Round One: Paris Saint-Germain vs. The Eagles, a.k.a. Football vs. Football a.k.a. Glace Vanille vs. Vanilla Ice Cream

Welcome to the inaugural episode of Now Serving! Our culinary adventure begins with the Lello the Magic Gelato Machine, a long-awaited arrival to brighten my little kitchen nest. Lello arrived on July 29 at 4pm, at a hefty 33 pounds. The first thing I did was ring in my 38th year at 12:02 am with a batch of blackberry sorbet. It was tasty, but just as an education in cooking starts with learning how to make eggs in every fashion, I've decided to learn my future profession from the ground up, starting with the mailroom of the iced desserts world: vanilla ice cream.

Ice Cream: The Abridged History

Like every favorite food, from pizza to pasta, ice cream has a highly contested history whose cast involves the usual suspects: China, Italy, France, the US, with Persia as the unknown starlet who steals the scene.

Larousse Gastronomique commences its historical tour de glace with the keenly astute observation that "the history of ice cream is linked with that of gastronomy and refrigeration." It goes on to credit the Chinese with knowing "the art of making iced drinks and desserts long before the Christian era." This art, the Chinese supposedly taught to "the Arabs, who began making syrups chilled with snow, called sharbets (hence the word 'sherbet' and 'sorbet.') At the court of Alexander the Great, and later under Nero, fruit salads and purees were served mixed with honey and snow. It was not until the 13th century, however, that Marco Polo is said to have brought back from the East the secret of cooling without ice, by running a mixture of water and saltpetre over containers filled with the substance to be cooled. Thus the great fashion of water ices began in Italy." The Gastronomic Committee at Larousse then goes on to credit Catherine de Medici with bringing this technology to the French court when she wed Henri II, but that this culinary novelty was not discovered by the Parisian hoi polloi until Francesco Procopio opened his famous Cafe Le Procope there a century later. Although ices made with milk, cream, and eggs appeared on the scene around 1775, this technique had apparently been discovered in 1650 by a French cook (mais bien sur!) in Charles I's English court, but had been paid by the king to keep his method a secret.

In any case, Larousse essentially gives the French and Italian chefs credit for all advances in the field until 1822, with the creation of such flavors as: "Malmsey wine from Alicante, angelica liqueur, the yolks of finch eggs, sugary melon, hazelnuts and mint liqueur, green tea and citron juice, pistachios and peach juice." However, the US is given its due for taking the ball and running with it in the 20th century, with "itinerant ice-cream vendors ... selling in the streets;" Larousse notes that the US "has been particularly creative, inventing myriad new flavours and ways of eating ice cream, including sundaes..., sodas..., milk shakes..., malts...and pie a la mode (pie with a scoop of ice cream)." I think it's hilarious that they translated pie a la mode.

For me, the Larousse is, as Jacques Pepin is quoted on the flap as saying, "the first place I look when I need to clarify a cooking question." Due to my own knowledge of French views on cooking, however, it is rarely the only place I look if I am concerned about historical accuracy and, surtout, impartiality. The tip off here was the egregious error in ascribing the Persian place in ice-cream making (taking place, according to Larousse, prior to Alexander the Great) to the Arabs, who did not conquer Persia until 900 years after Alexander's death around 323 B.C.

In any case, there is an excellent unabridged history of ice cream, with appropriate source citations, at The Nibble, and What's Cooking America but the key dates are:

4,000 B.C.: Chinese master the art of frozen desserts, including the key discovery that using salt and cool water/ice on the outside of a container lowers the freezing point of the contents inside the container. [Ed. Note: It has been brought to my attention that this is an inaccurate description of the science behind the method, but it's too long to explain here - stay tuned for a post on why ice+salt is necessary to make the ice cream freeze. In short, it lowers the temperature of the ice/liquid outside the canister, enabling the contents to freeze. Don't think too much about this or your head will hurt. Just trust me on this.]
2,500 B.C.: Persians, whose empire borders China, learn these nifty tricks. They are renowned for drinking fruit syrups cooled with ice (sharbat), a proto-Sno Cone of fruit ices sweetened with honey and cooled with snow. In a "you got your chocolate in my peanut butter moment," they also cross two favorite desserts - sorbet and rice pudding - into a dessert called faludeh around 400 B.C. - a delicious concoction of milk and vermicelli still served today and featuring rose water, saffron, lemon, and dried fruits.
300's B.C.:Alexander loves Persian snowcones so much, he has slaves climb mountains and bring down snow and store it in 30 foot deep trenches to ensure that his troops can enjoy their sharbat during battle, helping to eventually secure victory over the Persians after 10 years of war.
50 BC: Nero, the copycat, does what Alexander did, but makes his slaves run up and down the mountains for his snow.
700 AD: Arabs conquer Italy, bringing sorbet and pasta, which they acquired from their conquest of Persia 100 years earlier. Italians make granita, the much chunkier, and easier-to-make version of sorbet and commence securing their place in ice cream history.
1500s: Renaissance starts and while royalty dined on iced desserts, there is in fact no support whatsoever for the stories regarding Catherine de Medici (who was a mere 14 year old at the time of her marriage) nor Charles I's chef having invented ice cream.
1660 - 1690: - first recipes for flavored ices appear in French cookbooks and Starbucks-precursor Le Procope opens, serving coffee (of which Voltaire is said to have drunk 40 cups per day) and some sort of frozen dessert -whether sorbet or true ice cream, seems in dispute - to wealthy Parisians and later to Ben Franklin and Thomas Jefferson. You can have it too, if you want - Le Procope is still open and still a Parisian highlight.
1744: A group of Virginia commissioners dine at the Maryland Governor's home, where they are served "a Dessert no less Curious; Among the Rarities of which it was Compos'd, was some fine Ice Cream which, with the Strawberries and Milk, eat most Deliciously."
1769: Elizabeth Raffold's The Experienced English Housekeeper includes a recipe for what looks like ice cream to me.
1770 - First U.S. gelateria opens in New York.
1777 - Philip Lenzi advertises in the New York Gazette that his business has ice cream available almost every day.
1802: Thomas Jefferson serves ice cream at a state dinner. He also writes his own recipe for vanilla ice cream, available for view on line here or in person (apparently) at the Library of Congress (I feel a subsequent episode coming along, perhaps with assistance from my dear friend and fellow foodie, Hannah).
1813 - Sallie Shadd, a freed slave, claims to have invented ice cream made of fruit, cream, and sugar, in Wilmington, Delaware. Dolly Madison travels to taste this new specialty and loves it so much that she serves it as the dessert at her husband's second inauguration, and at all state dinners thereafter.
1834 - Augustus Jackson devises the first modern method of manufacturing ice cream using ice and salt (per the Chinese method) to make ice cream in tin cans. After quitting as White House chef, he sells his ice cream to Philadelphia ice cream parlors. Augustus is African American and, as usual, some white person gets the patent and most of the credit.
1843 - Nancy Johnson receives first patent for the hand-crank ice cream maker, not unlike the same version sold by White Mountain today, enabling everyone to get their kids to crank that sucker for 45 minutes on hot summer evenings, with the end result that most pleasurable of childhood memories: homemade ice cream. I can still taste the eau de rock salt, and I say that fondly.
1851 - Jacob Fussell, a Baltimore milk dealer, has so much milk that to keep it from going sour and to expand his clientele, he starts manufacturing ice cream on an larger scale, and is credited with being the father of commercial ice cream production.
1865 - Term "hokey-pokey" enters the lexicon due to explosion of Italian ice-cream vendors on U.S. streets after the Civil War. Term itself is likely a corruption of "ecco un poco" (here's a little) or "O, che poco!" (oh how little) - presumably a reference to the price of the product.
1926 - Invention of continuous process freezer leads to the birth of the industrialization of ice cream production.

Whew! And there is so much more to learn, especially at Linda Stradley's What's Cooking America website.

The City of Lights vs. The City of Brotherly Love: Ice Cream Styles 101

So why the title of this post? As the history above hints at, modern ice cream really has its roots in Italy and France but its heart in America. Paris is where ice cream was first made fashionable, but Philly is where it became the Brangelina of the dessert world. One of the first differences that crops up when you start reading about making ice cream is the major dividing line between what is now called either French style ice cream or frozen custard vs. Philadelphia style ice cream (no alias), or as is seen on display in the ice cream case: French vanilla vs. Vanilla.

These two items are not dissimilar from football in France (aka soccer) vs. football in the U.S. in that both involve similar ingredients. In soccer vs. football, both have a field, two teams of about the same size, and a ball - and similar rules - your team has one side of the field, your opponent the other, and to score, you must get the ball across the furthest line on the opponent's side of the field. It is how one scores that differentiates the two games - one is primarily done with the feet; the other with the hands. Paris Saint-Germain vs. the Eagles. And oh what a difference is found in the "how."

French and Philadelphia style ice creams are much the same in that they both have a base of milk, cream, sugar, and some sort of flavor or fruit, you're heating it up to dissolve the sugar, then cooling it down and churning it all the while to prevent it from freezing solid or crystallizing. The difference between them really comes down to one thing: French vanilla has eggs; Philadelphia vanilla does not. So if you wondered why French vanilla looks yellow and regular vanilla looks white, that's the difference. Like soccer, eggs impart a magical sophistication, skill, and depth to cooking that is hard to imitate. Eggs bind, they emulsify, they stabilize, they add depth, they are the magical shape-shifters of the culinary universe. Eggs are ridiculously talented. And when blended into an ice cream base, they act as an emulsifier and a stabilizer for the fat from the cream and the milk. They also add a richness to the flavor. Ice cream without eggs is an act of brute force, much like the Eagles' running game. You're forcing the fat to freeze and you're churning it to keep it from crystallizing, but the fat never really binds to the water of the concoction, and the moment the heat hits that puppy turns to a milk shake. On the other hand, like many French dishes, French-style ice cream is dense and rich and it can overwhelm delicate flavors. There is nothing so all-American as Philadelphia-style strawberry ice cream on a hot summer's day - it's sweet frothiness is the perfect end to a dinner of grilled burgers and corn on the cob.

In saying this, I have in some ways told you the ending of the story. But like all sports, there is joy in the playing, regardless of who wins the game. And so begins our first match: The Thrilla of Vanilla.

You Say Vanille...

I have chosen The Perfect Scoop, by David Lebovitz, as my initial guide into the world of ice cream making, along with the Lello instruction manual and recipe booklet. He has a head-to-head recipe of French vanilla vs. Philadelphia style vanilla which are the basis for this first episode of Now Serving. First up, French or custard-style ice cream or glace vanille.

The ingredients are simple: 1 cup whole milk, 3/4 c. sugar, 2 c. cream, pinch salt, 1 vanilla bean, 6 egg yolks (6!!), and 3/4 tsp. vanilla extract.
Quality out depends 100% on quality in, in my experience, so I shuffled off to the organic market for the freshest, least-doctored dairy products I could find, from Trickling Springs Creamery in Chambersburg, PA. Yep, those are glass bottles, which they swear makes it taste better (I agree) and they also adhere to the first principle of environmental conservation: rinse and reuse. I haven't seen these since I was a kid visiting my grandparents in Wahoo, who still got daily deliveries from the Roberts Dairy milkman. The milk box was a standard component of my front porch games. Anyway, there you have it: the components of my glace vanille.

Step One of any ice cream is to heat the milk and some of the cream with the sugar and salt until the sugar dissolves. Then add the vanilla bean (scrape out the seeds first, then add the seeds and the pod) and let it steep, covered for 30 minutes. It looks like this:

Now comes the tricky part: making the custard. It's like riding a bike though. Figure it out - including falling down once - and you've got it forevermore. In Lebovitz' version, 1 c. of the cream and the extract have been reserved to receive the custard - I put them in a stainless steel bowl. Whisk the egg yolks in a measuring cup (you can freeze the whites for use in other things) and add about a cup of the steeped vanilla mixture (should still be warm, take out the bean) to the eggs, whisking while you work. Once mixed, pour the eggy vanilla mixture back into the remaining milk/cream mixture in the pot and turn the heat back on (low-medium) and stir constantly. A spatula helps reach every corner of the pot, but isn't necessary. What you're looking for is that moment when the liquid turns slightly solid and coats the back of a spatula such that you can run your finger down it and the divide remains (Lebovitz says this happens around 170-175, but it was closer to 180 for me). Do not overcook or you will end up with a separated eggy concoction which, fortunately, you can reconstitute if you work fast, by sticking it in the blender on high.


See the finger line down the spatula? Ta-da: custard!! Once you have your custard base, you now need to cool it, pronto. This is done by pouring the custard in the stainless or other non-reactive bowl (metals just transfer cold faster) with the remaining cream, putting it in an ice bath, and stirring constantly until the mixture feels cold. You can tell this is the case if the bowl itself (above the mixture) starts to feel cold.

Once cooled, pour the base into a container and put it in the refrigerator for several hours or overnight until thoroughly chilled. Then pour it into your mixer and freeze according to directions. Lello took about 45 minutes to reach this consistency:




...I Say Vanilla

Take 2. Now we've got 2 c. cream, 1 c. milk, 3/4 c. sugar, pinch salt, 1 vanilla bean, and 3/4 tsp. vanilla extract: Same general idea: Heat 1 c. of cream with the sugar, the vanilla bean and its seeds, and heat on medium until the sugar is dissolved. Remove from the heat and add remaining ingredients, stir, and put into container and chill the mixture until cold. Then process according to your machine's instructions.

In the end, here are our contenders, scooped out of their plastic containers after a night in the freezer, and displayed side by side:

Can you guess which is which? It's pretty easy: Philadelphia style is on the left; French vanilla is on the right. As one might predict the Philadelphia style version was much lighter and closer in taste to the memories I had of hand-cranked ice cream - fresh milk and sugar with the perfume of vanilla dancing on the palate. However, to my surprise, this version has a slightly waxy mouthfeel to it, the cause for which will be explored in future episodes, but in short comes down to the fact that I was using unhomogenized dairy products. I think.

The French style vanilla was superb. It was rich, very vanilla-y, and had a luxurious mouthfeel with no waxy sensation. It also held its shape better and didn't melt as rapidly. Because of the eggs, the vanilla was a bit more muted, but overall the glace vanille won the battle, edging its Philadelphia brother out on the basis of texture.

Well, I hope you've enjoyed the show and will come back for our next installment of Now Serving. If you try this, let me know how it went for you and whether you had similar results. Cheers!

I Guess This Means Summer's Over

There it is: an entire summer's worth of work by Dominion Power. And they didn't even give me the digital meter I requested.

I should be breathing a sigh of relief. Sadly, I saw this:



What that is, to the untrained eye, is 2 days' worth of excavation and concrete slab prep work obliterated by Dominion, which didn't follow the approved plan. I suspect our contractor will bill me to redo it, which means me billing Dominion. This project is so full of irony it's slipping into absurdity.

So Far Down the Rabbit Hole It's Pitch Black

Is this funny, sad, sick, ironic, or just insane? To wit:

I received a call from Jose, the contractor Dominion has hired to finally connect the power so we can move on with, you know, our lives. Jose has stated that he would like to just connect the existing conduits together and run the power through that. He would like to do this because it would save him considerable time and money, as it would eliminate the need to dig any new trenches. I inform him that I was told by Dominion that this was not permitted because they hadn't installed the portion of conduit running from the temporary meter to the house. (This idea was, in fact, the one I proposed to the Dominion project coordinator as being the most obvious, fastest, and most cost-saving option.) He says he talked to someone who thought it would be okay to use the existing conduit and that he was the one who had installed the first part of it from the pole to the meter 2 years ago (I guess he remembers us. I bet they all do). He asks me if I would "call someone at Dominion about this and get back to him."

No way, Jose.

We Interrupt This Blog, Part 2: Health Care Commentary

This week's "off-topic" post is on the insanity of the health care "debate," a word that is supposed to suggest reason and discussion, neither of which seem to be involved with the subject anymore. While I thought about including a section ranting about How Obama Sold Out HealthCare (i.e., The Public Option), I would rather try to put something out there that actually forces people to think reasonably about the problem and its many complexities and, perhaps, its myriad solutions. The caucophony of voices out there drown out a couple of really undeniable truths, which have been brilliantly highlighted by Atul Gawande time and again in his various writings on medicine, including the recent article in The New Yorker and opinion piece in the NYT. I also highly recommend his book, Complications.

But this article, by David Goldhill, in next month's Atlantic Monthly, is an excellent, common-sense starting point for meaningful discussion on a comprehensive solution to the health care crisis. Not that I agree with all of his ideas, but I do agree with his main premise: possibly the biggest problem with health care is that most of us don't even have a clue about how much any of it costs. Admit it - it's true! Do you really know how much it costs - not just for you but for your insurance company - when you get medical care?

If we're one of the lucky insured, a visit to the doctor involves a $20-30 co-payment during the appointment; maybe we pay another $100 when we get a bill a month or so later for some tests that we were never informed about the cost of in advance. Maybe, if we have a bum knee, or broken arm, or pneumonia...something requiring surgery or a hospital stay (or both), then we end up looking at another $500-2000 in bills after the insurance company pays for the rest. The form you sign when you arrive gives the facility the right to bill your insurance company and to bill you for whatever difference they may be contractually entitled to based on their agreement with your insurance company. But we're rarely if ever informed in advance of what anything we're about to approve actually costs. If we're unlucky enough not to have insurance, well...it can get ugly fast if you get seriously ill, and even then, you enter only deeper into the labyrinth of what the retail price is versus what you can negotiate with the hospital (if you're that kind of person). My husband has repeatedly asserted, and I know this is true, that if you don't have insurance, you get charged more than what an insured person ultimately pays a doctor. I know this is true not just from Mr. Goldhill's article, but from pre- and post-dental insurance life and from a second surgery. So here are my 3 personal anecdotes about medicine to add to the debate:

Straight From the Doctor's Mouth

I once met a doctor at a local university's mental health clinic who told me the story of being on a task force to investigate cost-cutting measures at the clinic. After spending a year looking into all options, they discovered that their biggest cost was their billing department. In fact, they discovered that the cost of employing so many people to deal with insurance companies and hiring bill collectors was higher than what they were collecting from those bills. The panel concluded that the cheapest thing they could do was to use the university resources they were already getting to put all the doctors on salary and quit billing the patients altogether. The doctors would be making the same amount (roughly) that they were before, everyone would be less stressed, and the university would save money. The recommendations were, as I understand it, declined.

Dental Insurance Sure Is Nice For Me, But Bad for My Dentist

I got vision and dental insurance for the first time in my life last year. My dentist and endodontist are very talented, which means they are not inexpensive. While uninsured, I paid $800 for a crown, plus the shocking cost of the root canal beneath it, and paid full price for every x-ray, appointment, getting my wisdom teeth pulled, etc. I definitely kept going to the dentist at a minimum...which is a bad idea if you are cavity-prone. As a result of my avoidance, I ended up needing a second crown, by which time I had a medical savings account, which helped somewhat, but was still a hit in the wallet.

With my new dental insurance, I now go to every check up on time and generally walk out paying nothing, but I do get a courtesy copy of the bill in the mail. I noticed that my insurance company pays less for all the things I paid for than I did, so I wasn't surprised to read Goldhill's statistic that uninsured people pay 2.5 times more for health care than the insured. How is that fair? All of those years when I was barely scraping by, I paid $800 for a crown that an insurance company only paid $500 for. I know about economies of scale and how insurance companies use membership to negotiate lower prices, but think for a second about the fact that this is medicine and people are sick, and people who are uninsured are usually people who are already hurting financially. How does it make moral sense to charge the uninsured more than an insured person, especially when an uninsured person who hands over their credit card is inherently less costly to the service provider? For example, when uninsured, I was expected to pay for my services before I left the office, so the time spent to bill me: 30 seconds. By contrast, my dentist is still waiting for reimbursement from my new insurer for a January appointment, and they're all patience and light about it, despite having spent at least, what, 30 minutes? an hour? submitting bills to them (which also requires postage). WTF? An uninsured patient costs less to treat but is charged more. This makes zero economic or moral sense.

Don't Play Soccer If You Have Bad Genes

There are two morals to this story: the first is that if your grandmother has had both knees & elbows replaced, you should avoid knee-intensive sports. The second is that medicine gets away double billing and price gouging, yet no one seems to care.

Background

I was a mediocre at best soccer player (shout out to the stopper/sweepers!), starting in high school and continuing for a couple of years in college, mostly as a benchwarmer for our sad sack team that came in 8th in the Seven Sisters Tournament. It was something I did for fun/PE credit.

After I graduated from college during the Recession of 1993, I was working at Borders bookstore because there were no other jobs and thought "Oh, hey, we get health insurance. Cool." Prior to this, I'd never had health insurance that wasn't provided by my college. When I went to the doctor as a kid, we got a bill, and my folks paid it, including the surgery to fix a tendon injury. In college, the school had an on-campus medical center with college-employed medical staff and our $80 fee for insurance covered anything they couldn't provide. I had never wanted for medical care and had never seen a bill for it.

Five months into the job at Borders and my knee started hurting very badly. Every night after work I was in tears of pain. So I went to a primary care doctor (required by the HMO), who prescribed physical therapy, which I duly commenced. And then I changed jobs - from a $8/hr job on my feet to a $21k/yr paralegal job mostly on my butt - that also had insurance, but not until you'd worked there for 6 months. For the first time in my life, I was really, really worried about my health insurance. I was so worried that I paid for a COBRA to keep my old insurance from Border's for an extra 6 months (the maximum allowed), because when I read the phrase "does not cover pre-existing medical conditions" on my new insurance policy, I knew I was in trouble.

Despite the shift from feet to keester, my knee continued to hurt and I was referred to an orthopedic surgeon who diagnosed me with of a torn meniscus, likely the result of my soccer playing days, and was told I needed a meniscectomy - or a cutting away of the torn meniscus, which was causing my knee to lock and swell up. The surgeon was all confidence - I was told it would be a half hour-hour surgery, I would be an outpatient, I'd be walking again in 3 days, running again in 6 weeks - it was easy, breezy, Cover Girl! So I took his word and since my insurance just said "$500 deductible" (I had no idea of the full cost - no one mentioned it) I got some dough from the folks and signed up for the next slot. Surprisingly, it was a 4 hour surgery, I was a sick mess, I started law school on crutches 8 weeks later, and didn't run again for a year. After I finally healed, I did feel okay, thought I was all good, and started playing intra-mural soccer on the Mall (the peak of my skills and career), because I had been told that I was healed. I did this for a couple of years and then my knee started hurting again. I ignored it because my new insurance at my public interest law firm job wouldn't cover pre-existing conditions, either - not even for physical therapy- and with all my law school debt, I didn't know how much treatment would be, but knew I couldn't afford it. Eventually, I changed to a job with insurance that covers pre-existing conditions, as many states now require. But I still relate fully to people whose insurance doesn't cover them for things they were diagnosed for 10 years and 4 jobs earlier.

After awhile my knee pain could no longer be ignored and after considerable research went to a new doctor. He informed me that sadly, meniscectomies are a really bad idea for women with lateral meniscal tears (which is what we usually have - the opposite is true of men), because the way we are built tends to put continued stress on the lateral meniscus, making it likely that a compromised meniscus will continue to tear. Because a cut meniscus is a forever compromised meniscus, every effort should have been made to fix my meniscus in that first surgery - but it's more work to stitch them up than it is to cut it out, and so a lot of doctors just defaulted to the former procedure because (a) that's what had been done for years on men - I was one of the first wave of orthopedic injuries of Title IX, it turns out, and (b) surgeries are generally not hourly fees; they're usually by procedure, and fixing a meniscus is more time consuming and difficult than is trimming it. So it would make a lot of sense that if my insurance at the time paid 3k for a meniscectomy and 5k for a fix, but the former took 30 minutes to perform and the latter over an hour, it doesn't take a rocket scientist to see the path my former golf-obsessed Porsche-driving orthoped (with vanity plates!) would take. Whether he made his decision based on a lack of knowledge about knee injuries in women or to make a quick buck, I will never know. I only know that his choice set me up for a lifetime of knee trouble. After trying all kinds of treatments, I finally scheduled the inevitable second meniscectomy with the new doctor when my knee started locking again. Thankfully, the second time did go the way the first had been described, and I was rollerblading again in 6 weeks, but was under strict orders to cease soccer and any other high-impact sports forevermore, which I should have been banned from after the first surgery.

No, sadly, it's not over...that is really just the prelude. Five years after the second surgery, the pain was back to the point where stairs were now a problem. This is because over time, the gap caused by the increasing lack of meniscus caused my femur to sort of collapse on that side - grinding away more meniscus and getting down to the tibia itself - i.e., bone-on-bone. The standard response to that is a knee replacement, but because they only last 15-20 years and replacement surgery is a mess, they don't do them for 35-year olds. My options were: meniscal replacement (using one from a cadaver), and an osteotomy, where they realign your femur (aka "the thigh bone") by cutting a wedge in the bone (you heard me right. If you really want to freak the hell out, do a Google image search of osteotomy). I will skip a massive part of the story on the aborted quest for a meniscal transplant, except to say that the guy I was referred to - the only one doing them here at the time - was very much trying to sell me into the procedure until it became undeniable that I was not a good candidate, and then he was trying to sell me into letting his buddy do the osteotomy. And he called women "babe." And also drove a Porsche.

So I went to New York, where my boyfriend lived, and went to a sports medicine specialty hospital, and talked with a surgeon who is (no pun intended) on the cutting edge of researching biological fixes for cartilage injuries. The plan became: get the osteotomy, which would buy me another 5-10 years of space between bones, and hope that the bio-medicine made a leap forward in the meantime. I really liked my surgeon in New York, and he spent hours with me on the initial consultations. He did not push nor rush. He answered all questions honestly and did not spare the gory details. He wasn't trying to sell me on it. This would not be an easy surgery - I would be in the hospital for at least 2 days, non weight-bearing for weeks, crutches for 8-10 weeks, and only at around 12 weeks would the bone be healed enough to walk unassisted. But doing nothing was really not an option for me anymore, because it was just getting worse and worse, so I opted for the surgery.

Things went very badly. I crashed out of recovery and had to go back down for drugs to revive my low blood pressure. I couldn't get out of bed for 2 days. I was in the hospital for 5 days with a roommate who got the window and with her thick Brooklyn accent kept telling everyone how be-you-tee-ful the view over the river was, while I looked at wallpaper and a curtain. The only thing that hurt worse than the surgery was the spot in my hip bone where they had had to remove bone to add to my leg to help spur new bone growth. Several personnel rotated through and tried more than once to give me medications I wasn't supposed to have. I finally went home and started rehab. But the bone wouldn't heal. At week 8, my doctor in DC (i was back and forth between them) took an x-ray and informed me that the bone had been set off of center in the operating room. And while being off by a degree or two can heal, mine was much more than that and unlikely to heal as a result. The NYC doctor, who had been seeing me regularly, had also hinted that this was likely the case, and finally admitted that yes, the surgery - the grueling surgery, the inability to care for myself by myself, the pain meds that made me sick, the shower chair because I couldn't stand/balance, the 12 weeks I had spent on crutches, etc...I'd get to go through all of that again.

The weekend after that happy news, my boyfriend proposed, which was a rare and cherished bright light in what would be 24 weeks of hell.

And then we went through the surgery again. I crashed again - worse than before - and when sent back to recovery, lost my spot by the window to a crazy, senile, epithet-spewing woman who kept me up the first night. I got out in 4 days instead of 5, though, and they didn't have to take more bone from my hip, thank god. Combined with the bone-growing protein they got special permission to use, my femur finally healed in 9 weeks instead of 12. And although I wasn't back to a normal knee, I definitely was better than I had been before having either of those surgeries.

Here's the key point of all of this really personal information, which I am sharing for a reason. Four, actually.

1. The Medical Malpractice Myth

I had several friends tell me I should sue. I'm a lawyer, after all. But the fact is, doctors do make mistakes, and if I got sued every time I screwed up at my job, I'd have been fired long ago. Who wouldn't? The other fact is, lawsuits are awful. They take money on the suer's end, and even if you hire an attorney who will front the costs for 1/3 of your recovery, the suits themselves are exhausting and exact a significant emotional toll. And I was emotionally tolled out. I just wanted to heal. It was also clear to me that my surgeon felt awful. The man called me twice a week at least...from airports, at home with the kids crying in the background, etc. to check on my status and answer questions. It was written all over his face and voice how badly he felt. He explained that it was a mistake and said he was sorry. And from looking at the way the procedure goes, I can see how it was not gross negligence to make such a mistake, and I am guessing although have not confirmed because I just didn't want to know, that he probably let a resident do the surgery. The place I went to is a teaching hospital, and doctors have to learn somehow. I'm not saying that it was great or even okay that they screwed up, and part of me really wishes they would have offered to pay off my law school loans for pain and suffering, but at the time, I just wanted to be well and the only person who wanted that as much or more than me (and my family) was that surgeon. And so I had him redo it because he certainly had more at stake in seeing it fixed than a new doctor would. I never even threatened to sue. Sometimes, I wonder if I shouldn't have demanded some recompense or at least brought it up with the hospital president. But in my mind, he said he was sorry, made clear that he would fix it, and he did. As far as I was concerned, it was over. I wasn't interested in exacting a pound of flesh or needlessly driving up medical costs for others.

The truth is, most people end up suing because of the way so many doctors and hospitals behave. They generally will not admit mistakes and prior to this experience, I had never heard one utter "I'm sorry." As in, I'm sorry you are in pain. I am sorry I had a role in causing that. I'm sorry I f'ed up your life. As with most human interactions, those are two underused and magical words that can avoid a world of hurt. I am not alone in preferring not to sue and have friends who have chosen not to sue despite receiving negligent treatment. Evidence backs me up on this - when the hospitals start admitting to mistakes upfront and offering to fix them/settle right away, and fight tooth and nail to defend against frivolous claims, the number of suits and overall legal costs go down.

The AMA has been arguing forever that litigation is the problem with the cost of health care, but this myth has been thoroughly and repeatedly debunked. See Slate's article summarizing this and Tom Baker's well-researched book The Medical Malpractice Myth, among which data is the rhetoric-deflating statistic that all malpractice costs - including all costs associated with all lawsuits- amount to a mere .05% of the annual cost of health care. Additionally the Harvard folks found that while doctors were injuring 1 in 25 patients, only 4% of the injured sued, and of 1400 malpractice lawsuits reviewed by the medical review team, 90% were found to have clear evidence of malpractice and 60% involved the death of a patient; of the remaining 10% of the cases, when in doubt, courts generally threw the case out (even when the team found potential malpractice) and of the 1400 lawsuits filed, only 4 cases received token awards where the review team felt there to be no evidence of malpractice at all.

The real problem in rising health care costs despite poorer results, as Goldhill's piece gets at, is not the cost of litigation. It is that there is a lot of avoidable error in the medical field that causes a lot of serious and deadly harm to patients, and currently the medical industry sadly has little interest and fewer incentives to fix that. An example of this is the often omitted aspect of the tort reform debate regarding the very real code of silence under which doctors/hospitals operate with regards to admission of error. Most medical folks will immediately point to litigation as the reason for the code of silence, but the studies above show that litigation is more often avoided when hospitals and doctors are open about their errors.

Additionally, it is rare for a doctor to lose his/her license to practice even when s/he is repeatedly found negligent. While I don't think one mistake should end a career, I do question why several major mistakes do not. There are some really inexcusable horror stories out there about doctors who are repeatedly found negligent for pretty awful cases but never lose their licenses to practice or lose them in one state but get them in another. The only recourse most wronged patients have right now is through the judicial system, and even then, no lawsuit can require that a doctor's license be revoked; that power rests solely with the boards of medicine. The Harvard study cited above shows that if the medical community wants to stop getting sued, the first step is to admit right away when they're wrong and immediately fix it; the second is that they should weed out the bad doctors once and for all, as it is often a small percentage of doctors causing a large portion of malpractice cases. This seems vastly more reasonable to me than taking away the only thing currently forcing the medical community to do anything to redress its errors, and would go a long way in increasing the quality of medicine.

2. Double Billing

What amazed me about my experience is that when my doctor said he would take care of the surgery, I assumed it would be on the hospital's dime. But they billed my insurance company for the second surgery at the same cost as the first (around $30k, if memory serves), and my insurance company paid the bill without a peep. It was nice for me in that I didn't have to fight with them, but I was left stunned that the hospital billed my insurance company for a mistake its doctor made, and my insurance company either didn't notice or didn't care, and I certainly wasn't going to risk getting stuck with the bill by questioning my insurance company's rationale. This is where I regret not having gone to the hospital president, because I did get billed for a bit of my deductible, but the amount was fairly nominal, so it wasn't worth my effort to fight it. But if that hospital had had to present the bill for the second surgery to me, there is no way they would have done so, because I would never have been liable to pay for fixing their mistake. Like any other company that sells a defective product, they would have given me a "replacement" surgery without cost to fulfill the contract we had for them to do the service correctly in the first place.

One of the things that does get lost in modern medicine through insurance is that we are paying customers. We are in a terrible negotiating position in that we are ill and want to be well, which is part of the problem, but medicine seems to have become wrongly immune to the one good thing about competition: better products. Competition leads people to find innovative ways to get customers and in medicine, I can only imagine this would be (a) excellent results and (b) good bedside manner/customer service. However, we're seeing increasingly less of either as time goes on. Doctors blame insurance pressure for having so little time to spend with patients (= poorer service) and when we're losing to Cuba on infant mortality levels, that tells you we've lost the war for excellent results. So, despite spending more on health care than any other nation, we have poorer service and poorer results. I'm not saying free market health care is the answer, since it is the free market that has given us the crazy insurance system that we now have. But I would definitely argue that when a hospital gets paid for a second surgery to fix the first botched surgery, that is an excellent example of how there clearly is no incentive to provide either (a) or (b), because you'll still get paid regardless of the outcome. Additionally, because people need a doctor covered under their plan and because that pool is limited, people are less likely to shop around for a better product, again removing the incentive for (a) or (b).

3. Q: What Does This Cost, Anyway? A: Whatever We Say It Costs.

Another aspect of the surgery that defies logic from a customer service perspective has to do with not knowing who is in or out of a network and finding out what you'll be responsible for in advance. For example, the NY hospital was a preferred provider, so I assumed going into the surgery that all aspects of the procedure would be covered under my deductible, since "preferred provider" is supposed to mean that the hospital will waive any difference between what it bills and what the insurance company pays. But it turned out that the hospital's anesthesiologists were not preferred providers. No one informed me of this in advance or said anything, ever, about how much any of this would cost. I was always referred to my deductible, but this key extra expense was omitted. So the anesthesiologists charged $5k for their work and my insurance company paid about 2/3 of it, which is what they pay anesthesiologists who are in their network. I got a bill for the remaining $1600 under the "you are responsible, per your signature, for the difference" clause of the forms I had signed. I was upset about the money, but really irate about the fee on principle, because no one ever told me any of this up front and why would I ever have assumed that I would go in for surgery at a preferred provider hospital, but that the anesthesiologists at that hospital wouldn't be part of the same team for billing purposes? Did they think I would bring my own drugs, or perhaps opt for a wooden spoon to bite on while they sawed my leg in half? My surgeon told me to write a letter to the anesthesiologist asking them to waive the balance because I was a government worker, thought they were included, etc. I did, and they waived the balance. Which is great for me, but what happens to other people who are not thinking that these prices should be negotiable and just pay what they are billed? I suspect a number of them are the folks who end up in bankruptcy over their medical bills. I'm all for haggling for rugs and other unnecessary goods in foreign souks, but getting a fair price for health care shouldn't resemble a trip to the car dealer.

To add insult to injury, I got the same bill from them after the second surgery, sent the same letter, and got the same waiver. But again, why was anyone being billed for the second surgery? Where was the hospital administration in all of this? I know they have reviews on when cases go wrong and know my surgeon had to report the whole thing to his superiors...why didn't they step in and call me and take care of everything both financially and paperwork-wise? Because it was in their best financial interest not to.

4. Nickeled and Dimed by the "Death Panels"

I hadn't really thought about how much I am paying in insurance premiums until the Goldhill piece. When you add the copays and deductibles to all of this, if all you ever get is a cold once a year then like any of Madoff's clients, your money is going to pay for the extravagances of others and you'll have nothing to show for your investment. But this kind of gets hidden by the fact that (a) you never really think about how much your employer is paying for your insurance that is, in fact, salary money they could be paying you instead or money they could use to expand their business to the benefit the whole economy, and because it's part of your paycheck deductions, you probably never think about the $100/month or so you're paying in insurance premiums. Instead, it's a bunch of little costs here and there - the $20 deductible, the $50 x ray, the $100 bloodwork, and none of them seem terribly bad. But they're nickel and diming you along the way on top of the $12,000/year your insurance is likely costing you and your employer.

As for the death panels, i just cannot believe how little attention is drawn to the fact that insurance companies already ration care and make life/death coverage decisions based on cost ALL OF THE TIME. While I am fortunate to have generally excellent insurance, one thing came up that made me scratch my head. There is a bone growth protein used frequently in Europe and approved in the US that has a great benefit of not requiring what is called an autograft, which is bone harvested from somewhere else (the iliac crest, usually) and ground into a paste that is added to the site of the osteotomy to help spur growth of new bone, which heals the leg. An autograft is extremely painful and about 20% of autograft sites have complications of their own. But the reason US doctors don't use the protein out of the gate is because it costs about $3000 and insurance companies want to save money. When I was researching the protein and the costs, etc., I read that most US insurance companies, including my own, will not cover that cost for a first surgery, but generally will for a second. And part of this is based on a formula where even with the 20% of complications the insurance companies pay for with autograft, it's still ultimately cheaper for them to go that way first. No one making that decision cares a whit about the pain inflicted on the patient by that choice. Because of the insurance company's choice, I didn't even know about the protein's existence until after the failure of the first surgery - no one mentioned it and I'm not surprised, because few people want to tack an extra $3,000 onto their bill. But what if my insurance company had worked out the break-even formula for them and offered to let me make up the difference the first time around? As Goldhill says, if everyone starts opting to do the protein, the cost would come down, and a lot of patient pain and potential future complication could be averted. I can say with certainty that if my doctor had told me all about the surgery and then all about the protein, with its risks, and about the bone harvesting from my hip and its risks, and if I wanted the protein, I would have to pay an extra $300-500, I absolutely would have done it and everyone would be better off in such situations. Patients would be better informed and insurance companies can still make money.

My Plan for Health Care Reform

I have learned several lessons from the current system in my own experiences:

1) The inanity and inefficiencies of the current insurance industry is costing us more than it would to put doctors on salary.

2) There must be more customer education up front about health care costs and there must be an uncoupling of the number of procedures and the income to the hospital. It must become results-oriented.

3) People not having insurance, or not having pre-existing conditions covered means they don't get preventative care, which means they get sicker, which costs everyone much, much more in the long run.

4) Openness about mistakes and fixing them will take care of much of the litigation problem, but medicine needs to do more to get bad people out of the system. No one has the right to be a doctor.

I don't really have a plan for health care, but I do like a lot of Gawande and Goldhill's analyses and suggestions. Still, I think the fundamental problem in modern medicine and the role of insurance is the moral quagmire of making a living off of sick people. Where is the line between compensating doctors fairly for a grueling job and having them needlessly subject patients to procedures to get more money? Part of the problem starts with the fortune doctors spend on their education, which fuels the rates they charge on the other end. So, in light of the fact that the government already pays around 90% of the cost of a medical school education, I'd just make it pretty much free to go to med school, but a lot harder than it is now (especially ethically) to get in, to graduate, or to keep a license. I don't like the joke about how the guy in the bottom of his med school class is called "doctor," and our poor mortality and morbidity rates means that we have a lot of bad institutions/practitioners out there.

Further, like the out-of-control banking industry, while improved consumer information that comes with the simple act of knowing what the costs are is helpful, given the complexity of modern medicine and the immediate need of the consumer, there is still too much potential in a straight-up capitalist system for 5 minute doctor appointments that really need about 45 minutes, and the unethical pushing of unnecessary tests and services at partner hospitals that give doctors kickbacks, all in the name of getting rich (as identified by Gawande's piece). I think a hybrid public-private system that involves local clinics and public hospitals with doctors on salary for basic care for anyone walking in the door is likely to be the best solution that guarantees reasonable health care for all and ensures that people get in front of illness, when it's cheap, rather than waiting until crisis mode, when it's costly. I would staff these clinics with doctors who just finished their free education - a sort of Americorps for the medical community - who would spend the first 3 years in medicine earning a livable salary of $70k/year learning how to be good doctors and paying back the taxpayers. After their 3 years, they can stay on permanent staff at the public clinic/hopsital or go private as they see fit. Public doctors would be paid a salary commensurate with the stresses/education requirements of the job, so I'd say $150-300k depending on whether you're the GP or the neurosurgeon. With this hospital system, you get less money than you would in the private sector, but you also don't have to deal with billing or any of that crap. As it is, most doctors who work for hospitals are paid a salary, so this wouldn't be all that new for them, but it would be worlds of difference for the hospital. No, their chiefs and CEOs will no longer make millions of dollars. They will be on the GS scale like the rest of the government that we all trust to make our water safe, build our roads and bridges, teach our children, protect us from criminals, and put our fires out. Don't say you don't trust the government, because it's just not true.

I would still allow private hospitals and private insurance for those who can afford and want it. I think they'd have no trouble finding a niche market even in the face of free public medicine - as I understand it, cosmetic surgeons are some of the most highly paid folks in the field, and no one's insurance covers that. Further, private companies successfully compete with the government all the time since the government hires contractors to do everything from analyze data to fight its wars. Public schools on the primary and secondary levels haven't put private educators out of business. If private doctors are better than the public option and they're truly competitive instead of all covered under someone's insurance, then people will still pay for their services, but they should do so directly and perhaps, if there is insurance, it works more like your home owners' insurance where you get the estimate first and then get reimbursed. This works with medical savings accounts - I have a pot of money to use for eyeglasses or copays, but I pay for the thing first and then get reimbursed. This makes me aware of the costs, which means I make decisions about whether I really need the designer frames or can live with the basic pair of glasses.

Sure, the rich might get better health care in a public and private hybrid, but how is that different than any other aspect of life or any other society? I don't really care about the ability of the top 5% to live a fabulous life; I'm concerned about making sure that all 100% of us don't go bankrupt and that the other 95% have access to decent health care.

What do you think?

Now Serving

I'm a sucker for the subplot, the twist, the undertow, the show-within-the-show. As I am sure several of my posts have already exhibited, I tend to wander off the main storyline into TangentLand fairly frequently. I'd like to think that this is due to my own interest in the behind-the-scenes action, but it's more likely a product of my poor storytelling skills and lack of focus.

Yet it strikes me, especially of late, that the main story of Hausaufgoblin can kind of feel...unoriginal...in its plot. Hapless Homeowners With Good Hearts Naively Get Suckered By Evil Greedy Contractors is a story with a Dickensian formula that, while I hope is well-written on better days, is also perhaps as formulaic as American Political Masterpiece Theater: Tonight's Episode - Naive Obama Twist tries to save us from impending health care doom, but will this good cause be cruelly sabotaged at the hands of the conniving Rush Limbaughburgerbottom who seeks to take us all down just to ensure Obama Twist doesn't succeed? Stay tuned!! And I hope you do stay tuned for the occasional bon mot, the rare elegant turn of phrase, or perhaps just to remind yourselves why renting is better. However, I think the time has come to add an unexpected twist in this tired old plot.

So, to keep things lively, my new blog-within-the-blog will feature culinary escapades called "Now Serving." It'll be surprising, informative, adventurous, and most importantly will not involve whining of any sort! And check out the cool button on the side (created by my fabulous spouse) that will enable you, dear reader, to go straight to this and all future episodes of Now Serving with a single click. Season 1 of Now Serving features my current muse: Lello the Birthday Gelato Machine. It's the gift that keeps on giving. Here's a trailer for the first episode: Eagles vs. L'OM/Football vs. Football/Vanilla vs. Vanille

Fraud Alert!

I got the following voicemail today:

...if you are our customer, Ms. X, press 1..........if you are not our customer, Ms. X, press 2.......Hello! This is a a FRAUD ALERT FROM CITIBANK calling about your Visa card that ends in XXXX. Several transactions have been posted to your account that raise high concerns of FRAUDULENT ACTIVITY! Please call us right away at 1-800-PHONETREE and dial access code XXXXXX to discuss these transactions by tomorrow or your card will be suspended to protect you from fraudulent use of your account!

Gee, I wonder if the seemingly random repeated installment payments to Dominion Power over the last 8 days have triggered the credit card company's automatic fraud search. I'm guessing they have an algorithm that raises fraud flags when there are repeated transactions of same/similar amounts going to one company. I certainly think it sounds suspicious.

I can't wait to tell the folks at Citibank how Dominion Power's payment policy designed to protect them from fraud is what triggered Citibank's fraudulent activity algorithm.

Ahhh, life under The Corporate Thumb.

(Me)..........................(Citibank)...(contractors)...(Dominion)