The new doctor shortage - Michigan

The pipeline to produce physicians is so long, and the costs to students so great, that it is not at all surprising that we go through boom and bust cycles. In my career I've seen family practice cycle from startup to boom to bust. Unsurprisingly the cycle may be shifting again, though I wonder what role Michigan's economic and liability issues play in their pending shortage:

Crain's Detroit Business

... The Michigan Department of Community Health on Wednesday said it will create a data clearinghouse of medical professionals to help the state’s health care providers deal with a looming physician shortage.

According to a recent state survey, about 37 percent of Michigan’s physicians are 55 or older, and more than 38 percent of physicians say they plan to practice medicine for only one to 10 more years. A separate state study indicated that Michigan will need to fill more than 100,000 professional and health care jobs in the next decade.

Normal boom/bust cycles, atypical demographic cycles, and the possibly permanent decline in the appeal of primary care practice may conspire to make this coming shortage more severe than most.

The obvious approaches are to train more paramedical staff (NP and PAs), to encourage immigration of more physicians, to do more outsourcing of services overseas (radiology, dermatology, etc), and to move more care to 'disease management' programs. I am confident all these approaches will be tried and all will have a role. I also suspect that, within 10 years, we will reinvent the GP/FP/General Internist/Pediatrician once again -- though possibly under a different "brand".

The publicly traded politician - and other reform proposals

Wow, political reform is back again. For a week. I read one semi-serious proposal that I quite liked. It reminded me of something. Took me a few minutes to remember what.

It turns out that in 1996 I wrote a web page with two radical and semi-serious approaches to reforming politics. The old pages are topical again ...

Campaign Finance Reform: Voluntary Mandated Sharing:

... Campaigns need money. Powerful people need good things. Both needs can be satisfied by transforming politicians into publicly owned corporations. After meeting standard accounting requirements, a politician would be sold through an IPO. The usual futures and options markets would develop. Standard reporting and accounting regulations and SEC enforcement would apply. Cheaters would be delisted, and thus be effectively removed from future campaigns.

Read the page for the other proposal.

A critical military analysis of the war on terrorism

Crooked Timber does a nice job of excerpting a longer post by a military historian

Crooked Timber: � Shadows and Fog

.... To summarize, then—sorry about that—a too-hierarchical, too-orthodox U.S. Army, and U.S. military in general, leans heavily on lumbering equipment, high technology, and major ground offensives against an enemy that relies on tactics that are often not even conventionally military in nature; we mass artillery against threatening letters and infrastructure sabotage. In equipment, doctrine, tactics, and leadership structure, we’re organized for the wrong enemy, in ways that can’t be easily or quickly changed.

The entire excerpt is quite interesting -- well worth reading. The original is a bit long.

BTW, the latest rumor is that Cheney is trying to get Saudi Arabia to fund a UN authorized Egyptian force to save the Iraqi Sunnis after the US pulls out. Blocking Iran is a not small fringe benefit.

The drug discount debacle -- one illustrative story

Just one tiny story in the midst of the immense drug discount card debacle.

The U Share - Medicare-Approved Prescription Drug Discount Card site is one of many associated with the "benefit". It lists, for example, commonly prescribed medications. Alas, any elder (or family member) navigating the list of covered drugs would be perplexed when they clicked on the 'next' button and got a page error. The site builder forgot that UNIX is case specific, and the URL uses an upper case letter when it needed a lower case letter. Of course there's no link to a webmaster to tell them what the bug is.

No feedback loop. Runaway complexity. Debacle squared.

Getting an ovation for your speech

I've never gotten a standing ovation for a speech or lecture, but I'm no Guy Kawaki. When I do some of what he says here, however, I do get applause. I can live with that.

A terrific list of tips. Use them for your next lecture, presentation, or even speech.

Kawasaki's blog, by the way, is terrific. I recommend starting from the very beginning.

Exercise and Alzheimer's: How to fix the demented media

I read yet another bulletin declaring that "exercise can prevent alzheimer's". Sigh. The elderly who exercise 3 times a week are 50% less likely to be diagnosed with dementia. All that means is that it's worth funding more research. My bet is that a loss of commitment to exercise is an early indicator of a dementing process.

Some of the stupidest coverage came from the Wall Street Journal. I was feeling annoyable today, so I did a quick study. Someone who needs a pub should write this up as a letter to Lancet. I bet they'd get a nice cite.

I googled on the news: exercise alzheimer's - Google News:

Exercise Research
WOWT, NE - 18 hours ago
... More research is needed to better understand how exercise may help protect against diseases like Alzheimer's, but for now researchers say one thing is clear ...

Research Notebook OregonLive.com, OR - 6 hours ago ... years, 158 had developed dementia, including 107 diagnosed with Alzheimer's disease ... older adults who exercise Another study that looked at physical activity in ...

Study: Exercise May Reduce Risk of Alzheimer's Disease ABC News - Jan 16, 2006 ... Researchers emphasize that this study is not proof that exercise reduces the risk of Alzheimer's disease, but they say the results are consistent with several ...

Alzheimer's Disease May Be Prevented With Exercise Fashion Monitor Toronto, Canada - 23 hours ago ... The six core strategies to prevent Alzheimer's disease include exercise, diet, a program of vitamin and herbal supplementation, regular brain stimulation, a ... Exercise Not Enough to Prevent Alzheimer's Disease PR Web (press release) all 3 related »

Exercise Significantly Reduces Risk of Dementia in Senior Citizens SeniorJournal.com, TX - Jan 16, 2006 ... growing evidence that exercise – particularly if it starts early and is maintained over time - is beneficial in preventing dementia and Alzheimer’s disease ...

Health Roundup: Alzheimer’s And Exercise, Sibling Drinking ... NBC 10.com, PA - Jan 16, 2006 ... The things that reduce our risk for Alzheimer's are: exercise, reducing our cholesterol with statins, eating a lower fat diet and lowering our blood pressure ...

Exercise associated with reduced risk of dementia in older people
EurekAlert (press release), DC - Jan 16, 2006
... Additional study also may provide information on the possible merits of varying types of exercise. For information about Alzheimer's disease, visit the ...

It turns out that about half of the top-ranking Google results used "may" and a few even used "associated with" (they get five stars). The rest, alas, were as dismal as the Wall Street Journal.

So here's how to shame the media into doing better. JAMA should run a report after each report of a finding associated with reduced cancer, dementia, etc. The journalist can simply execute a Google News search and extract the titles. Titles are then ranked for words like "may" and (best) "associated with". Report the results by dividing press into "Good", "Bad" and "Ugly" categories.

After six months on the "Ugly" list, the Wall Street Journal gets a special prize.

Eventually, they improve.

Good-bye cross country skiing

The first time I tried cross-country skiing, I wasn't done healing from chest surgery. It made my tentative pole plans particularly poignant -- I paid for each slip. Maybe that's why I remember that 1970s day particularly well. It was the start of a great relationship. I was never a competitive skier, but I loved skiing the skinny skis on skinny woods trails (classic only please -- no highways for me). It was a great sport for an outing in Montreal's big city parks, and a spectacular sport in the stubby Laurentians.

In those days we had months of decent snow cover in Quebec. In the early 1980s, I even had one very memorable ski outing in the San Gabriel mountains overlooking Los Angeles. Things were turning though. In central Pennsylvania, where I did my residency training, the nordic ski resorts were closing by the late 1980s. Since then it's been mostly downhill.

This winter looked like it might be an exception; we some great snow cover in the twin cities before Christmas. I saw a park packed with skiers. Alas, the weather has returned to form -- gray and mild. The Twin Cities now has the climate of central Indiana or Iowa.

There will still be snowy days in Saint Paul, and even some days below zero, but the world is moving on. Global Climate Change may mean Europe gets much colder, but for the northern US it mostly means milder weather.

I don't think our kids will ever cross country ski -- unless we move to altitude or to Houghton Michigan. I do miss it though.

iPod and iTunes: an unexpected effect

Results 1 - 30 of about 524,000,000 for ipod [2]

I have a love/hate relationship with Apple, as compared to a hate/hate relationship with Microsoft. I cannot deny, though, that Apple has brought one good new thing to an old dog -- music.

The iPod/iTunes combination has transformed an all-but-forgotten CD collection (bought, inherited [1], married) into something I'm getting to know. This is novel for me -- I was never a knowledgeable listener. It's the iTunes playlist, rating, listening, refining interaction that's helped me learn the collection, and the iPod technology has let me integrate it into a compressed modern existence.

Years ago I liked Joni Mitchell -- but I confess I'd never really paid much attention to her music. She's fallen a long way since I started hearing the lyrics. Joan Baez, on the other hand, has returned from the depths. The more I hear him, the more I like Springsteen - including his unfashionable mature work. Stan Rogers wears well. Rock, country, folk, jazz, classical, eventually opera. Names that are familiar, and those that almost no-one listens to. New and old. There's a lot to explore in 500 years of music.

The difference, which radio of any form cannot bring, is learning the music.

[1] The inheritance of digital music libraries will be an interesting story to track. There's a lot of music out there on CD, and it's not clear that new technologies will greatly change our listening experience. Unlike video, audio recording started to converge on human perceptual limits over 15 years ago. The staggering volume of what's already been purchased by families, and rarely discarded, may be as big an issue for the industry as digital file sharing. The fact that iPod/iTunes greatly enhances the value of existing music collections is very ominous for the music industry. Short of preventing encoding of extant CDs, is there anything the industry can do to escape this trap? I suspect recent falling digital music sales may be in good part due to users rediscovering old collections.

[2] A half-billion hits on Google? That's a lot of splogs!

Iran's program: what's so complicated?

The WSJ has another somewhat dull article on Iran's nuclear weapons program. There's been remarkably little informative discussion.

Iran wants a nuclear weapon and they'll likely get one sooner or later. Many nations would like Iran to get its nuke as far in the future as possible, ideally after a regime change. All the efforts being expended are to delay the acquisition date. The only real question is whether China and Russia will cooperate. That cooperation will depend on a lot of trading and swapping with the US and Europe.

One can argue that Bush's cavalier attitude towards treaties of all types, and the NPT in particular, hasn't helped. I don't have much of an opinion either way. Once Pakistan had its bomb (mostly built pre-Bush), and once the US invaded Iraq, the die was pretty much cast.

All this chatter about treaty obligations etc etc is mostly irrelevant. I can imagine that if China and Russia fully cooperated that Iran's nuclear program could be delayed for a few years, which might just allow for a less whacky Iranian President. (Maybe we'd get a less whacky US president too.)

Update 11/18/06: It looks like Russia is going to block sanctions, so it's pretty much game over now. There's nothing quite like fundamentalist zealots with nuclear weapons. At least Iranian fundamentalists don't seem to have the end-time enthusiasms of our religious extremists.

If Al Gore had been our president, would engagement with Iran have prevented the "election" of their current nut-case president? We'll never know.

Why the democrats should filibuster Alito

Not because of Roe v Wade. Because Alito supports Bush signing a bill banning torture while issuing a 'signing statement' that he is not obliged to abide by it:

The Imperial Presidency at Work - New York Times

...Both of the offensive theories at work here - that a president's intent in signing a bill trumps the intent of Congress in writing it, and that a president can claim power without restriction or supervision by the courts or Congress - are pet theories of Judge Samuel Alito, the man Mr. Bush chose to tilt the Supreme Court to the right.The administration's behavior shows how high and immediate the stakes are in the Alito nomination, and how urgent it is for Congress to curtail Mr. Bush's expansion of power. Nothing in the national consensus to combat terrorism after 9/11 envisioned the unilateral rewriting of more than 200 years of tradition and law by one president embarked on an ideological crusade.

A filibuster would likely fail, but it is a noble cause and, given where Bush is going, history may judge it well.

Hard core libertarian praising Ted Kennedy?

Wow. The end times must be near. A friend with libertarian sympathies sends me a link to a libertarian pundit -- praising (albeit through clenched teeth) Ted Kennedy's criticisms of Alito:

Agreeing With Ted Kennedy by Anthony Gregory:

... How sad it is that we have come to the point that we have to rely on Ted Kennedy to be the voice of reason on some of the most fundamental issues of the day. How frightening it is to be agreeing with Ted Kennedy and disagreeing with nearly the entire rightwing on these issues, all while most of the talking heads ignore them nearly completely...

Rockwell's Kennedy quotes are great, and, yes, I agree the media ignored them. The mainstream media is plumbing new depths of inadequacy every day; blogs are helping but they're no replacement. We are hurting because the Fifth estate is in the toilet.

As to Alito, forget Roe vs. Wade. Alito is bad because he believes the American President can have the powers of a tyrant -- at least when the president is Republican. I rather doubt his sentiments would extend to a Democrat.

Douglass' judgment upon Lincoln

[correction: I was guilty of the great faux pas of spelling Douglass with one s.]

DeLong has put together an excellent post, combining Lincoln's words from his debates with Frederick Douglass 1876 judgment of Lincoln:

Brad DeLong's Semi-Daily Journal

...Viewed from the genuine abolition ground, Mr. Lincoln seemed tardy, cold, dull, and indifferent; but measuring him by the sentiment of his country, a sentiment he was bound as a statesman to consult, he was swift, zealous, radical, and determined...

Douglas was a terribly eloquent writer. I do recommend reading the entire post.

Listen to Stanford lectures on iTunes

Jon Udell pointed me here. You can listen to Stanford lectures -- but only on iTunes. I gather Apple is cosponsoring the project. Jon is rightly concerned about the iTunes lockin; he connects it to the DRM plague. I'm confident Microsoft will sponsor something similar -- with a lock-in to Windows Media Player.

In fairness though the lock-in part is not really DRM, it's the same old technique that made Microsoft the most dominant corporation in the past century. Apple's very good at it too, just not as clever as Microsoft.

Medlogs is looking good on Bloglines

Jacob Reider and his cohorts recently added an RSS feed to their RSS aggregator: Medlogs.com - The News Aggregator for Medical Topics.

The initial version didn't render well on Bloglines -- it included a section of unwanted descriptive text. Jacob has just fixed that it looks quite good now.

I now get my medlogs in the same space as my other syndicated reading. (So is Bloglines a meta-aggregator, since it's getting a feed from an aggregator?)

You can't win - the trap of the home office depreciation

On the advice of an accountant, I depreciated my home office. Bad mistake. When you sell, there are lots of headaches. Grrr. The infuriating part is that if even if you deducted expenses, but not depreciation, the IRS taxes you as though you claimed the depreciation.

Between Digital Rights Management and the IRS I'm ready for a life of crime.

Depreciation Appreciation 101: The Ins and Outs of Deducting for a Home Office - New York Times

By DAMON DARLIN

... The I.R.S. allows you to take a home office deduction if you meet certain conditions, and about 30 million taxpayers manage to meet them. The rules are pretty clear for the self-employed. The home office has to be the primary place of business, used exclusively and regularly for that business. If your office fits that definition, you can write off a percentage of the utilities, the mortgage, repairs and maintenance and, of course, all the office equipment and furniture stuffed into it.

... when you sell your home for a profit you have to recapture the depreciation you took on that office and pay taxes on it. For example, say you bought a house for $500,000 and used 10 percent of it for an office. (You figure that out by measuring the square footage of the office and dividing that by the square footage of the entire house.) You are allowed to depreciate 10 percent of the purchase price of the house each year using what the government succinctly calls the "39-year commercial property straight time depreciation schedule." That adds up to about $6,000 in depreciation over five years.

You later sell the house for $750,000. The $250,000 in profit is excluded from tax. But the $6,000 you took in depreciation over the years must be reported as a gain on Schedule D, in the gains and losses section. It is taxed at a 25 percent rate.

What if you take other home office deductions and skip the depreciation? Nancy Mathis, an I.R.S. spokeswoman, says that will not help. "Even if you don't take this depreciation, it will be treated as if you did when it comes times for calculating the basis of the home sale and capital gains exclusion." The I.R.S. will not say why it makes that assumption, but accountants surmise it is because the government cannot keep track of home-office owners who might depreciate some years and then stop right before selling in hopes of avoiding the extra tax.

Here's something to think about: If you rent, you avoid this entire frustration when claiming a home office deduction.

Now for the more complicated question: Remember that the government allows a single person to exclude $250,000 of capital gains on a home sale and a married couple, $500,000. If you claimed 10 percent of your home as a home office and wrote that off over the years, when you sell the house, do you owe capital gains tax on 10 percent of the profit? This is what is tripping up Mr. Sigal, the chemical engineer.

The government used to say, you owe the tax on the portion of the residence that is used for commercial purposes. But it gave taxpayers a little gift when a new rule took effect in 2002. The home office inside the structure of your house is no longer considered commercial property. Everything is covered under the capital gains exclusion. If your accountant is not up to date on that, ask him or her to check it out.

Indeed, Mr. Sigal does not owe as much as he was told and a new accountant confirmed that he owes taxes on only the $2,000 of recaptured depreciation.

But in changing the rules, the I.R.S. also made things more complicated. Funny how that happens. That no-tax rule applies only if the home office is part of the structure of the main residence. "If it is a separate building," said David Gitel, a New York City tax accountant, "you are out of luck." When you work out of a detached garage or shed, you must compute the profit that is attributable to that structure and pay a capital gains tax of 15 percent on it, plus the tax on the depreciation recapture.

In that case, what you can do is make what is called a 1031 exchange. Don't do it without guidance from an accountant, but buy another piece of commercial property within 190 days and you can avoid paying taxes.

Given how complicated it is, many people might ask whether it is worth the bother to deduct a home office on Schedule C, the form for private businesses. Would it be easier to just write off most of the expenses as nonreimbursable business expenses on Schedule A?

You probably are deducting your interest payments and your property taxes on Schedule A anyway. The benefit to using Schedule C - you'll need two other forms, 8829 and 4562 - is that the mortgage, the taxes and other costs of running the home office decrease the income you made from your home-run business. That means there is less that is assessed the 15.3 percent self-employed Social Security tax. "You get more out of it on Schedule C," Mr. Gitel said.

But if you don't qualify for a home office, Schedule A is the place to deduct business expenses. A good tax accountant will make easy work of this. Tax software, like the Premier edition of TurboTax, can do it, too, and will also walk you through the process of depreciation recapture in a series of interview questions.

You can deduct other things if you have a home business. In addition to a share of utility bills, you can deduct an extra phone line, any business equipment you buy or the business use of the car.

You can hire your spouse as an employee and provide medical insurance. He or she puts you on her medical plan and your business swallows the cost as a business expense, reducing your taxable income. Retirement accounts for private businesses are also quite generous and another good way to shield income.

As for Mr. Sigal, he has a home office in his new condo. But this time he is cutting his taxes by deducting business expenses that were not reimbursed by his employer.

In Minnesota, when you sell, you're asked if you ever took the home office deduction. I'm told savvy people give the same answers as Judge Alito -- I can't recollect that.

I do like the bit about the spousal insurance though.