthalmologist is that I can almost always identify the problem, and once identified I can almost always find a solution. Indeed, I’m kind of intrigued, a little amused even, because this is the very rare time when a sinus problem is actually the cause of eye pain! Just like the majority of my patients with headaches think that the problem is coming from their eyes, so too do most of my patients with pain in the front of their face believe that it always comes from their sinuses. In fact, neither is very true very often. But in this case my patient is actually correct; her pain is referred pain to her eye and her eye socket from sinus problems. We can probably “fix” this, and I start to run through my mental Rolodex of good doctors near her home.

A little bit of unease is setting in, however. My patient is 89 years old, doesn’t have a single medical problem on her problem list, and isn’t taking a single medication. She hasn’t seen a medical doctor since 1978. Her only problem is an ache  around her left eye which she is successfully treating with Tylenol and warm water.

“May I take off my Dr. White hat?  Would it be okay if I talk to you as just Darrell for a few minutes?” A little smile comes at the corners of her mouth and she nods.  Here’s what I said:

“My friend lost his dad last week. By all accounts his dad was a great guy. He led a very active life pretty much through the last day he was alive. Went for a walk. Watched a wrestling practice for one of his grandchildren. Had a big dinner and went to bed with a smile in his face. He never woke up. Your mother  lived to be, what did you say, 104 years old? I think the best chance for you and I to have you leave this world at age 103 like my friend’s dad did last week is if I DON’T give you the name of a doctor to take care of your sinus.

Here’s what will happen if I send you to a medical doctor. Any medical doctor. They will hear you, hear about your pain, and they will do what doctors do. You will get an x-ray and you will get a CAT scan. You will almost certainly get some kind of medicine for your discomfort, medicine that may or may not be any better than Tylenol and a cup of warm water. You’re 89 years old — the doctor will probably find something else “wrong” that needs to be  “fixed”. More medicine… more tests… more time. No one has enough spare time to hang out with doctors! Think of all the wonderful things you have done for more than 30 years in all the time you HAVEN’T spent in doctor’s offices. Do you think you can continue to treat the discomfort in your left eye with Tylenol and warm water? Would that be OK?

Remember, I have my “Darrell”  hat on,  not my “Dr. White” hat. as I’m sitting here talking to you I’m thinking of my grandmother, my beloved Gama. I lost my Gama when she was 86. She broke her hip, went into the hospital, and never made it out. She was really pretty good, not terribly healthy but pretty good, right up until she broke her hip.  She thumbed her nose at all of the well-meaning doctors my Mom tried to bring her to, doing pretty much whatever she pleased right up until the end. Smoked her cigarettes while reading trashy novels…a few beers after supper every night. I’m convinced she wouldn’t have lived a day longer if every little medical problem was identified and “treated”, but I’m sure that her life would have been much less enjoyable if she had received all that care.

Do you think you can handle this discomfort? Would it be okay to continue treating it with an occasional Tylenol and some warm water? (I gently placed a hand on her knee) I really think this is the best thing to do here. I’ll give you the name of MY doctor in case you ever get really sick.”

At the end of the day, whether you are a generalist or a specialist, each of us needs to remember that we care for patients. Entire human beings. Not organs or organ systems, not symptoms or diseases or complexes. We take care of people. Even someone like me, someone who takes care of an organ not much bigger than a large grape. The eye, or the heart, or the left third toe are all connected  to a whole person.

I put my “Dr. White hat” back on. I told her I was available anytime she had a problem, and I looked forward to seeing her again next year. We walked to the front desk together arm in arm.

“Thank you, Darrell.”

It’s Easter and all of my friends have been asking if my kids are home for the holiday. It’s funny. I find myself saying that half of them are here and half of them are away. How can that be, you might ask, that I can have half of my kids home for Easter when I only have three children? How do you have half a kid at home and have a kid away? Well, I guess I should tell you about my “Sometime Son”, Alex.

Some years ago, I think it’s five  now, my kids came home and announced that Alex would be joining us for dinner. This in itself was not really all that extraordinary as Alex had been joining us two or three times a week for dinner for many months. My response was  “great, I’m sure we have enough to eat .” What they said next was really quite extraordinary, however. “Alex is going to be here for dinner and he’s not going to be leaving.” THIS was different.

Alex is one of two boys from what is, by any definition or description, a rather troubled family. It seems that at the time Alex had been bouncing around between multiple homes as his father was working through some legal problems. His father was about to be unavailable to him for many months, and Alex was clearly having a difficult time with not having a single, secure place to call home. Alex was and is one of my son Dan’s closest friends and was also very close with my two younger children, Megan and Randy. My kids essentially decided that Alex would be living with us.

So there you have it. Beth and I had gained a fourth child, a second son. Alex moved into Dan’s room and joined Megan’s sophomore class at the local public high school. Alex lived with us full-time for the better part of his sophomore year until his father once again had a place for the two of them to live. Although we offered Alex the opportunity to stay with us, and although leaving the White house meant changing schools, Alex’s father insisted that he leave us and live with him. Although Alex no longer lived under our roof, he was no less a part of the white family. We saw him for years most days of the week, and we continued to enjoy his company at the dinner table with great frequency. One of the two most poignant pictures that Megan keeps from her high school graduation is one of her and Alex celebrating their shared milestone.

Unfortunately the troubles in Alex’s family had simply been better hidden over the final two years of high school, and once he graduated it became too difficult for him to remain under the same roof with his father. Alex found himself working three deadend jobs in order  to stay in an apartment that he couldn’t afford. He economized on food — the rockhard bundle of muscles that graduated from high school with Megan had turned into something that looked more like the body of an elite miler. We simply couldn’t believe how skinny Alex had become.

Once again the white kids reached out. All three of them took Alex’s aside separately and told him, in slightly more colorful language, that he was being silly and ridiculous. “You need to quit one or two of those jobs and come home!” And so it came to pass that our “Sometime Son” came home to the White house during the summer of 2009.

When I tell this story I end up receiving all kinds of accolades, comments and congratulations on being such a wonderful person and doing such a wonderful thing. I must confess that this is quite a little bit embarrassing since it was actually my children who were responsible for this; my only contribution was that I didn’t get in the way. Frankly I’m not really sure how extraordinary this really is. If you take even a cursory glance at your family tree you’re likely to find a “cousin” or “uncle” whose lineage just doesn’t seem to have any genetic connection with yours. It turns out that in days of yore this practice of taking in folks who might be a little less fortunate than you was actually quite common. That “cousin” was in all likelihood a 1950s or 1960s version of Alex, a kid who just needed a place to call home, a place to be loved. That  “uncle” or “aunt” was probably his mother or father. I think this probably happened a lot in days gone by, and if I think  if you look just a little bit you’ll probably find that it happens quite a lot even now.

So what’s become of Alex? All of the  “other” White children are either in college or about to enter. Well, toward the end of last summer Alex was still working two of the dead-end jobs. We found ourselves alone chez White one afternoon watching a lacrosse game together. I told Alex that he had much more to offer, that he was much better than what he was doing at the time. You see, Alex is actually very, very bright. He’s at least as book smart as he is “street smart.” If he felt that treading water by doing low -end restaurant work was what he wanted to do at the time why not do it in a new place? Rather than staying in Cleveland, a city that he clearly had mastered, why not do the same thing in Albuquerque or Anaheim? Miami, or even Madrid? How about college? Beth has assisted about  a dozen kids in their college process. What did Alex think about college?

I asked him about the Marine Corps. For several years Alex  had talked about his desire to be a Marine. It turns out that his grandfather was a Marine, and Alex is very fond of this particular grandfather. Alex had a couple of minor legal issues that would need to be cleaned up prior to enlistment, and I offered our assistance in helping him overcome these if the Marine Corps was still his ultimate goal. After a couple of days of reflection and thought Alex returned with his decision: he’d like to be a Marine. And so on September 11, 2009 (the date still gives me chills every time I mention it) Alex was sworn in as a US Marine, and on February 22, 2010 Alex reported to Parris Island for boot camp.

So there you have it! I am home here for Easter with exactly half of my children. My daughter Megan is home from college and my son Randy still lives with us full-time as he completes his senior in high school. My son Dan, “The Heir”, is finishing up his junior year at the University of Denver, and we anxiously await his first summer here at home since he left for school. And my “Sometimes Son”, Alex, is halfway through boot camp in the swamps of South Carolina. The collective concern that we all feel for him and the collective sense that we will have not one, but two empty seats at our Easter dinner table makes the term “Sometime” seem to be not quite right anymore. We all think about him much too much for him to be only a “Sometime Son”.

It’s Easter, and I miss both of my sons who are away.

That’s what the Cleveland plain dealer and Stephen Koff, Bureau Chief, are with regard to medical malpractice reform — exactly wrong! In a front page article in the March 20 Plain Dealer on tort reform Koff commits the equivalent of journalistic malpractice.  Allow me to explain.

Some time ago I wrote a post explaining my position that medical malpractice tort reform was essentially equal to health-care reform. I wrote a follow-up piece explaining that everyone who is involved in a medical malpractice case ends up losing. In fact, the specter of losing is so onerous that doctors will do pretty much anything in order to avoid a medical malpractice lawsuit. Hence we have the enormous problem of defensive medicine, medical care that is prescribed in order to prevent the filing of a medical malpractice lawsuit, and medical care that does not do anything to improve the health of the patient. There are actually two very distinct forms of medical malpractice tort reform and by confusing and intermingling the two Koff does a disservice to everyone reading his article.

Some 10 or 15 years ago there was a medical malpractice “crisis” where the medical malpractice insurance premiums started to rise so fast and so high that doctors were having difficulty affording them. Premiums rose higher in states that had a more friendly atmosphere for the filing of malpractice lawsuits. In these states many doctors in high-risk specialties like obstetrics and neurosurgery either curtailed their practices, or left the state entirely. Our own state of Ohio was particularly affected by this crisis. Multiple efforts at  “tort reform” were made in Ohio, but it wasn’t until a significant change in the makeup of the Ohio Supreme Court occurred that these reforms took root. Ohio, California, Texas, and other states capped non-economic awards in medical malpractice cases, and this produced a more predictable economic environment for medical malpractice insurance companies. Consequently, medical malpractice insurance rates not only stabilized but began to fall.

Here’s where Koff starts to go astray. Despite the fact that Ohio’s tort reform efforts were specifically directed only at malpractice insurance rates, Koff conflates this with true tort reform that would eliminate nuisance lawsuits. Even though tort reform targeted at stabilizing and decreasing insurance rates would be EXPECTED  to have no effect on medical expenditures, Koff proposes that  the fact that medical insurance costs have risen since 2004 (the year Ohio passed lawsuit liability reform) proves that “tort reform” does not lower the cost of healthcare. This is, of course, nonsense. The medical malpractice tort reform bill passed in Ohio in 2004, similar to all of the tort reform bills passed across the country, was designed and expected only to limit the size of medical malpractice awards in order to stabilize malpractice insurance costs.

Believe it or not, the obfuscation and confusion actually gets worse!. Koff admits that medical malpractice insurance for insurance premiums for doctors have dropped on average 22% since 2006 in Ohio. Success, right? Well, not according to Koff. He goes on to conflate malpractice insurance premiums with family health plan premiums, noting that health plan premiums rose from $9590 in 2004 two $11,425 in 2008. But commercial family health insurance plans aren’t even a good proxy for medical expenses! Numbers, numbers, and more numbers. Let’s just keep throwing numbers in until no one can figure out what number goes in what basket.

Here’s the rub: the type of medical malpractice tort reform necessary to affect the practice of defensive medicine is totally different from the type of medical malpractice tort reform necessary to stabilize and lower malpractice insurance rates. It’s just so painful and so disruptive to a doctor’s practice and doctor’s life to be involved in a medical malpractice case that the only type of reform that will have any effect on defensive medicine is reform that prevents the filing of all but the most clear cases of medical malpractice. There just aren’t enough barriers to the filing of weak cases, or throwing in the names of any doctor whose name appears on the chart of a patient who has suffered some harm while in the medical system. And once you’ve been named in a lawsuit it’s an incredibly time-consuming and expensive process, even if you are subsequently dropped from the case long before it ever goes to trial.

So what are we to do? Well first let’s make sure that we are talking about the right type of tort reform. Tort reform that makes it very difficult to file nuisance lawsuits, lawsuits that have very little chance of succeeding, or lawsuits that have no support from independent experts is where we need to start. Removing the “wild card” aspect of jury trials where a defendant doctor is at the mercy of 12 men and women who are (quite humanly) more sympathetic to the plight of an injured patient than they are to the word of the law is where we would go next. How about the creation of a “compensation pool” to provide for the care of all injured patients whether or not true malpractice has occurred? This would remove the stigma of malpractice or “bad medicine” from what is otherwise simply an adverse outcome, and this would still leave open the possibility of further action in the case of true malpractice.

Let’s also do away with the national databank where every case of malpractice that is either settled or found on behalf of the plaintiff or injured patient is recorded. More medical malpractice cases actually go to trial now than before this databank was created because no doctor wants to settle even the smallest of case if it means his or her name will end up on this “black list”. I have made the point several times before that no one, no doctor and no hospital and no health organization, will report errors until the risk of liability for doing so is either reduced or eliminated. We will continue to have the same errors over and over again, causing the same injuries over and over again, until doctors and hospitals feel free to report these errors without fear of retribution or lawsuits. This, and only this, is the type of tort reform that will have an effect on defensive medicine.

How big a deal is defensive medicine? Here, too, we see a willful underestimation of the impact of defensive medicine in Koff’s article. The CBO reports that nationwide liability reform could cut the federal outlay for medical care by $54-$110 billion per year over the next 10 years. However, in response to a request from the American College of surgeons, the RAND Institute found that the MINIMUM  impact of defensive medicine was approximately 10% of all medical expenses per year. That would be 10% of $2 trillion. Minimum. $200 billion per year. Other estimates by healthcare economists have gone as high as 20% per year. Think saving $200 Billion per year might be helpful?

Two types of medical malpractice liability reform confused and conflated, mingled and muddled by Stephen Koff who gets it exactly wrong in the Cleveland Plain Dealer. This article should be embarrassing to the editors of the Plain Dealer if not for the fact that it probably represents their own level of understanding of tort reform, or even worse represents the editorial view of the Plain Dealer. As an educational piece this is such a bad example of reporting and analysis that Stephen Koff probably deserves to be fired.

I’m betting it gets him a raise.

In a recent post I asked for ideas and advice about the difficulty we’ve been having at Skyvision Centers scheduling emergency patients in a way that did not adversely affect the experience enjoyed by scheduled patients. The responses I received demonstrated a deep understanding of consumer service businesses, supply and demand, and classic business theory. Given the superior intellect of the readership of this blog this came as no surprise. That is except for the fact that almost all of the suggestions that I received were unusable because almost all of them assumed a free market for the services offered and received. Nearly everyone suggested that we charge more for ER services, or that as the senior doctor I should personally charge more for services I perform. Essentially none of the people commenting has any understanding of how doctors are paid.

Since I know most of the people who offered their thoughts this surprised me.  It certainly doesn’t help that neither our elected officials nor our esteemed professional leaders seem to be terribly interested in educating the lay public about how money moves around in this $2 Trillion part of our national economy. The fact that our system of “health insurance” actually insulates all of us from the true cost of our care only leads to more confusion. The recent Business Week cover article on the “$618,616 Death” is a good illustration.  Allow me to step into the breech.

Once upon a time doctors came in two varieties: the esteemed physician who visited and cared for the sick in his own town, and the traveling charlatan who rolled into town with promises of health and longevity out of the back of a covered wagon or Model T. The town’s doctor owed his position to a lifetime of selfless service to his neighbors, while the traveling expert made his name through clever marketing.  They had very little in common, these two different types of early doctors. Indeed it was to protect the average citizen from the hucksterism of the traveling “expert” that the original cry came out to license doctors. What they DID have in common, and which neither of them would share with their present day brethren, is that they both were paid directly by their patients. The town doctor might be paid in chickens or eggs (it didn’t matter which came first), and the “doctor on wheels” always insisted on cash, but both were paid face-to-face by their respective patients. A service or product was provided, a fee agreed upon, and payment exchanged.

So what happened? Well, healthcare became free of course! No one pays for their healthcare, at least insofar as they know. Rare is the patient who has any idea about how much their care or their medicine or their hospital stay actually costs. A tiny little throw-away law written in the WWII days of wage-controls that allowed businesses (but not individuals) to provide health insurance as a pre-tax expense (and the willingness of labor unions to negotiate for health benefits instead of wages), followed by the creation of Medicare in the mid-1960’s has combined to insulate most Americans from the cost of their care.

So what does this have to do with how doctors get paid? Well, Medicare started to run out-of-control cost increases in the early 1980’s, starting first with hospital costs. This begat the “alphabetization” of medicine. DRG’s, RBRVS, HMO, PPO–medicine in America got over run by capital letters! In short every insurance “company”, led by Medicare and the federal government, got into the business of paying less for medical care and did so by entering into progressively more exclusive and restrictive contracts with doctors and hospitals. Wanna take care of Aetna patients? Sure. Here are our rates. Take ‘em or leave ‘em. Take away the ability to charge patients for the amount of money not covered by the insurance contract, demand that doctors either opt fully in or fully out of a plan, and tie all of the fees to a politically driven budget (Medicare) and poof! Away goes not only a doctor’s ability to set her fees but also her ability to pass on mandatory cost increases like rent, payroll taxes, and insurance. In comes the era of irrational pricing and willful price ignorance like that seen in the $618,616 death that actually cost something like $250,000.

It’s not market-based, it isn’t capitalism, and it ain’t healthy.

For some 15 years now every single one of your doctors has experienced a decrease in payment for each service they have provided to you. That’s right, despite the dramatic increase in the quality of care in the United States, the dramatic improvements in the comfort and health of our senior citizens, every hip replacement and cardiac bypass and cataract surgery is now paid at a rate that is a fraction of the rate paid in 1990. Total expenses for medical care have gone up only because more medical care is being consumed, NOT because the cost of that care has increased. The only inflation that has occurred in medicine is in the overhead costs borne by your doctors and hospitals. Wages, rent, insurance, licensing fees, payroll taxes…all of these have kept pace with the overall rate of inflation in our economy. Fees have decreased in real dollars, not just  inflation-adjusted dollars.

To be sure some of these fees were too high to begin with, set at a level that reflected pricing anomalies caused by prior government contracting. A good example of this comes from my world of eye surgery. When I finished my residency a cataract surgery typically cost somewhere in the range of $2200, clearly too high given any reasonable market evaluation. We now do cataract surgery that gets better outcomes with a nearly 0% significant complication rate done more quickly and with a better patient experience. Today’s fee? $649. Pretty good value, that, seeing how it also includes 3 months of postop care. Doesn’t matter if the surgeon is a nationally recognized superstar or the kid who barely scraped by to graduate from his residency, $649. When you take into account the overhead structure of an eye surgeon’s practice, time spent training, risk accepted, and constant seeking of better technique and technology the fair-market trading value is probably closer to $1100 or $1200 per case.

So what’s coming? Well, as I type this the U.S. House of Representatives and the Senate are getting ready to usher in a new era of politically driven price controls. Will these so-called “reforms” lead to lower costs to the system? That surely seems to be the intent. Will this new system of healthcare produce the same degree and scope of breakthrough treatments that we’ve seen over the last 40 years? Will we still see so many of our best and brightest entering the field of medicine, and will our best doctors stay in the game? A tiny article buried in the middle of the Cleveland Plain Dealer might be the sentinel. It seems that between 1997 and 2007 the number of hours worked per week by American doctors decreased by 7.2%, a figure propped up by older doctors who have continued to work 60+ hours each week. Overall doctor fees have decreased 25% between 1995 and 2006, and the authors of the JAMA article quoted note that doctors today “may have less incentive to work.”

Gramp was right. There ain’t no such thing as a free lunch. In the end, as always, we’ll get what we pay for.

No good deed goes unpunished. Everyone’s heard this. Do you think it’s true? Does fear of the unforeseen consequence give you pause, make you think twice and maybe choose NOT to do that good deed?

There’s a young man who bags groceries at my local supermarket. He’s a special needs kid who went to school with my guys.  Let’s call him Billy, obviously not his real name, but he’s still a little kid in a young man’s body and he goes by a kid’s name like Billy. I always try to check out in a lane where Billy is bagging because he’s just a nice kid. Always smiling. Happy to be there. I’ve never seen him having a bad day. Sometimes if the line is long in back of me I’ll bag alongside him and we’ll race to see who can bag he most groceries the fastest. He kicks my ass every time.

Billy is a huge Cleveland Cavaliers fan and an even bigger LeBron fan. In season we always deconstruct the last game and make predictions about the next. I’m tellin’ ya, if Mike Brown and Danny Ferry spent just a couple of sessions with us the Cavs would be hoisting their third championship by now! Billy always tells me about his viewing plans for tonight’s game, and we talk about any game he might be attending for weeks in advance. The kid just loves his Cavs.

I’m a pretty lucky guy. Check that, I’m a VERY lucky guy. I live in Cleveland, not Boston or New York or LA. Even though I’m just a guy, not a big hitter or classic gobbersnopper, I know some pretty cool folks here in town. Several of my friends have seats that would make Jack Nicholson or Spike Lee jealous. How cool would it be to take Billy to a Cavs game and sit courtside? Give him a chance to see how big LeBron is in real life. So I asked him if he’d like to take in a game with his sneakers on the court, sitting across from the home bench and chatting up the refs from, oh, 3 or 4 feet. He said he’d ask his Dad, which I agreed was a really good idea, and he seemed pretty psyched.

Flash forward a couple of weeks. I’m on my way into the store and I stop by Billy’s aisle and apologize that I haven’t been around, tell him I’m still working on those tickets. Billy’s face kinda drops and he sheepishly says that his Dad doesn’t think it’s such a good idea, seeing as how his Dad doesn’t know me and all. I agree with Billy’s Dad and tell him so, and I promise that I’ll give his Dad a call if the tickets materialize. And then I start the second guessing.

Was I wrong to offer those special tickets to Billy? Was it a little bold to offer to bring him to a game? I can definitely see his Dad’s point of view; I can almost hear the conversation at the dinner table between Mom and Dad, can’t you? Who is this guy? Why Billy? What does he want? All reasonable questions, so I thought I’d ask them of myself and maybe have a little virtual conversation with Billy’s Dad in the process.

Why are you bringing this kid to a Cavs game, using courtside seats with a kid you barely know? The first and most obvious answer is because I CAN. I can get the tickets. I can drive the car. I can make a little something special happen in the life of a nice kid  whose universe is happy but a little small. I imagine him asking “But why? What are YOU getting out of it?” There’s the rub, eh? What would I be getting out of it?

Have you ever been presented with that rare opportunity, a chance to do an unpunished good deed? A freebie. Almost no one knows about it but you and maybe the recipient of the good deed. The internet corollary of “no good deed goes unpunished” seems to be “no good deed goes UNPUBLISHED”, but that’s not the case here. You’re gonna do the deed, you’re gonna feel good, and you’re gonna move on. That’s what I’d ask Billy’s Dad. That’s what this one feels like. It’s just a kid who loves basketball and LeBron and his Cavs. An open shot…the ball feels good…the basket looks as big as a hula hoop…a freebie…a free throw.

Listen, nobody does any good deeds without some kind of payback. Some need more payback than others, but if it didn’t feel good you wouldn’t do it. Maybe that’s where I went a little wrong here. I didn’t really look too much beyond the universe of me and Billy at the end of the aisle in a grocery bagging frenzy. He’s a special needs kid; his family doesn’t know me. Duh. Bad execution built on insufficient forethought, albeit based on good strategy. My heart was, and is, in the right place. It’s still that rarest of good deeds, one that might very well go unpunished. The execution just needs a little polish. Maybe it’s Billy and his Dad who need to take in that game, four feet from one family on the floor.

That’s not the point, though. How you pull it off is really not the point. The take home message is that there are good deeds out there to be done. Little deeds and large. Equally good whether the stage is grocery store or global. The essence of these good deeds that may go unpunished lies in both intent and outcome. The net benefit must land with the recipient, no predictable or probable harm should befall the recipient (it’s your responsibility to perform that particular due diligence), and for Heaven’s sake it should be unpublished, a private deed for the sake of nothing other than the deed itself. (This still qualifies; you have no idea who Billy is, and you won’t have any idea whether or not I’ll be able to pull this off.)

Have you ever been here? It’s a freebie. No one will know. You’ll probably get away with it, that most rare of things, the unpunished good deed. You’re right there at the free throw line. The ball feels good in your hands. Really good. The basket looks as big as a hula hoop.

Take it. Take the shot.

Teen drama. Remember it? Of course you do. If you’re like most of us, no matter how old or young you might be, there’s more than enough teen drama still  rolling around in your life. There’s very little of it in the White house right now (knock on wood), but I had an interesting conversation about this in the office with some grandparents talking about watching their teen grandkids being raised. We all had it, the drama, and so did they, but they were pretty distressed by what they’ve been watching in the homes of their grandchildren. It seems to be a universal observation that teen drama is of a greater magnitude now. Why is that?

If you are of a certain age (like me) you communicated with your friends by telephone. You know, the one on the wall in the kitchen, typically the only one in the house, the one that you shared with everyone else in your family. I know, I know…those of you NOT of a certain age have only seen this on “Leave it to Beaver” re-runs on Family TV, but it was really like that. One telephone with a rotary dial, no call-waiting and no voicemail. Maybe there was a Texas Instruments calculator the size of a toaster in your Dad’s office, and somewhere in the house you had a manual typewriter with a worn-out ribbon. The only computers in existence lived at the Pentagon and GM; you certainly didn’t have one at home. Cell phones? Please. You couldn’t even spell “cell” on your 10th grade biology test.

Your teen drama took place primarily face-to-face in school, or transpired one-on-one on the phone at night. You had a limit to how long you could talk (your stinky brother wanted the phone), and the “phone game” of a story growing and evolving with each transmittal was the real deal because, well, there was only one call at a time. You learned to deal with your drama face-to-face because you actually stood in front of someone and talked to them. This wasn’t all good, of course. I seem to remember many more real, honest to goodness fights, boys and girls, in my high school days. Teen drama was like a slow moving train heading toward disaster.

Fast forward to 2010. Verrry fast forward. Teen drama, whether it’s a bunch of teenagers, a bunch of Crossfitters, or a bunch of workers at Google  involved, is indeed a much more intense phenomenon. It hits harder and faster, and it spreads at the speed of light because it TRAVELS at the speed of light. Cell phones, Twitter, Facebook, Text…drama transmittal is now exponentially faster so drama growth is not linear but exponential as well. No longer is the “telephone game” played in a daisy chain of teenagers, each juicy nugget of incendiary chat passed along from one combatant to the next like so many buckets of flaming kerosene. Nope, now it’s 5, 10, dozens of drama queens all in the arena with flame throwers lit firing away in all directions (have you noticed how “drama queen” is no longer gender specific?).

Teachable moment? Eh, I dunno. I guess if you are a parent or grandparent it helps to understand why it is that your teen and young adult kids seem to be hit so much harder and so much faster when the same stuff you experienced hits them. Remembering how much slower everything developed when we were teenagers probably shows us the proper intervention: hit the brakes. Time out. Unplug. Yes, this is how our kids communicate now, but not a one of them will be irreparably harmed if we disconnect them for just a bit. Let the roaring flames die down.

As an adult exposed to your OWN drama, though, I do think this knowledge should give you pause, encourage you to actually pause when in the midst of this kind of thing. No one is going to unplug you. You may actually be required to stay plugged in order to remain employed. But the multiplier effect of modern means of massed communication, everyone in and on at the same time, explodes our adult versions of teen drama at the same exponential rates. Hit the brakes; downshift. Compose YOURSELF before you do any composing.

Because you can’t un-ring a bell, and when you ring that bell in 2010 the sound travels at the speed of light. Whatever tune you tone rings forever in the vast electronic symphony hall. Teach your teens, but don’t forget yourself.

You’re a big kid now; slow it down.

Like most physicians my age I have been sued in a medical malpractice case. It happened to me many, many years ago, and the error in care actually happened before I did anything for that particular patient. An anesthesia accident occurred prior to the OR, and my role was to simply identify the problem, do what was necessary to stabilize the patient, and then refer the patient to the appropriate specialist. Although I had no role in the actions that caused the harm to my patient I was included in the lawsuit because my name was on the chart.

Welcome to the American medical malpractice experience.

While I have yet to be sued again (visualize me running through my house frantically tapping every wooden object), that first case brought an invitation to become an expert witness. As nervous as I was in the deposition for my own case I  managed not to drool, vomit, or soil myself ; this apparently constitutes the minimum requirement to be an expert witness in med-mal cases. I have been a consultant in dozens of cases in the years since. I enjoy the intellectual challenge of deconstructing  a case, the detective work involved in recreating the history. I find the tactical discussions with the attorneys to be intellectually stimulating, similar to creating a game plan in my former life as a football offensive coordinator. Each case unfailing provides some precious nugget, some valuable piece of information that can be brought back to my own practice to make our care and our outcomes better.

But mostly what I have learned from my exposure to the American medical malpractice tort system is that everybody loses every time the game is played.

Let’s break it down, shall we? I’ll use a case in which I was recently involved, among others, to illustrate (obviously all of the names and any other identifiers have been changed). Dr. Z saw Patient X who probably already had a particular disease in 2004. Dr. Z didn’t really pursue some of the findings present in the exam and history at that time, and in effect failed to make a timely diagnosis. Patient X then had a dramatic change in vision after a surgical procedure, a procedure that was done perfectly without any adverse events or complications. This dramatic decrease in vision was really a burden for Patient X, and so an attorney was hired and Dr. Z was sued for malpractice because he failed to make a particular diagnosis in 2004 which MAY have caused the loss of vision in 2006. As it turns out the loss of vision was NOT caused by the disease that went undiagnosed and Dr. Z prevailed at trial.

Let’s quickly look at another case, one in which I had no personal involvement but one that I am familiar with on a personal level. A young mother and father, parents of three healthy little kids, notice a bulge in the belly of their youngest. Maybe he’s two or three at the time. A little umbilical hernia, very common, a snap for a pediatric surgeon to fix, is the diagnosis. They live in a city with many very fine medical institutions and they choose one with a sterling reputation for the surgery. A terrible accident occurs during the surgery, a “never” event, a clear case of medical malpractice. Their beautiful third child suffers irreparable, irreversible brain damage and will now require 24/7/365 care for the rest of his life, a life that will likely be cut short, but a life that will dramatically alter the lives of this young couple and their two other children. The case never goes to trial; the hospital and all of the doctors settle the case and the devastated couple and their children receive a very large settlement.

Let’s look at these cases, shall we? Let’s see who won and who lost. First off we should deal with the lawyers. Think of the defense lawyers, the people who defend the doctors (and their malpractice insurance companies), as the “house”. Defense lawyers ALWAYS get paid, just like the casino always takes its cut. Neither a winner nor a loser, the defense attorney just takes his cut. How about the plaintiff’s attorney? Didn’t they lose the first case and win the second? Well, sort of. A better way to think about the lawyers who sue doctors is to consider them professional gamblers who place their bets with someone else’s money. Some are backed by investors who cover their expenses, and others simply use the proceeds of the first settlement they receive. If the defense attorneys are the “house”, the plaintiff’s attorneys are professional gamblers who make their bets using “house money”. Neither winners nor losers here, just scavengers who feed on the carcasses of…

…EVERYONE ELSE! The doctors, the patients, their families, the hospitals, even the spectators–you and me. Everyone loses. You don’t agree? Let’s dial in a closer look.

In the first example Dr. Z made a mistake. He made a delayed diagnosis. Didn’t provide very good care for that particular problem. When Patient X had something bad happen he was convinced it was because Dr. Z missed a diagnosis, and an enterprising plaintiff’s attorney convinced Patient X that he suffered his bad vision because of malpractice. So they sued. It’s pretty clear that the patient, poor X, lost any which way you look at this. Bad vision in one eye. Hopes raised that not only would that bad ol’ Dr. Z be made to pay for his mistake, but Patient X would also receive a financial settlement, maybe even a windfall. BZZZT. Wrong. Sorry. Johnny, tell Patient X about our lovely parting gifts. Not only do you STILL have bad vision, but now you’ve had all of your false hopes dashed adding bitter disappointment to your loss column, not to mention all of the time you spent in the company of all kinds of lawyers.

But…but…what about Dr. Z? He WON. Really? Ya think? Look back at the story. Dr. Z was sued in 2006. He has had to live with this case and everything that went along with it for 4 years. Time out of the office. Time on the phone with lawyers. Giving depositions. Reading depositions in which his patient and a hired-gun physician expert said he was a bad doctor. 4 years of wondering and worrying, thinking about the case, thinking about losing. Looking at every patient as “the next case”. No, Dr. Z lost, too. My world is littered with the carcasses of physicians, and lives, and practices, and marriages, and families that were destroyed by the process of malpractice cases that the doctors WON. Alcohol abuse, depression, suicide, all in cases that the doc won. Nah…Dr. Z lost, too.

How about the second case? Pretty clear that the doctors and the hospital lost this one. Big time. Huge settlement. They messed up and paid the price. That young family won. Made ‘em pay, just like the fancy lawyer ads on TV. Big money. But really? Seriously? That child was still grievously injured, and that family is still living with the knowledge that he will never be the child he might have been. 24/7/365 care for 10 years. Housing, schedules, LIVES all determined all the time by medical malpractice, a case in which they prevailed legally. Winners? Hardly. I know this family, and they are gracious and wonderful people who have soldiered on for 10+ years, the only ease being a freedom from the financial burden of their tragedy. What if they had gone to trial and lost? That happens, you know. Sometimes real malpractice happens but the doctors win in court. Nope, no patients ever win in medical malpractice. Not here; not ever.

And the spectators? You and me? Well, we lose every single day. Every time a doc does a little extra just to cover himself in case of a trial, orders an extra test or X-Ray that doesn’t really do anything to promote a better outcome but makes for a little better paper trail, we all suffer due the expense of that defensive medicine. Every time we wonder about why our doctor might be ordering that test or asking that question we lose. When a doctor looks at a patient and sees a potential lawsuit instead of a patient who needs help he loses. The patient loses. We all lose. Think about how many medical errors there are that happen again and again because they are never reported, and therefore are never evaluated and examined to see if they could be prevented, because a doctor or a hospital was afraid that reporting the error would launch a lawsuit. Lose.  Everybody loses in the Medical Malpractice Game.

Well, ALMOST everybody. I guess the “house” continues to win, and the folks gambling with the “house’s money” continue to win. It’s just everybody else who loses. Everybody who counts like every single patient and every single doctor in every single medical malpractice case.

Everybody…like you and me.

We have an interesting problem a Skyvision Centers, one that we have all anticipated with a combination of longing and fear. We are about to become too busy to see emergency visits.

Let me back up a little bit and explain why the entire Skyvision crew is experiencing agita over this before it becomes some version of reality. Skyvision is that rare entity that continues to try to be exactly what it professes to be. In our case, while not unique, Skyvision is a rare example of true patient-centered medicine. You can read about our story here http://skyvisioncenters.com/blog/?p=108. I’ve also been very frank about how I feel about the mega-trends in medicine, trends that is seems will be magnified and accelerated in the coming “Healthcare Reform”. http://skyvisioncenters.com/blog/?p=145. None of these current fads or trends are terribly helpful blueprints for the solution to our new “problem” at Skyvision.

The ultimate consumer service industry is healthcare. Oddly enough, I wrote something about that: “The Ultimate Consumer Service Business” http://skyvisioncenters.com/blog/?p=56 (I’m clearly not above self-promotion here!). Everyone at Skyvision Centers is  on board with that concept. We’ve all quaffed the same Kool-Aid as it were. That’s how we have come to the conclusion that we are about to run out of time to see patients with an emergency, at least in the patient- centered way in which we have done so in our first 5 years. For you see, we have allowed our patients to define what it is that constitutes an emergency FOR THEM; we have not imposed any internal definition of “emergency” on our patients, and we have responded to every single patient-defined emergency with the same response: “come right in.” We have also evaluated and responded to every “oh by the way” additional problem that our patients brought up in the exam room but forgot to mention on the phone when they scheduled an appointment.

So how do we know that it’s a problem now, or about to become a problem really soon? Well, we still measure and evaluate all kinds of metrics that relate to the customer experience in the office. Some of those metrics are really kind of objective, like time and volume and such, and they lend themselves pretty easily to trend analysis. We know, for instance, that our average patient volume is dramatically up, especially over the last 6 months. We also know that the average time that a patient spends in the office for our core service has increased by 6 minutes over the last year, and that one of the internal intervals–how long it takes to be brought into the exam after your paperwork is ready–has increased by 4 minutes. We know that the average number of emergency visits (ER’s) is now 6/day, and that the range is 0-12; there is no meaningful pattern to the ER’s, no actionable mode.

We have been able to handle our ER load in the past because of our dedication to the concept of “process”, our adherence to clinical protocols and flow protocols, aspects of Skyvision Centers that were learned and adopted from the Toyota manufacturing processes. Our internal benchmarks for patient experience were established when we had so few patients and so much time to see them that I found myself telling childhood stories to entertain my patients, lest they feel they were getting the bum’s rush. We find that we have now bumped against the outer limit of “acceptable” by our own standards, standards which place us in the top 1% of patient experience, and must now make capital investments in order to remain there.

It is the ER load that has forced our hand, for it is the ER visits that have pushed us into the “discomfort zone” of longer patient waits and longer patient “transit times”. Without ER visits we would still be have “running times” like 2008 or 2007, even though our schedule volumes are dramatically higher, and we would perhaps be able to make smaller capital and staff investments more slowly. Adding more equipment and more staff is scary, especially in this economy and with all of the uncertainty surrounding Healthcare right now. Skyvision Centers is a business after all, and no one has received a raise in our first five years (indeed, I am still working for what amounts to an 80% pay CUT). Simply throwing more staff and more exam space at the problem isn’t so effective if it bankrupts the business. Kinda tough to provide a wonderful patient experience if the doors are padlocked.

So the question is now how do we handle ER visits? I know of a number of practices, probably the majority in our region, that simply give the ER patient the next available open appointment, whenever that may be, even if it is days or weeks ahead. Should we do that? Still others send patients to a local Emergency Room; it’s an emergency after all. One of our local institutions, widely lauded by DC gobbersnoppers including our President as the bellweather example of all that we should aspire to in healthcare, directs all patient-defined same-day ER visits to the World Class Hospital Emergency Room; even if you are an established patient with an established doctor-patient relationship their triage in the Emergency Room directs you to a doctor-in-training for your ER care. Should we simply “turf” our ER visits like World Class Hospital?

Thus far we have allowed our patients to define an emergency as anything they, the patient, feels is an emergency, and we have seen them right away that same day. Should we take back control of the definition of emergency and perform telephone triage? My staff and I certainly know the difference between emergency, urgency and inconvenience. We can define and ascertain what constitutes severe and what constitutes minor. Should we perform triage and schedule ER visits in open slots on subsequent office days according to long-established standards of severity and then availability? Tough call. A foreign body sensation is a “next couple of days” triage, but have you ever felt like you had something in your eye? It’s maddening. Imagine waiting a couple of days to be seen.

Should we openly state to all of our patients that we will continue to see ER visits as we have always done? Severity defined by the patient and “come on in” our response? In tandem with this will our scheduled patients agree to the implied contract that any increased wait they experience is an “investment” in their own future ER care? That they are agreeing to wait a little longer for their scheduled visit because of the “there, but for the Grace of God” phenomenon, that they, too, will go to the front of the line should an emergency befall them?

We’re all patients; I fear that that we  will all experience this in the near and not so near future, especially if the DC gobbersnoppers get their way with “Healthcare Reform”. We at Skyvision Centers are quite frankly way better at providing an enjoyable patient experience to go along with best in class medical outcomes already, and I fear that we are going to find the going even more lonely as we agonize over issues like this. I don’t see a whole lot of folks on the “service” side or the finance side of this equation spending too very much time thinking about the effect of emergencies in the medical office and how they affect our experiences as a patient, the person receiving the service.So what do you think? You’re a patient. From the patient’s point of view what would YOU have us do?

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Man, turning 50 has not been an easy proposition. I’ve been turning 50 since the day after my 49th birthday and quite frankly I haven’t been doing such a great job of it. The highway between mile markers 49 and 50 seems to be strewn with all manner of psychological speed bumps and potholes, pretty much all of which I’ve placed there myself.

Why is this? Why so much angst about 50? I didn’t really have any issues with 18, 21, 30, or 40, at least not any that I was so keenly aware of. In fact, I don’t recall ever thinking about the process of TURNING any of those milestone ages, not a minute spent thinking about the run-up to any of those birthdays. I suppose 40 might have presented an opportunity for at least a little introspection, or at least a little taking stock, but “turning40″ angst was preempted in the course of a single ride on a chair lift in Utah the week prior to my 40th birthday. My chair-mate, noting his own near existential angst at the prospect of turning 40 several years prior shared the wisdom a priest friend had offered. 40 is when your still healthy, strong, and vibrant body meets the experience and wisdom of your now mature mind. That worked for me! 40 made sense after that.

In a dazzling display of prescience and foreshadowing, my lovely bride Beth responded to my epiphany with “wait ’til he turns 50! That’s gonna be a problem!” Shortly thereafter she contracted the mother of all cases of pneumonia and tried to die on me. Any little bit of an issue with turning 40 got pretty much short circuited in the elation that accompanied her recovery.

And yet, here I am. Turning 50.

What’s the big deal you ask? It’s just a number. You’re a January baby. It’s nothing more than another calendar to throw out.  One more tax return. What’s the problem here? Aren’t you the guy always looking forward, wanting what you have? The “no regrets” guy? Cut the crap! Find your balls. Snap out of it.

To which I respond sure! There you are going all left-brain/left nut on me. Trying to impose logic and rational thought on what is clearly a right-brain, visceral “feel” kinda thing. It’s all about the right nut, the squishy can’t get your hands around it illogical nonsensical unease that resists both explanation and resolution.

My own left-brain gets it. Hari, one of my Crossfit buddies, nailed the rational aspect of turning 50. According to Hari our first 50 years are all about preparing. We spend our lives preparing either ourselves or someone else for something that is yet to come. We grow and get ready for kindergarten, so that we can prepare for grade school. Grade school begets junior high where we get ready for high school. High school prepares us for college which leads to job and adulthood. We then transition to the task of preparing others, our children, and spend the next however many years engrossed and engulfed in that pursuit. 50 is when we are done with the preparing. 50 is when we we exit Route Preparation and begin our journey on Route Me. At 50 we can learn for the sake of learning, not because we need to knock off a pre-req. We exercise and eat for the here and now, for how we are hoping to feel right at the moment. The first 50 years are about preparing; the next 50 are about living.

Why then, if I get that, am I having so much trouble TURNING 50?

As I’m sure you’ve gathered if you’re spending any time here on Random Thoughts, I am a physician by day. I finally think I figured it out one day in the office when one of my patients mentioned that she was having some issues with turning 60. We took a little detour, talked a little while about our “turning” issues rather than her eyes. 60 meant “old” to her, and old was more than a little frightening. She didn’t see “old” in the mirror, and didn’t want to think about any part of “old”. Her tactic? Classic–She simply decided that she was younger and told everyone she’s  55! How about me, she asked. You’ve made it. Successful practice and a wonderful professional reputation, healthy family, a marriage to be envied. Your biggest problem should be deciding how to celebrate! How will you mark this milestone, this success?

And there you have it. There, in that lovely compliment from a patient I barely know, was the issue. How indeed would I mark this milestone? The cartoonist would have put an enormous light bulb over my head, for here was at once the solution and the problem. I couldn’t say how I was going to celebrate turning 50 because I can’t celebrate in the way that it turns out I always thought I would, and that fact lies at the base of all of my angst, all of my discomfort, all of my difficulty in turning 50.

Physicians play a game early in their lives called “delayed gratification”, a game in which they willingly put up with the hardships of training and postpone most of the trappings of success. Tiny apartments and old clunker cars are OK because there is a world of plenty just over the horizon, a reward for both the sacrifice and the success that students of medicine encounter on their journey. Their preparation, as Hari would say. Once out in the real world, out of medical school and finished with residencies and fellowships, both the willingness and the ability to play “delayed gratification” slip away to be replaced by a sense of pride in having played,  not terribly fond memories incentive to never play again.

There’s the rub–I am once again playing “delayed gratification” and I simply can’t even consider doing some of the things I thought I could think about to mark this milestone. You know, classic 50 year old dumb guy birthday stuff like, I dunno, buying a Porsche. I don’t think I’d actually do that, but I DID always think that at 50 I would have been able to decide NOT to buy a Porsche, even though I could have if I really wanted to. Even the more meaningful stuff I’ve talked about to mark turning 50, stuff like climbing Kilimanjaro with my sons or accepting that invitation from Geoff Tabin to teach native surgeons how to do cataract surgery in Tibet, I’m not going to do those things because I CAN’T, because I am once again playing the game of “delayed gratification”. I might never have done any of those things, or any of a number of other things I might have thought of, but I always thought I’d be able to decide, that I COULD if I wanted to.

I can’t, and I find that I resent that. It makes my sad, and both of these feelings make my left-brain more than a little unsettled, for there is no rational response. No solution. No pithy sentence to conclude this particular Random Thought on an up note. At the end of the day there will be nothing other than sucking it up, moving on, and getting over it, getting over myself. There will be nothing other than trying to play the game of “delayed gratification” just as well at 50 as I did as a much younger man, for in the end I really have no other rational choice. I will have to hope, to try to be much better at BEING 50 than I have been at TURNING 50.

Because I’ve really sucked at turning 50.

Admit it. How many times have you heard or read a professional athlete utter the words “it’s not about the money” and forced yourself not to gag? Seriously, it’s ALWAYS about the money.

We hear this ad nauseum during the free agent season in every professional team sport as players from superstars on down to less-than-super subs angle for the biggest payday possible. The phrases “max contract”, “salary cap”, and “veteran exception” vie for our attention with batting averages, rebounds, and sacks. We the fans are spectators not only to the games but also to the gamesmanship between owners and players, each trying to maximize their piece of the pie. It’s ALL about the money.

The realist in me wants to acknowledge that this is simply the labor/management battle played out on the front page of the Sports Section. How, I ask, is this any different from the headlines in the Business Section where the “Masters of the Universe” keep score with their multi-billion dollar spoils?

But then it hits me…in the board rooms and the banks how much money you make is the ONLY scorecard. There is no other way to rank the players or the teams. The person with the highest salary wins. That’s it. Nothing else. The company/bank with the highest profit is the “best”. If Goldman Sacs makes more money than JP Morgan then Goldman is the better bank and Lloyd Balnkfield is better and smarter than Jamie Dimon. Money is the only metric, and no one sits at home playing Fantasy Wall Street or cheering for their home town Hedge Fund.

And there’s the rub–the games we watch all have a scorecard, and we keep the score of the games the same way whether it’s the Cleveland Browns vs. the Miami Dolphins in the NFL, or the Shaker Heights Eagles vs. the Southbridge Mass Ponies in Pop Warner. A free throw is one point whether it’s Bingo Smith at the line in the NBA or bingo (yours truly) at Tri-City Park in Rocky River. If you’re playing the game in the back yard, or if you’re a fan of the pro game it doesn’t really matter. What you care about is winning. Period.

When was the last time you heard the words “it’s not about the money” from a big-time athlete, spoken or unspoken, and you believed them? I can come up with exactly one, and I’ve been following pro and college sports since I could turn on a TV. I really did believe Tim Tebow, the kid from Florida, who came back for his senior year to play quarterback. I mean, what did he have to gain money-wise by doing that? Heisman trophy winner. Leader of two NCAA champions. Top five pick in the draft whenever he came out. I really think the kid just loves college and being a college student and football player. Other than him? Shut-out.

But there’s something really interesting blowing in the winds of the NBA. You know that place, home to the “Bird Exception” that allowed the Celtics to pay Larry $33 Million in his last season. Where Michael Jordan took home a cool $30 Million despite making somewhere north of $50 Million in endorsements each year for 10 + years. Some upper mid-level power forward–I can’t even remember his name–agreed to hold off on signing his contract with the Cleveland Cavaliers, promised a huge raise and the chance to play with LeBron James, only to exile himself to Utah when an offer of more money arose. I DO remember what he said in the paper, though. Yup…you guessed it…”it’s not about the money.”

Still, there it is, a whisper dancing just outside the conversation. Someone, a very important someone, has a chance to utter that fateful phrase, “it’s not about the money”, and really mean it. Here now is LeBron James, a free agent at the end of this NBA season, who has the opportunity to sign a contract that is all about his team winning. LeBron, who makes somewhere in the vicinity of $80 Million in endorsement money, can sign a “max contract” that will pay him around $100 Million or so over 7 years, maximizing his income from playing the game but also maximizing the difficulty that General Manager Danny Ferry will have gathering talent to surround LeBron in order to win. Win like you and I think about winning, as in winning NBA championships.

It’s just the tiniest of breezes now, barely enough to tickle what’s left of the leaves on the trees in Cleveland, not even enough to rustle the top sheet of the Plain Dealer as it sits in your driveway. LeBron could sign for the veteran’s minimum, about $2 Million per year. The $2 Million wouldn’t even count against the Cav’s salary cap! Doing this would free up, what, $20, $25 Million per year? That’s enough to sign not one but TWO major players, especially if they, too, sign on just a little bit to “it’s not about the money”, it’s about playing with LeBron and WINNING. Dwayne Wade AND Chris Bosh in Cleveland with LeBron James. In Cleveland, playing to win.

It’s still about the money, of course. I’m not naive enough to think that there wouldn’t be massive positive PR for LeBron if he took a minimum contract and stayed in his hometown city and then won. I also know that he can revisit his max contract option in 2 or 3 years and get pretty much the same number he would get now, even with the massive increase in off-court income likely to come his way if he played it my way. But still, a chance to say “it’s not about the money” and really mean it, even if it’s only for a couple of years? It’s man bites dog stuff.

Who knows if it will happen but I get a little smile as I think about the hurricane that will tear through the Player’s association if LeBron does this. I love thinking about David Stern’s office after the tornado plows through if LeBron comes out and says “it’s not about the money” and means it. If LeBron James is the first professional athlete in modern sports history who literally puts his money where his mouth is.

Hey…anybody out there have Maverick Carter’s cell number?