Tuesday, June 30, 2009

Insult


This morning in my email was the following message:
Hello,

Your blog at: http://surgeonsblog.blogspot.com/ has been identified as a potential spam blog. To correct this, please request a review by filling out the form at [link deleted by me.]

Your blog will be deleted in 20 days if it isn't reviewed, and your readers will see a warning page during this time. After we receive your request, we'll review your blog and unlock it within two business days. Once we have reviewed and determined your blog is not spam, the blog will be unlocked and the message in your Blogger dashboard will no longer be displayed. If this blog doesn't belong to you, you don't have to do anything, and any other blogs you may have won't be affected.

We find spam by using an automated classifier. Automatic spam detection is inherently fuzzy, and occasionally a blog like yours is flagged incorrectly. We sincerely apologize for this error. By using this kind of system, however, we can dedicate more storage, bandwidth, and engineering resources to bloggers like you instead of to spammers. For more information, please see Blogger Help: http://help.blogger.com/bin/answer.py?answer=42577

Thank you for your understanding and for your help with our spam-fighting efforts.

Sincerely,

The Blogger Team

P.S. Just one more reminder: Unless you request a review, your blog will be deleted in 20 days.
But the real insult was in following the link to explanations, finding this (emphasis mine):
As with many powerful tools, blogging services can be both used and abused. The ease of creating and updating webpages with Blogger has made it particularly prone to a form of behavior known as link spamming. Blogs engaged in this behavior are called spam blogs, and can be recognized by their irrelevant, repetitive, or nonsensical text, along with a large number of links, usually all pointing to a single site

So much for my assertions that this blog has been of value, or, at least, once was.

I should add that in order to perform any action in posting, I now have to do a word verification. The distortion of the letters is so extreme that I can barely read them. So you might not actually be seeing this. I await the judgment of the blogger overlords. Meanwhile, I'll have the words in my brain:
irrelevant, repetitive, nonsensical. Alas, it is I.

Monday, June 29, 2009

Trauma Call



In response to a call for ideas, Mike asked about trauma. Specifically, he mentioned hearing that the most common cause of death in motor vehicle accidents (MVA) is injury to (and, presumably, exsanguination from) the femoral artery. He didn't hear it from me. (In fact, he admitted he heard it on an episode of "ER." That surprises me a little, because that show -- despite a completely inauthentic and distorted portrayal of emergency care -- didn't often give out-and-out false medical information. Or maybe they did. I stopped watching a few years ago.)

I'll admit I didn't look it up. But I can say that in several years working at one of the busiest trauma hospitals in the US, during training, and having cared for many MVA victims including fatalities then, and subsequently in my private practice, I don't recall seeing a femoral artery injury resulting from a car crash; certainly not a fatal one. By far the greatest number of deaths were from head and/or chest injuries, and I'd guess that is universally true.

During training, trauma care was the center of the world, the cauldron in which the steel of the surgeon was annealed. At every level of training, and especially as Chief Resident, my involvement in trauma care taught me more about surgery and surgical patients than any other time I spent in hospitals. I'm grateful and lucky to have put in several years, literally living there much of the time, at one of the (at the time, probably still) preƫminent trauma centers in the country. Brilliant and tough, my teachers at SFGH (actually, when I was there, the emergency wing looked like this) gave me my sense of duty and commitment to my patients, the ability to make difficult decisions and to take responsibility for them, an understanding of the sort of "digital" thinking that a surgeon needs in the operating room. From them I learned a lot of technique, too; but the frosting on that cake I really owe to another, a decidedly non-trauma surgeon, Vic Richards, a legendary innovator, surgeon of singular intelligence (M.D. at age twenty, give or take), and a significant figure in my book.

But in real life, trauma was a pain in the ass. Unlike training, when we waited hungrily for the next case to roll in, in practice it was by definition a disruption. Destroying an operative schedule, crashing a full office, or robbing a night of sleep before a fully scheduled next day -- those were the least of the problems created by a call to the ER. It was the circus of managing a complicated and unexpected case in a hospital not primarily devoted to such things. It was dragging in a bunch of reluctant other surgeons (depending on the problem) -- orthopods, neurosurgeons. And the worst were the MVAs, for that very reason: multiple organs, multiple docs. If I had to come in to see a trauma case, give me a tidy gunshot or stab wound every time.

And I DID see a few injuries to femoral arteries from those causes. And to much bigger and bleedier vessels than that.

Once I got over the frustration at having been called (I'm an orderly sort of guy), it was never hard to be swept into the torrent. There is unequaled immediacy to trauma care, a series of "yes-no" decisions, absent "maybes." Real time, instinctive, urgent in the extreme, it's invigorating. There's nothing like the intrusion of certain death, turned around and sent away by the coming together of everything you know, to give a sense of purpose. There's nothing like slashing into a dead man's chest, sticking a finger into his heart, and watching him awaken even as your hand is beyond the wrist into him.

And I can do without it just fine.

Friday, June 26, 2009

Gotcha. Not.


From a commenter:

I think as long as Obama admits that he wouldn't subject his own family to the limitations he proposes for everyone else, his plan will fail.

Regards,
A Better Angel
I assume he/she refers to comments by Obama during the recent ABC News "town hall" held at the White House, in which there was this exchange, edited selectively in many "news" sites:

"Q: If your wife or your daughter became seriously ill, and things were not going well, and the plan physicians told you they were doing everything that could be done, and you sought out opinions from some medical leaders in major centers and they said there's another option you should pursue, but it was not covered in the plan, would you potentially sacrifice the health of your family for the greater good of insuring millions or would you do everything you possibly could as a father and husband to get the best health care and outcome for your family?

OBAMA: [....] I think families all across America are going through decisions like that all the time, and you're absolutely right that if it's my family member, my wife, if it's my children, if it's my grandmother, I always want them to get the very best care.

Predictably, this has been jumped on by detractors and touted in pretty much the way the commenter did: Obama's plan is good for your family but not for his, says Obama. Since we all love our country and don't wish our President to fail, I'm sure it was just an honest misunderstanding. Like my snippet above, most of the criticism leaves out the President's next sentence:

...but here's the problem that we have in our current health care system. Is that there is a whole bunch of care that's being provided that every study, every bit of evidence that we have indicates may not be making us healthier.

Which, of course, is the most important thing he said.

First of all, the wording of the question was, well, questionable. It's a false premise. It implies there are "plan physicians." It implies that treatments recommended by "medical leaders in major centers" wouldn't be part of "the plan." There's simply no reason to think either is true. There isn't, as far as I know, a proposal to separate "plan physicians" from others. And there most certainly is NOT an implication that therapies that carry the weight of "leaders" in "major centers" would be off the list. The opposite is true.

And it's exactly the point Obama was making. But it's neither sound-bite worthy nor easily explained; and, as we've seen, it's very much selectivequotable and outofcontextable. (Incidentally, that he got tough questions like that sort of shows the right wing fury (ie, Fox News) over the "unprecedented access" ABC was granted was so much hot air...)

Among the many ways to control health care costs is to establish what works and what doesn't. As I've written, severally. Patients and families, as President Obama said, face such dilemmas all the time. "The very best care," he said. Exactly. Would that it were always as easy as the example that the questioner (a doctor) gave, in which there would be general agreement from the creme de la medical creme. (It'd have been better if Obama had pointed that out: again, showing the session was hardly planned and canned.) On the contrary. It's often a decision involving futile care: the operation with a one in a million chance of helping; prolonging life in the ICU; trying dangerous drugs with virtually no chance of helping. Or -- and one assumes this would not be covered, since it currently isn't -- heading to Mexico (or, like Farrah Fawcett, to Germany) for entirely bogus treatments.

These sorts of things are, in my opinion, way too difficult for our political system, as currently manifested, to handle. Rather, at best (if that's what to call it), we'll get a plan to pay for insurance for those who can't afford it, leaving the excess costs of insurance untouched and not tackling effectiveness in any meaningful way at all.

But, perhaps, we could at least do it or not, without deliberately taking out of context what the President said.

Yeah.

Right.

Thursday, June 25, 2009

Why It Won't Happen


An eye-opening (for those with closed eyes) interview with a former executive in the health insurance industry.

As long as there is an enormous industry whose aim it is to make money from insurance premiums, and as long as that industry is able to influence politicians and credulous reporters, and as long as that industry remains between money spent and money received to deliver health care, we'll always have care that is too expensive and which fails to serve those who need it most.

Simple as that.

Wednesday, June 24, 2009

Progress




Kodak announces it will stop making Kodachrome, and I don't care. I'm down with digital. I mention this so as not to sound like a Luddite in the following paragraphs.

I don't know if we'll get health care reform or not; nor, if we do, whether it'll be in any way significant. Unlikely. Meanwhile, there are examples in surgery which illuminate one aspect of the problem of skyrocketing costs. Technology, in a word. Technology as selling point; technology as sexy; technology for its own sake. Unlike my digital camera, medical technology includes much about which it can be asked: "Huh?"

Previously I've expressed an opinion on "NOTES" surgery. More recently, I opined about robotics. I've also described the way I did gallbladder surgery through a single small incision, as an outpatient, with recovery times the same as laparoscopy, at significantly less cost. The latest hotness is single incision laparoscopy. The linked article describes a half-inch incision. Maybe. What they stick in is this baby, which, according to what I've read, requires a 3.5 cm incision, or about an inch and a half. In total, that's at least half again the total length of incisions made in standard laparoscopy, for removing the gallbladder, anyway. No less painful, one would assume; although the pain isn't that great, usually, in either case.

Now I must admit I've neither seen nor done it. As I've said about laparoscopy and robotics, it's fun to do, and I have no doubt this wrinkle is fun, too. So far the operative times are longer than "regular" laparoscopy, which equates to more expensive. In that article, the recovery is no different from standard stuff. Without knowing for certain, I'd say there are also issues with exposure and perspective, since the camera and tools are all coming in at the same angle. That, one might predict, adds up to higher risk. Time will tell.

The other day I read an article about a kid who had his spleen removed this way. Nice scar in the belly button. Humbly, the surgeon says it's not about fame, or being first. It's about preventing the trauma of a scar. The cynic in me says it's about referrals. But what do I know?

Here's my point, about which time might well prove me wrong. In my opinion, NOTES, robotics, and single-incision laparoscopy, so far, have one thing in common: dubious value compared to other options, more expense, and possibly more risk. For what? In the case of robotics, marketing. In the other two, marketing and cosmetics. These are examples, it seems to me, of therapies which, if effectiveness research becomes pervasive and meaningful, may well be taken off the list of covered procedures. And then what? Well, for one thing, the disconnect between reform and having it all will be illuminated. Maybe, rather than disallowed (which, realistically, is unlikely) the extra costs of these operations will need to be paid by the patient. Surgery which is purely cosmetic, after all, is never covered by any payers.

In any case, this is the sort of thing that doctors and patients alike will need to face if and when real cost control is effected. It won't be pretty, even if the data are there. Because when have data had anything to do with anything?

Monday, June 22, 2009

The Nubbin



One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums.

Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

This might be a good time to insert a cartoon that Ellen sent me:

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

Wednesday, June 17, 2009

Fee For Service


Not too many years ago, as the many-layered onion that is physiciandom brought tears more and more constantly to my eyes, I said, "What the hell, I give up. If this is all just a way to break us down and put us on salary, bring it on. Just tell me how much I'll get, and I'll decide if I want to keep doing it."

Paperwork propagating like potatoes; rules compounding themselves like viruses; payments receding like ice-caps. There's no doubt it affected my enjoyment of my work, steadily plunging the pleasure, the honor, the gift, and the psychic rewards of being a surgeon deeper into the bulb of the allium, harder to find without crying. And yet such thoughts find little if any resonance with the public. Fee for service, it's said, is the root of the economic evils of our health care system. I don't entirely disagree: what we have now is the worst of all possibilities.

There are many ways in which health care doesn't follow other capitalistic models. Attempts at controlling costs have included, for instance, both restricting and increasing the number of doctors produced in medical schools. Neither worked. To date, disguised and dressed in many pretty outfits, the main tool for cutting costs has been reducing payments to physicians and to hospitals. At best, results are mixed: forced to work harder and harder to maintain income, many doctors (speaking) have burned out and quit in their prime. Turned into bean-counters, those that stay have adopted methods that frustrate patients: cramming more visits into an hour, charging for phone calls, etc... Ancillary charges are outrageous: a friend recently wrote me about a $3,500 CAT scan, a charge of $850 for a simple automated blood test. (Not that anyone but the uninsured actually pays them: in some sort of dance macabre, insurers reimburse ten or twenty percent of those fees and the rest is smoke.)

(In a related note, I read that President Obama's doctor isn't happy with Obama's health reform proposals. In the article the good doctor says neurosurgeons get $20,000 for "cutting into the neck" of his patients. Now, I have no idea what goes on in Chicago, but I'd propose that, if twenty grand is an actual fee, like the $3,500 CAT scan, the reimbursement is a small fraction. In this post I don't want to get, yet again, into the frictions between surgeons and real doctors; but such a claim suggests a certain amount of hyperbole in the discussion. On the other hand, he implies he's for a single-payer plan; on that, we agree!)

Pay for doing stuff is the wrong incentive, so we are told. It leads to over-ordering of tests, over-doing of procedures. Can't entirely disagree. Read Atul Gawande in The New Yorker, or Buckeye Surgeon in Buckeye Surgeon. But if it's a problem, what is the solution? Salaries, says Atul. Better docs, says Buck. And me. With the right incentives.

I've said before -- to hoots and snark -- that I don't think many physicians are in it primarily for the money. But I do believe that, as in most other professional pursuits, people willing to work hard and who produce superior results have an expectation of some sort of recognition. Which includes income. And that's precisely why I said above that what we have now is the worst of all possibilities; fee for service with no incentives for quality, no differentiation among bad, mediocre, and excellent providers. For doing a colon resection in half the operative time (saving thousands in OR costs), sending a happy patient home two or three days (or more) sooner than average (saving thousands in hospital costs), with a lower rate of complications, I got exactly the same reimbursement -- from Medicare, from any insurance company -- as the surgeon who did none of those things. If, to a payor, a colon resection is a widget, the only criterion for payment for which is agreement to accept the latest slice in compensation, why bother to do those things? (Getting patients home quickly requires, among other things, making rounds two or three times a day, which most docs no longer do -- but which I always did. Faster operative times result from many things, among which are attention to detail, making sure in advance that what you need is in the room, keeping the team informed of what's coming next. Even helping move the patient and clean the room. Not seen frequently. Since I retired.)

A high percentage of doctors are human beings. That means they often respond like other people. Incentives and disincentives have an effect on behavior. Which is among the reasons "effectiveness research," or whatever the proper name for the effort (the blocking of which is desired by several legislators on the rive droit) to identify best treatments, makes nothing but sense.

I suppose it gets tiresome to read such treati. The bottom line is I think a system works best when there are incentives -- positive and negative -- to do the right thing. Some will, no matter what. (Of those, some have hung it up...) Salaries (at least those with no opportunity for adjustment based on performance) encourage laziness; capitation encourages the withholding of care. Fee for service which makes no allowance for differences in quality encourages abuse. And burnout.

Based on the snippets coming from the halls of Congress, I'm pretty well convinced that whatever so-called reform we get will fail substantively to address the real problems in our system: insurers, excessive or inappropriate "care," reasonable reimbursement across all fields of medicine, costs. And, for the life of me, I can't understand why.

Well, of course, I can.

Monday, June 15, 2009

Reform School


What if every American of a certain age knew they had medical coverage; what if all they had to do was register? What if, in this program, they could choose their doctors, who would be privately or self-employed, not government workers? What if the hospitals they went to were the very ones they go to now? What might you call such a program?

Medicare.

And what if this coverage were extended to all Americans? What might you call that?

Single-payer.

For those who have insurance, the only thing different would be the paperwork: it would become far less, or cease to exist. Neither the care nor the people and places providing it would change. From the point of view of the consumer, I simply see no advantage to having multitudes of companies standing between them and care, sucking money out of the system which goes into the pockets of executives, investors, and into the paychecks of tens of thousands of workers filling out forms at both ends of the transactions. No one -- NO ONE -- is talking about a national health service, ie, a plan whereby everyone goes to government-run hospital, staffed by government employees. (Well, that's not entirely true: several in Congress are comparing the so-called "public option" to the Department of Motor Vehicles. But that's completely disingenuous. The comparison, as I've said, is to Medicare.)

I'm not saying there are no arguments to be made against that "public option," or to a single payer system that enrolls everyone. Many doctors worry about losing control over reimbursement, having to accept ever-decreasing payment for service; they fear the monolithic. It's not without reason, or precedent. Funny thing is, as I've said, Medicare is already pretty much calling the shots: insurers largely take their reimbursement cues from them. Moreover, I've seen several situations in which an insurance company plays docs against one another: fearing losing their patients who are covered by a particular company, they cave to the demands to accept lower fees. It works particularly well in towns that have several competing physician groups.

It's also been a repeated theme of mine that endlessly cutting reimbursement to "providers" is a policy doomed to failure. We're about as low as it can go, if there's an expectation that smart and dedicated people will take up the caduceus. Rather -- and President Obama at least speaks the words -- the real savings will be in identifying those treatments that are the most cost-effective; and, even more importantly, finding those docs that provide the best care at the lowest cost and spreading the word.

The concept is ripe for demagogurery. "Do you want the government to get between you and your doctors?" they ask. As opposed to, what, a high-school grad in an insurers cubicle, telling the docs what they can and can't do? Like it is now? (In the linked article, it would also appear some want to prevent -- by law!! -- research into what treatments work best. To me, that's pretty hard to explain. How awful could it be to be told you can't have one operation that has been shown to be inferior to another?) (Okay, I recognize the potential problems. But if an idea is a good one, surely there's a way to implement it with safeguards.)

Reforming health care, it seems to me, is a perfect metaphor for everything that's wrong with our political system. While faintly acknowledging that for tens of millions it's not working, some in Congress nevertheless want only to maintain the status quo. Their efforts, unashamedly, are mainly limited to coming up with loaded (and disingenuous) phrases calculated to obfuscate. Given the complexities, it would be daunting even for legislators committed to comprehensive and effective reform. Would that we had some.

I'd bet very few people feel loyal to their insurers, per se. They may be loyal to their "providers" and to their preferred hospital. (Sort of. I read a study a few years ago that put the price of loyalty at, as I recall, about twenty bucks: ie, if switching docs meant saving more than that per month, it was hasta la vista, dockie.) What is the argument, from the consumers' point of view, of having insurance companies in the middle of the system? Where, specifically, is the value-added?

I fault the whole gang: Republicans, Democrats, and those in the White House. I can think of no reason why single-payer isn't on the table, except for the fact that it has so little support in Congress. But why? Whose goose is being greased? (If that's the term...) If a plan were to provide the same care we're now getting (or, hopefully, better), using the current infrastructure of doctors, nurses, clinics, and hospitals, while costing less by keeping more money in the system, why would that be bad? Because some call it.... SOCIALISM? Might not the result be more important than the name?

Some who've traveled these parts before will know I've made some suggestions. Funny thing: President Obama seems to have read them and bought everything but the single-payer part. He talks about identifying best practices; he talks about a larger role for the Medical Payment Advisory Commission. The latter, of course, is a double-sided axe; how acceptable it might be to physicians and hospitals would depend on its makeup and its responsiveness to reality. But it's the idea that is a good step. Cautiously endorsed.



[Acknowledgment: I know I said recently I didn't want my return to this blog be by way of the politics of health care. But I find myself unable to cast it out. I think I may have to get a little rubble off the desktop before I can find my way back into the mind of a surgeon.]


I Dream


I dream of surgery. It's in my mind, if not always on it. The fact is, I miss it. A lot. The good parts, anyway. The doing.

Even though the dreams aren't always pleasant, it's frequently disappointing to awaken to the realization that I'm no longer a surgeon. Last night, I was showing some sort of student how to repair a hernia, showing the anatomy (not exactly accurately rendered), explaining why I was doing what I was doing. The fact that it turned complicated, and that the student seemed annoyed that I was asking him to participate didn't diminish the sense of pleasure. (I think it's possible to sort of meta-dream: when I'm a dream-surgeon I feel like I contemporaneously know it's just a dream but also take pleasure in the pleasure of it. Like watching a movie, I'm simultaneously enjoying the story, the unreality, and the art of the making of it.)

There are many possible directions from the above: a plea to my fellow surgeon-bloggers not to do what I did, to find ways to prevent early burnout, so you might keep your craft active longer than I did; a discourse on the difficulties of leaving behind such an all-consuming profession; the wonderment at having achieved a measure of competence in such a thing; the extent to which leaving it behind confirms something I always said -- that surgeons in particular, and doctors in general, aren't really special. We're just people who learned some stuff. And now I'm back to that unspecial tabula, heading toward rasa.

I does convince me of one thing. I do want to resume this blog, if only to retain or regain a connection to that former self. Consider this another step, after the previous post. A stretching before the ride, a calesthenic. I'll see if I don't pull a muscle, flabby from disuse.

By the way and for the record, it's hard as hell to remain silent about the insanity of the real world. Surgery blogging is a weak set of arms, paddling toward the surface, trying not to drown in the sea of stupid which laps ever more insistently at our shores. Pretend I didn't say that.

Thursday, June 11, 2009

Rumbling


I feel a disturbance in the force, a stirring. Desire precedes delivery; but just this side of the edge of possibility I see resumption of Surgeonsblog, if only for a while.

There's no doubt I've always wanted to; it's been a combination of running low on ideas, and the taking over of my mind by the disignorable realities of politics, of our nation, our world. And it was easy: every day there are outrages aplenty, no end of blogfodder, as the evidence of devolution of our politics is everywhere. I suppose I got a few things out, decongested my hepatobiliary system. But really, it was the ever-truth that nothing I said on my other blog mattered. I always knew it. I don't know what led to the final recogniton that there was no point. Partly, I think, it was re-reading some posts over here, and the comments they engendered. It's not cold fusion, but I think it was useful, once in a while adding something to the common good, if only a tiny blip.

Here's the problem, though: now fully retired, I have only my diminishing memories on which to draw. My estimable surgical colleagues in the blogosphere are out there every day, doing good things and storing them up for good writing. I might have to steal ideas from them. I may have to repeat myself on a topic or two; spiff it up, add to it, make it better.

And I'd happily receive suggestions from any reader any time; comments here, or later. Barge in anytime. Meanwhile, I need a little more fermentation. But I think it's brewing.
.