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Newsflash to the U.S. Healthcare System:

We can't afford you.

Otherwise, we (mostly) like you.

Signs we can't afford you:

1.) The leading cause of personal bankruptcy in the United States is inability to pay for medical bills.

2.) Over 45 million Americans have no health insurance, which does not include the under-insured. Add to this the uninsured non-citizen immigrants.

3.) The cost of a universal health insurance program is a primary barrier to its implementation in the U.S.

4.) Health care expenditures continue to increase at a rate exceeding economic growth, which is unsustainable. For every $6 of income generated in the U.S., over $1 goes to healthcare, or about $7,500 per year for every U.S. citizen. This is over $2.2 trillion per year. In contrast, the current proposed healthcare reform will cost $0.9 trillion over 10 years.

5.) Hospitals are reporting record costs to treat those who cannot pay for their healthcare. In the hospital health system where I work, these uncollectable fees have exceeded the system's capital expense budget for the first time ever.

I want to put the healthcare reform debate in another perspective. Healthcare is already too expensive. There seems to be a public perception that national healthcare reform itself will carry a price tag too great for the country to bear. I argue these costs already exist below the radar, absorbed across multiple areas, such as bankruptcies and indigent care provided by hospitals.

Granted, a universal system will increase total costs short-term, but supporters claim long-term savings. The theory is that by providing less expensive preventative care to the uninsured and under-insured, they will stay healthier longer, be more productive, and avoid the need for expensive medical treatments and emergency room visits they cannot afford (which will be absorbed by the economy one way or another).

Preventative care has long-term healthcare savings by delaying the need for more expensive medical treatment. For example, most chronic health conditions are progressive or degenerative diseases, which increase in severity over time, especially if left untreated. Examples are diabetes, high blood pressure, dyslipidemia, osteoporosis, rheumatoid arthritis, asthma, and Alzheimer's dementia. Such diseases are less expensive to treat early when symptoms are less severe and when treatment can slow disease progression and delay more expensive treatments... but the early stages of such diseases are also easier to leave untreated, and they progress more quickly into expensive, debilitating diseases.

Why I Encourage a Change in Perception

So, why am I saying healthcare is already too expensive? And why do I say the transient cost increases of healthcare reform is not the crux of the issue? Because if the healthcare sector is already too large, then logically, it must contract and shrink. I'm not necessarily saying healthcare professionals must be laid off (on the contrary, there aren't enough of us), but the total costs of healthcare must decrease.

Consider the recent real estate bubble and the tech bubble of the 1990s: whenever an economic sector has a prolonged period of vigorous and unsustainable growth, what is popularly called a "bubble," it is followed by an inevitable crash, as the bubble bursts. Healthcare is a bit different, however. The real estate bubble burst when unsustainable growth made property too expensive, and demand plummeted when the foreclosures began. The tech bubble burst when unsustainable growth and investment failed to produce returns, and demand plummeted when customers and investors pulled their funding.

Other bubbles burst when demand plummeted. But demand for healthcare is increasing, and will continue to increase as baby boomers age. Long-term, demand will decrease as baby boomers die, because the next generation is smaller and will be a smaller elderly population... but I think the crisis will reach a critical point before the baby boomers have died. More precisely, I think the crisis will reach a critical point because of the baby boomers.

The healthcare bubble will burst because healthcare will be too expensive for us to pay for the services we need. How will this play out? Well, if you think public rage over Bernie Madoff and bonuses paid to executives by corporations receiving federal bailout money was unprecedented, just wait until you see what's next.

Hospitals and healthcare systems are terrified by the current proposed healthcare reform because President Obama has said Medicare payments to them will be cut by $500 billion annually. Hospitals don't know how they will remain economically viable. In fact, a study by (I believe) MIT has said virtually all hospitals would operate at a loss if this happens. Of course, this assumes hospitals take no action to improve the efficiency of their cost structure.

But here's the irony: this $500 billion cut that terrifies hospitals, which threatens to make all of them operate at a loss, is a soft landing. It's the best case scenario! If we do nothing, and the bubble bursts, and the public is enraged about the healthcare they cannot afford, one or more of three things will happen:

1.) We adopt a national healthcare policy of the "Have's" and the "Have Not's," where those who can afford it get it, and those who cannot suffer. The U.S. has already implemented this to a degree, but the distinction will become greater. As any public health policy expert will tell you, having so many ill and unhealthy people living and working near well and healthy people is not practical. The spread of disease will be rampant, and this will lead to either #2 or #3...

2.) As a nation, we'll continue to go in debt to pay for unsustainable increases in healthcare expenses, until other nations and their economies stop buying treasury bonds and investing in the U.S. dollar. The dollar will be worthless, inflation will be unimaginable, employment far worse than the 25% it was during the Great Depression. This will lead to #3...

3.) The U.S. government will be forced to implement Draconian cuts to healthcare. Healthcare workers -- including as doctors, nurses, dentists, pharmacists, radiology techs, psychologists, medical office staff, and hospital workers -- will either be out of work or be forced to take drastic salary cuts, or both.

I have no solution to propose, but merely describe the situation as I see it: either we, as a nation, have a bumpy, uncomfortable landing now, or we continue to delay the inevitable, bringing an increasingly catastrophic crash the longer we wait.

When I say healthcare is already to expensive and we can't afford it, I mean there are excessive costs, and they must be absorbed somehow. There are a few basic choices. There is no "ideal" solution, but the best would be a nuanced blend of these. Here are your choices, folks:

1.) Shift the costs to the healthcare system (a.k.a., "government takeover"). Healthcare will be cheaper... which may comes at the cost of fewer services, but also a more cost-efficient system.

2.) Shift the costs to the government. Everyone might get healthcare... but by itself will not reduce rising costs.

3.) Shift the costs to the payers, that is, insurers and patients. Reduces wasteful spending... but also reduces preventative care, and increases long-term costs.

I wish I have it all wrong, but basic economical concepts of limited resource allocation and supply and demand have an uncanny way of asserting themselves. Sometime in the next 10-15 years, between 2020 and 2025, I'll revisit this post, and discuss how prophetic or foolish I am today.

:: Bryan Travis :: 09/29/2009 @ 13:53 :: [link] ::
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On Our New President

Cited in this post:
A&E Biography: Barack Obama - online video
This American Life: The Inauguration Show (link to mp3 here)

There was a time, let's say a year ago, when the presidency was much less certain, and I leaned toward Hillary Clinton as the safer choice. This was a time when Mike Huckabee was the Republican front-runner, and my reasoning was that under no circumstances should another openly evangelical become president. At the time, Clinton and Obama's policies seemed more-or-less the same (there was, you recall, their struggle to differentiate themselves). So, Clinton was the safe and roughly equivalent choice. She would be a lightning rod for Republican derision, the singular individual Limbaugh, Hannity & Co. love to hate, but it seemed she stood the best chance against a relatively inexperienced newcomer, and, let's face it, a mixed-race black man. Despite his charisma, the thought of an Obama's presidency was surely a pipe dream.

I remember telling my wife that Republicans (of course) wouldn't use race outright against Obama, but they would find subtle, very subtle ways of using it to prey on people's fears and prejudices. When I first heard Sean Hannity and his talk show callers referring to him solely as "Barack Hussein Obama," I was ready to retract my prediction that it would be subtle.

As the seasons changed, winter to spring and eventually summer, so did my perception of Barack Obama. At first, I began to hope he could pull off the primary, because the man was downright inspiring, although I still worried his race would unfairly be his downfall. For this reason, in late winter, I still would have voted for Clinton, but I live in Kentucky, whose primary was in late May.

By May, I fully supported Obama. Again, I didn't perceive much to distinguish on platform and policy issues, so it came down to personality and, more importantly, ability to win the final prize, the presidency. I cast my primary vote for Obama. In Kentucky's primary, Clinton handily defeated Obama by more than 2-to-1, 65% to 30%. This was expected. I can say without reservation that race was a leading reason for Clinton's landslide victory in Kentucky. I've lived here my whole life. I grew up in a rural area, and hearing racial slurs and epithets was common, even in my family. It's particularly insidious when it's subtle, allowing it to be explained away as no big deal. The most frustrating excuse I heard was when someone 40+ years my elder would say something racist, only to have it explained away as "the way things were when they were brought up." Personally, I've always believe one should behave and act according to the way things are, not the way they were, but such concepts are difficult to articulate when you're young. Worst of all, I've never been confrontational, so I'd let it stew inside my mind, venting my frustrations in less confrontational ways, such as I'm doing now.

By this time, McCain had the Republican nomination. McCain's Centrist appeal, his ability to draw voters from the middle, was an advantage over Hillary Clinton, the chink in the armor this Republican lightning rod could not overcome. Barack Obama also had a Centrist appeal, but I still doubted he could defeat McCain. I began to rationalize to myself that a McCain presidency wouldn't be so bad, anything was better than Bush. McCain was friendlier to environmental concerns and actually acknowledged that the budget deficit was a problem. Reproductive rights would suffer, with abortion rights one Supreme Court nomination away from being lost, but at least there was hope McCain would accept the clear evidence that "abstinence-only" education has been a failure.

Everything changed after the Democratic National Convention. When McCain announced Sarah Palin as his running mate, there was a surge of excitement. In those first days, I thought McCain had won for sure. But it was like a wave, a surge of high water, which was followed by a return to a normal level, which was followed by a trough of low water, a trough which never recovered.

When Sarah Palin opened her mouth, the tide began to turn. I couldn't imagine a president worse than Bush, Jr. until I thought about what would happen if McCain died in office. I mean, even Bush went to Yale, but Palin? Well, whenever she spoke, it was clear she was uninformed and lacked curiosity about the world outside Alaska before she was tapped by McCain. I'm no politician, but even I could best her in knowledge of current events. Okay, I admit I didn't know what the "Bush Doctrine" was by that name, but if told it had to do with foreign policy, I immediately would have known it was the philosophy of pre-emptive strikes against perceived foreign threats, a.k.a. Operation Iraqi Freedom. And in my adult life, no one has had to explain to me that Africa is a continent of 50-some nations, not a single country.

Things only got worse for John McCain when the economy began tanking, and he insisted the fundamentals of the economy were strong, then said economic matters have never been his strongest suit. Finally, when McCain suspended his campaign to return to Washington to deal with the undeniable economic crisis, only to re-engage when Obama responded in his calm manner, it was clear who was strategic and thoughtful, and who was tactical and knee-jerk.

On election night, that fateful night, my wife and I knew Obama had to win, it was so obvious, but still, we weren't certain, weren't confident, until late that night. I cried, folks, yes, I did. I was joyous my candidate had won, I was happy for him and for history. I was proud of my country for proving me wrong and overcoming generations of racial bias to elect Barack Obama president.

Still, though, all the McCain and Clinton campaign rhetoric about Obama's lack of experience took its toll on me. What if... what if he couldn't deliver? About a week after the election, I happened upon an A&E Biography episode about Obama available on our cable's "OnDemand" service. It removed all doubt.

Obama came from diverse backgrounds. Kansas, Kenya, Hawai'i, Indonesia, Harvard, and Chicago. He struggled with his identity as a child, which ultimately led to his respect for all backgrounds and being a consensus-builder. President of the Harvard Law Review. Community organizer. Voter registration programs. Constitutional Law professor. State senator. National senator.

Obama's life has taught him to understand people, to see how we are more alike than we are different. He has developed a systematic approach to accomplish his goals by winning the support of those around him. I've heard critics say he inspires by telling everyone what they want to hear, which makes everyone identify with him, but when it comes to putting all his promises into action, he will fall short and fail.

Well, sure, he probably won't be able to deliver on everything. But after that Biography episode, after getting a better understanding of the man and his accomplishments to date, there are a few things I believe about Barack Obama:

  • He will prioritize and concentrate on his "grand slam" promises.
  • He will address issues strategically in order, so that a chain of events will fall into place. For example, bandage the economy just enough and bolster infrastructure so that when the wave of recovery begins, he can address energy independence by stimulating innovation, and use the mounting economic momentum to begin addressing the national deficit, or at least pave the road for the next president.
  • His inspirational and consensus-building personality is his most valuable asset. It's not "bark and no bite" as critics claim, but the perfect execution of the Dale Carnegie philosophy. That is to say, How to Win Friends and Influence People. His ability to inspire others is what always has helped him succeed, and will continue to do so.
  • He genuinely cares about people.
  • He's going to do just fine. Do great things, even.

There was honesty and truth in his inauguration speech. He said things I couldn't have imagined a president saying before. Things like...

  • Our economy is badly weakened, a consequence of greed and irresponsibility on the part of some, but also our collective failure to make hard choices and prepare the nation for a new age.
    ...
    But our time of standing pat, of protecting narrow interests and putting off unpleasant decisions that time has surely passed.

Our collective failure to make hard choices and prepare the nation. Wow. That's Social Security, healthcare, and deficit spending he's talking about. Presidents to date have ignored Social Security reform out of fear of the political repercussions of changing the program. Someone needs to go there and fix what's broken. I hope he will.

  • We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost.

He shouldn't have to restore science to its rightful place -- it never should have been removed from it. But you know, if it hadn't been for George W. Bush, would the nation have been ready for Obama's new way of thinking? It took a frustrated nation hungry for change to pave the way for Obama.

And speaking of fresh ideas and new ways of conducting business, these last three quotes from Obama's inaugural speech are a bold departure from the Reagan-style politics that have dominated for nearly 30 years:

  • The question we ask today is not whether our government is too big or too small, but whether it works...

Some will say this is typical Democratic "big government" and "tax and spend," but the last four words make the difference. The Reagan-style assumption is that government must always smaller, and big government is bad. Do you want better government or bigger government? That's a false choice. The real choice, the question we should always be asking, is "whether it works."

  • Nor is the question before us whether the market is a force for good or ill. Its power to generate wealth and expand freedom is unmatched, but this crisis has reminded us that without a watchful eye, the market can spin out of control - and that a nation cannot prosper long when it favors only the prosperous.

A truth can be so obvious that it seems it doesn't need to be said. But in saying it, stating the obvious, a great realization and awakening can occur, a realization that sometimes what is so obvious is so easily forgotten or overlooked. "A nation cannot prosper long when it favors only the prosperous." Again, I say, "wow."

  • Recall that earlier generations faced down fascism and communism not just with missiles and tanks, but with sturdy alliances and enduring convictions. They understood that our power alone cannot protect us, nor does it entitle us to do as we please. Instead, they knew that our power grows through its prudent use...

Just when it seemed diplomacy was dead, along comes Barack Obama to remind us that while the military has its purpose, not every problem is a nail that can be solved with a hammer. In the age of George W. Bush who would not "negotiate with terrorists," or anyone else he didn't like, for that matter, it's important to remember Republicans like Nixon failed in Vietnam by use of force, but when he used diplomacy, we found out that "only Nixon could go to China," and a diplomatic Reagan helped Gorbachev peacefully end the Soviet Union.

While I never expected my home state to support Barack Obama for president, I was pleasantly relieved that the nation as a whole would. I'm glad I was wrong about the importance of race in national politics. But most of all, as I was reminded by this episode of This American Life, I'm glad we have a president who will listen, as was explained by a member of an Iraq and Afghanistan veterans organization, IAVA, who was shocked when the Obama Transition Team contacted his group for input who they'd like to see appointed to the Veterans Administration, something that made them do a double-take after their dealings with the previous administration.

No matter what happens, this president has a different approach and philosophy. I don't know how many problems he'll manage to solve. But when was the last time we had a president come into office with such a mess to manage? The fact there are so many problems to manage from day 1 suggests many things were not done well before. An administration with a new mindset and a leader who seeks input from all the stakeholders could hardly do worse. I am proud, so very proud, to have a thoughtful president, this breath of fresh air. Not to mention one who speaks in complete sentences without mushing his words.

Yeah, I'm sorry, Mr. Obama, because I know you wouldn't approve of such gloating and mean-spirited pettiness directed at your predecessor, which flies in the face of what you're trying to achieve. I couldn't help myself this one last time.

:: Bryan Travis :: 01/24/2009 @ 15:06 :: [link] ::
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Passed

Well, I made it - passed the boards and am now a pharmacist. Everyone passes, so passing the boards is nothing miraculous in and of itself, but it's the getting here, the four year journey, that makes the accomplishment.

It would be nice if I could relax, but such is my personality, that I always worry. Tackle one thing, and transfer the anxiety to something else. Pass an exam, then worry about the final. Get all the coursework behind me, then worry about rotations. Finish rotations and graduate, then worry about boards. Pass boards, then worry about being human and making a simple order entry error that seriously harms someone.

On the subject of order entry, I dream about inputting orders. Regularly. I never dreamed about my job at GE. I'd dream about the people there, but never about doing my work. In my order entry dreams, I'm simply inputting medication orders scanned down from the hospital units. They are not nightmarish -- I don't make mistakes, nothing bad happens, I don't worry -- so I'm not transferring my anxieties about making an error into them. Order entry requires concentration and critical thinking, but the workflow itself is repetitive. I'm not sure if it's the concentration, the repetitiveness, or both, that causes the dreaming. And it's not just me -- several other pharmacists dream about it, as well.

Our daughter is three months old. Time flies. She's almost doubled her weight. She tracks movement, makes eye contact and smiles, makes increasingly complex vocalizations over time, and has started grasping objects with intent.

It's fascinating to watch an infant develop her consciousness. When they're born, the senses aren't integrated. A couple weeks ago, she didn't realize her hands were under her control and capable of manipulating objects in her field of vision. She still doesn't realize the causal relationship between her sense of touch and physical contact. As she learns these concepts, she's not only forming her conscious awareness, but also her worldview, her perception of reality. Being able to hear food cook, smell it, see it, taste it, and realize all that sensory input is coming from the same object isn't something she can do. She's only beginning to realize one object can affect multiple senses, and that she can integrate the different senses to broaden her understanding of the world around her.

I love watching her start to put it all together, and I photograph or record every new activity that suggests she's developing a new awareness or skill.

:: Bryan Travis :: 07/17/2008 @ 01:32 :: [link] ::
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Happy Birthday

April 19, 2008: Day 0

Happy Birthday.

Born Saturday, April 19, 2008 at 1:29pm ET

7 pounds 12.4 ounces, 20 inches

:: Bryan Travis :: 04/19/2008 @ 22:21 :: [link] ::
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Today

April 19, 2008: Day 279

This is it.

:: Bryan Travis :: 04/19/2008 @ 08:23 :: [link] ::
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Did It Again

My mother wouldn't let me eat around the computer when I was a kid. What am I doing right now? Eating some sort of shrimp pasta dish my wife brought home from a baby shower. The to-go box is on the desk, with the sliding keyboard tray between my food and me. I nearly dropped piece on the keyboard, and it made me remember why my mom said that. When this baby grows into a kid, we won't let her eat around the computer, either. That means I won't be able to eat around the computer anymore. A baby changes everything.

After that meltdown over not being able to paint the door trim, the sun came out and evaporated the rain, and it finally got painted. Today I powerwashed the floor of our deck to remove the old paint so I could repaint it hopefully Monday. Just the floor, because that's in the worst shape, and I can paint it in about an hour with a roller brush mounted on a broom handle.

That same weatherman who predicted a 0% chance of rain says Sunday and Monday will be sunny, and Monday will be warm enought to paint. Oops, I did it again, getting myself into a precarious painting situation. We want to sign the contract with our selling agent and put the house on the market Monday, so I really set myself up this time.

I checked the forecast, and our beloved meteorologist Bill Meck predicts a 20% chance of snow on Sunday, but still 0% chance of precipitation on Monday. Meanwhile, there's an 80-90% chance of rain tomorrow and Saturday. Hmm. I'll be interested to know how the deck timbers are going to dry out before I paint them on Monday, because I am painting them Monday afternoon. I was rumaging through the garage and found a large roll of plastic dropcloth the previous owner left behind. Can you believe that? After living here nearly four years, we still find things the last guy left. Anyway, I could spread the plastic sheet over the deck to keep out the rain. The plastic would trap heat, and water vapor would dissipate below the deck. We'll see. And after all this time, we kept a can of the deck paint so we'd know the color should we ever have a need to repaint.

I'm taking a nuclear pharmacy rotation this month. Since the radio-labeled scans start early in the morning, and the customers can be up to a couple hours away, the pharmacy starts preparing doses at 10pm the day before and goes all night until 2-ish in the afternoon. All of this to say that this week, I've been going in at 5am to catch the tail end of the second batch of doses being prepared. It's nearly 11pm. Therefore, I'm sleepy, really sleepy. So sleepy that I dozed off for a few minutes while sitting in the computer chair. I'm going to bed.

:: Bryan Travis :: 03/13/2008 @ 21:59 :: [link] ::
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Rain, Rain, Go Away

I wish I were waiting for paint to dry, but instead, I'm waiting for rain to dry. We're trying to put our home on the market ahead of the upcoming birth and move to northern Kentucky, where I've accepted a job. I replaced some exterior door trim nearly two months ago, and I've been waiting to paint the darned thing. We also replaced a fencepost on our wooden privacy fence, which needs to be painted with wood stain. These projects require a dry day with temperature above 50F for many hours. We were in Hawai'i for the first half of February. Now, don't get me wrong -- we missed out on a lot of typically crappy Kentucky winter weather, and I'm way grateful for the escape to a pleasant, tropical climate -- but there were several perfect painting days during our absence. And there haven't been any since our return... except today.

Well, it was supposed to be today. I watched the weather forecast all week. "We're setting up for a wonderful weekend," they said, and "the first cold front will be moving out to make way for clear weather this weekend before the next storm system comes in early next week." Every day as the weekend approached, the 8-day forecast displayed a Raisin Bran-esque sun and "0%" chance of precipitation for Sunday. I thought today was a sure thing.

As for those raindrops running down the door trim and the soaked fencepost I planned to paint today, I don't know how that happened, but there's no denying the heavy clouds and the water falling out of them. Check out the current doppler radar, courtesy of the television station who's been forecasting a perfect Sunday all week. I live below where the "L" meets the "E" in "LEX" on this map, near the county line. Notice how it's just a little bit of rain, just enough to wet everything down so I can't paint outside today before it seriously starts raining and snowing tomorrow? YES! That's the kind of luck I'm talking about!

I'm banging my head against the wall in frustration... figuratively, that is, because I've done enough touch-up work on the interior walls, trim, and ceiling of this house, because I've already screwed up enough things as a result of trying to fix something else, and then had to fix my screw ups. In other words, the only thing keeping me from literally banging my head into the wall is the awareness it'd probably do damage to the wall that I'd have to fix later on, and I've had enough irony with this house already.

Okay, so I admit it -- I'm easily frustrated over this house thing, and this unexpected crappy weather day is just the latest in a chain of small annoyances that have nickel-and-dimed my positive outlook savings account deep into the red, much as this house will do to our financial savings account if it sits on the market for months and months without selling, because we have to move, and if this house doesn't sell, we have to carry two mortgages. Much like Kentucky weather in February, my demeanor is seriously lacking in bright, sunny days to support cheery optimism.

Hawai'i was nice, however. Perfect weather, beaches, perfect weather, mountains, vacation, perfect weather, coral reef snorkeling, relaxing, perfect weather, coffee and good food, volcanoes and lava, perfect weather, humpback whales. I brought back a ukulele, a most fun and quirky little instrument to play. More on that in another post.

March 2, 2008: Day 221

The baby... she's gettin' big in there. Kicking all the time, her butt visibly protruding through mom's belly. She's positioned herself head down, which is a good sign against a breach birth, even if she is positioned somewhat laterally instead of head straight down. Our nurse-midwife showed me how to feel her head and body to guess at her position, and that's a cool, if not somewhat eerie, trick. The first baby shower is today. It was originally scheduled for last Sunday, but it was cancelled because of snow, but I don't want to get stuck on that weather thing again.

Maybe, with a hair dryer or heat gun, I could get that door trim dry enough to paint. I'm so ready for spring.

:: Bryan Travis :: 03/02/2008 @ 13:58 :: [link] ::
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We'll Leave the Light On

January 25, 2008: Day 184

It's been six months since you were conceived, and you're two weeks into the third trimester. You're due in 82 days. If you were born today, you could probably breathe on your own and at least respond to changes in body temperature, even if you would still have to be in an incubator since your little body couldn't generate enough heat. But the important thing is, if you are born today or any day after, the odds are overwhelmingly in your favor. The nurses and doctors will fight for you and do whatever it takes.

I realize that in my writing, I often comment on your survival odds, and upon reflection, I admit it might seem obsessive and even morbid to dwell on such things, but you know what? Damn right I dwell on these things! I'm practical, and I'm a realist. It doesn't change my love for you... quite the opposite, in fact, because it's how I've expressed my concern for your well-being. I never allowed this line of thinking to escalate into a frenzy of worry, but there was always enough concern to keep us (your mother and me) aware of and focused on your health. We never lost focus, we never considered your successful birth to be a foregone conclusion, which means we were never complacent or flippant about your pregnancy, we never took this for granted. We were always in your corner, pulling for you and cheering you on.

I believe that every once in a while, when we're in the privacy of our home and not around other people, it's worthwhile to go a day or two without a shower, because that next, much needed shower is a most rejuvenating experience. You can't appreciate how good it feels to be clean until you've known the misery of being grimy and dirty. In the same way, being aware of all that can go wrong in a pregnancy helps us appreciate how fortunate we are when things go right. Our family has been extremely fortunate thus far, enough so that whatever challenges may come our way, we can take them head-on with confidence. Not arrogance or complacency, but confidence. Of course, some couples try so hard to have a child, some spend a small fortune trying to adopt, that'll we'll never truly know how lucky we are.

We enrolled in a Bradley Method childbirthing class. This was your mother's planning, and it's been a valuable experience. We've learned exercises to strengthen your mother's body and prepare her and you for birth, simple ways to help birth go better for everyone involved, things I think the medical community should teach all expecting mothers in a country where one-third of babies are delivered by Caesarean-section and birthing interventions abound.

The Bradley Method has also taught us a new way to approach diet. For example, avoiding excessive weight gain is important, but it should never trump proper nutrition. The Bradley Method teaches what a balanced pregnancy diet is, and how a proper diet will maintain proper weight gain. Traditional obstetric practice addresses the issue in backwards fashion: stressing proper weight gain to expecting mothers, and placing less emphasis on diet. So, by telling a pregnant woman she's gaining too much weight, but not teaching her how to make informed diet choices, many medical professionals unwittingly motivate women to eat less and get inadequate nutrition.

I always thought it was normal and healthy for the breaking of the waters to signal the start of labor (in fact, many ob/gyns will puncture the amniotic sac to help labor progress). Breaking the waters early is not necessarily a good thing. The forewaters around the baby's head provide cushioning and protection during labor, and reduce the mother's discomfort as the baby's skull pushes against the pelvis and pubic bone. Consuming plenty of protein helps strengthen the amniotic sac, ideally keeping it intact for cushioning until moments before birth. So now, we hope for a birth where the water gushes out as the head begins to crown, and we will not allow a physician or midwife to break your amniotic sac simply to progress labor for convenience's sake.

Episiotomies are to be avoided. Even a few minor tears are preferable to the single incision of an episiotomy, because on the whole, vaginal tears heal with fewer complications than episiotomies. Call me crazy, but I believe that our good friend Evolution has responded to crowning by developing vaginas that can heal from tears, but hasn't had an opportunity to respond to the relatively new practice of episiotomy. But in the meantime, squatting and consuming plenty of unsaturated fat and protein helps make the perineum all stretchy-like.

I could go on, but you get the point: these childbirthing classes have given us a new perspective. And to think I was initially resistant to the $250 cost and 12-week commitment! I'm almost ashamed.

What else? We have your crib and dresser with hutch. That crib is quite nice, I must say. Solid, heavy construction, the kind that won't wobble when you grab on and push and pull. Unless we use it for a second child, you'll come to know it as your childhood bed, for we also bought the rails to convert it into a full-size bed. This, too, was your mother's doing. She takes the lead on most everything, while I sit around and pontificate about them in my weblog.

Well, I did take the lead on the electronics: a camcorder to record your milestones, and a camera to capture the moments that go by so quickly and only come once, the moments we want to treasure and not forget, the very moments you'll hope we never show a significant other before a date. Please understand we do it with the best intentions at heart, as a test. For whoever adores our daughter at her most precious or entertaining moments, only these people are worthy of her heart. Trust us on this one.

You're kicking quite a bit, your poor mother's bladder... and sometimes, when you flip, it's your poor mother's ribs we talk about. Not only have I felt you kick, I've seen lumps and bumps move around. A couple weeks ago, we first heard your heartbeat with our own ears through a stethoscope, not amplified through a doppler microphone. The other day, when I coughed next to your mother's belly, you kicked as if startled, so we know you're aware, if not consciously so. I've been shining a laser pointer and moving it over your mother's belly, trying to elicit a response... none yet, but we're certain the glow penetrates blood and tissue, because it's red and bright. Perhaps you think the red glow is nothing to be concerned about or worth moving for, at least not enough for us to feel. Of course, you can't even open your eyes for a few more days.

Until then, we'll leave the light on for you.

:: Bryan Travis :: 01/25/2008 @ 23:49 :: [link] ::
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Getting To Know You

First Ultrasound
December 9, 2007: Day 138

The story so far:

Back in 1975, when your mother was still unborn in her mother's uterus, the egg cell that would become you was formed. Fast-forward through time to August 1996 when your mother and I met, to July 2004 when we married. In mid-May 2007, an unknown and unremarkable spermatogonium in my body became a committed stem cell, one of a million to do so that day, and began the process of producing numerous sperm cells. On July 25, 2007, your mother ovulated and released an egg cell; sometime during the next 24 hours, it was fertilized by a sperm cell descended from my unknown and unremarkable spermatogonium. Thus you were conceived, a lone zygote. Over the next few days, the zygote divided time and again to form a blastocyst, and implanted into your mother's uterus. Thus began your pregnancy, the result of a long series of highly improbable events leading to your creation.

A few days ago we found out you are a girl. I suspected as much, but knowing with certainty is a new perspective. I try to imagine what the start of your life will be like, your personality and who you will become, based solely on your gender. No doubt, you will surprise me at every turn. I am told raising girls is easier than boys for the first few years, then puberty comes, and the tables turn. I will always question the example your friends set, as well as my own actions. No boy you bring home will ever be good enough for you, and I will probably make them painfully aware of my opinion with my critical glare when you're looking the other way.

As for now, we can begin preparing to indoctrinate you in the gender roles ascribed by society. This starts with your name, which we've given only the briefest of consideration, but I imagine a name starting with a letter in the first half of the alphabet. Next is clothing. I pledge to keep the number of pink and/or poofy articles to a minimum, insomuch as I can influence the family and friends who may give you such gifts. The rest is up to you. Then the toys. I expect you will have dolls, appliances, and houses to simulate being a homemaker in your own family someday, and as long as you feel free to aspire to anything you desire, I will be happy to help bake cookies, choose outfits for dolls, and have tea parties with you. I'll even do the dishes.

:: Bryan Travis :: 12/09/2007 @ 10:32 :: [link] ::
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Birthright

November 3, 2007: Day 102

You are the lucky one. Birthwise, that is. Your mother has been coming home with a box of diapers every now and then. Stocking up, she says, to spread costs over time and soften the blow. Yesterday, I saw Winnie the Pooh bibs on the kitchen counter (yellow, of course) when I came home, and I suspect your grandmother may be responsible for those. My mother has taken her daughters-in-law to Gatlinburg for the weekend, and I think she brought those bibs with her. Your mother will return from her trip with clothes for you, I am sure.

Your younger sibling won't enjoy anything approaching the level of attention you've had during your pregnancy. We'll be too busy with you, taking care of you, reading to you, peeling grapes for you (seriously -- you could choke), to devote as much time and energy preparing for pregnancy number 2 as we did for number 1. Number 2 will have to peel their own grapes, or brave the skins alone. The infant clothes you wear will be the same clothes number 2 will wear, with the added fashion statement of the stains you left behind... and if you are both the same gender, number 2 will be wearing your stains for years.

I won't write as many weblogs to number 2. We won't take a weekly picture of your mother's belly. She'll forget to take her prenatal vitamin and omega-3 supplement more often. You'll learn to read sooner than number 2 because we'll read to and work with you more. These things are unfortunate realities for number 2, but a boon for you.

Starting when I was 6 or 7, until I was maybe as old as 10, I would ask my mother who her favorite child was. Her answers were appropriately non-committal: she loved us both equally, she said. I obsessed with the question for two reasons: one, I had a brother after four years as the spoiled only child; and two, his health problems earned him coddling and attention I never knew. I understand now that my mother's evasive answers were truthful. A parent does (or should) love all their children equally, but that doesn't prevent the firstborn from enjoying an unfair advantage because of the excitement and newness the parents experience the first time around, both before and after birth.

Someday, years from now, when you are a toddler, and your mother and I have a second child, you may feel forgotten when we bring home a new baby. You may act out, and, if you are old enough, you may experience a most unpleasant emotion, jealousy. If you experience these emotions, you will perceive your situation as unfair. I felt that way, too. Not until years later did I see things from a different perspective. In fact, it wasn't until I began writing this weblog that I realized what I actually lost after the birth of my brother wasn't fairness, at all. In reality, I had lost part of the unfair advantage of being the firstborn... just a part of it.

What I considered unfair was actually a leveling of the playing field, but the field can never be perfectly level. No matter how many babies we bring home after you, you will always be the first. Your mother and I will always devote that extra effort, that unfair advantage, to prepare you and us for your milestones. Walking. Talking. Learning the alphabet. Reading. Spelling. Writing. Making friends. Going to school. A second language. Memorizing multiplication tables. Algebra. The first relationship, first kiss, and it's painful end. Driving. You'll always be our first child to do anything, and that means we, your parents, will always spend that extra time sweating and fretting for you.

:: Bryan Travis :: 11/03/2007 @ 15:53 :: [link] ::
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Follow Your Heart

October 19, 2007: Day 87

We heard your heartbeat last week, 155 beats per minute.

Welcome to the second trimester. Since the last time I wrote, you've tripled in size, from just less than an inch back then to over 3 inches today. A couple weeks ago, you were growing 250,000 brain cells every minute. Like glitter in a snow globe, many of those neurons will flash into life only to flicker out and be replaced by others. No one knows why the brain develops that way. It seems wasteful, but there is always a reason. Prenatal development is the most amazing time of an animal's life. In the weeks ahead, you'll grow faster than you ever have, or ever will.

I have no way of knowing if you are a boy or a girl, but before next month when we'll find out, I want to say it for the record: I think you're a girl, based solely on my "Spidey Sense." We'll find out soon enough.

Something that's been troubling me is the matter of religion and how you will or won't be indoctrinated into it. Your mother and I have differing opinions on the subject, and mine is undecided. I was raised evangelical Baptist, once considered myself a student of Buddhism, and today I am agnostic-about-as-close-as-it-comes-to-atheist.

Part of me hopes you'll follow in my footsteps, and part of me worries for you and hopes you don't, because it isn't easy believing this way. There are those who fear and despise people who believe as I do. I know -- I used to be one of them. I don't want that for you, for you to have to endure that. After a recent school-shooting in South Carolina, TV crews interviewed the school's students, and every one of the shooter's classmates said he didn't believe in God, as if to imply, if only he believed in God, this horrible tragedy would not have happened. The popular opinion seems to be, that of those who believe in God, some are good people and some are bad people, but of those who don't believe in God, all are bad people.

What is it that I want for you? What will make me happy for you and proud of you? I've been pondering those questions as I've been thinking about how to write this.

Roughly 7 in 8 people practice the same religion as their parents. If you believe as I believe simply because I taught you to believe what I believe, I could never be happy knowing that. Conversely, I could never be satisfied with you growing up in a church and being taught to believe what the other members of that church believe. It doesn't matter if the belief system is mine, your mother's, or a church's -- either way, it's indoctrination into a belief system not your own. I will be happy if you are never afraid to think independently and critically, to always and relentlessly question why, and decide what you believe based solely on your own reasoning.

:: Bryan Travis :: 10/19/2007 @ 20:56 :: [link] ::
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Here's Looking at You

First Ultrasound
September 11, 2007: Day 49

Today we saw you for the first time. I have many private anxieties about you and your well-being, and today, two of them have been laid to rest: first, there's only one of you in there; and second, you are securely implanted in your mother's uterus, not a fallopian tube. Your mother got to see you move, but I wasn't there, and only got to see the pictures later on. You were 2.24 cm long, but since you grow about 0.15 cm each day, you're already larger than that by now, only 10 hours after the ultrasound.

You've been moving around for about two weeks. Your first muscle cells form around your spine and actually ooze through your body to their final destinations. You still have no awareness, no sight, no hearing or other senses, no thought. But your heart beats, your legs kick, your arms thrash, your head turns, and your kidneys make pee. You're well on your way to your first dirty diaper.

:: Bryan Travis :: 09/11/2007 @ 21:12 :: [link] ::
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It Had To Be You

August 6, 2007: Day 13

Your mother and I were surprised to discover today that you exist. We know you are there, but we don't know much else about you. We don't know if you're going to be a boy or a girl, the color of your eyes or hair, or what your favorite flavor of ice cream will be. We only know that you are.

Know that you were wanted. We planned to make you happen. Your mother had it down to a science. For the past three months, the first thing I heard in the morning was the beeping of the thermometer as she took her temperature, waiting for the spike that signaled ovulation, learning the pattern of her body, learning when was the best time to make you. There were ovulation test strips, ovulation predictors on the Internet, and other things about which I won't go into detail. After all your mother's planning and watching patterns, the first month we tried, we made you. We took a picture of the pregnancy test. It said, "Pregnant." That is the sum total of what we know about you.

We know when you were conceived, to the day: July 25. When you were conceived, your parents loved you and loved each other. I was in love with your mother that day as much as I ever have been. You were created about 12 days ago, and today you are a blastocyst, a tiny ball of cells. In another day or two, your nervous system will begin to form and you will become an embryo, but right now, you have no fingers or toes, no brain, no heart, no awareness. This will all soon change.

I must be honest with you. Life is a constant struggle, but once the ball gets rolling, things take care of themselves, and it gets easier. Why, in the first 12 days, you've overcome nearly impossible odds, and there's a 3 in 4 chance you'll make it until the next month, and a 2 in 3 chance you will be born in the spring of 2008. Those aren't the kind of odds you want to play Russian Roulette with, but just a week ago, the odds were very much against you. I am not a religious or spiritual man, but I do believe in the miracle of life. The miracle is that, despite unimaginable odds, the egg and the sperm that became you managed to meet and merge in the first place. The fact that you even exist makes you incredibly lucky and special. You could easily have been someone else, but it had to be you. That is the miracle of life, your life.

I am a pragmatist. No romantic would fret over their unborn child's odds of survival. Despite my best intentions, you will be exposed to this part of my personality from an early age, I'm sure. All apologies if it makes me seem neurotic, distant, or cold, and I will never forgive myself if it makes you any of those things. In any situation you find yourself, I want you to have a realistic perspective and expectation. There's a fine line between realism and cynicism, however, and constant anxiety and risk aversion are traps I hope you will avoid. When you find yourself up against a challenge, instead of asking "why me?", I hope you ask "why not?" Instead of saying "I can't possibly," I hope you say "I possibly can." In other words, I hope you aren't hindered by the negative attitudes I sometimes have.

Know that your mother and I have always loved you, from the time when you were no more than a tiny ball of cells.


August 8, 2007: Day 15

I told the first person about you today, someone you'll probably never meet or know: my pharmacy preceptor at Samaritan Hospital. His name was Lanny. We were eating lunch in the break room, and I mentioned we were ready to have kids. He asked if your mother was pregnant, and I told him yes, we had just found out two days ago, and asked him to keep it in confidence until we were ready to tell our families. And he did.


August 17, 2007: Day 24

Your heart began beating a few days ago, and you are a little bigger than an apple seed. Your mother's cramps have ceased, and she's taking an omega-3 fatty acid supplement to help your brain and nervous system develop.

When I was born, breast milk and formula didn't go well for me. I was colicky and screamed for six weeks. Distraught, at wit's end, and against doctor's advice, my mother fed me the only thing that didn't make me scream: powdered milk. It's meager on fat, and infants need plenty of fats and omega-3 fatty acids to gain weight and develop a healthy brain and nervous system. I guess I turned out okay, but I'm hoping for better for you.


August 23, 2007: Day 30

Today we met with a nurse-midwife. Obstetricians deliver most babies in the United States, but your mother and I have concerns with the status quo. I find it ironic that your mother, an optometrist, and I, a pharmacy student, as part of the medical establishment, would have such strong concerns with allowing said establishment to bring you into the world. For one, most obstetricians work in a group practice, so when it comes time for the birth, the mother's obstetrician may or may not perform the actual delivery, depending on availability. Second, we believe U.S. healthcare's approach to birth and delivery is overly aggressive, quick to employ interventional techniques such as induced labor, caesarian and vacuum-assisted delivery, and forceps to hasten delivery more in the interests of the healthcare system than in the interests of mother and baby.

Our hopes for a nurse-midwife would be someone who could deliver you in a hospital in lieu of an obstetrician. Sadly, no midwife with hospital privileges is to be found in Lexington. Many cities don't even have professional midwives, so it seems we're fortunate simply to have a nurse-midwife nearby.

The practical upshot of all this is that we're actually considering a home delivery. Only two weeks ago, I would have thought it crazy, but now... if you were not a high risk pregnancy... and a maternity hospital only 15 minutes from home in case we needed it... home births being the only method of delivery for thousands of years... I think I'd go for it. But the final decision is your mother's -- she's the one who would have to do this without any pain meds.

In country where 98% of births occur in hospitals, people may think we're taking a huge risk, but the World Health Organization advocates home births for low-risk pregnancies. In the United States, the infant mortality rate is 7 per 1000. In the Netherlands, it's 5 per 1000 in a country where 33% of births occur in the home and most low-risk pregnancies are delivered in midwifery units, not hospitals. On the other hand, in Sweden, with an infant mortality rate of 3 per 1000, over 99% of births are in hospitals. So at the end of the day, I wonder... in a developed country with access to advanced medical care when needed, does home birth significantly impact infant mortality? And if not, then the logical conclusion is that it's safe for low-risk pregnancies, and should be done without reservation if the parents so desire.

So... only time can tell if you will be born at home, but if you were, it was done because of what happened today.


August 25, 2007: Day 32

This is the weekend we're announcing you to our families. Today we told my mother, grandmother, and brother. With the element of surprise, we met my mother and grandmother at grandmother's house, chatted for a while, and gave my mother a baby picture book in a gift bag. The first picture is your positive pregnancy test.

We talked to your grandmother about a birth defect both my brother and I had, anal stenosis. It causes painful bloating and constipation, and requires gradual instrumental dilation of the anus, also painful (at least it was for me, I am told), but the long-term prognosis is good. Sometimes anal stenosis (the mildest form of imperforate anus) is associated with other birth defects in what is known as VACTERL association. I mention this only because my brother also has cardiac congential deformities consistent with VACTERL association. Actually, VACTERL usually requires 3 of the defects, and 2 defects qualifies as "VACTERL-like."

The important thing to know is that VACTERL association does not appear to have a genetic origin, but there is some evidence VACTERL-like does, because cases tend to cluster in families. To add to the rub, though, VACTERL-like is more common in girls, and neither your uncle nor I are.

I mention all this now not only because we talked about it today, but because the defects associated with VACTERL arise from events occuring between weeks 7 and 10 of pregnancy when the embryo reshapes itself from a mass of cells into the characteristic embryo body, a crucial period of time you are about to enter.

I'll be thinking of you often during the next few weeks, hoping all is well.


August 26, 2007: Day 33

Today we told your mother's family about you. Your grandmother had already become suspicious of us. Your mother told your cousin Emma to pull the gift bag out of my backpack and take it to your grandmother. We gave both of your grandmothers the same baby picture album with the picture of the positive pregnancy test. Your aunt April is also pregnant, due about a week before you. We had meatloaf, mashed potatoes, green beans, rolls that failed to rise in the oven, and angelfood cake with blackberries and strawberries for dessert. Between lunch and dessert, we drove down to the creek where your grandfather is building a cabin on stilts in the woods to stay in while he builds a regular-size house not far away in a clearing. Perhaps someday you will spend the night on a camping trip with your cousins in that cabin high among the trees. While you were taking shape in your mother's belly, so was that cabin. On this day, it was still a frame, with only three exterior walls and no roof. After dessert, I took a nap at your grandparent's. It was sunny and hot outside, but shady and almost comfortable in the woods; 2007 was the hottest and driest year in a long time.

I don't know why I tell you all these small details... I think it's so you or me or both of us will read this one day and recreate the event in our minds, for you to see it through your imagination, and for me to hold on to the memory for as long as possible.


August 27, 2007: Day 34

Today I told my father about you. Your mother and I were going to visit him at home when we told my mother and grandmother, but he was at the state fair judging the karaoke contest. Don't ask. Suffice it to say, I had to tell him over the phone. I was driving home from Samaritan Hospital, where I was doing my pharmacy rotation that month. After some chit-chat, I told him exactly as I was driving home on Clay's Mill Road, going through the intersection at Keithshire. I remember looking at the green traffic light passing overhead as I told him, "Rachel's pregnant."


August 30, 2007: Day 37

Today I posted all I've written so far on my weblog.

:: Bryan Travis :: 08/30/2007 @ 18:20 :: [link] ::
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Remembering Phil Rizzuto

I didn't know Phil Rizzuto as anyone other than the spokesman for "The Money Store," a bank specializing in second home mortgages. I'll never forget his Brooklyn accented voice saying, "I'm Phil Rizzuto for The Money Store."

The Money Store commercial

:: Bryan Travis :: 08/15/2007 @ 20:47 :: [link] ::
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It's Not TV

HBO makes for an expensive cable bill, but you get what you pay for. The movies are good, but I'm mostly speaking to the series. I'm giving them props for three recent series, one which may last for a while, another which may not (which is a shame, because I think it's fresh and witty), and one which already has been canceled.

On that note, I don't know how HBO researches their ratings. Do they use Nielsen, which is more geared to commercial networks? Do they have focus groups? Do they gather stats from OnDemand viewing?

The first is Big Love, a drama about a polygamist Mormon family trying to blend into mainstream society. I'd rank it up there with Six Feet Under, but unlike that popular series, I haven't heard much buzz about it. Of course, my circles number two: poor college students who can't afford HBO, and 40-something pharmacists who don't seem the HBO type. Then there's where I live... many people here may get hung up about a show portraying a polygamist family, even though it doesn't promote the lifestyle. But Desperate Housewives, which enjoys its highest viewership in my part of the country, is fine. [I privately steam in my own frustration]
Update: HBO will produce season 3 of Big Love

The second is Flight of the Conchords, a comedy about a two-man folk band and comedy troupe from New Zealand come to New York City. In addition to themselves, their quest for fame is hindered by a distractable manager unable to secure real gigs who is also a cultural attache in the New Zealand Consulate office, a single stalker fan, a continual struggle to pay the rent, and serious co-dependency issues preventing them from separating long enough to pursue normal dating. The standard formula is two songs performed per 30-minute episode. The songs are gems. Enjoying the show may require a warped sense of humor possessed by few. I hope the show will find such warped individuals and form a cultish fanship; however, they're almost unheard of in the U.S., and the show may never catch on. A pity, that.
Update: HBO will produce season 2 of Flight of the Conchords thanks to the vocal cult following it has generated.

The last show is Rome, which wrapped up its second season earlier this year with a series finale. Apparently, it had a movie-size production budget and was designed for two seasons only. Nevertheless, I really liked the show, and was sad to see it end.

:: Bryan Travis :: 07/27/2007 @ 12:56 :: [link] ::
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