It Is Hard To Believe There Are Only 7 Days Of School Remaining And That Another Ama: Fill & Download for Free

Just like the famous movie Taare Zameen Par… Every Child is Special, we can have a movie titled CA Zameen Par… Every Attempt is Special.If any day, you want to gain the attention of a Chartered Accountant, just ask him/her the story of how he/she became a Chartered Accountant. And all of a sudden, you will see a new vigour in the conversation, just like this question has fascinated my attention. The above part might sound reasonable, but the interesting part is, they will share the story of their failures with equal or more pride than the story of their success. This might feel weird, but I tell you, there is nothing wrong in it. There is an adamant reason for it which you will understand by the end of this answer.The world might call it a Strange Story, but we call it a Great Story. More the number of attempts taken, the more great story it is considered. Hence, a disclaimer, since I never had the opportunity of giving a second attempt in the CA course, my story is not any great story or a strange story. It is an ordinary everyday story of every Chartered Accountant and hence, sharing the same so that people who do not belong to our fraternity will understand our life a bit.My Story / Normal Strange Story of a CAChoosing CareerLike all those Engineers today, even I too wanted to be an Engineer - something related to Computers & Softwares. I was very enthusiastic about the same. My acquaintance with computers was since primary schooling, but in Class V, when my father bought a computer, I finally had the opportunity to befriend them. Since then, Computers became my best friends. We had a lot of fights as well, during which I deleted its entire Operating System twice, but the doctor did well in recovering his senses. Ultimately, as time flew, we became great friends and eventually, this drew my interest in Engineering. I had also topped an exam which was conducted by a Premiere Institute, who gave coaching for IIT exams, which provided an impetus to the same.However, when I reached the point, where I had to decide the future course of my life, the IT sector in India was in deep, deep trouble. The hungry recession had eaten up most of the opportunities in this area and thereby my father made me join the Chartered Accountancy course instead of Engineering. I was disheartened then, however not today. Keep reading.If you ask Chartered Accountants, a majority of replies would be “I wanted to become x or y, but somehow I landed doing this course.”Commerce StreamClass 11th - 12th was genuine fun. The syllabus was easy, except for Mathematics. During entire Schooling, Mathematics was my favourite subject, but then it got replaced with Accounting. What a fun subject it is! Debit the receiver, Credit the giver, drawing lines, Accounts & T-format statements. In contrast, Mathematics felt like the worst subject ever, especially with the arrival of derivatives.This laid the foundation for “What will be my strategy to pass CPT examination.”CA - CPTThe affair with Accounting and hatred for Mathematics continued in CPT. The strategy was simple - Score in Accounts, ditch Maths. When I gave CPT, they didn’t disclose subject wise marks, but I am pretty sure that I scored 60/60 in Accounts, probably 38/40 in Law, 40/50 in Economics and balance 20/50 marks in Mathematics.Welcome to CA Profession, here everybody hates Mathematics, we love Accounting!CA - IPCCThere weren’t Coaching Classes in my city and therefore, I had to move to Pune for further studies. I don’t remember much about this part of my life because all we did those days was Getup-Class-Breakfast-Class-Lunch-Class-Juice-Class-Dinner-Homework-Sleep. That’s all. This is how those 6 months passed by, followed by 3 months of studies. Of course, the best part was hostel life which was an entirely different experience of life.This next part might attract your interest. In those days, all the time I used to keep thinking about- “How to Study for CA IPCC?” or “Is 3 months of Self Study enough?” or “Which books should I follow?” etc. Today the same questions exist on Quora, and I am providing answers to the same.When I joined Quora and explored the Chartered Accountancy topics, I realized, how every Chartered Accountant faces the same type of issues while pursuing this course. Ironically, we get the right answers to these matters only after clearing the examinations and then we realize, I wish I knew this before!Now I had studied only half the portion of IPCC, yes, only 50%. But I still managed to pass. No, I had not planned to study selectively. I had a detailed plan for studying the entire syllabus. I was happy that I will be able to cover the whole syllabus within 3 months, along with Paper solving. But it turned out that, 10 days before the exam, I had hardly studied 40–50% of each subject. But then, I took it sportively; because on my mind was“CA course is a tough course. It is not possible to pass with this kind of preparation. But there is no harm in giving it a try. Let's consider it as a Game, where some people will win, and some have to lose. It would be a helpful experience for the next attempt.”Undoubtedly, my exams were horrible. I knew proper answers to 50% of the questions since that is what I had studied. But I went on to solve the balance paper. All I did was recall what was taught in classes, remember the concepts, try to merge the concepts & the facts in the question and present a logical answer in my own language, irrespective of the answer given the books. But I had accepted the fact that there is no chance of passing, because of my poor preparation. Especially after the last paper of ITSM, where I had to take a 5-minute nap in between the three hours so that my brain actually functions. It was a terrible paper, and therefore, I knew 3 hours is more than sufficient time since I hardly know the answers, so taking a small nap is not a bad idea.I was so terrified with my performance that for almost a month post-exam, I couldn’t sleep. When I used to close my eyes, suddenly all Accounting Standards, ITSM concepts, etc. used to revolve in my mind. You can imagine my situation similar to Harry Potter who had dreams about Voldemort! Never in my life, I felt so depressed about my exam performance.Result day. I passed both groups. That’s when I realized, the CA course is not about how well you have prepared, but it is about how well you have understood. If you know the concepts, you can quickly answer the questions by logic, and you get the marks for the same. You don’t need to follow the book answers or their pattern.CA - ArticleshipTo summarize in one line, I can quote the famous dialogue from the movie ‘The Pursuit of Happyness’, “Now this... This little part of my life is called Happiness.” I can go on sharing for days about Articleship because there are tons of stories. But I choose to share the first ever story of Articleship, which can be nothing but your interview for articleship!My strategy for articleship was very simple - for few days become a Postman, post the resume in as many firms as possible, don’t say No to any call for an interview, gain as much interview experience as possible, since it will be useful in future. The first amongst the series of interviews that I gave was along with a stern interviewer who didn’t ask difficult questions but gave the scariest looks, who later became my principal. My Sir is 6+ feet tall, a handsome person with excellent command of English and Communication skills. Interestingly, he had completed his Schooling from Marathi medium school but the way he spoke, one will never have an idea of this fact. It turned out that I wasn’t able to answer “What are the three fundamental accounting concepts as per Accounting Standard 1.” I mentioned the two but forgot the third. And we still have a good laugh on it today. However, I got selected. But this was the first interview that I gave.I had offers from 3–4 other firms to join and the other firms which were much bigger in scale and size, but that Interview had so much impact on my mind that I decided to join it, just because I felt, this is the person who can really make my career worthy. I can say my Sir didn’t interview me, actually, I had interviewed him, because he made a long-lasting impact on my mind. I decided to compromise on the office, but not on the Principal.That’s when I learned friends, your principal is the key to your articleship. If he is good, your articleship will be great. So choose your articleship firm on the basis of how good your principal is and not on the basis of the firm, its clients, the areas of work, etc.My Principal supported me a lot during articleship, allowing personal development beyond the office work, backing all kinds of initiative ideas that I shared at the office and answering all kinds of queries, sometimes even the personal ones. My Articleship period, especially after the end of the first year, is till date the most heroic period of my life and probably will stay for an outstretched time.CA - FinalThe most crucial part of this course. I started with coaching classes in the second year, planned the whole strategy well. However, since exams were 2 years later, never felt the seriousness of regularly attending, besides Articleship also affected a lot. So my FR and SFM classes were ruined. However, later I strictly followed my plan realizing the grave problem I could be in if I didn’t become serious at that point. You might feel this strange, but I started keeping a record of my attendance on the first page of class notes, to encourage myself not to take too many leaves. I remember my record - while attending AMA, ISCA, DT, IDT - I missed only 6 lectures in a total period of 10 months, where Sundays were not holidays, so this was 10 months regular classes along with articleship.But this really paid off later. The regular attendance at class helped me a lot later in self-study and during exams. So friends, if you are attending classes, be regular, and you can try my stupid technique of keeping a record of absenteeism, it helps!When it came to preparatory leave study, unlike IPCC, this time, I was aware of what has to be done, what is not to be done. But that turned out to be of no use. CA Final was very much different from IPCC. Of course, answering logically does help here as well. However, the papers are exceptionally lengthy, besides being difficult. This makes the situation worse. If you are not well prepared, you can never write the full paper.I had CMA - Inter examination in December, right before my CA - Final exam in May. Until December, my entire focus was on CMA - Inter and therefore, although I secured rank in CMA - Inter, this affected my preparation for CA - Final. Just like IPCC, I started with a full plan for studying entire syllabus. And just like IPCC, I ended, not being able to study the entire syllabus. However, this wasn’t as bad as IPCC, since this time, I at least managed to study 3 subjects - FR, SFM & AMA in full. But the situation was worse with theory subjects Audit, ISCA & Law where I had managed studying only 50% of the paper. And Paper solving, once again, just remained a concept on paper.But preparation was not the real problem. When I went for the first exam, in reading time, I assessed the paper and found that all 120 marks paper is from sums that I have studied well. So I was happy. However, I was able to attempt only 40 marks paper, and 30 marks paper by way of merely one line answers. My answer to Value Added Statement was “40000 + 50000 + 10000 - 20000 + 20000 = 100000. Thus, GVA of XYZ Ltd. Is 100000”. That’s it! I answered 30 marks papers in this manner. And the balance 30 marks paper was left unanswered. I have a sweating palms problem, owing to which I cannot write fast and my handwriting speed is very slow. Since Class 10 to CA Final, when Papers are lengthier than school days, I have lost a lot of marks due to not being able to cover paper.My problem was different, but still, there were many students across India who were not able to solve the entire paper. So friends, moral of the story is “Paper solving bhi jaruri hai” (Paper solving is important)I still remember, how many times, I recounted my paper to check if I can score 40 marks or not. When I came out of the classroom, while all my friends were moaning for a difficult paper, I was moaning at not being able to cover the entire paper, even after knowing answers to full 120 marks paper. The good news is, I passed with 56 marks. How? The 40 marks paper that I solved, surely bagged me 40 marks. The balance 16 marks came from those merely-one-line-answers!Now you understand the importance of not giving up? If I had given up that day in the exam hall, when after 2.5 hours I had solved only 40 marks paper, today you won’t have been reading this story. This is what I call, being sportive at exams, trying to score as many possible runs off those last overs by slogging!FR paper was not the end of the story. SFM Paper turned out to be even worse. Some of my friends appeared directly for Costing Paper after SFM, since according to them, they neither had the chance of scoring 40 marks in FR or SFM nor the chances of scoring exemption in Audit & Law! This is called giving up, totally not recommended. The same story continued in Audit & Law. But I was already in deep tension after the double trouble of FR & SFM papers, since these were the papers that I had studied fully.After the first two exams, I had given up studying before exams. I just used to study 3-4 hours for each subject and used to watch IPL, play games, etc. This was because, I recognized, in FR & SFM I could have performed better had if I kept my cool. So to avoid tension, I started relaxing more before exams and studying less. And it worked. Although my preparation for Audit, Law, ISCA, etc. was not good. However, by being relaxed in exams and thinking logical answers on the basis of Articleship Experience, I wrote answers. And the result is open truth today - I am a Chartered Accountant.People thinking articleship is not important and has no connection with CA - Final, this is what you need to understand, how articleship experience can come to rescue in exams!Important PartThe syllabus, the exam papers, the articleship, etc. are not the only problems that a CA student has to face. There are many other problems that a student soaks before he ultimately becomes a Chartered Accountant. And I was no exception to it. Being a class topper since childhood, there was always a high pressure of family, friends & relatives expectation, at every stage of this course. One failure and I would be leading down the hopes of so many people!The world doesn’t have only good people. There are lots of people who will constantly keep telling you “These are the 10 things Saurabh, that you can never do in life.” or “You are good for nothing” or “You don’t possess the ability to do this” etc. *used-softer-words* Normally either people agree & develop inferiority complex or they will argue, fight & try to prove that they have the capabilities. I chose a different way. Every time somebody told me that you cannot do this or that, I made my point that in life, I will give a try to exactly these same things. And it turned out that many things out exactly these things that I was criticized for, became the assets of my life - the best skills that I possess today!So if next time somebody criticizes you, say nothing, just go back and give that very thing a try. The added benefit is - you know, who your real friends are, giving real advice, amongst the other people who are merely speaking out of jealous.Today becoming a Chartered Accountant alone is not enough to have a good career. I also had to make sure that besides good experience in articleship and good marks in exams, I also possess the communication skills, the innovative mind, the general awareness, work ethics and many other similar qualities. This made life difficult.But exactly this problem taught me, how to invest my time. If you invest your time properly (both in right activities and on right people) you can get everything that you want to achieve and leave behind all those people who mean nothing to you.The opportunity cost foregone due to studying for CA, articleship and the extracurricular activities for becoming a good CA, is very high. While many friends on social media pose & post photos at different places, many enjoying parties or outings, some engaged in relationships or some happily enjoying being free; we CA students had to be in restricted circles with restricted people and limited socializing, in order to have a good career.This makes many people a little depressed, but if you choose the right company & right way of spending your limited social time, you may not feel the difference from other friends.I said I had a deep interest in Computers and Softwares and not doing Engineering was disheartening at that time. However, as I progressed in the CA course, I realized that people here are not very Technosavvy. So indeed, my techno-savvy nature makes me special amongst Chartered Accountants, which actually amongst Engineers won’t have been a stand out feature.See how life makes the best use of your skills, it is just that you need to believe in yourself that good things will happen to you since you deserve it.Strange Stories / Great StoriesAmit Tated (ISCA Faculty) - He shares his story during the ISCA classes. It took him 5 attempts to pass CA IPCC. FM was the worst subject for him. Until his 3rd attempt, he didn’t even know how to calculate the Present Value Annuity Factor! He used to learn the factors, he didn’t know that they can be computed on the calculator, until one day he met a person in the library who taught him.Swapnil Patni (ISCA Faculty) - Another ISCA faculty who shares his story during the classes. Indeed, there is a special lecture that he keeps especially for sharing the same. I have not attended, but the people who attended it said that they literally cried while attending that lecture which comprised of his story and other motivational points.Venkataraman Murali (BOS Ex-President, ICAI) - He had failed 5 times in IPCC, but cleared CA Final in the first attempt. Today he features in the most elite committees of ICAI. So moral of the story is if you don’t get a job after multiple attempts, join ICAI! *Sarcasm*Shailee Choudhary (AIR 1) - She failed 7 times in IPCC and especially because of ITSM. However, the same girl, later in CA-Final, secured All India Rank 1. Besides, she also scored the highest marks in ISCA across India.Kailash Narayan Purohit (Jodhpur) - According to CA Groups 4 All this person kept trying to clear CA Final for 20 years and thereby, in 32nd attempt he cleared CA Final.Prema Jayakumar (AIR 1) - With no money in hand, with no coaching in CPT & IPCC, this Girl, who happens to be a daughter of Auto Rickshaw driver, topped CA Final exams. Her coaching in CA Final was possible only because the coaching classes gave her scholarships because of her exceptional talent.A Friend - Months ago a stranger contacted me. He wanted me to help him with the CA Final Audit preparation. He told me, he had given 6 attempts for Group I. All these 6 attempts his total score was between 190 to 199. Out of which, a couple of times he failed in Auditing. I helped him with Auditing paper this time and to my happiness, he passed in Auditing, however, failed in SFM! He is not a CA yet, but he is still trying, has not given up yet. However, he already works in Bank and earns reasonably well.ConclusionThese are not just stories, they are life lessons. Every attempt, every failure, every success, every stage of CA course is a life lesson for CA students. And this is the reason why Chartered Accountants present their failures with a lot more pride. They are a lot more mature than students from other professions, due to their experiences in the CA course. They have already learned the lessons of life while doing the CA course itself!In the end, all the efforts that you take in CA course, all get paid off when you become a Chartered Accountant. The people who had a great social life then, when you were busy preparing your career, the same people will be busy finding and developing some sort of career & earn personal respect, while in contrast, you will be enjoying money, respect & social life - all together.

I was very arrogant about my health until recently.At 59, I had never been sick, I’m very fit, and look quite a bit younger than my age. My father is 90 and lives the same lifestyle now as 30 years ago, living in his own home in the Texas Hill Country.I’m a physician and have almost daily occasions to offer health advice, and I have a healthy, thriving practice.I am a fan of Nortin Hadler, MD, who writes extensively on intelligent, informed healthcare, offering facts and studies a healthcare consumer should be aware of before giving or refusing consent to commonly recommended medical screenings and treatments for conditions such as high cholesterol, blood pressure, or glucose; colonoscopy; mammography; PSA screening and more. Lest you think he’s fringy, he’s Professor Emeritus of Medicine at UNC School of Medicine at Chapel Hill, and Harvard and Yale educated. You can see his brilliance and relevance in this PBS interview.For 20 years or so, I’ve seen a wonderful internist yearly, but, would abdicate responsibility for this behavior, saying. “The only reason I have a doctor is I have a wife.”Thank goodness I have a wife.September, the year before last, 2018, I had previsit labs for my annual visit with Rick Earnest, who was Chief Resident during his internal medicine residency at Emory, he’s top notch.My white count was low. Rick’s nurse called and said he wanted another CBC and a folate. White count low; folate normal.Then, I saw Rick in his office and we chatted dispassionately about the neutropenia… WBC was around 2, with 4–12 being normal.He told me he had talked to a local heme/onc that morning and then, he shrugged his shoulders and said, “Looks like you need to see a hematologist…” I agreed.About a month later, I had extensive labs at the local oncology center; met the delightful hematologist, Kavita Nirmal, who recommended a bone marrow biopsy.I knew this was coming and, once again, being very healthy and having no signs or symptoms, I thought serial CBC’s would do.However, after my consult with Kavita, I had no urge to refuse the bone marrow biopsy, and it was done that day.Things moved quickly from there.The next day, Kavita called and said I needed to see a specialist at Baylor. Five minutes later, she called back and said, “You could also go to MD Anderson.”Baylor is two hours, MD Anderson is four.Initially, I balked at accepting an MD Anderson referral, as this meant, in my mind, saying, “This is serious.”Over the next 24–48 hours, I had the strong intuition I should go to MD Anderson.I responded to Kavita’s phone call about my treatment choice in a way I found funny/odd… I said, “I owe it to my family to go to MD Anderson.” I thought, “Wow, Dude, you can’t even take responsibility for your choice to go to MD Anderson.” (It wasn’t a big deal… but, interesting.)My records and actual marrow specimen were Fedexed to MDA; I went there for labs and another bone marrow biopsy; and met with a national leader in leukemia, Naveen Pemmaraju.All this occurred in a very compressed period of time and in a context of general surreality, punctuated by briefs periods of extreme surreality.I had accepted there was something wrong with my bone marrow. I had actually been aware I was neutropenic as far back as August 2016; but, again, arrogant invincibility had me ignore it.In Longview, I was told, based on microscopic evaluation of my marrow, and an estimated 13% blast count, I had myelodysplastic syndrome (MDS), something I was familiar with when a fellow staff psychiatrist told me he had it. It was a significant health scare for him, but that was in the 90’s and he and I were in touch for at least 10 years after that, and to my knowledge, he’s still fine today… (we both moved on from that mental health center years ago).Then, as I was going through the process leading up to seeing Dr. Pemmaraju, a nurse who was checking me in and reviewing my chart, was reading out loud to herself… as I listened, it was all quite routine to me as a health care provider, until the letters “AML” came out of her mouth.They weren’t intended for me; she was just one of those people who reads out loud when they read. Perhaps she thought I knew. Perhaps she didn’t know she was reading out loud. It is a cancer center…I can’t think of an adequate adjective to put in front of “stunned” and “frozen” to adequately express that instant as the biggest WTF! of my life rang out in my mind…“It’s leukemia?! I have leukemia?!!!” My mind was reeling with that shock…It was quite a mental shift, in an instant, unsuspecting, unprepared, from MDS to AML.I suppose it was helpful to have the time to be past that initial reaction later, as I sat in one of Dr. Pemmaraju’s exam rooms, waiting to see him. He burst into the room almost as enthusiastically as Kramer on Seinfeld. He was young, energetic, positive and extremely enthusiastic.There I was, sitting face to face with one of the finest allopathic physicians… a hematologist/oncologist who only treats two types of leukemia and MDS.It was a briefly challenging/confronting situation on a philosophical level.You see, I’ve been writing, Power Without Pills: A Curious Psychiatrist’s Guide to Healing and Growth in the Modern World since Googling John Sarno, MD in February 2006. And, I have talked some trash about modern medicine. Not irresponsibly or inappropriately… but, trash talking nonetheless.I was challenged with substantial, in-my-face cognitive dissonance.I resolved it for myself quickly.I had been throwing the baby out with the bath water.I had been all “mindbody medicine is where it’s at!” and, then and there, I realized I had been going to an extreme.I once heard a man say, “You’re just as half-assed no matter which cheek you got.”So, I decided, “Alright... I like this guy... I trust this guy... I’m going to roll with this, and I’ll handle the mindbody part... and he’ll handle the traditional medicine part…”Both cheeks were suddenly firmly in place.He told me they have a clinical trial, using the CLIA protocol, where they’re getting upwards of 90% complete remission rates in frontline AML.All three drugs are FDA-approved for AML, but no one is using all three together. “We are gonna rock this thing! We are going to crush it together!”, he said, beaming.He told me I’d need some preliminary tests, like an echocardiogram, to qualify for the study... a formality.Then, I would be admitted, given five days of chemo, be in isolation, and have a total of around 28 days inpatient before being discharged to outpatient treatment where I would receive five consolidation rounds of the same three chemotherapy drugs every 28 days.He said I’d be in complete remission by Day 28.That conversation was on the Friday before Thanksgiving. He told me to go home and spend time with family... my wife was there in that initial consult and throughout, but I hadn’t seen my father in Austin in a while... it was a wonderful, deeply meaningful break/visit with close family before I went inpatient… ostensibly 28 days, in isolation.On the eve of Thanksgiving Day, I was admitted to the Leukemia Specialty Care Unit at MDA, at around 7 pm, and began chemotherapy that night.How I’ll be bathing in isolation for the next 3–4 weeks…My wife and father-in-law visit me in the square bubble…This woke me up in the middle of the night, tickling my nose…Going…Gone. My hair didn’t survive.It went exactly as he said; except I had a Day 21 bone marrow biopsy in the hospital. The next day, the attending on the service strode briskly into my room, smiling, and said, “Go home. You don’t need to be here any more.”My blast count had gone from 30% to 4%, complete remission, in 21 days.I said, “Uh… I’m not ready.” (My wife was four hours away and expecting me to be discharged in about a week).I went home the next day, six days early, for good biological behavior.I was in complete remission.There was suspense though. I was told through some magic called flow cytometry, they could give a measure of prognostication, MRD, Measurable Residual Disease. With MRD, they could find traces of leukemia, the presence of abnormal blasts, “down to levels of 1:10,000 to 1:1,000,000 white blood cells (WBCs), compared with 1:20 in morphology-based assessments.”[1]A few nervous days later, at my first outpatient follow up, I was given the news, “You are MRD negative.”A Senior Coordinator of Clinical Studies, Department of Leukemia, MD Anderson Cancer Center, Rabiul Islam, who’s worked there since 2003, gave me that wonderful news, and he added, “I have never seen an MRD negative patient at Day 21.”As I have said, I highly value and practice mindbody medicine; parts of that are a positive mental attitude and faith in the healing propensity of the body and the intelligence of life.And my positivity and faith had been rewarded at every turn (even developing leukemia, which I would not have consciously asked for); but it was never the kind of faith and positivity that produced a reaction to, “You are MRD negative,” of, “Well, of course, I’m MRD negative.”I cried when he told me and it brings tears to my eyes now as I write this. I am deeply grateful.And, along those lines, I have taught mindbody medicine concepts for over 20 years and was pleased to find nothing changed with being diagnosed with an illness that has a 25% five-year survival rate. I found, not surprisingly, I walked the talk. Yet, you don’t know how solidly your ship is moored until there’s a storm.As interesting foreshadowing, for years, as one approach to mindbody medicine, I would discuss the hypothetical situation in which someone was diagnosed with a type of cancer that had their physician say, “The 5-year survival rate is 5%.” I would then say, “I wouldn’t say, ‘Oh, no! Those are terrible odds!’ I would say, ‘What did the 5% do?’’’ (My apologies for the complex, and possibly incorrect sentence structure.)I have had many profound blessings in the powerful life lesson leukemia brought to me.To address the question:The leukemia was caught on a yearly routine blood test before I was symptomatic.I am young and healthy, with no comorbid illnesses, and I really stood out on the Leukemia Specialty Care Unit because of my youth, fitness, and lack of comorbid illness.I got the best cancer treatment in the world, I assert.I’ve had an excellent attitude throughout.I never fought the leukemia. I was never inclined to. At the local cancer center, the narrative was everywhere about fighting cancer; even the wifi password had that rhetoric… yet, I could not abide by that narrative.I’m not suggesting that people not adopt that narrative; it’s fine with me if they do; it’s just not for me. I’m not going to start a “Fight Fighting Cancer!” campaign.I do want people to know there’s more than one narrative to adopt in the face of cancer. Pick according to your gut.I’ve said thousands of times: “What you resist persists.” I would not fight. I would listen.I viewed the leukemia as a messenger, and my job was/is to get the message.I have enjoyed Louise Hay’s work, and was aware of the fact she gave meaning to particular illnesses.I thought, “Leukemia is a childhood disease…” Hmmmmmmm…I had started guided journaling at What is Self Authoring? many months earlier, and had started with the Past module (there are also two for the present and one for the future… starting with the past made the most sense to me…) but, I quickly fell into procrastination…One obvious message was, “I wouldn’t do that if I were you…”, meaning, I got one message as, “Don’t keep putting off deep work.”Now, acute myeloid leukemia is relatively rare with about 20,000 newly diagnosed cases a year. That’s an incidence of 0.006%. It’s rare.But, things would likely be much darker (which sounds weird to write, because I can’t say they’re dark (though I can admit if one looks at the five year survival rate for AML, one would be inclined to say they’re dark… but, that’s a statistic, and part of good mindbody medicine is not being negatively influenced by stats…)) if I hadn’t been getting yearly routine labs.TLDR:Get yearly routine labs like a CBC and complete metabolic panel.The risk/benefit ratio argues for it.Think of it as insurance… you definitely want to have it, even though you don’t want to use it.Extra credit edit:So as to exclude as few readers as possible, I am adding an important point…I have used the word, “blessing” more than once, and said that there is meaning in this life challenge/lesson, thereby asserting/strongly implying it’s not random; we don’t live in a strictly mechanical Universe, in which we humans are machines that break and consequently go to doctors that intervene on our behalf and restore us to health.I was ultimately convinced of that mechanistic worldview until the age of 23. I no longer believe in or inhabit that worldview… but no matter…I’m working on a reply to the gentleman’s comment in which it’s asked what I think caused the leukemia.My reply involves logic I learned from my mother, an adept at logic. She changed her worldview late in life with logic.She told me one day, she had done a thought experiment in which she made a matrix of cells… the particulars will be in the reply when I post it.It is the particular thought exercise that’s relevant here:Let’s say you can’t abide by the notion of an actual blessing, or the idea there’s meaning to be mined in a disease, especially a life-threatening one like leukemia, you can still potentially get the value of that system/belief through this exercise:Let’s construct a matrix of four cells: 2 rows, 2 columns…I’m blessed really/I’m not actually blessedI believe I’m blessed/I reject the possibilityThen stand in each cell and look out at the world as if those conditions are so… what do you see? Is that possibility empowering?You see, it isn’t the truth that I was blessed and it isn’t the truth there is meaning, not randomness, in the leukemia… it’s a powerful place to stand.For the strictly “If I can’t see it in a lab, it doesn’t exist,” Do you want to be empowered, or do you want to be right? Or, if your health isn’t good, do you want to be healthy, or do you want to be right?Consider everyone is a house with four rooms: physical, mental, emotional and spiritual.In the modern world, you risk falling prey to the paradigm, the physical level of reality is all there is… It’s all matter and energy… if you can’t see in the lab it doesn’t exist.That worldview may be true, and obviously, it may not be.If you hold yourself as a house with only one room, physical, which gives rise to the illusion of the other three rooms and that’s not the case, there may be a dear price to pay.EDIT (April 16,2019):I can’t say I’m about to add materially to my answer of the question; however, I can see how the reader might be curious as to what’s up as of today… I don’t remember when I wrote this; I see my last update was February 16th.There have been three excitements and one very sad loss since I last updated. I’ll end with the loss.About six weeks ago, after receiving a unit of red blood cells, an infusion which took about two hours, I drove home and sat on the couch. I started to feel cold and hot at the same time. Cold won out and I got underneath an electric blanket and turned it on. Very shortly I was having hard chills.My instructions from MDA since my December discharge were, “Go to the ER if your temperature hits 101 or more.” I didn’t have to take my temperature. My wife drove me to the ER. It was a Friday afternoon and the ER was packed. Getting into the ER was fun; because I have staff privileges there, but the staff up front and the triage nurse don’t know me from Adam. So, I went in the back doors of the large ER, bald, with an overnight bag slung over my shoulder and said, “I’m Dr. Murphy. I’m in treatment for leukemia and I have a fever.” Most of the dozen or so doctors, nurses, technicians and unit clerks behind the counter stopped what they were doing to stare at me. I stared back at them. Eventually, a nurse broke the deadlock. “17 is open,” she said stepping out to escort me.I was deathly ill. All the routine things… blood cultures, chest xrays, etc. were done, looking for a possible source of infection.For the next three days I lay in the dark, sleeping as much as I could. They left me alone, which I thought was odd, but appreciated. At MDA I don’t think they would have let me lay in the bed 24/7, and didn’t even when I had RSV (another story).Monday rolled around; nothing had grown in the blood cultures; and, I had started to feel better. About 11 am, having enjoyed a great rapport and relationship with everyone there, I said politely to the nurse, “Um, I’m going to be discharged. I just need to know whether it will be AMA or not.” 10 minutes later I was signing routine discharge orders, and I went home. I felt like crap.In retrospect, the most likely explanation was a non-hemolytic transfusion reaction, something that occurs in about 1 out of every 1,000 RBC infusions. This can occur if WBC’s stow away in a batch of inadequately washed RBCs. They cause a cytokine reaction, the kind of thing that makes you feel awful when you have the flu.Gradually, over the next few days, my energy came back.The second excitement was going back to MDA on a Friday, my chemo rounds always start on Friday, and had labs in the morning to prep to see Dr. P, who would then order the 3-day round of chemo.My WBC was below 1,000, even though, due to circumstances, I was on Day 35 of a cycle. Being in a clinical trial at MDA, there are protocols and guidelines and chemo was off; it couldn’t proceed.Once again, Dr. P predicted the future. He said, “We’ll do a bone marrow biopsy; you’ll still be in remission. You’ll go home. Have a great weekend. Come back Monday morning. We’ll do labs and give you a shot of Neupogen Monday and Tuesday mornings, and we’ll restart your chemo on Wednesday.”That was an exciting weekend; because, while the blast count was likely ready Friday afternoon, no one was there to read it. And, while I mentioned a couple of potentially arrogant sounding behaviors around febrile neutropenia hospitalization; I’m not the type to be inclined to try and get the results before Monday.I was able to think positively throughout most of the weekend. I did allow my mind to think about a recurrence, but not to dwell on that possibility. I wasn’t in denial; I knew the results of the biopsy could be bad news staying alive-wise. But again, I mainly stayed in positivity and continued to visualize my 90th birthday party (my father, Stu’s 90th birthday party is next month) and to affirm, “I am so happy and grateful now that I’ve released the patterns that gave rise to the leukemia.”Monday morning, after having had my labs, I was sitting and waiting in the 8th floor leukemia waiting area, waiting to be called back for an injection of Neupogen, my cell phone rang. It was Dr. Islam. “Your blast count is 2%.”I cried with joy, once again, as I did when he told me, “Your MRD is negative. I have never seen an MRD negative patient at Day 21,” months before.To be continued… fatherhood calls at the moment…there’s more coming… and… 95% of what I write on Quora is via iPhone… somewhat constraining…My two older sisters and I with our father at his 90th birthday party last month, May 2019. He’s a huge inspiration, and not just because that’s his house we’re visiting and he’s had CLL for ten years and has only accepted monitoring of it.I’m coming up on 6 months complete remission. There’s much more to write; and, my commitment is that what I write make a difference for you.And, as promised above, there’s more to the story and I will flesh out what I believe made the difference in the face of a potentially terrifying disease…Today, my hair, like springtime blossoms, is sprouting again… a sign of the life force, irrepressible, pushing up through the cracks in the sidewalk…Here’s to New Life……and again, more to come…Edit: July 4th, 2019Today, the 4th of July, enjoying Life. I’m 60 now… my hair’s sprouting… the sprouting started this Spring after the chemo was finished… I gave that timing meaning… Springtime… new life…I intend to share more about this experience, and yet, I’m not sure this is the place to do that given the original question.So far, it has been a pleasure to have this forum to share my experiences with leukemia and everything related. If you have a suggestion as to a better forum/platform to share my knowledge, experience and hope with regard to leukemia, let me know.EDIT Saturday, July 27, 2019:I had surgery Thursday to have a myringotomy and tympanostomy tube placed in my left ear. It went perfectly.Fluid filled my left middle ear during my last hospitalization (for febrile neutropenia) in April. There were two complications from that hospitalization, I presume from high dose IV vancomycin and cefipime… a sudden and persistent left ear effusion and neuropathy of my distal feet bilaterally.The tube has all but resolved the effusion (it’s present in the morning, but drains within and hour or two). And the neuropathy, which consists mainly of the sensation my socks, no matter what their fabric, are filled with sand in the toes, and there is pain at times, increased initially with hard shoes and jogging. However, the jogging actually seems now to be a force for its resolution.I set a goal of running a 10K by September 29th, a goal RunKeeper helped me to decide on. Thanks to my varsity tennis playing son, Elliot, for that app tip.I had preop labs Tuesday, and coincidentally, two month followup labs for my heme/onc, Kavita Nirmal, on Wednesday. Not surprisingly, they were both very close…WBC 4.1Hgb 16Platelets 157,000It’s all good.EDIT Thursday, September 12, 2019:Reporting in for the curious…My post above starts with the yearly routine labs I had done September of last year, 2018. That’s cool, and relevant to the question.I’ve had two haircuts since my nuked hair decided it was OK to start growing again. Gone is the childhood fear of the barber or stylist getting it too short.I’ve run 5 days a week since July 21st, and I am registered in Texas Oncology’s Celebrate Life Survivor’s 5K on the 28th.There are two big benefits of running 5 days a week.One is the health and fitness benefit which is enough on its own.The other is, who I am for myself today is larger than who I was when I was saying, “I need to start running again,” for SEVEN years. (I was shocked about 4 months ago, in a moment of self-clarity, I caught myself running that line of bullshit past myself, and I stopped and asked myself, “When was the last time I exercised regularly?” …2012. Damn, Dude. You’ve been saying that to yourself for SEVEN years.)About 3 months ago, I started making the bed if I were the last one out. I’d heard Dr. Jordan Peterson recommend this one before solving any of the world’s problems. “Make your bed.”About a month later, during breakfast with my varsity tennis playing son, I downloaded an app, RunKeeper, he’s using to log his many runs.It started pressuring me to run a 10K in a month. I reacted, “I’m 60 years old. I’m not running a 10K in a month… I’ll run one in two months,” and on July 21st, I started running 5 days a week.Another recent shift in who I’m being in the world is manifested by the fact that I’m writing again.UPDATE: September 30, 2019I beat my oncologist in a 5K this weekend! Sorry, Dr. Nirmal. Good run!Not that long ago, my hemoglobin was 7 and I got winded climbing a flight of stairs. Now it’s 17 and I can run a 5 kilometers!UPDATE: October 25, 2019:It just occurred to me it is getting close to the one year mark that I went to MD Anderson for the first time and I don’t think I’ve adequately acknowledged them.To me, and probably by objective measures, MD Anderson is the best cancer treatment center in the world. It must be one of the largest with over 20,000 employees and over 15,000,000 sq ft of space. Yet, it is one of the best run organizations I’ve ever seen of any size. That’s important. But, not as important as the care and concern I saw everywhere. The ethos there is healthy, upbeat, nourishing and inspiring.In particular, I want to acknowledge and thank to a depth appropriate to one given to someone who participates in literally saving a life. Naveen Pemmaraju, thank you for saving my life. I am the father of a now 3-year-old, precious boy. I am also the father of two other boys, 19 and 17, who shouldn’t lose their father, either; yet, the biggest save was saving the life of the father of this precious 2-year-old boy.December 13, 2018 - Just discharged from MD Anderson’s Leukemia Specialty Care UnitThis is what I’m talking about, Naveen. This is such a huge gift. Words aren’t adequate to express the depth of my gratitude. Thank you.Rabiul Islam, thank you for your relentless close support and encouragement. You repeatedly went above and beyond calling me on my cell and keeping me informed. And, the moment you told me I was MRD negative is one of the happiest moments of my life. You didn’t have to add, “I have never seen an MRD negative patient at Day 21.” But, you did and that made a deep, profound positive impact. It has been some of the best medicine mentally and emotionally, and probably physically and spiritually. All boats rise with the tide. What a profound gift. Thank you.Michael Andreeff, thank you for who you are personally and professionally. You were my first inpatient physician contact, and it was, interestingly, on Thanksgiving Day. You walked into my room with an entourage of residents and fellows and said, “Who are you, and vot are you efen doing here?” (Sorry, that’s my recollection of your delightful German accent.) I loved our banter. When I told you I was a psychiatrist, you told me, “I vanted to be a psychiatrist, but I vound up being this.” You were part of the development of flow cytometry in the early days in Heidelberg. Flow cytometry told me the leukemia was gone down to a resolution of 1:1,000,000 WBC’s compared to 1:20 resolution possible with a microscope alone. Thank you for the quintessential physician that you are; and, thank you for having me look forward to witty banter every morning at morning rounds. What a delight.Zeev Estrov, thank you for who you are. Two memories stand out. You came into my room the morning after my Day 21 bone marrow biopsy and said, “Go home. You don’t need to be here anymore.” And, after I started to recover from the seeming near death experience from RSV, I perked up for your morning rounds; and, you and your entourage of residents and fellows came in. I had finally had a good night’s sleep and told you so. You turned to your students and said, “That! will tell you more than any lab test.” To me, such a brilliant moment of teaching. In medical school, I remember the lesson of one of my professors, “You treat the patient, not the labs.” You are another star in the MD Anderson firmament.To the staff of the 12th floor Leukemia Specialty Care Unit and to the nurses who inserted my PICC line, I cannot say enough to thank you and express the gratitude I have for my treatment there. It is a difficult thing to be a young man, otherwise healthy, diagnosed with a life threatening disease and facing an uncertain future, knowing it included, at the least, chemotherapy and weeks of isolation. I don’t think I’ve told anyone this because it sounds weird. When Dr. Estrov told me to go home on Day 22, I was disappointed. That’s partly your fault. Good job. I’d say, “Keep it up,” but that would be silly. It’s who you are.To the 8th floor Leukemia Clinic and staff, thank you for always being friendly, upbeat, professional but not dry or stiff, and always being a well-oiled machine. Wow. You and your clinic and lab are part of the reason that the thought occurred to me, “This is the best run organization I’ve ever seen of any size.” Amazing. Thank you.To my individual nurses, inpatient, outpatient and chemo, because all of you were so extraordinary in skill, compassion and presence, I got to be right every time about how great MD Anderson is, every time. Every contact. Thank you.To the nurse who put in my PICC line, when I was the most alone and scared, Wednesday night, alone before Thanksgiving Day, thank you for your flawless insertion of a central line, your calming bedside manner, and thank you for telling me you had multiple myeloma years before and remain disease free. (The only thing that could have made the whole experience better, for the next patient, consider leaving out the part about your PICC line getting infected. :) ) Thank you.There are so many people to thank. Right now I am acknowledging you, MD Anderson. Thank each and every one of you. I am weeping now in gratitude as I get in touch with the magnitude of the gift and how you gave it. Jackson just turned 3. He will thank you one day. For now, I thank you on his behalf.Oh my! There are so many people to thank!To be continued…EDIT: January 7, 2020An interesting “problem” is arising here… the longer I live, the less appropriate the word “recently” in the opening line of this answer is… in December, less than a month ago, I went back to MD Anderson for my first checkup since July. All is well and my MRD continues to be negative over a year after entering remission. Thank you, Dr. Pemmaraju and all of you at MD Anderson.And, as I mentioned above, there are many more to thank. I will address two of you now:To Nortin Hadler, MD, of UNCSOM. Nortin, your startlingly deep compassion and ability to read between the lines of what I was saying moved me to tears. You heard me asking things I didn’t know I was asking. Your clinical acumen and profound compassion were so intense at times it was hard to be with. You encouraged me at a deep level. Not long before I was diagnosed with AML, I wrote you to thank you and tell you how much your work has meant to me as a physician and reader. I didn’t expect a reply, let alone one of such thoughtfulness. Then, during my struggles with leukemia, you shined as a lighthouse of steadfast personal and clinical wisdom. Thank you for hearing what I didn’t even know I was expressing and addressing it.To Steve Derdak, DO. My sister, one of the finest physician’s I know, refers to you as the smartest physician she knows. That’s quite an endorsement. I still remember visiting you when you were in medical school and thumbing through your Harrison’s Principles of Internal Medicine to find it thoroughly highlighted. Years later as an intensivist at Brooke Army Medical Center you brought your vast clinical experience to me personally in a very frightening and challenging time. Thank you for being there. And thank you for your sweet, personal bedside care of Marty at our home during her final days.And thank you Quorans for your views and upvotes. I deeply appreciate it!More to come.Edit: June 21, 2020Went back to MD Anderson a couple weeks ago for a routine followup. Results were all good except MRD.CBC great. Bone marrow aspirate showed 1% blasts (normal is < 5%). All very exciting. 6 days out a notification popped up on my phone that Dr. Pemmaraju wanted a telephone appointment with me.That was not welcome news, and I couldn’t wait until the next day to find out why. I called his PA, Rodney, and learned the news. My Measurable Residual Disease is now positive. I am in morphological remission, but not at the level of resolution provided by amazing technology.Dr. Pemmaraju’s recommendation is 3 rounds of venetoclax and azacitidine (VEN/AZA). Mild chemo… he used the analogy that the previous chemo is like a bomb and the VEN/AZA is like a Predator drone strike.He said my MRD will turn negative again. And he referred me back to the Stem Cell team.No problem seeing the Stem Cell team again for a consult but I was dead set against it.My thinking was why would I sacrifice feeling great for the devastation SCT is?And I’ve already created this narrative of how powerful mind/body medicine can be…It wasn’t an easy choice at all. And at one point in the last 16 days of wrestling with my circumstances I decided to do SCT but from a place of fear. (There’s a powerful distinction between choosing and deciding worth taking a look at.) Then I decided against it.At some point I looked at the scientific research and statistics on it; then I watched some inspirational videos by successful recipients and using the rhetoric from one of those people, switched to viewing SCT as an investment in my future. And I went back to my matrix of 4 cells and considered each possibility it boiled down to which mistake I would rather make…Have a stem cell transplant when I could’ve done well using mind over matter after allorNot have a stem cell transplant when in fact I needed one to prevent death by AML progression?Decision is derived from the root word “cide” or to kill off. In a decision the circumstances and considerations determine the selection… you have a pro list and a con list and the selection is based on which list is longer. The alternative is killed off by the considerations.Choice: To select freely and after consideration.Initially I decided no. Then I decided yes. All of that occurred in a field of fear and suffering.At some point I chose SCT and a feeling of peace came over me.I am at peace with the choice and the outcome.Once again, I think I will fare exceptionally well and I know that isn’t a given.I realize one outcome is death by overwhelming infection, organ failure or graft vs host disease.That is out of my hands. I accept my fate. I choose it.And I am happy to share the journey ahead.Edit: August 3, 2020Day 1 Cycle 2 of venetoclax and azacitidine. Mild chemo. The first cycle of this had few side effects and no hair loss. It was surprisingly hard on my kidneys… the cycle is Monday through Friday every 28 days (if possible) and my creatinine spiked to 1.5 on that Friday. It returned to normal and a nephrology consult concluded it was a reaction to the venetoclax. Dr. P concluded it was an idiosyncratic reaction and doesn’t think it’ll happen again.Edit: November 3, 2020Getting Busulfan at MD Anderson this morning in preparation for a stem cell transplant.I am quite well and continue in morphological remission. My MRD turned positive in June for the first time since December 2018. I’ve accepted MD Anderson’s recommendation for a SCT. It’s been their recommendation all along, but until June insurance wouldn’t pay for it and I didn’t want it. However, confronting a dead canary down here in the mine, two thoughts persuaded me.I have three boys, the youngest is four. In that context I look at this as an investment in the future; and, I’d rather have it and not need it than need it and not have it… I met a wonderful man in his early 70’s, John, in an infusion room last year. Delightful. I got to talk to him at length twice. Delightful man. He looked well to me. However, his chemo had never gotten him into remission and he died very quickly. His death hurt deeply. I grieved his death and I could feel the pain of it much more acutely than my mother’s 8 years ago, something I think odd. Perhaps it was the reminder of my vulnerability.I remain optimistic and grounded in my choice and commitments.Today is the first day the thought, “I am a writer” occurred so consonantly. Perhaps the dawning of the reality of death, not necessarily of its immanence, but of its ultimate reality, shifted my audience from what others think to what I think. I’ve a story to tell. It’s for me and that others may benefit.“The ill person who turns illness into story transforms fate into experience…” —Arthur Frank, from The Wounded StorytellerFootnotes[1] Minimal/measurable residual disease in AML: a consensus document from the European LeukemiaNet MRD Working Party

I am hungry. Let’s go shopping. Let’s buy chicken. (I am sort of vegetarian, but let’s keep it simple.) At local store X, chicken is $1.50 per lb. Next door, at local store Y, it is 1.58 per lb. About a mile away, local store Z is selling it for $1.48 per lb. All things being equal, that is to say, chicken is chicken, I suspect most of us would go to store Z.Why don’t we try something different. Not everyone eats chicken…at least not daily or even once a week. I have a lot of money and I am going to do something interesting. Why not sell food insurance. Tell you what, for a family of 4, I will charge $1,500 per month. (For arguments sake, let’s say a family of 4 spends $1,000 per month on food.) Additionally, you will use your insurance at the store, unless you buy particular items or more of a particular item than your insurance plan allows, then you have to pay a deductible.As my insurance business grows along with the monopoly on food it has created, the price of chicken is now $24.00 per lb.As you enter the store to buy less food than you could prior to my food insurance industry, you can see me in front of the store making extra money at a three card Monte table…or maybe a shell game…kind of a metaphor for what this is all about.Are you beginning to get the idea? Yes, the analogy is off the wall, but so is the medical insurance business.I am not going to go into the entire history of health insurance but I will touch on some points along the time line. At the beginning of the 20th century, with the industrial revolution in full swing, what we now know as workman’s compensation insurance began in 1910 when states began enacting laws to protect workers. Initially, an injured worker would see his own physician and the bill would be covered by the workers compensation fund. Subsequently, some companies hired their own physicians to provide care. Both of these models would evolve over time into models that we see today.Interestingly, even prior to this, since around the time of the civil war, some employers took a portion of their employees pay to put into a sickness fund that would be used to pay employees something during times they did not work due to illness. However, for the most part, absent workman’s compensation paid visits, the majority of physician and hospital visits were paid out of pocket by the patient.One must also take into consideration the fact that medicine as we know it today had quite a revolution since the first colonists came to America. At that time, all American physicians were trained in Europe. There were no CT scans, MRIs, blood work, or antibiotics. Jenner’s work on smallpox would not come until the end of the 19th century.During the 1700s a sophisticated diagnosis might be based upon the patient’s predominant humor. Blood letting was a popular treatment of the time. The “physician” doing the procedure might likely be your barber. The medicines of the day were predominantly botanical. Surgery as we no it today was non-existent.Interestingly, while the age of enlightenment would bring science or what we today call evidence based medicine into being. American physicians kept many of the traditional non-evidence based procedures in their armamentarium. Today, a patient going into cardiac arrest brings to mind the image of a crash cart, defibrillator, and CPR. Back in the 1700s a shortage of such equipment necessitated the use of other means. So, what did they do. The answer lies in a common expression uttered by an individual who believes he is being duped or lied to. Have you ever said, so in so is “blowing smoke.” For those that do not know the full expression, it is, “he is blowing smoke up my ass, or more properly put in doctor speak, rectum. Ever wonder where the expression came from? You guessed it. A method of revival was to give a rectal smoke enema. It started in 1774 in London by two doctors, William Hawes and Thom­as Cogan who administered the procedure at a cost of 4 guineas, about $756 in today’s dollars. (To be sure, the unconscious patient’s wallet would be examined to see if it contained a Blue Cross/Blue Shield card, or American Express.)In America both before and after the revolution, doctors could be paid in cash and if they could not afford the bill, they would likely pay in goods. At this juncture, an important point needs to be made. In the 1700s and 1800s, most notably in Europe, physicians in particular, and surgeons were highly respected members of society despite the fact that in reality, there was very little they could do for many of the common afflictions of mankind. While they may have been highly respected, what they were not was what we would call wealthy by today’s standards. One did not enter into medicine to become wealthy.We should look at this further by noting changes in language. The traditional definition of a profession is that it is a “calling.” It is something one does not for monetary gain or social status, but rather for the benefit of mankind. Historically, there were only three professions, the clergy, law, and medicine…nothing else. Physicians in the 1700s and 1800s were financially in what today we would call the middle class. One did not undertake medical training in the hope of attaining great wealth.Unfortunately, the concept of medicine as a calling has been lost. Approaching medicine as a personal calling is not a requirement for entrance into medical school although, perhaps it should be because in my opinion the practice of medicine requires a certain selflessness that I think is necessary to be a good physician. Of importance with respect to healthcare finance this plays an important role in understanding the economics of physician salaries today and differences in how the different specialties are compensated. If all physicians have answered a calling, then they would be paid equally. however, they are not as will be discussed subsequently.Getting back to the history of insurance, the depression hit hospitals very hard. Justin Kimble, an administrator at Baylor Hospital devised a plan that would pay hospitals and can be considered a forerunner of Blue Cross. He enrolled 1250 Dallas, TX teachers in to the plan. For 50 cents a month they would be provided 21 days of hospital care. The AMA was opposed to this so only the hospital and not the physicians were covered. In 1932 in Sacramento a plan was created not for one hospital but for all of those in a particular community. These plans were all non-profit. This geographic specification remains today in the Blues. It should be noted, especially because it is the crux of my position, the states did not view these plans as insurance. The looked at them as pre-paid plans. However, in 1933, the NY state insurance commissioner deemed these plans as insurance. His reasoning was that these plans were collecting money for services to be rendered in the future. In a sense, he likened them to life or casualty insurance both of which are paid out at a future time. As will be subsequently discussed I beleive this was a mistake that has had serious consequences in terms of its impact causing the healthcare problems we have tody.In 1939, the California Physicians Service developed what would become Blue Shield. It was an indemnity plan which paid the patient for each event. The patient would be responsible for paying the physician bill. Commercial insurance was another matter. The companies that provided Life, Casualty, and other insurance could not see how health could be insured. Once a patient obtained the insurance, there was no disincentive to be sick. This was resolved by only offering hospital coverage. An admission to a hospital could only be done after a physician determined the patient was ill. However, they did offer coverage for the surgeon because surgery was considered a discrete event. As will be discussed, I think this reasoning was also unsound.Around this time, prepaid plans for physician services would also develop. Physicians were against this because at the time they used a sliding scale with wealthy patients paying more. It was thought that the plans by ending the sliding scale would reduce physician profits because the wealthy were defraying the cost of the poor. However, the plans continued.We must keep in mind that up until the 60s and 79s, the majority of people had no insurance coverage for visits to their primacy care doctor. With the sliding scale, people were able to pay for a simple visit. You paid for your laundry, your food, a hair cut, a manicure. A doctor’s visit was just another expense. Let’s look at this more closely. In 1954 how much do you think a physician office visit cost. Before I tell you, a brake job was about 25 dollars. As for the office visit, around $3.50. A house call, many of you won’t remember them but yes, the doctor used to come to your home. How much….a dollar more…about $4.50. The point being this was an expense that could easily be paid out of pocket for most people. The fact that this was possible has an impact upon a potential remedy to one facet of healthcare costs, primary care and some other specialist office visits.Private Health Insurance grew rapidly in the 40s and 5os. for a number of reasons. World War II brought with it wage and price controls decreasing discretionary spending. The second reason was expansion of organized labor. The Taft Hartley Act of 1947 made health insurance a condition of employment. The US government stuck its nose where it did not belong. Taft Hartley then was an important milestone in the creation of the healthcare mess. The third reason is that the US tax code did not specify whether employee sponsored health insurance was taxable. In 1943 the IRS issued a ruling stating that employee sponsored health care was not taxable.There were also not as many insurance companies to drive a wedge between the provider of a service and the customer that interferes with supply and demand which drives prices in a free market.Physicians, (read surgeons) worried that hospital insurance would get into the physician business, created one for themselves that eventually became what we know as Blue Shield.Ever look at a physician bill? Your primary care physician might bill $100 for what amounts to a 30 minute visit. However, any medical specialty or surgical bill for a procedure will be much more. The reason is that since surgeons created insurance for themselves they were smart. Since people were not going to pay out of pocket, why not jack up the fees. The rest is history. This is why cognitive physicians, the ones who are supposed to help you stay well get paid less for their time than those who do procedures.One time I sustained a laceration to my finger. It was not a big deal. However, when I went to the ED, they wanted me to see a plastic surgeon. I thought it was a bit of over kill. Though trained in Internal Medicine, I had done enough Family Medicine and was very comfortable sewing up lacerations. However, I could not sew up my own finger. (I could teach you to do it.. it really is not hard!)I go to the plastic surgeon and he injects me with lidocaine and sews it up in a couple of minutes. Sometime later when I saw the explanation of benefits I hit the roof. The physician used a couple of different computerized procedural codes (CPT codes) to bill for the injection of lidocaine as well for sewing up the laceration. I used to charge $50 to $75 for doing the same procedure. He charge over $2,000. That is right…over $2,000.I called him up. At first I was polite. He became very defensive. His justification was simply that insurance was paying for it anyway. I wrote to BC & BS who at that time was my insurance company. I accused him of price gouging. What happened? Absolutely nothing! Was I surprised…no. The reason is that by that time in my career I understood what was going on. The company had no incentive to do something for the simple reason that the more physicians charge, the more they can charge for their premiums.Get rid of insurance. Make medical service competitive like any other service. We should stop hospitals from cost shifting, charging $25 for a band aid to pay for other services. Ever wonder what the real cost is for performing an MRI? I don’t know. Just look under the third shell. Maybe the answer is there.Note:Since writing this I have seen comments suggesting a one payer system. There was a time I thought that might be the way to go. However, there are several problems with that. Insurance companies are supposed to spread risk. If you move 5 blocks from where you live, your car insurance may go up. Why? They analyze many factors including how many accidents take place in a particular zip code. So, just moving a few blocks could make a difference. Hopefully, everyone will not have an accident! However, don’t worry, it does not much matter because if more people have accidents the company will increase premiums. It is said that the average profit is 4 to 5 percent. Whatever it is, they are in business and not running a charity!With respect to auto or any other insurance, actuarial analysis allows them to constantly monitor their exposure. This allows them to make what adjustments are necessary to insure they make a profit. So, how can one use this same model with respect to medicine. Think of all the people you know. Are there any of them who have never been ill, have a chronic illness or never required medical care?Pose the same question to yourself but stratify by age. As we get older, eventually, the likelihood that you are going to get something is sadly all too great. That this is true is a subject of another conversation. It has been said that 25% of Medicare outlays are for people during the last years of their lives. How far we go to preserve life and when to quit is also a topic for another conversation.However, no matter. Do you see where I am going with this. How can risk be spread when the risk that you will eventually be sick and have to use the healthcare industry is 100%. Its kind of like my concept of food insurance. There is no way around the requirement for food and unfortunately, as things are, medical care is a necessity.So, we are really not talking about the spread of risk. (Sure, not everyone will have their appendix taken out. That my happen to your buddy John. However, he will recover in time to visit you when you have your hernia repair. Some people may require less than others by virtue of good genetics, avoiding life style choices that lead to illness, and being educated about their health. However, just about everyone has something. Medical care is a service that all of us require at one time or another.The question than becomes how to pay for that service. Or is it? Why does it cost more to go to a doctor than to get a haircut? (I am playing the devils advocate here…a sore spot.) I remember working for a physician when I finished my residency in the early 90s. At that time he had signed up for a number of HMO panels. I suspect most of you don’t know how that works. Well, here is the deal. I will make up an example. Insurance company X gives you 1000 patients broken up into 400 men, 500 women, and 100 children. For each man, you get $6 per month, for each woman, $7 per month, and for each child, $8 per month. (I am making up the numbers…but they are different for men, women and children.) So, if my arithmetic is still good, that is $6,700 per month.For that amount, he has to take care of all those patients both at the office and in the hospital. Certain tests done at the office were also covered. If he referred too many patients to specialists, lab work, imaging, or modalities such at PT, he could be penalized and lose money. So, the incentive when Mrs. Smith calls about her 5 year old’s sore throat, to let the nurse handle it over the phone. The physician also has a disincentive to refer patients. This as opposed to fee for service medicine where the physician gets paid when the patient comes in. When Mrs. Smith calls about her son in this situation, the nurse tells her to bring him in. The doctor will order a strep test for which he can charge the patient.Now, the guy I worked for was a real doctor. To his determent, he did not care or think about money so he referred patients to specialists or for whatever tests he thought they needed. I remember one day after a phone call from one of his insurance companies, his face turned red, he screamed the name of the company with an epithet, and smacked his hand on the table. They called him to tell him that he had referred so much that essentially he would get less money that month.I was 100 K in student loan debt and making $40 bucks an hour in a DC suburb. I remember the early and mid-90s as we heard about these “kids” making a fortune on these things called PCs and something called the Internet. That doctor would shake his head thinking how hard he had worked and is still working busting his chops while these “kids” were making a fortune doing what? I am sure you get the idea. I have to be honest and say that whatever thoughts I had that my financial life would be easier after finishing my residency were quickly dashed by the reality of what medicine had already become and where it was going.Additionally, I wanted to work on my own. I remember wanting to start my own practice. The banks (well, the people in the banks) laughed at me. Physician practices were already having financial problems. To make matters worse, I, as did a number of colleagues who were similarly afflicted had a particular problem. We really loved medicine. We loved talking to our patients. We were terrible or perhaps we did not care about the fact that medicine is a business. One of my friends, a cardiologist, he had the same extrovert nature as I do and would spend a considerable amount of time with patients just talking to them. His wife, the office manager, a good choice because she had a vested interest in things running correctly, was constantly on him to move on.The things is, I think we were doing what we should be doing. You really have to get to know your patients, what they do for a living, their hobbies, their relationships…the whole nine yards. People are not automobiles. There is a psychological component which must be addressed. I do believe that our emotions and thoughts have a very significant impact on our health. Besides, how else to you get to learn about all the different things people do especially in and around a vibrant area such as the Nation’s Capital.This brings me to this. At one time, prior to what I call the egalitarian, inflationary pressure that everyone should be paid as much as the other guy, the Oxford Dictionary listed only three professions: the clergy, law, and medicine. That was it. You could not be a professional disk jokey or a professional sanitation worker (garbage man.) The definition of a profession is that it is a “calling,” something that people do because, perish the thought, they really like and want to help people. One might say you have to be a little bit nuts…perhaps in a good way.Prior to our moderns era, physicians were well respected but they were no rich or wealthy. This brings me full circle to my question. Should physicians be paid as much as they are. Should they be paid more? Should they be paid less? Sometimes I thought I would have been happier had I been independently wealthy and could practice medicine as a full time hobby! It may sound crazy but it isn’t. Certainly if we could remove the financial burden of medical education that would be a start.A guy I knew investigated Medicare fraud at one time. There was and probably still is lots of it. That is only one of the problems getting the government further involved in this mess. I sometimes wonder if there was a way to simply provide free care for everyone. Perhaps physicians should be paid while their patients are well and not paid when they get sick and shift the entire paradigm to prevention. I apologize if you feel I have led you on to think I have an answer because I don’t. I do know the present system is broken and The Affordable Care Act is not even a band aid.I do suggest that with the ability to access information that we have, that people take as much responsibility for their health as they can. Medical information is growing exponentially. The more people know the better they can make informed decisions about their health.