My wife’s youngest brother has been struggling with a chronic disease, and recently required a surgical procedure to correct another problem that in itself was potentially life threatening.  To a certain extent, the longer term condition increased the risks of the required surgical procedure, and, therefore, good communication between his primary care provider, his gastroenterologist, and his surgeon was essential.  The breakdown of that communication was only one of the hurdles he has encountered on his path to recovery.

My brother-in-law is a hard-working family man, and belongs to a HMO through his employer.  The provisions of the plan require him to obtain a referral for any care or procedure not directly provided by the primary care physician (pcp).  The pcp is the “gatekeeper.” His office staff is very important, and powerful as the accurate and prompt filing of requests for referrals from the HMO is their responsibility.

Rather than rant about ineffecincy or blame specific persons ( which was my first impulse,)  I will describe how I think the system is supposed to work, and offer some helpful hints for those having problems with the system.

First, my background.  I am a retired general surgeon, “grew up” in medicine, at the start of HMOs, and saw them evolve to the present state.  After leaving the provider side of the equation, I worked as a volunteer medical insurance counselor, primarily for medically indigent individuals, and for those on Medicare, and also as a patient, myself.   I struggled with insurance companies, Medicare, and Medicaid systems in three states, and became familiar, and often, frustrated with them.

A Health Maintenance Organization was envisioned as an insurance plan that would save money for the consumer of medical care in several ways: by reducing inappropriate specialist consultations and excessive laboratory testing, providing more preventative care, reduce Emergency Room visits, encouraging follow-up, etc.  Some plans are large group practices with centralized record keeping, “in house” specialty consultants, even their own exclusive hospitals, ERs, laboratory and x-Ray facilities, surgicenters, etc.  Within this type of system, the PCP is usually quite familiar with the available consultants, and referrals can be made more efficiently than in some other plans.

Another HMO has a “looser” arrangement.  This type is offered by an insurance company along with various other plans such as a PPO, or other fee-for-service plan (Medicare, for example.).  A primary care provider in this plan may also be caring for Medicare patients or may be on the panel, list of allowable providers, of any number of PPOs.  But for the HMO patient, he is the gatekeeper, provides an initial evaluation of any and all complaints, provides the total care, ordering labs and x-rays, prescribing medication or PT, or other modalities allowed in the plan.   If the PCP sees a need for specialist consultation, he requests a “”referral” which must be approved by the HMO reviewer.  The specialist will also be on the HMO panel usually with a predetermined fee schedule.  Most HMOs will also consider a referral for consultation with a non-panel specialists, but again a reviewer or even a committee must give prior approval.  Also, higher co-payments by the patient may be charged.

Unless he or she has been through the procedure previously, or even inspite of being through the procedure before, the task of obtaining approval,for a specialist referral can be daunting.  Here is where the PCP and his staff can really make a difference.  Most patients that are faced with a new serious diagnosis, one that might require surgical or long term treatment, are frightened, in pain, and, to a lesser, or greater extant, ignorant of the prognosis.  They hear only part of what they have been told, and understand even less.  The “bad news” is a serious distraction from whatever instruction or advice follows it.

So, patience with the patient/family is needed.  Handing them a pile of paperwork to fill out needs to be followed with helpful hints, or even some “spoon feeding.” Patiently repeating instructions is often necessary.  There is no room for a “just routine” attitude.  The PCP must be clear with his staff and the patient in explaining the steps involved.  His/her input on the referral request should be accurate, detailed, and prompt, providing the details the reviewer needs, without having to call/email/fax questions and answers back and forth, unnecessary delays.

My brother-in-law is fortunate in having a savvy sister, a registered nurse, who was politely persistent in ensuring that the proper steps were taken.  The provisions of an insurance plan are often complicated, the plan should be “second nature” to the provider, staff, and patient for the system to work smoothly.  The policy holder/family should study the policy when first signing up, and pay attention to the frequent, seemingly insignificant notices of amendments.  When we are well, looking at a lengthy and confusing document seems a waste of time, but it will prove to be time well spent when urgent care  is needed.

(to be continued )

They are not really our birds.  Among the creatures we share PB with, they are the most free.  Darting, soaring, fluttering through the air, they seem the most carefree of animals.  Perhaps that is part of the attraction for “birders.”  Back in Massachusetts, we lived ” out in the country.”  Dirt roads, fields and forests of many acres.  The birds did not come near the house, they didn’t need, or avail themselves of the support, if you will, of feeders, fountains, or bird houses.  They had all they needed without the benevolent human.  Maybe they don’t need it here, in our densely populated neighborhood, either.  Perhaps, our feeders, houses, baths are not really necessary here either, though we like to think they are.  However, I know we do provide some benefit here in PB, predator control.  Many is the time that we have chased the falcon out of the tree beside our feeders, many is the time we have chased the wicked neighborhood cats from the bushes beneath our window. I know we are not always successful, feathers and down are sometimes scattered about the yard.  But, I think our feeble efforts are sometimes successful in preventing an early demise for these youngsters.

Now, some may feel we are interferring in the ” natural order,” first by attracting the birds, then by attempting to protect them.  But the urban environment is not the same as the rolling hills and fields of the countryside, not the “natural order” as they might experience elsewhere.   Do the birds not belong here?    (I feel myself being drawn into the human/animal debate.).   I was born and raised in the Midwest and lived in the countryside of  New England.  I have lived in NYC, and other large cities.  I feel my personal experience of our varied environment is as large as most.  I  have a reverence for the creatures of the earth and see the value in protecting their existence.  I also see the value of our culture, as humans.  There is, it seems to me, a possibility of going too far in the “protection” of animals, to the detriment of ourselves.  So, a natural order problem for me, should I just let nature take its’ course and watch the natural predator (falcon), and the unnatural predator (pet cat)  eat the birds while I watch?

Conservation of our natural resources is a concept we ( born in the 40’s ), grew up with.  Forests, lumber, petroleum energy sources, open spaces, mineral and ore resources, animal and plant species, marine animals and fishes are all important.  Water, here in the southwest, including Arizona, Southern California, Nevada, is a precious commodity.  The Northeast, orthe Pacific Northwest,or the Atlantic coast , as examples, don’t have the pressure to conserve water that we do.  Our water is, to a large extent, imported, from the Sacramento and Colorado Rivers.  Melting mountain snow pack ( and rain), supplemented by ground water are the principal sources.  Efforts to get public acceptance of desalination and recycling of water are promising.  Perhaps, importation of water from farther north can supplement the supply.  (We seem to be pretty good at redistribution of income in this country, why not water. )   That, however, would not solve the smelt versus farmer controversy in the Sacramento Delta, but it would be less of a problem if SoCal were not so dependent on that source of water.

OK, I’ m getting pretty far from the birds in my front yard.  My very personal and limited conservation cause, at  present, is the safety of the sparrows, finches, and hummingbirds that are, for the most part, happily coexisting with the humans here on Beryl Street.  Our neighborhood email network is constantly bombarded by appeals to stop watering the landscape, to help find, feed, preserve cats, and pet exotic birds and turtles (captured and imprisoned), and to  worry about the American pit bull terriers that are walked on leashes on our sidewalks, etc.   We all have to draw some lines between our desire to conserve and our own desire to preserve human culture.  Pets, domesticated animals, and some wild animals, are commonly found in urban areas such as ours.   Not the natural order as I see it, but “it is what it is.”  One small dilemma after another, we all make our own compromises, large or small.

Oh well, might as well state my beef.  Keep your cats at home!  I am tired of watching for them in my little bird sanctuary, tired of cleaning up the poop they leave in my yard, and tired of being bombarded with entreaties to watch for or rescue a “lost cat.”   Amen.

I’ve always been interested in birds.  As youngsters, my sister and I had bird identification contests, little red bird calls, bird houses, and feeders.  Subsequent changes in living arrangements provided fewer or similar opportunities for “bird watching.”  Bird sanctuaries, aviaries, documentary films have all been enjoyed, but never to the extent of our viewing room, and nursery here in Pacific Beach.  Our back patio has large overhanging palms, there are dense foundation plantings, and a high evergreen hedge separating lots.  In addition to other palms in front, a large podocarpus tree is at the front corner of the lot.  Our ten by eight foot front window looks out on the trees, hedge, shrubs, and two feeding stations, a Yankee Droll for seed, and a pair of nectar feeders for hummingbirds.  There is a two foot diameter bird bath between the two, with a small pump-driven bubbler fountain in it.  Beyond the yard we look on various trees, buildings and power lines.

The feeders, bath, trees , shrubs, and power lines are usually filled with birds, who are constant company for Am coffee/newspaper, noontime snack, or after dinner relaxation.  We are able to recognize ” regulars” as well as seasonal and  “only occasional” visitors.  The SoCal climate allows some birds to stay the year around, including some species of hummingbirds.  Crows and red-headed green parrots are around, but don’t visit the feeders/fountain.  The parrots, my wife calls them “gangsta birds,”  are gregarious and noisy.  They fly in flocks of several to a dozen, or so. They rarely pair off.  When in flight, swiftly swooping about trees and buildings,  they chatter constantly.  In trees or on power lines they are usually quiet.  Fruit and nut eaters, they climb up and down the date palms, sometimes head down, sometimes dangling  feet up to feed.  A power line across the street is a frequent resting rest for them.  There is always a curious distribution along the line in that one bird is separated from all the others by a two to three feet, the others within a few inches of each other.  It seems he/she has to take a “time out”for bad behavior.

The seed feeder is a scene of constant activity.   There four perches for eating from the seed resevoir, and a lower tray to collect the spills from the messy eaters.  So six or seven birds can be feeding at a time.  However, some birds cannot share, and spend more time chasing others way than feeding.  Female finches seem most argumentative, followed by female sparrows.  There are many nesting sites in the area, thus the designation “nursery   area.”  The fledglings gather on the lip of the birdbath, or tray edge and peep constantly.  Adults hop over and disgorge seed into the youngsters mouths, the peeping ceases for at least thirty seconds.  For some reason, many of them then turn, step into water, poop,  and proceed to splatter water far and wide, especially on the glass window suface, the white  streaks, when dry, are clearly visible from our living room viewing area.  There my be four or five in the water at once,  a communal bath for chubby little birds.

Early one weekend morning, wife (she still desires anonymity) heard cconstant  peeping from the walkway east of the house.  A quick investigation did not reveal the source.  However, the peeping persisted, and lead to nested pottery containers, quite large stood next to the house.  It wasn’t until Wife started to remove the top container that she discovered Chubs, a finch fledgling in the very bottom tub of the stack.  By now he was quiet and trembling.  Wife slowly tipped the container on it’s side and left the area.  Chubs found his way out, not really able to fly, but sheltered in the shrubs and encouraged by his parents, he found his way to safety.  Chubs made many subsequent visits to the feeder tray for sustenance, “beak” fed from his parents, and later sprayed the front window joyfully with water from the fountain.  We cannot recognize him anymore as an adult. But we are sure he stays away from the pots.

What joy, to be able to observe these tiny creatures.  Speaking of tiny creatures, hummingbirds are REALLY small.  They buzz around the flowers and shrubs at amazing speed, constantly alert for the arrival of rival feeders.  Though we have two feeders for them, rarely is there more than one bird there.  A feeding bird will chase away any others until he or she has satisfied his thirst/ hunger.  They feed almost exclusively on nectar, catching insects only to feed their growing young , more protein.

Well, more about birds, later.  Wife tells me my posts are a little long.

Well, almost never.  We just had a two day rain “storm.”  We needed it, we are way behind the normal rainfall average these past few years, normal here means very low by east coast standards, rainfall average .  In western Ma we looked on a rainy day as a common occurrence, and often an annoyance.  Here we look forward to rainy days as it brings some relief from the otherwise arid conditions.

Did I mention why I moved to San Diego?  One big reason was the weather.  I left 100″ of snow on the ground in MA, to walk on the beach here in shorts and a T-shirt in February, 2004.  I had developed a sensitivity to the cold,  with severe pain in hands and feet, and also an aversion to shoveling snow.  I bought a sailboat, a life long goal.  Friends and family applauded my decision, and friends (new ones) and family magically appeared out here. All in all, a “good move.”

Weather reporting, in New England, is an adventure compared to SoCal.  As Mark Twain put it, if you don’t like the weather, wait an hour.  With the frequent wide swings in temperature and precipitation, and the full gamut of seasonal changes, wet Spring, hot Summer, cool Fall, freezing and snowy Winter and finally the month long mud season,  the weather forecasters really had something to talk about.  Of course, in that area, long term forecasts were really risky, but we would listen and watch, and make our outdoor activity plans accordingly.  That could be  risky, also.  Our car  trunks were usually equipped with an umbrella, a snow shovel, tire chains, cold weather shelter, blankets, etc. for the possible weather induced problems.

In San Diego, we have a plethora of weather forecasters, most are the young attractive women, tight dresses, same as elsewhere, except, they rarely have any new information to impart.  A few degrees up, or down, a few mph more or less, the hourly (it seems) forecasts are the same, day after day, week after week.  Now, Wife says she really likes the Fall, does not like the cold winters here, and loved this past rain “storm.”  After 10+ years, I think I can detect a slight drop in average daily high temps in the winter months.  I was famous my first month, Febraury, in Coronado,  for my shorts and T-shirts on the beach ( “oh, he’s from New England” my friends would say).  Maybe my problem is that I was accustomed to the 100-120 degree differences between winter and summer highs in MA.  Do not get me wrong, I do not miss the cold, avoid it at all costs. But, cold is cold, not “but honey, it’s going down to 56 tonight.”

I have seen  storms.  Hurricanes, which are extreme.  But without (choose two or more) driving rain, high winds, thunder, lightning, big temperature change, hail, or gutter flooding, need for rubber boots, etc., I don’t call a rainy day a storm.  Technically, a meteorologist might refer to the counterclockwise circulation about a low atmospheric pressure center as a storm.  That could be a hurricane, or  all the way down the severity scale to the series of showers that we just had.  It’s a matter of degree.  But when I use the term, storm, I have a mental picture of weather that is, oddly enough, STORMY!

Now, wild fires are a different story.  We did not have them back east.  There was one forest fire in a state park near my home in 30 years, small, self limited, barely made the news.  I must admit, I was glued to the TV reports here, last spring.  The drama, personal loss, and efforts of the firefighters was gripping, to say the least.  It rivaled a hurricane any day.

Our arid environment brings many challenges.  I love green.  Green grass, green, trees, green shrubs, comes from the thirty years spent in a New England landscape, 95% forests and lakes, at least three seasons of the year. (Gray and white the other season.)  The water situation has required several changes.  We have postage stamp lawns, drought resistant plantings, more pavers and concrete on the ground in our plot than in an average block in Pittsfield, Ma.  But, 1/10th the water use.  We are careful to irrigate sparingly, use a broom rather than a hose, turn off the automatic sprinklers when it rains, rare as that is.

Still, there are problems.  Wife and I are in constant fear of the neighborhood “water police” that might report my sprinkling of water on the patches of new grass seed, or the plantings that are struggling.  I occasionly get the stink eye from walkers-by who “catch” me using a hose to water containers 15 minutes after the 10AM cut off time for watering landscaping.  I think they feel the “water” their pets contribute to our yard, in the form of grass-toxic urine,  gives them the right to criticize my use of extra 2 gallons  per week for my container flowers, some of which they pick, in passing.

Oh well, who am I to criticize.  I walk down sidewalks streaming with overflow from poorly regulated  sprinkler systems, some so profuse that the runoff is muddy from dirt washed out of planter beds.  I have to step around sudsy puddles from people washing their cars in the streets, driveways, and alleys.  I walk in the street to dodge the irrigation systems that would otherwise soak my legs if I stayed on the sidewalk.  Am I annoyed by this hypocritical behavior of my neighbors?  They decry the use of water for agricultural purposes, rather save the tiny minnows in the Sacramento Delta.  They complain about the recreational use of water at Legoland and the Disney Parks, but I bet their children and grandchildren have great fun there, as I know mine do.

I didn’t plan to rant.  Sometimes it is  not easy to avoid here in CA.  There is plenty of water on the west coast of this country, it just needs to be distributed better.  Hopefully our government leaders will realize this before it is too late.  Another approach, cancel the wasteful spending on the bullet train, build desalination and water recycling plant, instead.  Anyone agree?

We survived the Thanksgiving Day feast!  A wonderful, warm(in more ways than one), family gathering.  That part was easy.  The preparation, and the clean- up were more work.  But, a great day nonetheless.  The advantages of hosting the day are several: set our own schedule, decide who brings what etc., but, one of the best aspects is enjoying the leftovers.  Many  “doggy bags” that went home with guests, but there was still a lot to deal with.   Most of the dishes do well in containers in the fridge, to be sampled, or gobbled,  over the next week.  I always make an excess of dressing (some in muffin tins), and gravy,  both of which can be frozen and used later.  The two turkey carcasses yielded a lot of meat (some for the freezer),  broth  and scraps that will become soups, casseroles, sandwiches, and snacks.  I never tire of inventing new uses for these ingredients.  The “cooking thing,” I guess.

Another result of the feast and following meals is a large measure of what I call diet/ guilt.  My  belt got really tight that day, and because of the continuing surfeit of high calorie food, it remains tight.  So, I have embarked on my recurrent program of more exercise, especially since my overindulgence has slowed minimally.

The boardwalk along the beach of Pacific Beach/Mission Beach is a few blocks away, my favorite low impact exercise venue.   The draw is obvious.  The ocean breeze to cool me, the ocean views, and  the continuous soothing sound of the surf are there every day, and in San Diego, so is the sunshine!  It may not be unique as beach walks go, but it includes other sources of pleasure, amusement, and annoyance that add to the picture.   First, though, I want to mention that the boardwalk is really an ocean- front walkway constructed of concrete with a low wall separating it from the sandy beach.  Not a board under your feet anywhere.  I grew up on the East coast where boardwalks are made of wooden boards (with splinters)  and in many places one can actually go “Under the Boardwalk.”   In PB, the vagrants are forced to sleep in the open,  the lovers do it on the beach, no privacy, no place to hide, for shame!

People, all kinds of people, as well as a lot of dogs are there.  Visitors, as well as beach neighborhood residents stroll, jog, bike, skate, skateboard, and occasionally Segway along it’s length.  I have overheard conversations in 4 or 5 languages on the same walk.   Wheelchairs and baby strollers are common.  Dogs in bike baskets, strollers and bike trailers, and on foot are seen every day.  San Diego Code prohibits dogs from the beach, walkway, and parks during mid day hours, but nobody told the dogs, or their owners, either.

Yesterday, As often happens, I  saw one of the PB institutions: Slo-Mo.  SM is a retired neurosurgeon, in his seventies, who enjoys in-line skating on the ocean walk.  His nickname refers to the slow motion, balletic movements which are accompanied by classical music (from a small sound system he carries).  On a busy day on the Walk, I might hear the music before I see SM, as he slowly and gracefully threads his way through the crowd, sometimes holding an arabesque for 50-100 feet, always smiling,  with a friendly greeting for all.

Frequent walkers, joggers, skaters, or bikers soon begin to recognize and greet  each other among the hundreds of people one passes. The “regulars,” as I call them are a varied lot.  There’s the football guy who will play catch football with anyone who is willing.  Extensive  quarterback  and wide receiver mannerisms are thrown for free.  There’s also the two OMBAC (Old Mission Beach Athletic Club, emphasis on old)  guys who have come up with Cruiser Frisbee, a variation on a classic beach activity.  They ride their fat tire beach cruisers up and down The Walk passing the Frisbee back and forth between them.  When a likely participant ( anyone who makes eye contact) is encountered, the Frisbee is zipped in his/her direction, and the resulting catch or flubb is cheered or jeered accordingly.  Any spectators are fairgame also, so anyone in the area might get a quick throw, also.  Could be embarrassing, but always fun.

One of my favorite “attractions” is the Flag Man.  I have not seen him in recent weeks, hope it is only turkey overdose related.  He is a middle aged redhead who sets up near World Famous, about ten yards out in the sand, with a beach chair, an umbrella, coolers, bread crumbs for the birds, and a horseshoe game setup for anyone who stops at his station.  But, the main attraction is the flag.  It is not huge, 4’x6′, I think, but it is HIGH.  A sectional pole skewered into the sand raises the flag about 12′ above the beach.  Why so high?  Well, here’s the story.  The Flag Man is a retired US Navy veteran.  He places the flag high enough to be visible to the sailors on the frequent warships passing offshore.  His respect for our Flag, his love of the USA, and his sense of brothership with other sailors spurs this display.  He remembers well his days aboard ship, remembers leaving on deployment from San Diego, remembers coming home after many months at sea and in foreign ports.  He knows the excitement of leaving port on a mission to protect our freedoms or to succor those injured by an act of man or nature, mixed with the sadness of leaving home and family.  He also knows the joy of returning, proud of the work well done, happy to be home, warmed by those who come to welcome him.  So, the Flagman is doing something that he hopes will add to those departures, those arrivals/returns.  In hopes that even one sailor will see his American Flag on the beach as he is leaving or returning to port,  the Flag Man flies it high!  I get it, I love it!  I hope you do, too.