Conversation with a Health Care Leader: the past and future of health reform with Dr. Susan Rudd Bailey

Today we talked with Susan Rudd Bailey, MD who is the President of the nation's largest state medical society about the genesis of federal health reform and what she expects for the future.  This nationally known leader of the Texas Medical Association is candid in her discussion of the role that physicians and patients play in determining the ultimate outcome of the recent federal health regulation.  She also discusses the implications of the flawed funding mechanism for Medicare -- the so called "SGR".

Is Obamacare unconstitutional?

Is Obamacare unconstitutional?  That's the question we address today on docdano.com.  Darren Whitehurst and Dan Finch from the Texas Medical Association join us today to discuss the Virginia federal judge ruling that the health reform bill is unconstitutional.  What does it mean?  And what effect is it going to have on the upcoming session of Congress?

End of Life: What to expect, what it will cost, and what you can do about it

When anyone brings up the idea of end of life care, you are thrown a political football. Yet, the failure to have these discussions with your loved ones creates an expensive and emotional mess.

I can't tell you the number of times I've been sitting at a table with friends and this issue has surfaced with almost unanimous consent: they all want to die with minimal terminal intervention.

Then why do we spend the majority of our Medicare health care expenditures on end of life interventions?

The answer is probably one of political correctness and emotional attachment -- both of which can cloud the decision making process.

This is making the assumption that we could even make the right decision if we wanted to.

Case in point: my father.

Seven years ago when my father was 83 years old he casually asked me to feel a "knot in his belly" on one of my trips to his cattle ranch deep in central Texas.

And, even as a dermatologist, I could tell that he had a pulsatile mass about the size of a navel orange under that cutaneous organ by the same name.

And sure enough, after a trip to the VA medical center, a sonogram and a CT scan, we correctly determined that he had an abdominal aortic aneurysm. And, without intervention, it most certainly would be his death sentence.

So we talked.

I think this is the first of many steps in dealing with elderly parents and end of life decisions. He wanted to know how serious was the surgery, would there be a risk he would end up disabled in the nursing home, or would it change his lifestyle?

As an octogenarian rancher who feeds cows every day, drinks a pot of black coffee, and has smoked at least a half-a-pack of Winston's since WWII, these were certainly concerns.

So we made a decision: no surgery.

If it ruptured and he died an instantaneous death then that would be the way he would leave our world.

We took this opportunity to also discuss asset management of his household possessions, land, cattle, and bank accounts so that my mother would not be a bankrupt widow in the event of an end of life event for either of them.

Time passed and my father lived in constant fear that the rupture could come at any moment.

Fast forward two years: I was attending a medical meeting in Austin, Texas and my father calls at 7 a.m. This is not his normal routine so I was immediately concerned.

He quickly told me that he was having abdominal pain, pain in his legs, and was feeling dizzy. He was rupturing his aneurysm.

I told him to get in the car with my 80 year old mother and drive straight to Providence Hospital in Waco -- 90 miles away.

I was hoping I could temper the dangerous caravan of my mother's driving by calling ahead and warning the emergency room. Within 20 minutes of his arrival we had confirmed that he was dissecting his aneurysm and death or surgery was imminent.

So, we talked.

The doctor suggested surgery and since he had made it to the ER, I encouraged him that he needed to give it a try -- my mother was concerned about the cost. (She is very frugal).

So he had the surgery, was in the ICU for four hours, and checked out back to home in 5 days. That was five years ago.

Now my 90 year old father still feeds and takes care of the ranch, drinks a pot of black coffee every day, and yes, still smokes a half-a-pack of Winstons. Very happy, very productive. No other health complaints.

So did we make the right decision 7 years ago when we agreed not to pursue treatment?

To our family, it was the right decision at the time. So when people make statements that make it sound like end of life care is easy, they are dead wrong. It never is.

But, there are probably some lessons here that we can learn from.

First, you must have the "discussion." It is imperative that you talk to your parents or older loved ones early -- while they still have all of their faculties and can participate in the decision making process.

These discussions are never easy. But it puts the wishes and desires of the parent in concert with those of the siblings. My discussion was easy with my parents, and my sister and I get along so well that there was really no differences of opinion. But it doesn't always work out that way.

You most certainly should formalize a living will. This puts pen to paper and makes the end of life time event easier because there is less opportunity for confusion on what was decided during the "discussion."

And finally, everyone needs to consider the financial impact of any end of life decision. This time is almost always the most expensive health care experience for any patient.

It is not uncommon for spouses to be left bankrupt with years of bills to pay There is also the issue of sitters, home nursing, and medications that also can feed the final costs of someones life.

The government has gotten much stricter on families using their own assets to manage the end of life -- even if it will be detrimental to the surviving spouse. So don't think you can just "transfer assets" into your kids accounts and that will satisfy the requirements to get the nursing home expenses paid for by the state (Medicaid).

You should enlist the help of a knowledgable attorney on all of these end of life decisions. That information can go a long way to making it more understandable for all the parties involved and that the older person's wishes are maintained.

Unfortunately there is no book in the mainstream press on how to deal with elderly parents like we have with pregnancy (such as: What to Expect when You are Expecting).

So, everyone has to write their own conclusion.


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Location:Wolf Island, Galapagos, Ecuador

Texas Dermatology supports the National Psoriasis Walk

The Health Care Cold War: Will ACO's Bring Down The Wall?

Although there are no sounds of B-52's flying at low altitudes above the hospital, there are salvos nonetheless between the partners in health care as the positioning of providers in the ACO marketplace starts to crystallize.

ACO's, or accountable care organizations, are the product of one of the Obamacare beta solutions for controlling health care costs and improving outcomes.

My friend Dan Finch at the Texas Medical Association compared them to unicorns: no one's ever seen one but you'll recognize it when you do.

I'm not sure he's completely correct, there are a few of these organizations forming around the country. One in Chicago offers to produce great data on the utility of the delivery mechanism though the jury is still out on whether it will net positive results for patients.

These new entities can be formed really by anyone -- that is, anyone brave enough to pioneer the business model. The risks are great because of the capital requirements to protect the integrity of the captitated payment system which is really the heart of the organization.

Capitation is an ugly word in health care financing probably because of the almost unanimous negative consequences of the insurance models funded in this manner in the 90's.

Everyone then left with a bad taste in their mouth.

Insurance companies couldn't rein in physicians and hospitals to control costs and patients never bought into the model that prevented them from using a infinite amount of resources in their own health care.

So why would it be different now?

The argument is mostly supported not by the change in patient expectations or the robust IT infrastructure that we have in this century, but rather by the necessity to control costs. That argument unfortunately will drive the business principles that formulate these new organizations.

The definition of a "cold war" must include the word "protectionism." Certainly the world saw the escalation in missile batteries and nuclear warheads until Reagan was successful in "tearing down that wall."

But, pardon the reckless use of the 1988-presidential-debate line: Mr. Obama you are no Reagan.

Why am I so pessimistic these ACO's will find a place in this market space?

First is the lack of a unified national standard concerning our information technology infrastructure. There is currently no data sharing among providers outside of their own controlled groups (you can thank another federal stature for the difficulty here: read HIPPA).

And although a standard can be created and implemented, there is still the fact that many of the ground war health care practitioners (the primary care physicians) are still not active users of this technology. Current estimates put this at somewhere around 30% tops.

And with the cost of implementation of an electronic health record setup in a physician's office near $40K it will be some time before we see widespread adoption of EMR's.

Then there is the issue of exactly what we will measure to insure that quality care is being delivered. These so called "measures" of quality are still undergoing national debate and peer review. They're close to getting the numbers right. The question is whether physicians and patients will buy in.

And finally there is the nasty issue of "gain sharing." This is where you reward the parties for achieving the goals of delivering high quality care in an efficient manner.

Paying physicians is particularly difficult because of a myriad of other federal statues relating to anti-trust and kick back regulations.

Some groups, particularly hospitals, believe that the answer to this issue is direct employment of physicians. But this business model is challenging in that not only must a hospital control the diverse interests of a multi-specialty group of physicians, but it also has to morph the health care of individual patients to fit a cost savings model.

Both of these groups are not historically responsive to direction by a third party.

Then you have the difficult problem that hospitals are funded by actually admitting patients and providing care. In the ACO model the profits only come from keeping patient's healthy and OUT OF THE HOSPITAL.

Now sure, business models can change. But hospitals will have to recognize and be able to adapt to this change in a swift and controlled manner to insure that they remain profitable and can continue their mission.

Oh lest I forget one other very important party to the ACO equation: the people who pay for health care services.

Whether these ACO's are created as a hospital-based entity or along the traditional insurance model, at the end of the day both the government and American business expect to pay less for health care services in the future.

So for the ACO model to be successful it actually has to have a declining net revenue line.

It is this money line that has everyone so concerned and lining up to protect their own interests.

Hospitals are arguing for a hospital-centric model so they can control the dollar at the end of the day. Physicians are either jumping on board with the hospital groups or they are lobbying for measures to protect their private practice.

Patient groups are seeing that there could be limitations on both who they can see for care and where they can go. This loss of autonomy in the doctor-patient relationship will be very hard for most patients to swallow.

Insurance companies and business groups don't trust hospitals, physicians, or patients to work to control costs in the health care economy. So they are lobbying for strong protective measures to insure that ACO's don't get out of the normal reserve requirements to sell an insurance product.

ACO's hold the promise of ending the cold war.

If all of the parties could work together on a fair and balanced model that puts the patient first in the decision making process, it could offer an opportunity for success.

But for now all of the parties are building up their arms to protect their own interests, or they are being overwhelmed by a well funded adversary.

Virtually every hospital is "creating an ACO" and physician's practices are being gobbled up health care systems.

I applaud the idea of collaboration and use of IT to improve the health experience for patients. Today, though, I'm not too confident that the current attempt at tearing down the wall will work.


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Location:Quito, Ecuador

So is there any difference in education between U.S. and foreign trained physicians?

If you've ever wondered about the difference in training between foreign medical graduates and those from the U.S., check out this video blog.  Join docdano.com as we discuss the education of physicians both here and abroad with Dr. Caitriona Ryan from Dublin, Ireland who is now a resident in internal medicine in Dallas, Texas.

Disability Insurance: Difficult decision when you're bullet proof and broke

An interview with Jim Stevens about the importance of disability insurance.  You insure your car, your house, and life -- but do you ever think about insuring your future income potential.  Check out this discussion about the world of disability coverage and what you need to be on the look out for.

Doctors and Medicare Cuts

Just a quick note on a great article from the Washington Post on the impending Medicare cuts:


"Washington Post Article"


It fits in well with our blog posts this week,

Dan


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Location:Dallas, Texas

Is the government telling me if I can see my doctor?

Medicare was touted as the social entitlement program that would forever change health care access for our seniors.

But is it becoming the biggest challenge to seeing the doctor of your choice?

For the first time in the almost 50 years of the program more and more Medicare recipients are facing the challenge of finding a doctor who will take their government sponsored insurance.

Sure, there have recently been problems with the over 65 finding primary care physicians. But these PCP's can be hard for any insurance class of patient to find, though much harder for patients with plans that pay 40 percent of current market rates.

As you have seen from my recent blog posts, we are facing a rapidly approaching meltdown of our Medicare system. With no substantial reimbursement increases since 1997, an expanding older population, and medical costs that are outpacing the rate of growth of GDP, more and more physicians and other health care providers are exiting the market space.

But the current state of affairs is about more than money. A whole lot more.

You see money won't necessarily buy you access to your physician if you are a Medicare patient.

For most capitalist oriented folks this doesn't make sense. This land of milk and honey we call America was built on one's ability to buy anything -- including access. Whether it be to the halls of Congress or the waiting rooms of medical specialists, the rich (or even the middle class) in the United States have always been given the golden ticket for access if they could afford it.

But current Medicare rules don't allow for the normal business relationships that have built the rest of our economy.

This stems from the limited participating agreements that physicians are forced to agree with if they desire to see Medicare patients. And, for laws that restrict the payment of benefits to seniors if they see physicians that aren't a part of the Medicare program.

Physicians are really given only two choices if they want to get paid for seeing a Medicare patient. They can either agree to be "participating" where they are paid directly by the government for delivering care, or "non-participating" where they agree to see an over 65 patient but the payment is paid to the patient and the physician is then responsible for collecting the fee.

If a physician "opts out," that is, decides to not be a part of the program at all ("par" or "non-par"), then they can see a Medicare patient only if a complicated set of constantly renewed contracts are completed.

But here's the catch: the patient cannot receive any reimbursement from the government for the cost of the care.

That's right, as a Medicare patient you lose your benefits from the federal government entitlement program if you enter into a contract with a physician who is not part of the system. You won't even get reimbursed for what Medicare would have paid if the physician was a program provider.

Now honestly this has never been much of a problem: most physicians participated in the program and very few were "non-par", much less opted out. A big impediment to even testing the water of opting out has been the mandatory two year waiting period that physicians must survive before they are allowed to rejoin the system.

That was until the post-Obamacare age we live in now.

Funding the Medicare system has become laughable with a recurrent litany of temporary fixes that now provide only a month-to-month operating budget for the program.

It is this uncertainty combined with the decline in overall revenue that is driving physicians to opt out of the program and into the world of direct contracting.

Is it fair for the federal government to get a free ride on the backs of American seniors by no longer being responsible for providing health care dollars?

If you are an entitled Medicare recipient and you see a physician of your choosing who might not be a part of the system, why shouldn't you at least be able to get reimbursed for your out of pocket costs to the limits of the allowable Medicare charge?

So I guess the answer to the question is, that for now, the government is not "telling patients they can't see the doctor of their choice" but they are telling them that they aren't going to pay for it.

As we move forward into the Republican controlled Congress, and free market capitalism begins to rein supreme, we are almost certain to see challenges to the current status quo. Not only will patients begin to demand the right to see the physician of their choice, Republicans may see changes in the law as a way to limit growth of the program and curb the government's responsibility for cost increases.

Of course, with these rights patients risk a higher amount of out-of-pocket costs.

It's unclear if the political winds will blow to enhance the laws surrounding direct contracting -- loosening the restrictions on physicians from offering these deals and for patients electing to sign up -- but it is almost certain to be a part of the discussion very soon.

Follow this story as we chronicle the debate on www.docdano.com.


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Location:32,000 feet over Virginia, AA Flight 730

Should Medicare patients fear creeps

There has been considerable concern recently about the viability of physician's practices as they face a dramatic cut in reimbursement due to the need to slow the growth of health care spending.

No where is that more evident than with Medicare.

This last century era government administered health entitlement program now supplies medical coverage for a growing majority of American citizens. And the cost of this coverage is even exceeding its expected growth rate due to an ever aging and sicker population.

In typical bureaucratic fashion to legislate policy, Congress tied the cap on Medicare expenditures to the sustainable growth rate in an attempt to see that health care costs in the program did not exceed GDP (Gross Domestic Product).

This flawed calculation created in the Balanced Budget Act of 1997 has generally resulted in reimbursement rates to Medicare physicians that have not kept up with the real rate of medical inflation.

Yes, this last measure would have been a better metric to use in the calculation. But who knew in 1997.

Now we get to experience the implementation of this policy decades after the budget sensitive Congress of the 90's have mostly long gone. And the results aren't pretty.

Congress and physicians realized shortly after its passage that the SGR was a flawed system. Rather than solve the problem and change the way the Medicare system is funded, though, they have created temporary "fixes" virtually every year since its inception.

These "fixes" have only served to magnify and put off the eventual point where system implosion is expected to occur.

And that point may be here.

The latest physician hostage crisis of course occurred this year with an impending cut that threatened to throttle the rollout of Obamacare and the new federal health regulation. This fix expires on December 1st.

At that point physician reimbursement will be cut an arbitrary 23.6 percent with another 6.5 percent to follow on January 1.

So will the cut happen? (You can read my prior post: "Dear Santa: I want a Medicare fix")

But more importantly what will physicians do?

That is the question that is becoming more and more the topic of not only surgery lounges where physicians commiserate between cases but also the murmur outside the halls of medical meetings.

Certainly I've seen no organized conspiracy. But it is interesting that many physicians across the country are coming to the same conclusion: is it worth it to stay a part of the system.

Booklets and articles have been written about how physicians can leave the Medicare program. Even more concerning are the materials being produced for patients teaching them how to see non-Medicare participating physicians or even to form "direct contracts" with physicians so they can continue their care outside the system.

Historically and currently there doesn't appear to be a wholesale abandonment of Medicare participation. In my home state of Texas, unofficial numbers put the number of physicians that have resigned their Medicare number at less than 500.

But I don't see this as the real problem. I think more likely we are going to see something I like to call "creep."

Let me give you an example. Recently I was asked to provide some strategic review and planning for a practice in another state -- one with a large retired Medicare population. We prepared a detailed analysis of revenue and expense numbers as part of the consultation service, but the physician seemed to gravitate to one report more than the others.

It was a simple calculation that compared the payer mix of the practice based on the number of patient visits. The physician found that 59% of his office visits were Medicare, but that this group only provided 32% of his total revenue.

He became obsessed with the fact that most of his and his staffs work product was only generating a dwindling minority of his revenue. And without my well deserved consultant-paid-advice he reached his own conclusion that if he only made changes in his schedule and payer mix it could start to minimize his Medicare exposure, decrease his work schedule, and likely either see no change or a slight bump in his practice income.

That is the concern. Creep.

As physician practices get tired of the recurrent uncertainty about the future of Medicare payments, will they begin to find the solution may be to limit Medicare patients within their practice, that is to "creep" their schedules -- and not leave the system altogether?

This would have the effect of exaggerating an already access challenged Medicare population. And since we don't have good data on the clinic slots available to Medicare patients it will be difficult to measure the rate of creep until its too late.

Congress will take up the new fix soon, and conventional wisdom dictates that there will be another temporary solution to stabilize physician payments.

But will it satisfy a physician workforce that is tired of the recurrent stress of practice financial viability on an annual or now, even a monthly basis?

I guess we will get see it play out in the health care access of our Seniors.

Creepy.





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Location:Over El Paso, Texas courtesy of American Airlines

Dear Santa: I want a Medicare fix

Well it's that time of year again.

No, not Thanksgiving or Christmas, or even the venerable Interim Meeting of the AMA. It's the time that physicians nationwide anticipate another mandatory cut in Medicare reimbursement rates.

This time the recurrent temporary fix will result in a cut of 23.6 percent on December 1st. Assuming political gridlock the rate will fall another fraction of 6.5 percent on January 1.

History dictates that there will be lobbying, bluffing, puffing and even some "take my toys and go to my room" childish attitude but in the end Congress will create another "fix". In the past this has been to stabilize payment rates to a Victorian-era fee schedule (ok, 1997 or so) and set up an expiration schedule that again is measured in months.

But this year might be different. Or, at least it threatens to be.

American voters stampeded to the polls to vote out the status quo in favor of a new Republican House and a "lack of cloture" Democratically impotent Senate. Many of these new Republicans campaigned on the promise of fiscal responsibility (read: make the Bush tax cuts permanent and curb spending, including entitlement programs).

The Republicans have as a group pledged to cut $100 billion in January.

Now enter the AMA.

This association is again lobbying for a fix -- though now it is not the "permanent fix" but rather a tempered 13-month patch to give physicians at least a year to worry until the next SGR induced armageddon.

But will this new Congress support the AMA proposal? I don't think so.

Rumors abound to the cost of the AMA idea but it ranges between $17 billion to upwards of $20 billion. I'm certainly not an insider, but a new Republican congressman might find it challenging to explain to those tea party goers about why one of his first actions was to vote to support a double digit entitlement extension.

The other options are also mind stretching.

The lame duck Democratic controlled body could pass a 1 month extension and leave it up to the Republicans to spend the money in 2011. Or, they could use the pout strategy and just grind out the final month with the cut in place with Medicare physicians having to deal with a very arduous Christmas present.

So what will happen? It's anybody's guess but a likely outcome will be a compromise of sorts.

It would be fairly easy to disguise a three or four month fix as part of a January revenue bill to add some permanence to the Bush era tax cuts. This would of course create another type of March Madness, but it also would only cost a minuscule five or six billion. Chump change.

There is the issue of raising the debt ceiling that will have to survive a potential Senate filibuster by one of our new freshman Kentucky senators who will be calling for a balanced federal budget. This ophthalmologist turned tea drinker may not see eye to eye with adding more money to a spending bill -- even if it would be good for patients.

But no one said it would be easy.

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Location:37,000 feet over Arizona

So what is an accountable care organization?

Mortgage meltdown or medicine meltdown?

As we enter the final phases of the election cycle you can get a good idea of the spoils of big government just by looking at the rhetoric in the campaign.

Clearly, one issue is dominating the election this fall: the economy, and more specifically the lack of jobs.

So I would like to pose a few questions and ideas on just how government actually performs in creating economic growth and in kick starting job growth. I don't necessarily have the answers, but I'm real good at asking questions.

Did government assisted mortgages help the economy? Certainly by artificially lowering mortgage rates and the creation of investor owned, government back sub-prime mortgage equities, the federal system of assistance in home buying has become the norm.

But given the meltdown in the mortgage industry, did we do a service to Americans by putting people in homes they couldn't afford? Flipping houses became the source for a evening cable television show and the folly of many particularly young home buyers.

As liquidity in the mortgage market disappeared so did the dreams and savings of many Americans -- including those that had invested in the "government" back equities of Fannie Mae and Freddie Mac.

Is government funded healthcare going to be beneficial for our country in the long term? Just like mortgages, are we going to put our country into a health system they can't afford?

Out current federal health legislation creates "coverage" for 85% of our citizens, but does nothing to promote access to care or an improvement in health care choices.

The latter is particularly concerning.

Regardless of the life style choices one makes, there is a guarantee of coverage. There certainly needed to be an improvement in health care services for the uninsured, and there needed to be some limitations on the growth in spending, but wouldn't it have been better to put incentives on the user?

The real question becomes: will we be facing a health care meltdown just like the mortgage industry? As the requirements for health care services rise, there being no limitations on cost, and no impediments to limiting health care decisions, can the system continue to function?

The biggest concern here is whether physicians and other health care industry providers (pharmaceutical companies, insurance companies, hospitals) can continue to function in an economic environment of continued declining reimbursement for services.

This is especially true given the proposed 23%+ cut in Medicare rates next month with more to follow in January.

Will there be a decline in health care liquidity?

Physicians and other health care providers may find themselves in a situation much like the mortgage industry: servicing consumers with health care services they and the government really can't afford.

I guess the real question is will there be a foreclosure on your new sub-prime health coverage?



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Perry-Palin in 2012? Hillary Clinton in 2012?

As we enter the final weekend of this political season I thought I would take a few moments to suggest some possible scenarios for 2012 that will begin as soon as the last ballot is cast on Tuesday.

Here are some thoughts:

Perry-Palin 2012? Could this be the next Republican dream team? Before I get the laugh lines and hate mail let me make my point.

Both of these individuals have been or are Governors from large states with many similarities. Texas and Alaska have faired much better than their counterparts in the latest recession, have enjoyed a relatively friendly tax environment, have benefited from the increase in energy demand, and, lets face it, represent geographically about a third of the United States.

But more importantly both Rick and Sarah correctly identified early on the upswing of the Tea Party movement and latched on. I think this "movement", I don't really think it qualifies as a Party yet, has surprised almost everyone's expectations about its growth and popularity. I'm not sure where it will end up, but these two mavericks have been riding the wave into this election season.

Both have also been able to run as "non-incumbents". This has been easy for Palin (read: jobless), but despite the anti-incumbent rage sweeping the country, Perry has been able to be the outsider in the current Texas governor's race. He has successfully painted his opponent as being part of the "problem" by using his mediocre performance as Houston mayor as the whipping post.

Will I vote for this team? Not sure, but it will make for an interesting discussion as we move into next year and both are not running for President. Right.

Now think about this: Hillary Clinton the Democratic nominee? I know this sounds far fetched.

But think about it for a moment. Assuming President Obama is defeated in his bid for reelection, Hillary would face the risk of a four to eight year stint of being on the outside of a Republican administration. (And she would likely be too old to run at the end of an Obama second term.)

So what would happen (assuming the Democrats get trounced in the Congressional elections) if Clinton resigns her post as Secretary of State, moves back home, and now jobless -- turns into the Palin-type evangelist of change and returns to the Democratic principles that she campaigned on (and remember, almost won).

She could certainly make the argument that the wrong choice was made in selecting Obama and he has moved way outside the mandate for American that swept the D's into power.

If she could somehow manage to recreate the mid-term rehabilitated mode of her husband Bill during his first term (move slightly to the center, fiscal responsibility, make the country's problems those of the Republicans), she might offer hope to the Democratic Party.

Particularly if there isn't a valid Republican nominee (read #1).

Plus, what an exciting political season. We haven't had a sitting President with a primary challenge in a long time.

I know everyone just can't wait to start this circus all over again.


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Location:AA Flight 2324: somewhere over Illinois

The Smoking Gun

Ok, the latest gadget that I'm food fascinated with is The Smoking Gun from the folks at Polyscience.

As someone who is a student, read: kindergarten student, in the world of molecular gastronomy, I've been playing around with sous vide and other new age cooking techniques for quite some time.

But when one of my culinary friends mentioned that he had been able to dramatically alter the flavor profiles of common dishes just by adding in flavored smoke I was intrigued.

I mean, I live in Texas, so if there is one thing we know how to do its smoke meat. But what about food you really don't want to cook....just have that smoky flavor?

Like, for instance, raw oysters.

Recently I participated in a little gourmet food covered dish supper with one of my great friends Lelia Hamilton. For my contribution I made a smoked oyster shooter -- fresh gulf oyster that I had infused with cherry wood smoke from the Smoking Gun.

It was really, really good. I'm not a big fan of "smoked oysters", but a "smoked raw oyster" -- that was cool.

Anyway, although it has the potential to be one of these kitchen gadgets that becomes a one hit wonder, you might want to give this little jewel a chance.

Just think how impressed your wife would be if she uncovers an upside down cereal bowl filled with apple wood smoke plus macaroni and cheese. Just might be a new cult hit and wind you up on Food Network.


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Location:Magnolia Dr,Stephenville,United States

Texas Dermtoon: Why you shouldn't tan

Great story on why PowerPoints are bad and how to fix them from CNN

Why we hate PowerPoints -- and how to fix them

By Nancy Duarte, Special to CNN
STORY HIGHLIGHTS
Army officer fired after publishing essay complaining about useless PowerPoints
Nancy Duarte says bad presentations obscure or conceal key points
She says successful presentations don't win because of a wealth of data
Duarte: What makes a PowerPoint work is great storytelling

Editor's note: Nancy Duarte is the author of "Resonate: Present Visual Stories that Transform Audiences." She is CEO of Duarte Design, a presentation design firm based in Mountain View, California, that worked with Al Gore on the presentation featured in "An Inconvenient Truth" and whose clients include Cisco, Facebook, Google, TED and the World Bank.

(CNN) -- A few weeks ago Col. Lawrence Sellin, a Special Forces officer stationed in Afghanistan, fell victim to a particularly modern hazard of war: PowerPoint fatigue.

Col. Sellin was fired from his post at NATO's International Security Assistance Force after he wrote an essay for the UPI wire service in which he voiced his frustration about PowerPoint-obsessed officers who spend more time worrying about font size and bullet points than actual bullets.

Col. Sellin's was just the latest in a series of complaints about the military use of slide presentations -- you may recall public ridicule of the famously incomprehensible "spaghetti slide," and a recent New York Times article, that cited other officers just as frustrated with the emergence of the military bureaucracy's "PowerPoint rangers."

But PowerPoint isn't inherently bad -- just misunderstood. And bad PowerPoint presentations aren't just a concern of the military. We've all sat through presentations -- or suffered or even dozed through them. The truth is, most are poorly constructed and instantly forgettable.

Why does this matter? Because presentations decide elections, military strategies and multibillion-dollar business deals; they educate our children and they spread the ideas that shape society's most important goals and directives.

Ultimately, a presentation succeeds or fails on the strength of its message and how well it's told. And those elements have nothing to do with the brand of the software package involved in its production. You know instantly when you're watching a great presenter at work -- you may even own the ShamWow to prove it.

Sometimes, presenters try to punch up weak content with stunts. I remember one speaker who rode onto the stage on a motorcycle -- and promptly lost control and crashed. (He was okay.) Another presenter rappelled down to the stage like a mountain climber. I remember the stunts, but not the messages.

Poor presentations can have disastrous consequences. Edward Tufte, perhaps the most important writer on the display of information, demonstrated how the disintegration of the space shuttle Columbia in 2003 might have been averted by a more objective presentation of the damage inflicted on Columbia's wing by a piece of foam debris during takeoff.

As it was, Tufte wrote in his article, "PowerPoint Does Rocket Science: Assessing the Quality and Credibility of Technical Reports," NASA officials came away from PowerPoint-driven briefings by Boeing engineers with an overly optimistic view of the situation, in part as a result of hard-to-understand slides overloaded with bullet points. In other words, a bad presentation may have caused that disaster, and a good one might have prevented it.

Of course, we can't be naive: a persuasive presentation isn't necessarily a good presentation. In 2001, Enron Corp. executives Ken Lay, Jeff Skilling and Richard Causey presented PowerPoint slides at an employee meeting that winningly depicted the company's robust health and the bright future of its projected earnings. By the end of that year the company was worthless. Eventually, the U.S. Department of Justice charged those executives with 10 counts of a variety of crimes -- based on their presentations.

Meanwhile, the Enron scandal may have been preventable by the right presentation. In 1999, a presentation by the Arthur Andersen accounting firm feebly warned the Enron Board of Director's audit committee of the company's sketchy accounting. Had that presentation sounded a bold warning, the audit committee might have been able to save the company. For that matter, it might have saved Andersen, which did not recover from its role in Enron's dealings.

Unfortunately, the development of presentations is a skill that is rarely taught and for which few sources of best practices exist. Bad presentations kill ideas, waste money and impede progress. Great ones illuminate, persuade, generate consensus and spark action.

How do you create a great presentation? I've been in the business for 20 years, but until recently even I couldn't define the deep structures and elements of truly superior presentations.

My research into this question led me in unexpected directions. The answers I found had nothing to do with technology or the internet; they were revealed in screenwriting, Greek and Shakespearean drama, mythology and literature.

Great presenters employ the basic narrative techniques used throughout history to connect with audiences and move them to action and new understanding.

The presentations that work are not the ones with the most data or the most elaborate charts and graphs; the winners are those with the most compelling and convincing narratives.

We're a distracted, multi-tasking society. So presentations need to lure and re-lure an audience simply to keep their attention. Audiences are looking at the clock or fiddling with their handheld devices throughout a presentation. You don't connect with your audience by throwing information at them -- you do it by taking them on a journey toward your perspective.

Whether you're a CEO, a salesperson, a general or a biochemist, you must understand how to connect with an audience, how to construct a powerful narrative argument, and how to visually display information for maximum audience comprehension.

I read recently that our nation is suffering a crisis of literacy, with only 35% percent of high school seniors able to read proficiently. Yes, you read that correctly (assuming you're not part of the 65% of high school seniors.) But literacy really means the ability to communicate effectively. For professionals and citizens in every strata of society, true literacy now includes the ability to communicate effectively through presentations.

The stakes could not be higher for our country. If corporate executives communicate poorly, businesses and the economy suffer, and jobs are lost. If teachers communicate poorly, our children don't learn and advance. If generals communicate poorly, our troops and their missions are put at risk. These are dangers we cannot ignore.

The opinions expressed in this commentary are solely those of Nancy Duarte.



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Location:Barton Springs Rd, Austin, United States

Is Obamacare in critical condition?

Check out this CNBC video from the Kudlow Report asking the question: is Obamacare heading for a repeal?

Do we have an end to "value investing"?

As someone who likes to study stocks and investments, I have always considered myself a "value investor."

Probably from reading Warren Buffett's books in college and being the nerdy type who actually enjoy's reading The Valueline Investment Survey, it always made sense to me to invest in companies with growth in earnings or same store sales with good fundamentals.

And, it's difficult to argue with this logic. I mean, why wouldn't solid companies that make money be good investments?

If you look at the recent history of the stock market (over the last 15 years or so) you start to see a change in the way stocks are traded that seems to erode this value logic. Although there has been general growth in the number of dollars invested overall, the amount in straight equities has been relatively stable.

So where is this extra investment?

Options.

There has been an explosion in the both the number of option contracts -- everything from the typical stock and futures, but also on positions like the index markers. So what does this have to do with "value investing"?

Well options of course give you the right but not the obligation to purchase stock at a set price within a given time. They are extremely sensitive to both the underlying stock (or index or future) price and also the time value (that is, the time until expiration of the contract).

By their very nature they are a short term investment. I know, I know, there are LEAPs and other issues where this isn't true, but far and away the majority of option contracts terminate in the short run.

To me at least, this has given the stock market a different flavor and bias in investing your hard earned cash. There is now a tremendous number of dollars being invested in short term price movements -- and therefore away from the long term positions of holding the stock.

Now, technically, if someone was going to purchase an option wouldn't there have to be a willing seller that "owned" the stock?

Well not so fast. Now comes leverage. Most of the time that option contract you purchase is from someone who doesn't own the stock -- instead using their margin account to promise you they will deliver if if you decide to exercise.

Options aren't the only reason I think value investing has tamed a bit. The other is "robo-trading". Or as one of my friends put it: "to be robbed trading."

You only have to look at the recent report concerning the "Flash Crash" that the stock market had in May and you can see the effect that one broker and one trade had in drying up the liquidity in multiple markets with a computer based trade algorithm. The result was millions of dollars of loss in a single afternoon.

These computer exercised trades open and close positions in milliseconds -- a far cry from working out your trade at night with a pencil and a copy of Valueline on end of day trading numbers.

So for me, both options and robots have changed the way I see investing.

No, I haven't cancelled Valueline (although I read it on the computer now), but I have spent time educating myself on option contracts and how they can be used to my advantage. And I have changed brokers (after a decade) to one with a more sophisticated trade screen with Level II quotes (its free now) so I get to see these short term price movements.

I've also come to believe that my previous thoughts that technical analysis was voodoo were wrong.

Unfortunately when all investors are at least to some extent lemmings, and more and more institutional investing is short term and therefore based on technical indicators, we small timers have to be able to read a chart too.

If for no other reason than to determine market entry and exit timing.

I still don't think pure technical indicators are a reason to buy a stock (I don't care how much price change there is in an insolvent company), but I think they do play a role in the overall gain or loss of an investment.

So for me, pure "value investing" is over. I think I've come to terms that there has to be a good blend between both long and short term investments.

I know that Charlie Munger and the folks at Berkshire Hathaway may disagree with me (and they are a lot smarter), but in this economy I think expecting to hold an investment for three to five years has to carry some inherent risk that the companies market share will change or there will be a decline in the fundamentals.

So the question now is, do you lower or exaggerate the risk by blending in some short term positions?

I don't know the answer. Ask me in again in 5 years.


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Location:Caruth Haven Ln,Dallas,United States

Obamacare - You want fries with that?

A recent article in the Wall Street Journal and the followup editorial concerning McDonald's decision to consider ending health care coverage for its work force has sparked controversy.

But it is a very compelling message.

Obamacare, or more correctly, the new federal health legislation passed in the spring by the Democratic Congress, promised to "keep your current health coverage intact."

But as the law goes into effect, it is confirming what we pundits have been screaming from the beginning: it will impact everyone in America.

Read: everyone. From the uninsured (which hopefully will see expanded coverage but still be challenged with with limited access) to tax payers to small business and yes, to physicians, everyone will see an impact.

And it will vary from the potential double digit increases on private indemnity insurance for those 25 year old new entrepreneurs to the seemingly bizarre requirement that small business owners will now have to issue thousands of additional 1099 forms to virtually every vendor they purchase products or services from.

So for McDonald's to be considering eliminating health care coverage may not come as a surprise. Now before my faithful readers start sending me emails about "how these were minimum benefit plans" and "these workers deserve better care," let me preempt you.

McDonald's offers ground level employment for thousands of young people -- and many part time workers. So for them to be offering any health care benefits to begin with was extraordinary.

And now to have them being forced to either enrich the plan with added benefits and cost, or abandon their current entry level health benefit structure is an example of how they too will be impacted by the legislation.

But for all the bad that has been said about the federal health regulations, the most chilling concern that I have is that at the end of the day despite the super-sized money and new statues that have been created -- we may not see an improvement in the access and quality of care.

There is no value meal here.

The dangers of unqualified people doing aesthetic fillers

Facial filler foul-ups thwart patients' quest for youth
Dubbed "liquid facelifts" by fans, dermal facial fillers offer the promise of renewed youth, but also the chance of complications. Though side effects are rare, they do happen, leaving some patients with lumps, redness and scarring that looks worse than before.

http://www.msnbc.msn.com/id/39333030/from/toolbar


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Everything is Bigger in Texas

Visit msnbc.com for breaking news, world news, and news about the economy

The new Texas Medical Association iPhone app

Why men are happier

My wonderful sister sent this to Kristen, who shared it with me. I think there's a lot of truth to it. I hope you enjoy it as much as I did.

Dan


WHY MEN ARE NEVER DEPRESSED:



Men Are Just Happier People-- What do you expect from such simple creatures? Your last name stays put. The garage is all yours. Wedding plans take care of themselves. Chocolate is just another snack. You can be President. You can never be pregnant. You can wear a white T-shirt to a water park. You can wear NO shirt to a water park. Car mechanics tell you the truth. The world is your urinal. You never have to drive to another gas station restroom because this one is just too icky. You don't have to stop and think of which way to turn a nut on a bolt. Same work, more pay. Wrinkles add character. Wedding dress $5000. Tux rental-$100. People never stare at your chest when you're talking to them. New shoes don't cut, blister, or mangle your feet.

One mood all the time.

Phone conversations are over in 30 seconds flat. You know stuff about tanks. A five-day vacation requires only one suitcase. You can open all your own jars. You get extra credit for the slightest act of thoughtfulness. If someone forgets to invite you, he or she can still be your friend.

Your underwear is $8.95 for a three-pack. Three pairs of shoes are more than enough. You almost never have strap problems in public. You are unable to see wrinkles in your clothes.. Everything on your face stays its original color. The same hairstyle lasts for years, maybe decades. You only have to shave your face and neck.

You can play with toys all your life. One wallet and one pair of shoes -- one color for all seasons. You can wear shorts no matter how your legs look. You can 'do' your nails with a pocket knife. You have freedom of choice concerning growing a mustache.

You can do Christmas shopping for 25 relatives on December 24 in 25 minutes.

No wonder men are happier.

Send this to the women who can handle it and to the men who will enjoy reading it




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Location:Caruth Haven Ln,Dallas,United States

My interview with Dr. Michael Burgess, Congressman from Texas, on some provisions of the new federal health plan

When to keep your mouth closed

I spent an enjoyable evening with my good friend Linda Timmerman who related a nice story from her recent vacation to Las Vegas.

As many of you know, Linda's husband David is a world class choir director who recently retired to his mansion on the lake and a tool shed that would rival The Home Depot.

But what you probably don't know was that David was Terry Fator's vocal coach many years ago when Terry was in high school. This was way before he won America's Got Talent and rocketed to stardom.

Fator, now the star Las Vegas act attracting thousands of people and millions of dollars to the Mirage Casino, has signed at least a $100 million contract for another five years of ventriloquism impersonations with his classy puppets.

David and Linda were guests of Fator at the Mirage and were spotted by the puppet paparazzi as they left the glitzy casino steakhouse. When David was asked how it felt to be the vocal coach of the now millionaire puppet star, David in his quite demeanor just said, "It wasn't me...I always told him to sing with his mouth open!"

I guess Fator put his money where his mouth was.




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Location:Dallas, Texas

Weight loss and pride in your employees

Few people know how important obesity is in the disease states that are regularly treated at Texas Dermatology.

Psoriasis is a big focus in our practice. And Alan Menter's landmark work on metabolic syndrome and this disease has really brought the concept of diet and exercise to the forefront of global treatment for our patients.

So enter Medifast.

Medifast is not a new diet having been around for years with thousands of patients and physicians utilizing it for weight control When we were deciding on an idea for weight management in our patients, Medifast was a logical consideration.

Medifast is a "meal replacement" type diet. Basically you are provided five small meal substitutes and you combine this with one "normal" meal per day. This is recommended to be a lean protein and several servings of green vegetables.

We hit on a plan to have several of us give the program a trial. We anticipated about five chubby guinea pigs would be in our first cohort. Since I was the instigator, of course I volunteered. Cynthia Trickett our beloved PA (who happens to be a Major in the Air Force Reserve - yes, we are proud of her!) was appointed to be our Medical Officer to supervise our weight loss.

Now this is where it gets interesting.

When we made our adventure public, there was tremendous interest from our employees asking if they could participate. So much interest, that we decided what a cool employee benefit this would be if Texas Dermatology would provide most of the cost of participation. And we did.

And now? To date 22 people will begin the Medifast program in the next week or so.

I am so proud of our employees for their enthusiastic interest in health and weight loss. We are not having a contest, but we are going to go through the process together to see how this program might benefit our patients.

I will keep you posted in future blogs.

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Location:Drane Place, Corsicana, United States

Bullets and Bull

These quotes and comments were shared to me by Russell Cravey, MD, and ophthalmologist from Kerrville, Texas. They are attributed to Clint Smith the director of Thunder Ranch, a weapons training facility in Oregon. I thought they were too humorous and entertaining to pass up.

Clint is part drill instructor and part stand up comic. Here are a few of his observations on tactics, firearms, self defense and life as we know it in the
civilized world:

"The handgun would not be my choice of weapon if I knew I was
going to a fight....I'd choose a rifle, a shotgun, an RPG or an atomic
bomb instead."

"The two most important rules in a gunfight are: always cheat
and always win."

"Every time I teach a class, I discover I don't know something."

"Don't forget, incoming fire has the right of way."

"Make your attacker advance through a wall of bullets. I may get killed with my own gun, but he's gonna have to beat me to death with it, cause it's going to be empty."

"If you're not shootin', you should be loadin'. If you're not loadin, you should be movin', if you're not movin', someone's gonna cut your head off and put it on a stick."

"When you reload in low light encounters, don't put your flashlight in your back pocket.. If you light yourself up, you'll look like an angel or the tooth fairy...and you're gonna be one of 'em pretty
soon."

"Do something. It may be wrong, but do something."

"Nothing adds a little class to a sniper course like a babe in a Ghilliesuit."

"Shoot what's available, as long as it's available, until something else becomes available."

"If you carry a gun, people will call you paranoid. That's ridiculous.. If I have a gun, what in the hell do I have to be paranoid for?"

"Don't shoot fast, shoot good."

"You can say 'stop' or 'alto' or use any other word you think will work but I've found that a large bore muzzle pointed at someone's head is pretty much the universal language."

"You have the rest of your life to solve your problems. How long you live depends on how well you do it."

"You cannot save the planet. You may be able to save yourself and your family."

"Thunder Ranch will be here as long as you'll have us or until someone makes us go away and either way it will be exciting."

More Excellent Gun Wisdom....... The purpose of fighting is to Win. There is no possible victory in defense. The sword is more important than the shield, and skill is more important than either. The
final weapon is the brain. All else is supplemental.

1. Don't pick a fight with an old man. If he is too old to fight, he'll just kill you.

2. If you find yourself in a fair fight, your tactics suck.

3. I carry a gun cause a cop is too heavy.

4. When seconds count, the cops are just minutes away.

5. A reporter did a human-interest piece on the Texas Rangers.
The reporter recognized the Colt Model 1911 the Ranger was carrying and asked him 'Why do you carry a 45?' The Ranger responded, 'Because they
don't make a 46.'

6. An armed man will kill an unarmed man with monotonous regularity.

7. The old sheriff was attending an awards dinner when a lady commented on his wearing his sidearm. 'Sheriff, I see you have your pistol. Are you expecting trouble?' 'No ma'am. If I were expecting trouble, I would have brought my rifle.'

8. Beware the man who only has one gun. He probably knows how to use it!

Thanks Russell for sending these to me.

Sauerkraut and Pig's Eyes

Last night Kristen and I had a great dinner with friends Caleb and MaRisha Gidcumb. Caleb as you remember from prior posts is my helicopter instructor.

MaRisha made a wonderful dinner, but one dish stood out: sauerkraut and meatballs. Ok, ok I know this sounds weird and different. Plus, there was no spaghetti involved.

The recipe went something like this:

2 pounds ground beef
1 egg
1 package of onion soup mix

1 can of sauerkraut
1 can of cranberry sauce
1/4 cup of water

Make the meatballs out of the first list, place in a dish, and cover with the second list. Bake at 300 degrees for 2 hours.

This was absolutely fantastic. Sweet and savory and the perfect evening meal. MaRisha complimented it with green beans, yams, smashed potatoes, and chicken and dumplings.

Caleb said that his dad referred to this as "pigs eyes". I've never had pigs eyes, but if it tasted something like this, I'm all in. Particularly if MaRisha is cooking!





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Location:W 15th St,Austin,United States

Life in Hawaii

Part of exploring new locations in the world is to experience life. Travel is certainly a entertaining way to pass the time. But ultimately it is the life experiences that happen when you see and touch new places that make that indelible imprint on your frontal lobe.

This week has been no exception.

Hawaii is a great example of how life and destruction coexist to form some type of harmony.

As I mentioned in an earlier blog, Monday night we made our trek to see the manta rays. Though not a normal event in nature, the mantas have adapted to participate in the human interaction by the coaxing of local tour guides.

Over the years, local operators have suspended large halogen lights either pointed from the surface or from the bottom to form a cone of light that attracts plankton. These microscopic life forms form a swarm in the light stream that the mantas enjoy by making one circle after another as they devour the small food particles.

We on the other hand get to watch the show. From our snorkel pose the 7 to 14 foot creatures fly by within inches -- even occasionally batting you with a smooth fin.

It's an amazing experience and the kids enjoyed the proximity and the beauty of these animals. One female was entangled in a fish hook and float which was removed by one of the guides with a pair of scissors.

Now compare this with the other side of the Big Island. Though only a couple hours drive away along Highway 19, it seems like its a different planet. The green landscape in contrast to the Mars-like lava flow of Kona is abruptly interrupted by the 13,000 foot Mauna Loa volcano.

Still active and belching smoke, though no lava this trip from the report of Kristen and Will's 2-mile hike to find it.

Sulfur infused air, the warm earth, the steam vents, the devastation placed on the roads and houses defines the enormous power of our earth. Processes that clearly we don't completely understand.

But in this black graveyard of molten rock and glass you still find life.

There are plants and animals that somehow manage to carve out an new existence in the wake of this volcano And even people rebuild their houses, albeit in a different environment from months before.

They first must carve a road to their final property line, rebuild the house or structure, and learn to live without running water or electricity. From hauling in water to large cisterns to windmills to harvest the constant southerly breeze, they manage to reform their lives.

So whether it's several miles below the surface of the water or several miles above, Hawaii and the Big Island define the coexistence of life and death. And somehow what is created is both magical and beautiful.


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Location:Big Island, Hawaii

Food on the Big Island -- From Miso to DQ

I have always been blessed with kids who enjoy one trait from their father-- the interest and joy in trying new foods.

Cathryn is clearly the one I can talk into the easiest, but Will too will join the rest of us as we take a culinary journey.

So what have we found this trip:

1) Japanese Breakfast -- Hawaii is a frequent vacation spot for the Japanese. Probably a combination of the American dollar and the convenience of air travel, there are abundant Asian cultures at the hotel. To cater to these guests, the food provides some comfort. This includes rice, fermented soy beans, fresh fish, and Miso soup for breakfast. Cat has taken aggressively to this offering and for the past week has not passed up the Miso and rice for her morning staple. I hope I can make this at home for her!

2) Organic produce and meat in Waimea -- Last night we had the privilege of dining in one of the island's best restaurants. In the small village of Waimea, a town of 10,000 situated in the shadow of Mauna Kei, we stopped with for an early meal at Merriman's.

We were dressed in upscale volcano gear, but they didn't seem to mind as we were seated in the dining room inches away from the herb garden. Many people think this is the most beautiful area of the Big Island and the most desirable to live.

Located on the area of the Parker Ranch, it is lush with green as you look over the mountains in one direction and the ocean in another. This is not a beach town by any sort. It is more of a mountain village and the cool breeze at 3500 feet elevation convinces you of that.

The food was mostly local ingredients. From fresh bread with strawberry jam and goat cheese, to a salad with all local produce (beets, radishes, lettuce, and much more but Kristen didn't offer a sample), to beef and lamb that were all delightful.

Will and I especially enjoyed the locally made and smoked bacon. Bacon as an appetizer -- my kind of place that will serve a pork product as an appetizer. Wow.

3) Sushi -- We were able to find a reservation at Norio's, one of the local sushi haunts. We were all amazed. Cathryn had Miso-marinated Butterfish (see a trend here?), Will a tempura of lobster and shrimp, and Kristen and I multiple courses of raw fish. The kids enjoyed their fair share of sushi and I'm proud of both of them for learning to eat this wonderful fresh cuisine.

4) Fresh Hawaiian Bread -- Sweet by nature, this bread is at every store. One of our most refreshing meals was pre-snorkel snack of an impromptu fold over with this bread, meat and cheese.

5) The Loco Moco -- We have been blessed this week by having breakfast at the hotel every morning. This was included in our hotel stay and is a big plus. The buffet changes daily so there's really no excuse for going away hungry.

Every day it seems Will and I find our way to the omelet station. Here a one-armed man cooks omelets and eggs to order for the hundreds of guests that pass through here every day. Friendly, excited about his job, conversational, and amazing in his ability to flip skillets and make eggs with one arm, we have developed a quick relationship as we both stand in line with him every morning.

Today he talked us both into having the Hawaiian Loco Moco -- a cup of rice topped with a hamburger patty, soft egg, and turkey gravy. Initially I thought it might be island version of Candid Camera, but the dish was quite good. The egg yolk mixing with the gravy and rice made the dish. And, I mean, is anything not good if it has gravy on it?

6) Dairy Queen -- After the manta snorkel trip, we were famished (all but Kristen) so we stopped at a familiar southern eatery. I think we were surprised when we didn't find a single Hungerbuster or BeltBuster on the menu -- only hot dogs! Hawaiians love their hot dogs. That is clearly the hamburger of this culture. So when in Rome, we enjoyed them too.

7) Kona coffee and ice cream -- Kona coffee just taste better. Its not as bitter as most coffee, and it has a warm soothing effect as it goes down in the morning. Its very easy to have too much of this black elixir and stay wired for hours.

I guess that's why they invented Kona coffee ice cream.

For a bedtime treat of course.


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Location:Kona and Waimea, Big Island, Hawaii

Children and Fish: first impressions

We had a remarkable day yesterday. Will and Cathryn, outfitted in snorkel gear, joined me for their first real exploration of an active reef.

Sure, they've snorkeled in Galveston, the lake, and even at Balmorrhea. But its that first experience of seeing ocean fish in a pristine environment that can be a little breathtaking. And it was. Including for me.

We finned out about 100 yards or so, Cat holding my hand at first, until we found our first reef. There we saw all the reef regulars from Sergeant Majors, Yellow Tailed Snapper, and multiple angel fish of all varieties.

We even stumbled upon an eel. It was challenging to tell who had the biggest eyes -- Cat or the eel. He (or she, I couldn't tell) was a menacing looking creature. Mouth open reaching out of his cave. When you first encounter a new sea animal for the first time there is a sense of nervous interest on both parties. We were able to engage this animal long enough that I think Cat won't be so surprised next time.

We were able to get close to several types of puffer fish and a giant Porcupine Fish that we followed for at least a 100 feet or so until he turned around and looked with those plate size eyes questioning our persistence.

We also were able to find the Hawaiian state fish: humuhumunukunukuaupa'a. From diving here before I new it would be easier to find than to pronounce. This beautiful fish is plentiful in coastal waters, is friendly, and typifies the beauty that is Hawaii. It is multicolored with a broad black throat and shimmering scales.

Just beyond the reef there is open water, and in this area it is somewhere around 10,000 feet deep, so we began our turn back. Immediately both Will and Cat developed the seizure stroke that divers usually take on when they see something exciting or unnerving.

Fleeting views at first, it then came into view: a giant sea turtle. We were able to find another one closer to the reef happily munching on sea grass. This area of Kona is know to divers as an area filled with "cleaning stations". These are bizarre and fascinating areas where turtles come to be "cleaned" of parasitic debris by reef fish.

Hovering over the turtle at about 4 feet or so, you enjoy the magnificence that is the ocean. The turtle I'm sure had encountered a human before, but both Cat and Will were wide eyed in awe at this beautiful green creature. It only takes one experience like this to understand the need to protect these animals.

Today was a preview and Kristen and I wanted to get our kid's feet wet with diving in the ocean and experiencing animals in their world.

Tonight we are taking them on a manta ray dive. One of the few places in the world where you can be close and see these animals is Kona. Kristen and I scuba dived this area on our last trip where I had the infamous head butt by a 20 foot Manta sitting on the bottom with a lamp on top of my mask.

We won't do that today, but I'm hoping that Will and Cat can get their first impression of these fine animals. They are large, beautiful, and truly magical as they circle the depths looking for plankton.

More to follow.

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Location:N Kaniku Dr,South Kohala,United States

Texnology? -- Technology at Texas Dermatology

Technology invades our lives and our medical practice at Texas Dermatology is no exception. Over the last two years we have been on an aggressive campaign to upgrade our practice to include replacing virtually all of our hardware to create a paperless clinical environment.

We use a "cloud based" web software environment to handle all aspects of the clinical encounter from scheduling, checking on insurance eligibility, recording information in an electronic health record, and billing. It surprises many patients to learn that we use data centers all over the world to help us sort and keep track of clinical information. This allows us to rapidly, securely, and accurately file the thousands of pieces of data that are received by our practice every day.

One of the things I'm most proud of is our electronic prescribing rate. We only hand write a handful of prescriptions every month. Instead we send prescriptions to pharmacies directly which allows for patient convenience (its usually ready when they drive to pick it up!) and safety because we can cross check medications against both allergies and potential drug interactions. Refills are also automated and usually have a turn around time of less than an hour after the patient calls the pharmacy during business hours.

We hope that by the end of the year we will have a patient portal active which will allow patients access to some of their account and clinical information, scheduling, and even to submit and receive answers to their health questions.

So what would be the logical next step? A television studio of course.

Yes, its hard to believe but we have just completed construction of a state of the art broadcast studio in our Dallas office. Located in the "green room", we have lights, cameras, and action! We wouldn't have been able to do this project without the great folks at Dallas-based VideoTech and video genius Daryl Newman. He outfitted us with microphones, two broadcast quality cameras, and multiple cool LED lights -- as well as a some instruction!

But the heart of the system is a device from the San Antonio company NewTech. Its called a Tricaster and is sold as a "studio in a box" and that probably describes it well. We are able to mix multiple video inputs, internet feeds from remote broadcasts like Skype, and even local DVD video to make really cool live or recorded productions.

But probably the most exciting thing the device can do is to create "virtual sets". This is where we can use computer generated graphics to change the look and feel of the studio from a news room type environment to an auditorium for a PowerPoint presentation.

Why did we do this? We think it will add to the mission of our practice in communicating information to our patients and to that of our educational program and residency program.

Stay tuned to our website -- www.texasderm.com -- for more details as the project unfolds.


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Location:Kona, HI

Blogging from the AMA Meeting

I will try to post a few comments from the American Medical Association meeting this weekend in Chicago. So far, not too much excitement. I was either hoping for a little more lively discussion given the debacle surrounding federal health reform. That's not been the issue so far. But you never know with the AMA House of Delegates -- sometimes there are explosions on the floor. More to follow and big thanks to John Dorman from TMA for letting me use his Bluetooth iPad keyboard. Really cool.

Insanely Cool Presentations by taking a look at Steve Jobs

I thought this slide video on the presentation skills of Steve Jobs was just way cool. Please let me know what you think:

Federal Health Reform - Telling Our Story

This is the presentation I've been giving across the state concerning information in the new federal health reform legislation and the importance of telling our story through social media.

Lily going after a bone

Helicopter Flight over New York City

Fredricksburg Flowers from Wildseed Farms

Check out this video of the flower photos from our visit today to Fredricksburg's Wildseed Farm:

Create your own video slideshow at animoto.com.

Trip through Central Park on a trash can lid

Evernote is ever useful

Constantly in search of the latest and greatest iPhone ap, I am surprised at how useful I have found Evernote.

When you find yourself living in a world where keeping track of random thoughts is necessary -- Word documents, photographs, or in fact, any item that streams across your mind -- Evernote fits the bill.

My computer documents folder had become a trash can. With papers stuck in virtually hundreds of folders and the search function limited to folder names only, Evernote allows you to create files that can be searched inside and out.

Let's see an example:

Now being challenged with creating new ideas for our "ready to be launched" video blog (MyDermGuy), I am focusing on archiving any tidbit of data that might be useful for the blog. So I was wandering around Central Market with Kristen picking up a late evening dinner-to-go when I ran across the bath salts aisle. Now Central Market is known for bulk sales. You can buy bulk coffee, candy, honey, and yes, even bath salts. So I thought "What about a video blog on the pros and cons of using bath salts?".

I remembered Evernote. I whipped out my iPhone, took a photograph of the bath salt display, and continued on my way. (You know, now that I think about it, it did appear that people were wondering why I was photographing bath salts. )

This is where the the Evernote magic begins. It will take my photograph, put it in my virtual cloud file where I can retrieve it either from my laptop or my iPhone, AND make it where I can search for it! Yes, yes...you can add "tags". But what a pain. Evernote will use OCR technology to search the upload for any text and allow THAT to be searched. So, in my picture of bath salts it found the words "bath salts" and made it part of the information.

Next time I work on a blog post all I have to remember is "bath" and it will find my photo for me.

As a plus it will also geotag the photos. This means that if I can't remember what great idea I had at Central Market, all I have to do is find the store on the map and it will link me to all the Evernotes I have archived from that location.

This is only one example. I can send emails from my computer with travel information, take photographs of restaurant menus (yes, the OCR makes these searchable), upload PDF files, and bookmark websites for later study.

I can recommend this product without reservation. The trial version is free, and the premium upgrade is only $45 per year.

Would Twitter improve patient compliance?

Would a social networking notification remind you to wear sunscreen?

That was the thought I pondered today when a patient told me he would comply with a cancer prevention regimen if someone would just remind him.

Last year my partner Alan Menter and I co-authored an article on patient compliance or "adherence" as the word in the trade is called. To be frank, the more complicated the regimen of treatment, the poorer the compliance from the patient.

And what a complicated world we live in. I mean, all I ask is for patients to wear sunscreen. I can only imagine the challenge of following a low cholesterol, low fat, low carb, low taste diet.

So enter Twitter.

Just how successful would a daily reminder from your doctor about the benefits of compliance have on your choices? It would go something like this: (note: I didn't verify that this is less than 140 characters...but you get the point) "Eating granola today can lower your cholesterol http://bit.ly/bMzZEE (@docdano)."

Would these 140 characters get your LDL below 140?

There is a reason that "compliance" and "complicated" share the same root word. Whether or not a physician's daily words of wisdom would increase a patient's desire to make good choices remains to be seen.

Regardless, there is no doubt that social networking will find its way into the doctor patient relationship. And if it can make a difference, physicians and patients should embrace it.

5 Cool Drink Ideas

We are a liquid consuming culture. When you sit at a traffic light just take a look at that car next to you. If they aren't holding a cell phone, chances are its a Starbucks. Let's toast five cool drink ideas:

#1: The Skinny Vanilla Latte -- Probably the greatest Starbuck's invention. Coming in at around 90 calories for a Tall and 0 grams of fat this really is a good deal on the beverage front. Not wanting it to be too healthy I usually opt for the Venti and add a little carcinogen (one Sweet-n-Low).

#2: The Venturi Wine Aerator -- My associate Linda Timmerman raves about this device. I'm not sure I believe it can turn a bottle of Two-Buck Chuck into a Caymus Cab but anything with that good of a 4 and 5 star Amazon.com rating can't be bad. (http://www.amazon.com/Vinturi-6700-Essential-Wine-Aerator/dp/B000UPOJ5W/ref=sr_1_1?ie=UTF8&s=home-garden&qid=1264997804&sr=8-1)

#3: The Sigg: Ok, not the hand gun -- this is the all metal eco-friendly Swiss made water bottle (www.mysigg.com). Not only do you look cool, but its a great way to keep plastic out of our landfills.

#4: Teavana: This is my addiction. Taking after my mother who is an avid tea drinker, I normally drink at least 32 ounces per day and almost all of it from Teavana. With wild and fruity flavors like Caribbean Breeze and a generous number of red Rooibos teas you can mix and match these like a mad scientist. And as long as you brew according to the recommended times it almost always tastes great. Probably the biggest lesson here is the Teavana brew pot -- loose tea and water in the top, filtered tea at the bottom right in your cup.

#5: Tito's Handmade Vodka: From the Mockingbird Distillery in Austin, Texas this crystal clear elixir has eclipsed its competitors. If you don't believe me, just go into your neighborhood Centennial Liquor and look at which vodka (from the hundreds) is missing from the shelves. Rumored to have started out in a garage as a vodka that "women would want to drink" it has quickly become my vodka of choice and the price is right too.

Drink up.

iPhone Increases Patient Satisfaction

Ok, this isn't by any stretch a scientific study. But let's think about it for a moment: when was the last time you were happy while waiting to see your doctor?

When I was a kid of course we were doomed to the eternal germ infested copy of Southern Living or Car & Driver that had been donated by the local physician (identified by the Sharpie covered mailing label). Residency brought the AA battery driven casino game. But now we have the iPhone!

Today, not to say that this is typical (some of my staff might argue), but I ran a little behind in my schedule. A little....might be 40 minutes. But before I get labeled as one of those doctors who think "my time is more important" than my patients, I really do try to stay on schedule...but that's a topic for another blog entry.

I noticed today in an informal observation that patients who had an iPhone were consistently more happy and patient while sitting in a paper gown than those with other kinds of phones, particularly the non-smart phone crowed.

iPhone users were busily sliding their finger through apps ranging from Bejeweled to TweetDeck. Blackberry users were a close second, but most of them seemed to be preoccupied with being away from the office...that is, they were working while sitting in the paper gown.

I was quite proud of my observation and would recommend to any prospective patient that there is no better way to wait than using the mindless energy consuming bandwidth of AT&T with your iPhone.

I did mention this to a patient at the end of the day, and he smartly remarked that I might need to be careful. The next app might just be a waiting room timer. Not what I wanted to hear.

MOOve on over traditional business cards! www.moo.com

I'm always excited to find new products and services, particularly those that turn an old product into something that is more practical and exciting. That is exactly what www.moo.com does to the outdated business card.

This European-come-to-America company is creating exciting new products including "mini cards." These small cards can be passed to include information such as your website name or your Twitter or FaceBook ID.

I would encourage you to check this company out as an interface between electrons and parchment. I've copied some info from their website -- let me know what you think:


MOO is a new kind of printing business

There are now more than a billion people online, many using the internet to engage in some kind of social activity. Over 4 petabytes of unique virtual content is generated a month, and in case you're not sure, that's quite a lot.

There's virtual communication like email, instant message or video. People belong to virtual communities like social networks, image sharing or interest groups. And in these communities they use virtual identities to share virtual content: writing, photography, design, music, video... Sometimes, we think life is just a little too virtual.

MOO dreams up new tools that help people turn their virtual content into beautiful print products for the real world.
Our Products and why we make them
Look familiar?

Handing out our contact details, the old way. It wasn't pretty. Really.
MOO MiniCards

Handing out our contact details via MOO. It's nicer. People call back.

All of the staff at MOO have active online social lives - not for work, just for fun. We love the web. Over half of us have our own website, or blog, and pretty much all of us share our photos online with our friends.

Our first product, MiniCards, came about when we realized that sometimes, we wanted to hand out details of our personal sites, and we just didn't have a nice way to do it. A business card was too cheesy, too serious, or too... businessy, and didn't represent us the way we really are. A hastily scribbled piece of paper is more personal, but who ever has paper or a pen when you want it? We needed something else.

So we made MiniCards. Little cards - about half the size of a business card - with your own photos, designs and text on. Made in boxes of 100 with the option of having a different image on every one.

We launched them into the big wide world towards the end of 2006, and now you can get them through a variety of MOO partner community sites, or by uploading your images directly to MOO. Don't have images of your own? Don't worry, we thought of that too.

Our other products are developed in the same way. As people with a lot of content online, we love the chance to take it offline again and hold it in our hands. To put it in our pockets, and hand it out to friends.

We make products we like and want to use, and we really hope you feel the same way.