The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
The Internet has made computing power ubiquitous. No longer need individuals to be at the mercy of institutions with whom they do business. However, new habits are hard to learn, so individuals still hesitate to challenge institutions. Sophisticated but inexpensive software from companies like Intuit nevertheless makes it nearly effortless for humble customers to have every bill and transaction cross-checked for them, and actually, in the resulting arguments. Its high time balance was restored because computers do send out lots of errors which have the effect of creating or destroying wealth. Indeed, much of the current credit muddle grows out of abbreviated records systems, organized for the convenience of only one party in a transaction. The transaction system would be streamlined, not hampered, by more adversary challenge and cross-verification at the level of individual items rather than merely cross-footing the totals. Indeed, add the filtering of information by third-party intermediaries, plus monitoring by regulators, and a need for some defined fault-tolerance emerges from the hopeless complexity. We must restructure relationships to ensure that small errors are trapped and isolated, not allowed to aggregate to a point where a mysterious failure of the books to balance can bring enormous systems to a halt. In this article, we mention the vulnerability of banks, financial derivatives, the Federal Reserve system, and the health insurance system. If everything worrisome went wrong at once, it could be quite a mess.
For the opening example, this article was written two days after the author discovered a sizable error in his stock brokerage reporting. It was in my favor, else I might sound less relaxed. Even so, the condescending stone-walling encountered was a powerful warning, since at the end of the day it proved to be entirely the fault of a software vendor for several brokerage houses. A few decades ago, a housewife would have been in a stronger position with her department store billing department because it was effective to refuse to pay the bill. Just try that today: the current practice of employing vendors to handle merchant billing soon separates the dispute from the circumstances of it. That's an underlying difficulty with all third-party arrangements; expedients selected to avoid a problem often make matters even more frustrating for the defenseless counterparty, who eventually longs for government intervention.
To a certain extent, customers have been forced to agree to this situation voluntarily, because of the mind-boggling complexity or greater cost of not agreeing. Until about fifteen years ago, it was conventional to place engraved stock certificates in a safe deposit box. Dividends were received as paper checks, endorsed and deposited in a bank. The bank microfilmed the checks, the customer could photocopy them.
Form 1099
Power was then reasonably symmetrical, arms-length and simple in concept even if overall it was an expensive, inefficient transaction. A mountain of receipts, a quarterly blizzard of mail. At tax time, an error-prone chore to manage the papers. So, in response to the gentle suggestions of tax accountants, it seemed heaven-sent to take certificates out of bank vaults and place them in "street name" with a broker. Tax time condensed to attaching a single piece of paper, the Form 1099, to the tax form. Instead of calling a broker and asking, "How's the market?" people now go to his website and review how a whole portfolio is performing, hour by hour. The efficiency gain is enormous; the transaction cost reduces at least 90%. But then -- you discover seven-figure errors can be created by an invisible computer programmer, initially denied as impossible and then defended with a blizzard of words. Worse still, the error did not come from an employee of the broker, it came from an employee of his software vendor in another city. The error did not surface in the brokerage house records, but in what was transmitted to a second software company a continent away, whose phone is answered in India. Two questions arise: what would have been the predicament if the error had been against me instead of in my favor? And secondly, what might have happened next if the misinformation about my imaginary windfall had been sent, not to a software house, but to the Internal Revenue Service as a Form 1099?
Now think of another order of magnitude. Instead of a housewife coping with the department store bill, replace her with a million brokers, a million investment bankers, a million electronic exchanges, and regulators, and tax collectors. Just one quantitative trader is known to handle ten thousand transactions an hour. Since transactions are global, a zillion foreign counterparties get orders for a zillion transactions. Underneath all this, a magnified error can emerge from one software vendor placing unwarranted faith in one programmer trainee, in a hurry to get home for dinner.
In Brief Summary. Suggestions for American healthcare reform are made, embracing the full potential of unencumbered Health Savings Accounts, and changing the physical center of healthcare delivery while turning some of the incentives of reimbursement in a better direction. Unfortunately, most of the intent of the suggested changes to the system cannot be appreciated without understanding the history and economics of health insurance, and the complexities of the modern health delivery system. An attempt to capsulize these matters is mixed among the proposed solutions to them in outline. They come from a physician with decades of practice behind him, fifteen of them before Medicare was created. No claim is made of lack of bias. The more important suggestions are:
A. INSURANCE REVISION
..1. Health Savings Accounts, linked to debit cards, reinsurance, investment vehicles, and marketing.
..2. Elimination of Co-pay, but increase of deductibles.
..3. Equalized tax-exemptions (for health) for all citizens, regardless of employer.
..4. Reduction of employer domination of employee health insurance choices.
..5. Increased deductibles for elective admissions to the hospital (or decreased deductibles for emergencies).
B. REIMBURSEMENT REVISION
..6. Revised ambitions for computerized medical records.
..7. Substitution of market-based prices for hospital cost-accounting in DRG calculations and patient bills.
C. ACCOUNTING REVISIONS AND APPEALS
..8. Establish a nation-wide appeals mechanism for both beneficiaries and providers.
..9. Independent negotiation and payment for aggregated hospital indirect costs.
..10. Inter-institutional comparisons of charge-to-cost ratios, indirect costs shifts, and indirect costs.
(D. LONG-TERM: INDIVIDUALLY OWNED AND SELECTED WHOLE-LIFE FUNDING)
..(11.) Payment of Last year-of-life costs from an escrow to Medicare, beginning last-year-of life pre-funding.
..(12.) Gradual substitution of whole-life health insurance for term-life health insurance, beginning with first year-of-life post-funding.
..(13.) Encourage migration of office medicine toward the campus of retirement communities. As a beginning, charge some agency with discovering obstacles to moving (independently competing) physician offices to the campuses of Retirement Communities.
Transitions to new programs from old ones, are usually difficult. The transition from a post-paid system of Medicare to a pre-paid one is no different; but the huge size of the program makes it harder, deficit spending of the past fifty years makes it worse. Congress tends to act a little like Queen Victoria, outlining what it wants to achieve, and leaving the details up to the professionals on the Congressional staff, or the regulations applied by the Executive branch. The following are therefore only suggestions.
Up to this point, we have alluded to the possibility of a "last four years of life" concentration of expenses creating ample decades for compound interest to accumulate on savings, before the savings are later needed to reimburse Medicare for them. However, some people will die within the immediate next year after enactment, so some expenses will surely begin immediately. (That would be awkward, so it might be better to begin after a delay, starting with a cushion of the accumulated revenue; but temporary deficit spending, partial yearly payments, and a trailing transition fund are all alternative possibilities.)
The revenue for the early years would probably best come from absorbing the 20% co-insurance premiums, as the useless co-insurance is wound down. Since the last four years are said to contain half of the costs, they could be approximately matched to about 6% of the annual co-payment revenue (3% of annual Medicare cost) during the first fifteen years of Medicare, and declining amounts until the copayment are completely absorbed. That leaves a small shortfall for the copayment fund, which would, in turn, be compensated by either the contingency fund or Medicare premiums, recognizing that increases in Medicare debt would be stabilized by investing the annual wage withholdings instead of spending them in "pay as you go"(see above).
After a certain amount of juggling, the consequence would be 1) the elimination of copayments, bad debts from this source, and double insurances, 2) the elimination of "pay as you go" for wage withholdings, and 3) the establishment of a permanent terminal care reimbursement system, independent of Medicare but reimbursing it.. Future scientific advances might somewhat reduce the cost of terminal care, but in general medical scientific improvements in productivity could all be applied to the health of younger people. As the system matures, the half-ing of cost for Medicare should become apparent to younger generations, but it will take time for the compound interest to build up to that level. At some point, the system should stabilize, and reverse funding for children could begin-- protected in the meantime by the fact that birth costs have already been absorbed for people who are currently alive.
Essentially all we have done is eliminate the secondary carrier and applied its revenue (plus a little massaging) to pay for terminal care. What happens to the premiums formerly paid on behalf of the secondary insurance? In all fairness, they should be added to the Medicare premium, because it is now carrying 100% of Medicare instead of only 80%. Everyone is better off, except the people who can't afford secondary insurance. Why not give them a tax deduction by allowing the Health Savings Account to pay their health insurance premium? After sixty years, they probably deserve that break.
Homer, the blind Greek poet, portrays Odysseus on his voyage home from the Trojan War, mistrustful of his own good intentions about approaching the Sirens, beautiful women with an enticing song. Odysseus lashed himself to the mast of his ship, as a precaution against temptation. The modern version is an escrow account, which protects more useful later expenditures against youthful temptations to spend, or else against hysterical reactions to less serious problems. In an escrow account, the owner specifies legitimate use, deviating only with the consent of some third-party custodian. Escrow has in mind the need for healthy young persons to save for more serious illnesses when tempted to spend on less serious ones, while there does remain an outside possibility for early spending to be more sensible. Buying a red convertible roadster with money set aside for retirement might be one issue best restrained, but not absolutely forbidden.
Escrow subaccounts become necessary when long-term saving is more central to some purposes than others. In a Health Savings Account, the bulk needs to be available for bruises and checkups, but an irreducible amount is set aside for serious distant spending. In the general account, partial escrow meets current needs, but a portion is forced into an untouchable future account. An entire age group may be solvent, while any individual member of it remains in serious deficit. So, insurance spread-the-risk covers some, while escrow protects against others. Both have a cost, kept as small as possible. The depositor must keep in mind, his fears invigorate his counterparty's business plan to make a profit. This whole issue depends upon the J-shaped cost curve of health care. The non-escrowed, general funds are mostly limited by deposits into them, but it must be recalled that health insurance itself adds 17% to medical costs. Escrowed funds depend more on frugal spending habits multiplied by investment and compound interest, boiled down to a few tenths of a percent increment over many decades. Long after bruises and check-ups have been forgotten.
Here's the battlefield. Professor Ibbotson of Yale has shown total stock market returns have averaged 11% for a century, and other investigators using other sources suggest it may have been true for two centuries. Never mind that future predictions may not follow past results -- it's all we have to judge by. Three percent inflation reduces 11% to 8% real return. Serious unexpected recessions ("Black swans") come along every 20 years or so, it has been traditional to protect against them by investing 40% in bonds, reducing the real return to 5%. Our calculation of the present rate of healthcare spending requires 6.7% for the plan we will sketch in later. On the other hand, it will be noticed the finance industry consumes investment returns in a manner which reduces 8% to 5% and meanwhile shifts most of the risk to the customer. Because of computers and productivity, it does not seem unreasonable to hope for 6.7% to the depositor. But it won't come easily since the finance industry is resisting fee-only approaches which the Wall Street Journal estimates would add 1% to the depositor's return. Since bigshot investors refuse to pay more than 0.4% for investing large amounts, and since HSA investors do not have a payroll to meet in recessions, it should be possible to approximate everybody's goals. After a struggle.
Most of our projections assume a 7% investment return for a simple reason. Money at 7% doubles in 10 years; $100 turns into $200 in a decade. Since the life expectancy at birth is now about age 83, eight decades of 7% doubles eight times and $100 at birth turns into (200, 400, 800, 1600, 3200, 6400, 12800, 25600) or more than 250 times as much as you started with. This simple calculation allows you to check data in your head. It is a subset of the "rule of 72", which says any interest rate within reason divided into 72 gives an answer of how long it takes to double. Thus, 7% doubles in 10 years, 6% takes 12 years to double, 8% takes 7 years, 10% takes 7. If you prefer, the Internet supplies many compound interest calculators, but be wary of false answers when a computer cache fails to empty completely. If you use an internet calculator, be sure to use one of the simple formulas for checking answers in your head. That summarizes why we used 7% investment returns instead of 6.7%. No matter what you use, projecting the future contains some uncertainty.
If math of all sorts bothers you, the following chapter may be skipped, since plenty of people with green eyeshades will check it. Ultimately, however, all projections of the future involve some guesswork, and therefore probably some errors. I stand in awe of the life insurance industry, which managed to make a stable business out of almost the same problem. They had to pick a premium decade in advance, invest it in a sea of uncertainty, and return a fixed but attractive guarantee decades later -- and still stay in business. That doesn't mean it will work every time, or that just anyone can succeed. But it does seem to show it is possible.
Let's summarize. The present system is going broke. Unless something changes, the Government will be unable to continue its present level of Medicare spending for more than a decade or so. The public is complaining about how much Medicare costs, but in spite of straining at the limits, 50% of its spending is borrowed by bond issues, and it does not provide any retirement benefits beyond present Social Security. Mrs. Clinton proposed lowering the age limit at a calculated extra cost of $7800 per enrollee per year, eight years ago; probably a third more in today's inflation, which the government protests are too little inflation to erase their deficits. And yet, Medicare covers half of all healthcare costs in the nation. As the Affordable Care Act demonstrated, the healthcare needs of the rest of the country cannot subsidize Medicare, Medicare is more likely to be asked to support other age groups. Medicare is the "third rail of politics, just touch it and you're dead." And yet, additional really sick people are moving into the Medicare age group; eventually, we will reach the point where, except for self-inflicted disorders, there will be no health costs except the first and last years of life. If we are on a pathway toward concentrating all, or mostly all, of healthcare costs into Medicare, it is futile to imagine doing away with Medicare. That's where we are, and it is pretty grim, forget about math to prove it. Please look now at our counter-proposal.
We propose to change the financing, not the delivery system. The total revenue is unchanged, the style and methodology of healthcare delivery are unaffected. Continuing bond issues to cover deficits are not contemplated, although one-time transition costs may have to be. Childhood costs are included, obstetrical and pediatric costs are transferred to Medicare. A moderate retirement benefit (nevertheless larger than sickness costs) is provided. Provision is made to include other programs, like additional pearls on a necklace, but only if they are self-sustaining, every ship on its own bottom. Everything is based on incentives and voluntary enrollment; nothing medical is mandatory. It may take longer than everyone wants, and it may include some approaches that offend some people, but at least they don't have to join if they don't want to. Since mathematical precision is impossible, it may fall short of its goals. In that case, it will only partially cover expenses. In that case, it will require supplementation. But it's hard to see how anyone would be worse off. If you think I am just ranting and raving, read on.
Fuller G. Sherman, M.D. was born August 15, 1894, graduated with academic distinction from Jefferson Medical College in the class of 19** with his second doctorate degree, was certified by the American Board of Internal Medicine, practiced for many years in Woodbury New Jersey, and retired from practice in 19** to live in his native state of Maine.
The competitive strengths of Dr. Sherman’s character have actually been easier to see during the so-far thirty years of his retirement from medicine. Past the age of 90, he attended Bowdoin College, taking courses in Shakespeare and geology, plays par golf, holds a Masters’ certificate in tournament bridge, is a distinguished cabinet maker, and does creditable work in oil painting. Two notable achievements were once, on the day after his graduation, to have flattened an Associate Dean of this Medical School with a single punch; and secondly to have consistently outperformed the Dow Jones Industrial Average on the New York Stock Exchange. Because of the latter, of course, he was able to endow the lectureship we inaugurate today. In both of these adventures, he illustrated the truism that in life, everything is a matter of timing.
He has been my teacher, employer, referring physician, and friend. He is now my patient, allowing me to judge he has as good a chance as any of us to live another thirteen years. If he does, he will have the almost unheard-of opportunity to observe the practice of medicine in three different centuries. There can be little doubt he will study the next century harder than any of us, as his patronage of computer science demonstrates today.
My subject has three parts: yesterday, today, and tomorrow. The exhilarating nature of the computer world lies in only a little yesterday, a little of today, and a great deal of tomorrow. For our purposes, yesterday began about thirty-five years ago when the Chairman of the International Business Machines Corporation, Thomas Watson, made the decision to gamble the whole future of his successful typewriter and tabular company on mass-producing computers. There were then only a few dozen of those machines in existence, mostly owned by the military. They cost millions and were expensive to operate. Typically, a bushel of worn-out vacuum tubes were replaced every day. You could walk around inside them without stooping over. By 1960, IBM was selling a thousand of these machines a month to large corporations for about $ 4 million apiece. Technology in 1960 had greatly reduced the maintenance cost, but the University of Pennsylvania still had to rent them for $300 an hour at the academic rate. Machines of equal power can today be purchased for a thousand dollars, and are the size of typewriters. I own five of them; there are about twelve million others in existence, up from nine million last year. One surgeon recently told me he bought one of the best, about a year ago, but had not yet had time to take it out of the box. The cost of these miraculous machines was thus trivialized in a single generation, and each year the Sunday supplements have promised us that within two years, five at most, such things as a medical diagnosis would be relegated to computers. It never happened, of course, because science fiction writers had not heard Dr. Sherman’s professor Thomas McCrea (Dr. Maddrey’s predecessor by seven) repeatedly intone that “most diagnoses are missed because the doctor didn’t look not because he didn’t knowâ€. The problem of diagnosis today, as then, is one of information gathering, not information manipulation.
A generalization can be offered. If you hear a prediction about computers, be fairly certain it will never happen, unless it already exists. So many brilliant minds are at work, with financial rewards providing unlimited resources, that the immediately achievable is achieved immediately. Mr. William Gates, a self-made billionaire at the age of 31, illustrates how among people who are successful in this field, there is no motivation for idle chatter.
The amazing drop in the cost of computers has made it possible to have a personal computer that is those dedicated to use by a single person. Personal, or stand-alone computers, can now do almost everything a large main-frame computer can do except cope with multitudes of users. But, having only a single master, they cater solely to his needs and undergo an unexpected transformation into tools not appropriate to big shared machines, becoming extensions of one user’s brain. Word-processors and spreadsheets transform the way we think and work; such generalized mind-expenders prove to be more powerful than programs which merely calculate acid-based balance or remind us of potential adverse drug interactions.
Word processing is a utility as revolutionary as Guttenberg’s invention of movable type; it can be expected to raise the standards of thought just as much as the standard of typing. A program costing less than $200 permits preliminary display on the cathode ray tube, where prose can be corrected and modified repeatedly before it is printed on paper. The machine will find all spelling errors and most grammatical errors, permit any character, paragraph or page to be replaced, repositioned or erased. It will index the material, automatically insert hyphens place footnotes and references in place, and allow unlimited experimentation with different margins, page size or paragraphing. When finally printed on paper, the right margin can be automatically justified, and the words become unified into important than these aesthetic advantages, word processing permits the author to revise repeatedly until what he writes finally says what he means.
A second innovative creation on a personal computer is a hybrid of two steps, the generalized data management system, and the spreadsheet. Many small stored globlets of information are aggregated on request, meaningful. If the unit of data is a single patient, with blue eyes can then be effortlessly linked with any other glob of information, such as antibodies to retroviruses. The spreadsheet concept then organizes such data cells into rows and columns which can be fed into formulas which operate serially on every row in a column, generating a new column of derivatives. The user need not, in fact commonly does not know statistical theory, but for example, can process anyway to command regression analysis on eye color and AIDS or any more plausible hypothesis in clinical research. These programs will then transform selected numbers into colored graphs on request (slide). The ability to use statistical tools without understanding them will, of course, create abuses of this system, which in the case of regression analysis would be to overemphasize the validity of 95% confidence limits. Ultimately, the value of the computer product will depend on the brainpower of the individual user. When convincingly packaged data can be processed in massive amounts by chimpanzees at the keyboard of $1000 machines, it is a little daunting to await the misinformation which will be generated by the 5% error content of mountains of data. By the rules of regression analysis, one conclusion in twenty will be reached by the operation of chance alone. Since editors are intrigued by papers which reach unexpected conclusions, thoroughly documented spreadsheets research which later turns into smoke will someday be their proper torment. The exciting future of computers is thus not to replace doctors in some profession-threatening way, but rather to extend the capabilities of their minds in powerful ways which continue to reflect the personality of the user. As has been said of corporations, the dedicated personal computer projects the lengthened shadows of the man.
Early steps in that direction would please Adam Smith, producing exalted results from trivial and mercenary motivations. Whether you like it or not, and whether cost-effective or not, the of medical practice with insurance and reimbursement is making it essential for every practicing physician to employ a computer; those who avoid it have done so out of fear of the disruptions, not because they deny the value of the office machine. Once the machine is installed, word processing is seen as a free bonus, and the financial affairs of the practice become raw materials for database program and spreadsheets. In this way, the practicing physician acquires a mind-expander when he merely sought to reduce his clerical expenses. He also, by way, merges into the mainstream of business computing, and like everyone else, will find that the new IBM model 50 has become the modern standard, just as the IBM Selectric typewriter became the business standard thirty years earlier.
To understand why this is so, notice that IBM continuously spends $5-6 billion annually on research but withholds most new products from the market. Then, about every seven years, a bundled package of innovations is released as a “new generation†which then makes existing machines obsolete and dominates the field for the next seven years. Throughout the seven-year gestational period, other companies also bring forward innovations but must recover their costs by releasing them immediately. IBM watches market reactions, preparing to submerge would-be pioneers in a tidal wave of releases. In effect, other companies test the market for IBM to exploit. Almost every component of the 1987 new generation is new and very little of it is unique to IBM (slide). However, an irresistible market standard is created when many innovations are released at once by the largest volume producer. The new 1987 machines seem mainly designed to permit for the first time several personal computer users to share one octopus machine, a mildly useful thing for the doctor and his secretaries. The main importance of using 32-bit technology lies in the fact that the doctor’s personal computer uses the same system and thus can talk the same language as the mainframes in hospitals, laboratories, insurance companies, and the Internal Revenue Service. The profession must not let itself get lost in the chatter of intercomputer communications; while he must adapt to the equipment that is available, the physician mostly needs many different mind-expanding applications on a single machine. The creation of a market standard will almost surely prove to be a dominant force even for physicians. The IBM model 50 will be what to buy until 1993, as will IBM stock, but physicians need to establish their own culture within the commercially available environment.
1993 will not, of course, be a far enough horizon for Dr. Sherman’s third century, so we might look across the valley over two intervening mountains. Fourteen years from now, the new 2001 models will also be composed of standardized refinements of whatever exciting advances may accumulate in the meantime. By that time, computers should be able to accept voice dictation since they can already understand a spoken vocabulary of about 1000 words. Computer scanners can now read pages of typing with 90% accuracy, so we can except much less typing for accession of much larger volumes of day-to-day information. I understand x-ray films require a resolution of 2000 by 1600 pixels; since advanced computer screens already achieve 1600 by 1200 pixels, the silver-coated films we use now should likely disappear.
In the shorter term, it would be a fair prediction that the exciting programs of the next seven years coming up will exploit the telecommunication power of 32-bit processing and the vast storage capacity of CD ROM’s. Large Multimillion dollar mainframe computers operate in units of 32, but personal computers now mostly use units of 16. Declining prices of transistor chips make 32-bit technology affordable for personal computers, so we can expect to see the doctor’s computer talking on equal terms with the big computer in the hospital, the drug store, and the Library of Medicine. It is exciting to predict role reversal, with once imperious mainframe owners outmaneuvered by users of agile PCs. Organizational whales like hospitals, department stores, banks, and the Internal Revenue Service have had their day of forcing everyone else to conform to their convenience; the little piranha fish will grow sharp teeth.
Since the profession of Medicine is after all in the knowledge business, it is breathtaking to contemplate the migration of medical journals and libraries from paper to electronic medium and the dissemination of libraries to the doctor’s consultation room. Compact disc technology is already the cheapest form of information storage, whose inevitable price decline has scarcely begun (slide). Grolier’s encyclopedia is now available on a plastic disc you could put in your shirt pocket; the entire encyclopedia only takes up 20% of the disc. This unerasable form of storage is sometimes called WORM (write once, read many). Inexpensive scanners can convert pages of print to a computer file in 20 seconds; rather accurate programs can convert foreign language to pidgin English. Between the two processes, whose only present limitation is price, whole libraries will surely soon be swallowed up on plastic disc, and medical journals may appear in that form as soon as someone figures out how to incorporate drug advertising. However, don’t run out and buy a CD-ROM just yet; there are twenty different types and they are incompatible with each other. The exasperating power of IBM is well illustrated by the fact that this titanic information storage revolution will not take a step forward until someone like IBM is able to impose a standard which will disciple the present Tower of Babel.
In closing, the point must be made that the main hindrances to adoption of computers by the medical profession will not be technical, they will be sociological. “Not in my back yard†is the Spirit with which most new things are greeted, even in the learned professions. A plain fact of human behavior is that how you stand is determined by where you sit. For years, banks have transferred patient payments to physician bank accounts without the creation of a single piece of paper. But electronic funds transfer has made very limited progress in 20 years, primarily because the payers and their banks do not wish to surrender the interest float which develops during the delay of transfer. Blue Shield of Pennsylvania has over a million floating dollars earn interest at all times while the obsolete paper check depositing process limps on. The videotape machines which are everywhere provide a warning example of how technical potential is easily frustrated. Instead of ten thousand college professors giving mediocre lectures on Hamlet, it is clear that some professor at Oxford could give the very best lecture on videotape which all students everywhere could watch at home without even paying tuition. Since it hasn’t happened, and it won’t happen, perhaps the point I am striving to make becomes clear.
Try to image the resistance which pharmacists would create to electronic drug ordering; indeed, the nursing profession is very resistant to physician orders which come in any way except handwriting on the floor chart. While I cannot identify the economic incentive which explains the delay, Jefferson Hospital has just installed a system in which laboratory results are instantaneously transmitted to the clinical floors. However, a similar system was installed at the old Philadelphia General Hospital in 1965. These and many other examples of apparently irrational delays most likely have their explanations in the motivation of people rather than the limitations of machines. Therefore, in predicting a revolution in medical information handling we must not, for example, underestimate the capability of printers and typesetters at the New England Journal of Medicine to hold up electronic publishing, or the librarians of the world to resist the destruction of their careers by plastic disks. IBM is in the business of setting bridal supplies and has repeatedly proved to be a shrewd judge of bride psychology. They obviously believe 1993 will be soon enough for the real wedding of medicine and computers; maybe it can wait for the year 2000. Meanwhile, it will not matter much that the bride’s father can easily afford the wedding, or the groom is anxious to perform. Medicine, the bride-to-be, hasn’t yet said “yesâ€.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
