George R. Fisher, III, M.D.

Obituary

George R. Fisher, III, M.D.

Age: 97 of Philadelphia, formerly of Haddonfield Dr George Fisher III

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.

John Bartram's Garden

Bartram Gardens

It's worth a visit to Bartram's Gardens, if only for the astonishment of finding a very large farm and stone Quaker farmhouse within a few blocks of our largest medical center, a stone's throw from the biggest oil refinery on the upper East Coast. And located on the edge of a neighborhood that is, well, past its prime. The trees on the farm are centuries old, so walking around the grounds imparts the feeling of being hundreds of miles from civilization when in fact you are only a hundred yards away from streets that are very urban, indeed. When you turn in certain directions, an occasional skyscraper peeps over treetops, and down the meadows, at the farm's dock on the leafy-banked Schuylkill, you can see oil storage tanks across the river, just a long shot with a 2-iron away. Look upward, to see the upper half of shining towers of Center City.

The farm property as it now stands dates back to 1728, but the site marks the earliest beginnings of the city, nearly a hundred years earlier. The river curves around this hill then snake on down to Delaware through flatlands which were originally swamps ("wetlands", as they say). The hill is as far downriver into malaria territory as the Indians were willing to go, so the Dutch traders had to sail upriver and dock there in order to take thirty or forty thousand fur pelts back to Holland each year. One thing or another has been dumped on the swamps for three hundred years, and the oil companies found it a cheap place to buy enough land for their refineries, close to four or five railroads near Bartram's place, and with access to the high seas. Right now, most of the oil comes from Nigeria, emptying two or so supertankers a week. There has to be enough storage capacity to take care of delays caused by bad weather on the Atlantic, and there has to be access to railroads and highways to carry the finished product away. The rest of a refinery is just thousands of miles of metal pipes, gleaming in the sun.

Sun Oil is trying to be a good neighbor, turning more and more of the area over to nature preserve, as chemical engineers have learned how to work in a smaller space with fewer employees. The banks of the lower Schuylkill are now mostly grown to shrubs and trees, concealing from boat travelers the rather extensive dumps of old auto tires and similar refuse. It's a placid winding trip, increasingly coming to resemble what the Dutch traders once encountered. Especially in May, when the Palomino or Empress trees are in purple bloom. It seems the Chinese packed their porcelains in dried Palomino seed pods, and the discards have grown up to quite a nice display. Logan Square is filled with such trees, quite artfully pruned and maintained; just imagine several miles of the river lined with them, and you can see why the Tourist Bureau is excited about the potential. If you have been to San Antonio you know the potential of an urban river ride, which in this case might go all the way up to the Art Museum. Given enough public response, you can envision two or three-day barge rides from New Castle, Delaware to Pennsbury, with side trips up past Bartram's to the Waterworks. Right now, trips are comparatively limited by the tides, with a few trips a year down from Bartram's to the refineries, and a few more up to the river to the Art Museum. They use floating docks, and permanent docks will need to be built.

Pennsylvania Railroad

Originally, the crude oil came from upstate Pennsylvania, near Bradford, and was the main source of the dominance of the Pennsylvania Railroad. Baltimore and New York were also the beginnings of transcontinental railroads, but their freight cars came back empty. The upstate Pennsylvania oil gave the PRR a dominant edge by supplying cargo for two-way revenue.

When George Washington had to retreat from the Battle of Brandywine, the armies had to cross the wetlands, and the river, to get to Philadelphia. Washington got there first and burned the boats after his army got across. He knew, but the British probably did not fully realize, that the first place to ford the Schuylkill was at Norristown. When the British finally got that far, Washington was waiting for them, but a fall hurricane came along and soaked everybody's gunpowder before there could be much of a battle. Unfortunately, Mad Anthony Wayne was unprepared for a nighttime bayonet charge, and there was still quite a slaughter.

You can't wander around John Bartram's house and gardens without getting the impression of considerable wealth. Bartram was interested in botany, becoming the most eminent authority on plants of the Western hemisphere, a very close friend of Benjamin Franklin, and probably the main force behind the creation of the American Philosophical Society. But although Bartram was a hobbyist, he was a shrewd businessman, selling curiosity plants to Europeans, and commercially improved fruits and vegetables to local farmers. There are still some Bartrams around Philadelphia, with a strong Quaker air about them. Around 1850 the place was sold to a zillionaire railroad magnate named Eastwick, who fixed up the place in the high style he learned building the railroads of Russia for the Tsar. The mansion has been torn down, but the stone farmhouse, stone barn, stone sheds, stone outbuildings, stone everything -- endures, like many of the curiosity trees and bushes. Well worth a visit.

Podcasts on iTunes

Philadelphia Reflections is now available on iTunes. There is a button on every page that will take you to the iTunes store where you can subscribe for free.

Also, a search in the iTunes store with the keywords "Philadelphia Reflections" will produce the following:

The iTunes store on an iPhone

Ben's Little Legacy

Benjamin Franklin and George Washington

ONE of the many compromises of the Constitutional Convention was to allow equal-sized blocs of people to choose their Representatives, but the State Legislatures of any size to appoint two Senators, in a bicameral Congress requiring affirmative votes from both bodies, for action. This was the first step in a separation of powers. After separation came apportionment: every state still got two Senators, but varying numbers of Representative districts would reflect population changes. The effect of this second step was to confer greater Senate power to small states because otherwise, a few states with large populations would probably always dominate the voting. (Shorthand for Constitutional scholars: favoring the House of Representatives means favoring big states.) When Franklin proposed a bargain to give the South time to solve its slavery problem, he needed to maintain balance. The small states were truculent about losing Senate power, so he had to give something else to the big states. The three big states of Massachusetts, Pennsylvania, and Virginia were very mindful that England had primarily targeted Boston, Philadelphia, and Yorktown for attack during the Revolution. Big states are paradoxically more anxious to unify with allies, to gain military strength, because enemy commanders seem to favor them as military objectives. Franklin's proposal was to allow the big states to control tax legislation, through the device of mandating that tax laws must originate in the House of Representatives. He may have known that eight states already had similar laws, but may not have realized such laws were regularly flouted. It's hard to be sure what Franklin knew because although he had once been Speaker of the Pennsylvania House, it was during a time it was a unicameral Legislature.

ARTICLE 1, Section 7. All bills for raising revenue shall originate in the House of Representatives, but the Senate may propose or concur with amendments as on other Bills. {bottom quote}

Washington's Gift to Franklin

Experienced politicians in the Convention snorted with disgust. There were a dozen ways to get around such a provision, and nowadays the traditional one is for the Senate to attach a tax amendment to some bill which had originated in the House. Any House bill will suffice, and thus we have Senate-originated Medicare Amendments attached to House-originated bills whose first page purports to be legislation about highway construction. Medicare, don't you see, is an amendment to Social Security, which itself began as tax legislation. Any politician of standing could see his way through that. And even in 1787, the delegates could immediately think of ways to circumvent this little trick. When Chairman Rutledge of South Carolina returned his report from the Committee on Detail, it included Franklin's gift to the big states. His fellow delegate from South Carolina Charles Pinckney immediately proposed a friendly motion to delete the rule. Edmund Randolph of Virginia however, felt the big states "should at least get what they had been promised", thereby upsetting others who felt Randolph was being indelicate. So George Washington stepped out of the shadows and supported Randolph, his long-term neighbor, and friend in the Virginia caucus. The matter was then referred to the Committee on Postponed Parts. After a decent interval, it was reported out of the second committee and adopted. After all, with Washington and Franklin as supporters, it would be embarrassing not to pass an inconsequential motion.

National Debt, Presidential Hat Tricks, Shale Gas and Argentina

Alexander Hamilton

This-here speaker at the Right Angle Club began a discussion of the "Fiscal Cliff" razzle-dazzle of 2012, by changing his mind about the causes of the financial crash of 2007. Originally, it seemed as though globalizing 500 million Chinese out of poverty had destabilized the exuberant American mortgage market by flooding it with cheap credit. Supplanting that idea, or perhaps only supplementing it, must now be added the overextension of national debt itself to a point of bringing national borrowing to a halt.

Early in the Eighteenth century the Dutch and English had monetized national assets through a system of national borrowing formalized by Necker in Europe, and Robert Morris and Alexander Hamilton in America. Aside from a handful, no one could understand what they were talking about. Try reading that sentence a second time.

It amounted to guaranteeing all the private credit in the banking, investment, and commerce systems, with a national debt (in the form of Treasury bonds) which monetized all the assets of the whole nation. That action more or less doubled their value, just as any bank loan is seemingly owned by two people at the same time. Carried to an extreme, it might imply that America could turn Guam and Hawaii over to China if we defaulted on our debt. That was never actually intended to happen, and it never has, because all nations now fear the deflation which could result from triggering a massive exchange of national assets. The nebulous issue of "National Sovereignty" interferes with territorial transfers by any means other than war. If one nation defaults against a second nation which is afraid to go to war, it is just the stronger nation's hard luck about the debts it has chosen to support unless a transfer of assets actually happens. The Treaty of Versailles did transfer assets to the victors, and set off World War II, although it is considered bad manners to mention it. That's a simplified view of our international financial system, which admittedly skirts uncertainty about how much national debt is too much.

In fact, no one knows how much is too much until everyone runs for the exits. Now that politicians have control of computers and "big data", a modern description places the blame on Alan Greenspan the former Chairman of the Federal Reserve. For eighteen years Greenspan produced delicious world prosperity by steadily increasing American national debt faster than the American economy was growing. Sooner or later this approach was going to uncover how much was currently too much Federal debt. With silver and gold removed from the equation, one could see that default would certainly loom whenever the size of the debt became so large it could never be serviced by the Gross Domestic Product (GDP), and possibly sooner than that, if enough people could guess what was coming. This reality might be obscured temporarily by reducing interest rates, modifying international trade balances, and inflation. When the stars were in alignment however, the system just had to collapse and start over. Because it happened gradually, perhaps it would unwind gradually. In 2007 what happened was that everybody tried to get out the door at the same time. Essentially, our two political parties made opposite assessments: the party of Hamilton -- Republicans -- announced this system was doomed, while Democrats --the party of Andrew Jackson -- announced they could stave off disaster by making the rich Republicans pay for it. Both parties were partly right but essentially wrong, and the Democrats hired a better magician.

Henry Clay

It will take months or even years to be certain just what strategy was pursued. It would appear the Democrats chose to repeat the performance of the Obamacare legislation, eliminating national debate by eliminating the Congressional committee system of examining details in advance of a vote. Given one day to digest two thousand pages prepared by the Executive branch, no time was allowed for public opinion to form about Obamacare. In the case of the fiscal cliff episode, Congress was given less than one day to consider 150 pages allegedly prepared the day prior to the vote. Some will admire the skill of the executive branch in orchestrating this secret maneuver, but eventually, it must become apparent that policy decisions have been transferred from the legislative to the executive branch of government. Perhaps the Congressional Republicans are as stupid as the Democrats portray them to be, but it is also possible that a decision has been made to tempt the Democratic leaders into repeating this performance several times until eventually, the public is ready to consider impeachment for it. No matter what the strategy, we are now threatened with imagining some moment when gun barrels come level and live rounds slide home. We may pass up the opportunity to criticize Henry Clay for concentrating undue power in the Speaker of the House, or to uncover the way Harry Reid was persuaded to surrender Senate power to the Executive; both miscalculations are fast becoming irrelevant in the flurry of events. We came close to borrowing too much, exceeding our means to pay it back, that's all. A New York Times editorial economist feels we can "grow" our way out of this flirtation with danger, and we all certainly hope so.

Seemingly, there are only two ways to cope with over-borrowing, once we step over the invisible line. A nation may cheat its citizens with inflation, or it may cheat foreign citizens by defaulting on their currency. We are indebted to Rogoff and Reinhart for pointing out there is no difference between inflation and default except the identity of the cheated creditor; so most politicians prefer to cheat foreigners. Either way, cheating makes deadly enemies. Two centuries ago, Alexander Hamilton suggested a third way out of the problem, which we would today call "growth". But here, cheating is pretty easy: If the limit is some ratio of debt to GDP, find a way to increase nominal GDP.

Shale Gas and Argentina

The most astonishing current example of the power of "growth", is shale gas. It may not be totally clean, but it is cleaner than oil or coal, and far cheaper. We suddenly have so much of it the price of energy is artificially lowered, and we talk, not merely of energy independence, but of restoring the balance of international payments by exporting it. Germany is constructing steel mills to utilize iron ingots made in America with gas instead of coal. Pittsburgh was once the center of steel production because that's where the coal was, the most expensive ingredient to transport. Suddenly it is now apparently cheaper to transport the energy source to wherever you find limestone and iron ore. JP Morgan got rich the other way, transporting limestone and iron ore to Pittsburgh, where the coal was. Russia now finds it has lost its leverage over Eastern Europe's energy supply, and the Arabs (?Iranians?) will no longer have a monopoly to provide the wealth supporting Middle-Eastern mischief. China may lose interest in Africa. And in America we may develop the courage to rid ourselves of the corn subsidies for gasoline; cutting the wind and sunlight fumbles also emerge as obvious ways to cut the deficit. That's what we mean by growth. It's so powerful it makes action by any American President seem trivial by comparison.

Presumably, President Obama does not welcome being upstaged by an economic force he doggedly resisted. He may seek ways to imply it was his idea all along. When that happens, rest assured that everyone else is then a fracker. But there is another alternative Presidential path, which in extreme form is emerging in Argentina without much media attention. In short, Argentina discovered signs of oil deposits but was unable to exploit them. A European oil company was enticed to develop the oil reserves at its own expense, and effectively did so in expectation of reward from the resulting oil sales. Suddenly, the Kirchner government expropriated the oil company, paying for it with Argentine bonds. The ink was scarcely dry before the Argentine government abruptly turned around and offered to buy back the bonds for 24 cents on the dollar. And unless someone is willing to send gunboats, the previous owners of the oil company are just out of luck. Appeals to the UN are futile; because on the one-nation, one-vote principle, there are more expropriator votes in the UN than potential victims. The only thing visible which could save capitalism in South America from the revolution in shale gas competition. Presumably, Argentina has lots of shale gas, but who will lend them the money to frack it?

Correcting the Co-insurance Blunder

In this chapter we are discussing health insurance problems which the Affordable Care Act did not create, and for which its only blame is that it neglected to address them. The implication must be that a better health care reform bill would indeed address them, or at least give the public the impression that it considered the problems and for sufficient reason had to pass them by. It highlights one more important reason why this book hopes to generate the creation of a Grand Strategy rather than specific legislation.

The Blunder of Co-payment. Let's state that co-insurance sounds like a deductible but isn't, has shown very little deterrence value at its customary 20% level, creates the market for an extra insurance policy, and would never be missed if eliminated in its traditional form. A deductible, by contrast, is a single lump sum imposed at the beginning of an expense period, a so-called "Front-end deductible", whereas co-insurance imposes a sort of tax on every service, ie. a "20% co-pay". Examples: a deductible would be the first five thousand on a twenty-thousand dollar cost, per episode, or per year, and it does not change with the size of the bill. A 20% co-pay, or co-insurance, takes 20% of every charge. As the Affordable Care Act begins implementation, it is reported that the ACA plans to introduce 30%, 40%, and 60% co-payments through its insurance exchanges, in addition to a $5000 deductible, and in addition to tripling the premium. The matter merits considerable discussion, and it will probably receive it but details are presently very scanty. For example, there is already a flourishing market for 20% copay insurance which pays for nothing else, so the insurance companies will enjoy this feature of Obamacare which stimulates twice as many insurances. Congress would find a large co-payment enjoyable, since a 30% copay means the patient somehow pays at least 30% of its cost, out of his own pocket. These are also the numbers which get the businessman's attention in employer-based insurance. They appeared in a two-line notice in the New York Times, just before the Fourth of July holiday, and only chief financial officers have a lot of information about it. That sounds like a trial balloon which could soon be revised, but possibly not. If this is the final word, it will certainly imply the Administration is desperate to find reductions in the cost of the program. Put it in context: premium prices are doubled, a $5000 front-end deductible is imposed, a minimum of 30% of the program eventually lodges in copayment insurance which the patient must himself pay. On top of that, the only reliable evidence for what is going on comes from Chief Financial Officers, who as a group are the most hostile to the program because it involves them in myriads of complexities having nothing to do with their corporation's core business.

The position of this paper is that copayments should be scheduled to be eliminated entirely, but deductibles raised as high as possible, at least to $5000. This is not a small technical issue. Deductibles have proven effectiveness, while co-pay shows no effect on consumer behavior at the traditional 20% level. It is impractical to extend either approach to patients sick enough to deserve hospitalization as an inpatient because a growing proportion of "patient responsibility" charges reappear as bad debts. Alternatively, to raise office and outpatient price levels much above the minimum cost of hospitalization is not only unrelated but futile. It creates a substantial incentive to admit patients to the hospital in borderline cases, especially from emergency rooms and captive satellite clinics, recently enlarged to take advantage of artificially low-interest rates. Hospital administrators already complain that unpaid co-insurance is their biggest financial drain. The fact is, co-payments have already approached a practical upper limit, without any sign of affecting patient attitudes. Unpaid patient coinsurance is a sensitive indicator of dissatisfaction; there should be more feedback about it between the hospital and accrediting agencies. Since most insurance has a deductible less than $5000, there is probably some room left to increase deductibles, but public outcry can be expected unless something like a Health Savings Account is provided to ease the pain. Insurance companies will rush to be first with a new and improved "supplemental policy", another expensive blot on the landscape, designed to eliminate cost consciousness on the part of those who can afford it. The contradictory message sent by supplemental insurance is that reducing patient cost consciousness is a good thing.

A much better inpatient solution is available in the DRG system, even though it could use some improvement. And there is the potential of using credit cards attached to Health Savings Accounts as a source of data for improving DRG (Diagnosis-Related Groups) by capturing outpatient market costs and using them for market-based hospital cost accounting rather than hospital cost reports, which contain massive distortions from several levels of cost-shifting. Patient cost sharing, in general, is already approaching its limits and cannot be relied upon to produce the order of savings suggested by 50% co-pay. Other, more sophisticated, approaches are needed. To become convinced of this, it helps to understand its history and politics.

The way to cut hospital costs is to cut the indirect overhead costs. {bottom quote}

How did we come to this? Because so many industrial workers were quite healthy, young workers have always subsidized older, sicker ones, on the untrustworthy premise that when young ones became old ones, their turn will come (if they still work for the same company.). Trying to maintain "community rates", it was hard to find ways to pacify the young ones, unless you left the old ones stranded. This created pressure to keep deductibles low, even trivial because they would apply to almost everyone no matter how small his annual medical expenses and the young ones were already complaining about how little they were getting. Just how much effect deductibles exerted on premiums was difficult to calculate quickly. By contrast, a co-payment rate of 5% would reduce employer (or government) cost by 5%, while 20% would reduce cost by 20%, etc. To make the immediate point, a 50% co-pay would cut the cost of Medicare to the government by 50%, whereas even an actuary would have trouble producing quickly how much the government would save by raising the deductible by 150%, or to $12,000 annually. Once the negotiators walk away from the table, important consequences for the patients and hospitals will persist and grow, and the long-term trend of costs will be up. One-time convenience for the negotiators should be the least consideration of all, but human nature is human nature. Legislators are implored to hire an actuary to tell them the answers to these numbers (in the form of a table of numbers), so they do not exchange momentary convenience for riots in the streets. And the President must be persuaded not to claim that the "service" benefits are unaffected, or his campaign promises of retaining benefits seemingly satisfied. If you double the premium and double the copayment, you are only providing 25% of the historical benefit, even if an appendectomy is an appendectomy and it's a "covered service". Because of bad debts, raising the copayment from 20% to 50% is only likely to increase revenue by 40% at most. The way to cut costs is to cut the indirect overhead costs, and this insurance talk seldom touches that subject. The place to get more revenue is from people who are healthy or to borrow it. At the moment, 50% of Medicare costs are borrowed, in the sense that they come from tax revenue, which increases the national deficit, which ultimately leads to borrowing.

Doesn't all that make it sound more attractive to look for new sources of revenue? The traditional sources are pretty well exhausted.