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September 6, 2014

SIX DAYS IN STANLEY

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SIX DAYS IN STANLEY

“Guess where the coldest place in the country was yesterday?” I asked.
She of course knew the answer, having heard the question many times before; many times, as in every morning for the past five years.
“Uh, Stanley, Idaho?”
“Yup,” I would say. “Thirty six degrees.”
This being the middle of June in Florida, where heat and humidity could wring sweat out of a corpse, thirty-six degrees was something to be coveted, almost worshipped. For at least the next three months, sweat and outside were synonymous. Even a trip to the mailbox could cause beads of perspiration to envelop the skin.
“You know…” I started to say.
“Don’t say it,” she interrupted. “We should go visit Stanley someday, right?”
“Yes. We could rent an RV and drive cross country and…”
“Forget it,” she interjected again, “You know I don’t do road trips.”

I had practiced medicine for over 35 years, most of it in Florida, and was on the cusp of retirement. One of my goals was to travel more, but my wife, Denise’s profession as an art teacher would damper that somewhat. She and our five daughters had carefully planned a retirement party for me on June 28, 2014. I never expected what ensued.
As music, drinks, and food flowed, my youngest daughter, Emily, tapped a spoon on a glass to get the crowd’s attention. My praises were spoken and then Denise presented me with a colorful folder. She briefly gave the back-story we shared daily about Stanley, and then presented a pamphlet where beautiful color pictures of a tiny town with the Sawtooth Mountains in the background. I laughed as I flipped page after page filled with pictures and fun facts: 2010 population 63, elevation 6253′ above sea level, and no stoplights.
“We’re loosing the audience here,” I complained. “I think they got the joke already.”
“Keep turning,” she insisted.
Taking a deep breath, I finally got it. On about page five or six, was a series of reservation numbers for flights, (in and out of Boise, Idaho), and car rental. Recently she had been painting furiously and made enough money to pay for our “dream vacation.”
What had at first been a “groundhog day” type joke, was now an imminent reality. The crowed laughed and our daughters giggled at my shock and surprise.
Having grown up in rural New York State, I was familiar with small towns. However, Middletown, NY, (pop. ~20,000) was a bustling metropolis compared to Stanley. I had been a boy scout and camped in the woods, cooked my own food over an open fire, washed my mess kit in a stream and even got up at 4 AM to watch beavers build a dam. But since then I have lived in large cities, Cleveland, San Diego, Houston, and now St. Petersburg. My travel was less tent and RV, and more upscale hotels, B&B’s and fine restaurants. Was I now ready for almost a week in a town with six dirt roads in the middle of a national forest?

PLANNING:

The only part of the trip Denise had left to me was lodging. Googling hotels in Stanley yielded eight choices, (not including cabins and guest ranches). After a few phone calls, a pattern emerged. The weekend of our trip someone was planning a wedding and most rooms were booked. With sixty-three residents I assumed this was most likely a “destination wedding,” From where? Boise? I finally got a room at the Sawtooth Hotel that looked lovely, but there was no TV. The Riverside Motel had vacancies but after two days we would have to relocate from a riverside unit because of the wedding. The temptation to fish off my front porch directly into the Salmon River was irresistible. Reservation made.
My niece in Ann Arbor, Michigan knew someone who had reputedly grown up in Stanley––really. She contacted her and then the girl emailed me. Alas no, she was not a Stanley native, but had spent time there with family and gave us some useful tips. Everyone seemed to mention McCoy’s Bait and Tackle shop, and after emailing them we got a reservation with a fly fishing guide. I booked her for Sunday August 17, my birthday.
I nervously monitored the temperatures in Stanley daily and saw they were having a “heat wave.” To us however this was wintertime Florida weather with highs in the 80’s and lows in the 40’s. The key was the humidity was less than 40% so no worries.
“I think we should get a Go-Pro for our trip,” Denise said.
“No,” I said. I’m not wearing that thing on my head and besides my small Canon Powershot will be fine. I’d rather spend $300 on fishing then another electronic device.” In truth part of me wanted to do this and then I found out a friend’s son owned one. Could we borrow it? Yes. Eureka!

DAY ONE:

It’s never fun to wake up at 5:30 AM, but with our adrenaline pumping, we made it out the door at 0630 to a cab and the 30-minute ride to the airport. We were drippiing with sweat from the heat and humidity, (Dew point in the 70’s––anything above 62 is rated as very uncomfortable and oppressive). Distant thunderstorm clouds roared over the Gulf of Mexico and we hit a brief shower over I-275 on our way across Tampa Bay.
At the airport, I wolfed down scrambled eggs and bacon. (On travel days I throw the low fat healthy choices out the door.) Our jet to Denver was full, but the prior evening I opted to pay extra for the exit rows and extra legroom. As is my usual flying tradition, 30 minutes after take off, ears ensconced in my noise cancellation headphones, I promptly passed out.
. Our flight from Denver to Boise was on time and knowing we would have a three-hour drive to Stanley, I again opted for the All-American high fat and protein favorite¬¬––a burger, fries, followed by Ben& Jerry’s ice cream. I calculated that my blood sugar would be all set for at least the next six hours.
The flight to Boise was only about one and half hours, and as we approached the landing strip, I could see the vast terrain of brownish green meadows, soft hills, pine trees, and granite mountains in the distance. After landing and baggage pick-up, Denise began snapping pictures of “Welcome to Boise and Idaho”. With only 1.6 million people in the entire state, “small” started to take on certain advantages. The rental cars were at the airport, so there was no extra shuttle bus ride to a distant lot. It was a five-minute walk from the baggage claim. We missed out on a Fiat 500 rental by one customer at the Hertz #1 counter-damn–and were offered a Ford Focus.
“No thanks, ” I said. “What is available in the next size up?’
We took a Volvo 860 sedan and were assured it could handle dirt roads. Subsequently, we found out that in rural Idaho there pretty much are only dirt and gravel roads. Perhaps it was a premonition, but I did something I almost never do when renting a car––I elected to accept, and not decline, the CDW (collision damage waiver). I didn’t want to be stranded off some highway in a gulch or worse, with a banged bumper and be liable.
“Yes,” the rental car guy told me. “You won’t be liable for any damage with this and you will have roadside assistance anywhere 24/7. Only later did I realize how useless the latter was, since most of the 129-mile ride from Boise to Stanley was outside of cell phone range.
Getting out of Boise was a snap. The rental guy had given us written directions to Stanley that would take us all the way there on Idaho-21. My plan was to stop at an Albertson’s food store, to get more water and food for later, but as it had already been a long day, we decided to just “go for it.” Within a few minutes we started to wind our way northeast and the topography changed. The cityscape yielded to rolling hills dotted with sagebrush and pine trees. Interspersed were huge reddish sand plateaus largely devoid of vegetation. They reminded me of the mammoth formations I’d seen in southern Utah while hiking there ten years ago.
Nearly dry creek beds bent along with the road, and piles of gravel and small rocks marked the shoulders, indicative of constant gravitational pulls on the rocky cliffs. The radio had been pre-set to KISS-some # country music––I turned it off. Leaving the 85 degrees of Boise, we started to climb and the temperature fell to the point where the A/C was gladly turned off and the windows opened with cool fresh mountain air. As we ascended, the number of mountain road switchbacks increased. Slowly the landscape changed as well from sand and sagebrush to dense forests of pine, interrupted by ever-deeper river gorges and streams with audible rapids.
Denise commented that every place we had traveled she could remember the smell. (This must be an artist-right brain phenomenon.) Jackson Hole, Wyoming smelled like sage. Alaska had smelled like salt-water and ice. Florida, which she detests, smells like mold, mildew, and rotting seaweed. She pronounced Idaho to smell like pine and sage and some as yet unidentified fruit. Later we would discover that the Idaho state fruit was Huckleberry. It grows on low shrubs all over the state, but more in the north. They look like blueberries but are more tart, and cannot be cultivated. The peak season is July-August.
Winding our way more north and east, the contrasts of the state struck me. There was so much land, trees, valleys and meadows, yet so few cities and people. One national forest after enough flashed by us. I was later told by our fly-fishing guide, Mary Ann Dozier, that per square mile of state land, there were more national forests in Idaho then any other lower 48 state.
Winding through the forests and cliffs, I couldn’t see any grocery stores next to the highway. Traffic was minimal and from small town to small town, the road was largely deserted. Scenic overlooks appeared and after about an hour and half, we stopped to stretch our legs. With the higher altitude and low humidity, we were both drinking a lot of water and were almost out. I envisioned driving off a cliff into a gorge with no food, water, or cell phone. We would only be found days later––half dead and dehydrated.
Compared to Florida, the contrasts were striking. As the forests became denser, I started to notice towering Redwood pine trees, which I had mistakenly thought only grew along the Pacific coast in northern California, Oregon, and Washington. Some were hundreds of feet tall and likely centuries old.
The mile markers flew by, and then suddenly everything stopped. A short line of cars was being held up by what at first appeared to be road construction. Later I heard about a morning mudslide, and only now the road was re-opening.
“Maybe we shouldn’t have listened to the rental car guy’s directions,” I uttered.
Relax,” said Denise. “We will be there soon enough.” We both exited the car to stretch again and breathe in fresh, arid mountain air with pine scent everywhere. It smelled like Christmas. After about 15 minutes, the eastbound line of cars was let through. I say cars, but there were probably only about a dozen backed up.
About an hour west of Stanley, I finally spotted a country store and gas station, set back from the road on the north side of Highway 21. Pulling into the gravel lot, the first thing I saw on the door and windows were pro-gun stickers, like “GUNS ARE WELCOME ON PREMMISES,” and “WE SUPPORT IDAHO CARRY OPEN AND CONCEALED.” If I hadn’t realized it before, I now knew we were in the American West.
Inside a tall blond woman in her 50’s was behind the register and was soon joined by a shorter man with longish gray hair, beard and handle-bar moustache. True to the signs, he had a 45-caliber sidearm holstered to his belt. I got some bottles of water; Gatorade, few apples and trail mix bars.
“You’re eating healthy,” the man commented.
“Yes, but I had beer for breakfast,” I joked. He barely cracked a smile.
“How far are we from Stanley?” I asked.
“Only about one hour and the road gets better,” the woman said.
We told them where we were from, and she said she was originally from Sarasota, Florida––small world indeed. I didn’t ask how she got to the middle of nowhere Idaho from there, but was glad to see humans and know our destination was close.
Around mile marker 130, the countryside changed again. Rising out of the east were huge jagged cliffs with snow still on top. I knew from pictures we were almost there.
“There’s the Sawtooth Mountain range,” I said to Denise. We both hooted with joy. Beneath the mountains were miles upon miles of meadows with zigzag worn gray wooden fences to keep cattle and horses in place. Minutes later we saw the sign and shouted, “Welcome to Stanley.”
We were too tired to explore the town, which indeed was only composed of a few dirt roads. However, Stanley lies at the end of Idaho-21 where in t-bones into Idaho-75. A quick left at the stop sign took us parallel to the Salmon River and 1/4 mile later the Riverside Motel on the right. In the office we met the owners Frank and Patti Wright. Frank was originally from Princeton, NJ, and was an ardent Philadelphia sports fan. Middle-aged, he and Patti welcomed us, and gave us the room keys.
“Where’s a good place for dinner?” I asked. They suggested The Bridge Street Grill in lower Stanley. I wasn’t sure I had heard him correctly.
“Excuse me, did you say lower Stanley?”
“Yes,” he answered. “We are in upper Stanley. Lower Stanley is about one mile north on 75.”
It was amusing to hear that a town of 63 people was divided into two parts but tired, travel-weary, and hungry, I chose not to debate the irony any further.
After dumping luggage in our room, we quickly walked out on the porch. The view was spectacular. The Salmon River ran past us with gentle rapids and breath-taking views of the mountains and meadows behind it. Cattle grazed lazily behind the Z-shaped fence on the far side of the river. We snapped pictures and headed off to the restaurant.
If Stanley was small, lower Stanley was even smaller. The Bridge Street Grill sat on the river edge, and was so named for a bridge that had washed away years ago in a flood and then rebuilt with concrete. We asked to sit outside and enjoyed a local craft beer and more water. We then discovered the daily Stanley weather phenomena. As the sun was starting to set, the temperature began to drop. Typically, the temperature swings were 30-40 degrees daily. We both ordered Ruby Red grilled Idaho trout with lemon caper sauce, and of course a baked Idaho potato. The trout was fabulous and the breezy night air bathed us in sensual luxury. We passed on coffee and dessert and headed back to the motel. We showered, unpacked, and then quickly passed out.

DAY TWO:

With the window left open, I awoke at about 0530, (0730 EST), bundled in blankets and covers. Stumbling in the dark, and aided with a small travel flashlight, I made coffee. Next I donned wool socks, long johns, sweatpants, sweatshirt, and my only knit ski hat that read NY PD/FD. Opening the outside door quietly, so as to not awaken Denise, I walked out on the porch where the thermometer read 43 degrees. The cold air was moister then last evening but exhilarating. I took in a number of deep breaths, did some stretches and gazed out over the river to the east until the sun started to peak up over the mountains. Tip-toeing back inside, I grabbed some coffee, and retreated to the porch again where I just sat.
Memories of my childhood flooded back¬¬¬¬––mostly camping outside in a tent during a cold autumn day and night, tightly snuggled in a sleeping bag. I don’t recall how long I sat there, but as the sun was coming out Denise peaked her head out of the door.
“How long have you been up?” She asked.
“About a hour or so––couldn’t sleep––still on Eastern Time. It always happens when I travel out west.”
“I know,” she said, disappearing back inside for bathroom then coffee. A few moments later she too ventured out, bundled up, and joined me on the porch. We looked like we were in Antarctica. All she could say repeatedly was, “Wow this is so wonderful. I belong here and not Florida.”
“Yeah, ” I said, “But I don’t think you’d like February very much.”
“I’m worried you’ll be bored,” she said.
“I don’t think so.”

As the sun continued to peek up over the mountains, mist formed over the river, hills, and meadows. We decided to try out the Stanley Baking Company. I pulled on jeans, turtleneck shirt, and leather jacket, and we drove 1/2 mile southeast into “town.”
Stanley is indeed made up of only a few dirt roads, and the “retail” area has a similar architecture––box like wooden buildings––like an old TV western. It took a few minutes, but we found the Stanley Baking Company by the line of cars in front. Opening at 7 AM, and serving only breakfast and lunch, this was the best food in town. We deferred outside porch seating to the locals as the temperature had barely pushed above 50. Dogs lay on the ground, some chained up, waiting for their people family to finish eating. Inside was the smell of fresh Peruvian coffee, huckleberry, butter, and bacon. The menu was country style with everything from breakfast burritos to sourdough pancakes. By this point both of us were quite hungry. Denise ordered the oatmeal pancakes, and I the sourdough. The fresh baked scones looked irresistible, and I ordered a raspberry-peach one to go. It had small brown mountains of perfectly cooked dough and was embedded with lots of fruit.
Now about the serving sizes in Idaho. They are huge. There were “only” two pancakes per serving, but each was the size of a dinner plate and dotted with real butter. The server who delivered them, reached in her pocket for a Grolsch beer-style bottle with a flip cap, holding real maple syrup. We ate slowly, savoring the coffee, watching the athletic and fit clientele, some adorned in biking spandex outfits. These folks are serious bikers. I later met a group of them leaving for the 60-mile trek up and down mountains back to Sun Valley.
We asked for take-home boxes and left a while later. Dropping the leftovers at the motel in the fridge, we put on hiking clothes. I had picked up a hiking map of the area and decided to try an “easy” trail.
About 5 miles south of Stanley on I-75 lay Redfish Lake. A well-known lodge, restaurant and lake resort, it is open, like most of the area lodges, only from late May to early October. Apparently, the only months without fresh snow in Stanley are July and August. We found the Fishhook Creek Trail head and parking lot. The latter was quickly filling up with serious hikers, apparently taking off for more challenging walks then we was seeking. Grabbing backpack, water bottles, Go-Pro camera, and collapsible Komperdell walking stick, we set off for what was billed as an “easy” 4-mile hike.
Apparently the easy definition was not two 60+-year-old flat-landers. By about one-half mile we took a water break. The trail followed a gin-clear stream or creek surrounded by pines, low scrub brush, and hills of sage and yellowing grass. Ponderosa pines and birch trees abounded. Aspen-wood tree leaves quivered in the wind. Large sections of woods had suffered some prior fire damage and numerous trunks had been sawed clean off to help clear the well-marked trail. The only wildlife we saw was some scampering chipmunks. The trail was suppose to end about two miles up in a large open meadow but we never made it that far. I had left the Go-Pro on my head recording for a little more than one hour. My feet were aching, and this being our first day, we elected to head back after about an hour.
We went back to the Bridge Street Grill and sat on the porch as the Salmon River leisurely tumbled by. Even at the “hottest” part of the day, (80 degrees), it was still comfortable since the humidity was only 15% and the dew point in the 30’s. I began to notice something odd about the river though. When I vacationed in Colorado, Wyoming, or Montana, in the summertime, the rivers and streams were packed with fly-fisherman. I had yet to see even one. Apparently, decades ago there were thousands of Chinook and Sockeye salmon in the Salmon River. They would make the 900-mile trek after spawning from the Rockies to the Pacific and then back again to die. Unfortunately the dams constructed on the Salmon, Snake, and Columbia rivers had interrupted this process and caused the salmon numbers to dwindle to almost nothing. There are however now active fish hatcheries and re-stocking programs.
If you are interested in learning more about Stanley, Idaho, and the depletion of the western fisheries, a great and entertaining book is “Traplines: Coming Home to the Sawtoothh Valley”, by John Rember. He grew up outside of Stanley and has authored several books about the region. I was able to read the entire work while there.
Our bodies were still on Eastern Time, so we elected to have an early dinner at the Sawtooth Hotel. This iconic landmark in Stanley lies on the western end of Ace of Diamonds Street. The small two story structure has six guest rooms upstairs, and a bar and restaurant downstairs. From the outside the signage is plain and simple: “Hotel and Dining Room.” Red-planked wooden logs and metal roof were updated in the 1990’s to improve on the original 1931 structure. If there was a hitching post out front, the building could have been from Dodge City or any other Western movie. Customers did not start showing up until about six, so we were seated immediately. Having had enough of the outdoors for one day, and watching a stream of triangular shaped flags on a clothesline bend straight in a stiff wind, we chose to sit inside.
The food was good, but the portions again were massive. I had a salad made of romaine lettuce, heirloom tomatoes, snap peas, baby carrots, feta cheese, and lemon-mint vinaigrette dressing that was as good as any restaurant salad I had ever had. My pork schnitzel with lemon butter and capers were two well-pounded and breaded thin cutlets, both the size again of a dinner plate. It could have easily fed four people. We were stuffed, but couldn’t resist coffee and homemade berry pies.
We both agreed our first full day in Stanley was a success.

DAY THREE:

I awoke to the sounds of the river rushing past our window and howling coyotes in the mountains. It was 37 degrees. Checking my IPhone for daily weather extremes––unable to cut the techie cord for a few days¬¬––I found out that Stanley missed the record today by 1 degree to Leadville, Colorado––damn. Before Denise woke, I discovered out coffee maker was broken, so after gearing up with more sweats and wool, drove to the Stanley Baking Company for more wonderful scones, OJ, and coffees to go. After enjoying another brisk morning on the deck watching the gray wispy mist rise over the river and meadows, we talked about driving an hour south to Sun Valley for the day. Sun Valley was America’s original ski destination. Ketchum is next to it and an old mining town.
The 60-mile stretch of Idaho-75 between Sun Valley/Ketchum and Stanley is one of the most beautiful in the country. Stanley is at the headwaters of the Salmon River, which actually runs south to north. There is 360 degrees of magnificent views. Heading south out of Stanley of course is the Sawtooth Mountain range on the right, and rolling meadows of grass and cattle on the left, intercepted by streams and lower sagebrush dotted mountains sides. About a half hour out of Stanley, I noticed what at first appeared to be large bales of hay on the left. However, after looking twice, the bales were moving. I pulled off and we crossed the road to see a large herd of sheep moving lazily over the summer grass. To the right a Sheppard and several border collies approached us. He was Hispanic, spoke little English, and I spoke little Spanish, but he implied it was okay to pet the sheep. We could never catch up to them however.
Back in the car we climbed over magnificent mountain ranges and some of the most splendid scenery in North America. Every turn was breathtaking with mountains, forests, and meadows as far as the eye could see. Our senses were overwhelmed. In roughly another half hour, we descended into Ketchum and parked just off of I-75 on Leadville Avenue, where the Kneedery was located. A popular local brunch spot, it had a large John Deere tractor outside for kids to sit on, and presumably parents to snap photos, and a large stuffed grizzly bear inside. We arrived about eleven on a Saturday and were told there was a 30-45-minute wait.
“No problem,” We left our names with the hostess.
We walked onto Sun Valley road and shopped a bit. Ketchum reminded me of other wealthy western ski resort towns like Jackson, Wyoming and Aspen, Colorado. Clearly this, and Hailey further south on 75, was where the wealthier clientele lived and or spent vacation time. The elevation is less than Stanley and out of the shadows of the Sawtooth range, and therefore, the winters less brutal.
It turns out the local Starbucks is where the city information office is located. At first an affront to the locals, they have now warmed to the idea. Hey, what better than to grab a cup of Joe and ask for tourist information? Besides, this doesn’t look like any Starbucks you’ve ever seen. The outside was constructed of side-by-side log poles, variable sizes, and packed tightly like one would see on a wood shipping truck on a highway––clever. On our way back to the Kneedery I spotted a large wooden Paul Bunyan-size chair on the street. I couldn’t resist climbing up onto it as Denise took a picture of me.
The lunch was fantastic. Breads, jams, eggs, pancakes, and the best bacon I have ever had––all super fresh and delicious. After filling up on more coffee, we drove for a while eastward on Sun Valley road. Walking and bicycle lanes paralleled it. Later, we were told this road made a big loop east, north, and then west again to hook up with 75. The trip would take about 3 hours and we elected to pass.
Tired of driving, we turned around for the non-stop forest and mountain views on the way home. After pulling into our motel lot, I saw Frank with a UC Boulder tee shirt. We chatted about how his son, and my daughter, had gone to school there. Frank had bought the motel after coming out to visit the area for a number of years. His wife, Patti, runs the front office with him. He seemed displaced and we talked about growing up and life on the east coast. Patti drives into Boise once a month for hair, nails, and other appointments. Frank said if she had a nail “emergency,” she would drive to Ketchum though, only an hour away.
I joined Denise across the street and after showering, sat on the back porch, reading “Traplines,” but mostly staring of at the mountains. The highest peak of the Sawtooth range is Thompson Peak at 10,751 feet––not as tall as other parts of the Rockies. However, it is the sheer size of this range that makes it so impressive. The range runs 43 miles north and south, 25 miles east and west, covering almost 680 square acres. Within the Sawtooth National Forest is the Sawtooth National Recreation Area, or SNRA. The Sawtooths are only one of its mountain ranges.
The SNRA consists of 756,000 acres of scenic mountain country. It has 250 miles of hiking trails, 40 peaks rising over 10,000 feet, and 1000+ plus high mountain lakes that add to the spectacular scenery and vistas. Recreational pursuits include outdoor activities of camping, hiking, backpacking, fishing, boating, canoeing, rafting, observing nature, photography, and bicycling. It is truly one of the best-kept secrets of the Rocky Mountains and western states.
After dinner, we sat across the street on the Riverside Motel porch overlooking the river as the sun faded to our backs. Cattle grazed lazily across the water. Sage-studded mountainsides glistened silver-gray in the slanted rays of early evening sun. A northern Harrier hawk with a three to four foot wingspan hovered over the river searching for prey. All seemed to be at peace.

DAY FOUR:

Mary Ann Dozier is a tall, stocky, middle-aged woman of Dutch descendent. I got her name as a fly-fishing guide from Silver Creek Outfitters, (via McCoy’s Tackle Shop), a few weeks before our trip. She and her husband live in Oregon most of the year, and near Stanley in the summer. We met promptly at 9 AM at McCoy’s and after purchase of Idaho fishing licenses for the day and release form signings, started to don long rubber waders. Driving a few miles south on 75 we parked along the side of the road and hiked down a gravel slope to a crystal clear stream feeding the Salmon River. Gentle rapids glided over the tan, brown, and reddish smooth stones. With the temp in the 50’s, we were bundled up nicely. She was very patient and taught us the basics of fly-fishing. Armed with a walking stick to help with balance, we ventured out into the stream.
“How cold is the water?” I asked her.
“Cold,” She said.
“So are we going to catch flies today?” said Denise in her usual witty tone. Mary Ann just stared at her as if she had heard that joke about 50 times––in the past month.
I was surprised by the force of the water rushing past by my insulated legs, which seemed to exceed my visual estimate of flow rate. With the Go-Pro on top of my hat, I repeatedly casted the thick green fly line and thin leader into the rushing waters. Then I heard an ominous click on top of my head. Reaching up to check the mini-video camera, to my horror, I saw that I was out of time and it had turned off. I didn’t know the device well enough to erase video, and looked sheepishly at Denise.
This is one of those “I told you so” moments that every husband dreads.
“What’s wrong?” She asked.
“The G0-Pro is full…it’s out of time.”
“I told you we were filming too much.”
I removed the small box from my head, embarrassed, and stuffed it into the horizontal chest pocket of my waders. Casting out again, I watched as the tiny “fly” lure swam swiftly and a dark shadow rose out of the water behind it to strike. I am sure it was a trout, and looked to be close to a foot long. Before I could set the hook however, the fish must have realized this was a fake, and dropped off.
“Damn,” I said.
“Yeah, I saw that too,” said Mary Ann. “Cast it back in the same place and see if it will hit again,” she instructed me. After about 15 minutes though there were no more leaps or strikes and then we moved further downstream, doing a slow shuffling walk to keep our balance. The walking stick was definitely helping––but apparently not enough. As we moved on to a swifter part of the stream, I tried to stabilize my self on top of some stone and sand and then began to loose balance. There is that instant when you know you are going to fall, can’t stop it, and gravity takes over. Icy water enveloped me up to my neck as I struggled to right the ship, amidst cold swirls. After falling Mary Ann came over, and stretched out a large hand so I could return to vertical.
“Are you hurt?” She asked.
“No, only my pride,” I responded. “But you were right––it’s cold.”
My only regret was not catching it on video.
We moved to another stream up the road, but time was running out on our half-day adventure. Near mile marked 186 on I-75 was another stream, with gorgeous views of the Sawtooth Range in the distance. Just prior to the end of our time, I felt a tug on my line and quickly set the hook. I hand-reeled in the line to discover a small, six to eight inch shiny fish hooked onto the fly. Mary Ann netted it, we took pictures, and she did some fish-CPR reviving the tiny pelagic.
“Not a trout, was it?” I asked.
“Nope, a whitefish.”
I chose not to tell her that back in Florida we used something like that as bait to catch “regular-size” fish. I kind of figured she knew that though.
“Thanks for the experience,” I said. “That was fun. I can see how this could become addicting.”
As we scrambled up the hill back to her truck, we saw other people using conventional, non-fly, spinning rods. Only then did I see real salmon in the wild. Hovering under the overpass, Mary Ann pointed out a school of Chinook and Sockeye Salmon. Whatever the guy was using on his spinning rod, they weren’t interested. We shed some clothes and made the short ride back into Stanley. With the lack of production, I’m guessing she expected a small tip. I gave her a big one––her efforts were sincere and professional.

DAY FIVE:

Leaving the window open, we both had progressively bundled up during the night. I awoke to the sound of a text message coming in on Denise’s phone. It was a bit after seven. A friend back in Florida had texted her that he too had begun to check the “chill cities” everyday in the paper and today it was Stanley’s chance to shine (or chill): 36 degrees––Yippee. I made some coffee and just stared out at the mountains. The rising sun hit the snow patches at a steep angle and long shadows loomed over the range from rock over-hangs and tall pines. I read a bit, and waited for Denise to stir. I started the coffee machine as I heard her say,” What’s on the agenda today, boss?”
“I’m thinking about one last hike, since we are leaving tomorrow, if you feel up to it.”
“Sure, that’s fine.”
We wolfed down our left over pancakes heated up in the microwave, and got on the hiking clothes. I had looked over a local hiking folder and the only other “easy” hike was called “Fourth of July Lake.” It was about 15 miles south of town off 75. With snacks, backpack, walking stick, water, and hiking shoes, we were off.
The minimally marked road to the lake had a small sign that said Highway 209 and was easy to miss. Fourth of July Creek met and paralleled the dirt and gravel road. Later, after a bit of research, I learned the creek was so named because the road was largely impassible from winter snows until the fourth of July. The map had said the trailhead was 10.2 miles up. The pitch and knobby surface of the essentially one lane road made slow speed mandatory. Any faster and I risked ending up in a gulch, stream, or bottom of a cliff. Small stones spit out from the back tires into clouds of dust. I’m not sure how much altitude we gained during the ride up but guessed it was about 1-2,000 feet. The views again were spectacular with wet and dry creek beds, all types of evergreen and towering bald mountains in the distance. We saw large swaths of burnt out woods. Charred pine trunks stuck up at random angles like giant burnt toothpicks. About one-half hour later we came to the well-marked trailhead parking lot, populated by many cars, trucks, SUV’s, motorcycles and ATV’s.
There were several lakes and trails but we stuck to the plan and left for Fourth of July Lake, as it was the shortest: 1.25 miles. Without an altimeter, it was impossible to tell how high we had climbed, but the lake is at 9,380 feet, so I’m guessing we walked up another 1,000 feet or so. After five days at altitude, our endurance was better. We crossed small creeks and again saw live active forests interrupted by areas of burnt patches leaving trunks a reddish-orange hue. Tiny trees were growing at the feet of blackened older relatives. It is not well known that many trees, including Jack pines, Redwoods, and Sequoias have pinecones whose seeds are glued shut by resin. Indeed it is only through fire, and the associated high heat that the resin can be melted and seeds released to repopulate the woods. In other words, the fires are essential in order to restock the forests.
Evergreens ultimately gave way to a small meadow and the large lake of unblemished water. Tall peaks of smooth pink granite slabs, and pines abounded. I searched the cold water for life and the only thing I saw was a small frog nestled in the mud. The hike down of course was much quicker, but the gravel road trip was no better. At several points, two vehicles would meet and someone would have to back up to a tiny shoulder and let the other pass. At a blind curve, about half way down, I saw the grill of a JEEP only a few feet from my car. Hitting the brakes I waited for the inevitable crunch of metal on metal contact, but a collision was avoided by inches. The JEEP just scooted around me as if nothing had happened. Following it up the hill were ATV’s, some with children driving. Denise and I were thankful when the paved surface of I-75 came into view.
Later we elected to go to Redfish Lake Lodge for dinner. It was Monday, and other restaurants were closed. In Florida, and the Gulf of Mexico states, redfish is synonymous with red drum, a highly prized shallow water game fish that makes excellent table fare. However, Redfish Lake was originally named for the vast number of sockeye salmon that populated it turning the water almost red during spawning season. However, after decades of dams, over-fishing, fish habitat destruction, and even poisoning, the salmon became almost extinct in the 1980’s. Ironically, the Idaho Department of Fish and Game had purposely poisoned the sockeye in the 1960’s to replace them with trout. This is a long and unfortunate story of recreational fishing thought not to be able to exist with good ecology. Again for more information, John Rember’s memoir, “Traplines: Coming Home to the Sawtooth Valley”, is a great and informative read.
There is only one road into and out of Redfish Lake Lodge. Frank told me a story of how in July of 2013; a camper had thought his fire was extinguished upon breaking camp. Apparently, he had never been in the Boy Scouts because he left without covering the embers with dirt. A smoldering ember was picked up by the wind, and a fire ensued. There were no deaths or serious injuries, but the authorities realized hundreds of people could have been trapped at the lodge, lake, cabins and campgrounds with no exit road. There is now construction to encircle the lake with a road so vacationers have more than one way to escape in an emergency.
The short road into the main lodge takes you past several campgrounds. Trailheads and parking lots lie to the left and then wooden cottages and the main lodge. After pulling into the dirt parking lot, we got out of the car and took in the surroundings. The small beach by the lodge has a long dock with wooden fingers extending out and boats moored. Vessels were coming and going and children were swimming in the cold water. Gratefully, I did not see any noisy wave runners. Children with swim wings ran in an out of the water. A snack bar was selling soft drinks, alcohol and some food. Round wooden tables, seats, and umbrellas were close by. Adirondack wooden slat chairs dotted the front of the main lodge and the grass––most were taken. Following dinner we relaxed by the beach then headed home.

DAY SIX

We had our last meal at the Stanley Baking Company of course. Not wanting to go back the same way we came from Boise, I asked Frank and Patti for a new route. They directed me back onto 21 but told me in Lowman to look for Idaho-17 or Banks Lowman road. This was shorter and would hook up with Idaho 55 north of Boise. Frank did warn me however that this route would bring us into the northwest part of Boise and the airport, and our hotel, was in the southeast corner. We were in no rush so it didn’t matter.
Lowman is a town of only 42––yes even smaller than Stanley, so it was easy to miss. It is nestled along the south fork of the Payette River. The latter is 82 miles long and a major tributary of the Snake River. Its headwaters originate in the Sawtooth Mountains at elevations over 10,000 feet.
If we thought the ride from Stanley to Ketchum on I-75 was breath taking, this road was just at equal in its splendor and topography. Winding west, it often parallels the Payette with deep gorges, rapids, and majestic mountains. Until a few decades ago it was a gravel road but now it is two lanes and well paved. There was one section of roadwork, and traffic had to proceed one lane at a time. However, we and the other west bound drivers simply got out of our cars, visited, and took in the view to our left, watching the river rush past. A stone tossed over the side seemed to take forever before hitting something. In front of us were some students from Boise State returning to college. Everyone was friendly and no one seemed the least bit bothered by the delay.
After crossing the mountain passes with our visual senses swarming, eventually the road began to drop. Although the river was ever-present, the countryside became dotted with more homes and small retail shops. There were still less imposing mountains but the brown grass was persistently interrupted with sagebrush and small pines. After about one hour on the road, it dead-ended on Idaho 55. We headed south into Boise.
Upon Frank and Patti’s recommendation we had a fantastic meal at the Cottonwood Grill in downtown after driving past the lovely Boise State Campus and seeing the grand Capital building in the distance. Since our shuttle to the airport left at 4:47 AM the next day we retired early.
What started out as a practical joke, ended as a fantastic journey to some great Western heartland. Were it not for my obsession with the daily extreme weather postings, and my wife’s quirky sense of humor, I doubt we would have ever visited Idaho––let alone Stanley and the Sawtooth Valley. Life takes us on some strange but wonderful journeys if we let it. Without hesitation, I can honestly recommend this trip to anyone with a love of the outdoors, nature, photography, fishing, and hiking. If you go say hello to Patti and Frank and under no circumstances miss out on the Stanley Baking Company.

August 23, 2014

Five Days in Stanley-Day One

DAY ONE:

It’s never fun to wake up at 5:30 AM but with our adrenaline pumping, we made it out the door at 0630 to a cab and the 30-minute ride to the airport. Dripping with sweat from the heat and humidity, (Dew point in the 70’s-anything above 62 is rated as very uncomfortable and oppressive). Distant thunderstorm clouds roared over the Gulf of Mexico and we hit a brief shower over I-275 on our way across Tampa Bay.
At the airport I wolfed down scrambled eggs and bacon. (On travel days I throw the low fat healthy choices out the door.) Our jet to Denver was full but the prior evening I opted to pay extra for the exit rows and extra legroom. On any flight more than three hours, I like not to be “sardined” if possible. As is my usual tradition, 30 minutes after take off, ears ensconced in my noise cancellation headphones, I promptly passed out.
Since my youngest daughter Emily had spent four years in college at UC-Boulder, the Denver airport was familiar. Our flight to Boise, Idaho was on time and knowing we would have a three-hour drive to Stanley, I again opted for the All-American high fat and protein favorite¬¬––a burger, fries, followed by Ben& Jerry’s ice cream. I calculated that my blood sugar would be all set for at least the next six hours.
The flight to Boise was only about one and half hours, and as we approached the landing strip, I could see the vast terrain of brownish green meadows, soft hills, pine trees, and granite mountains in the distance. After landing and baggage pick-up Denise began snapping Iphone pictures of “Welcome to Boise and Idaho”. With only 1.6 million people in the entire state, “small” started to take on certain advantages. The rental cars were at the airport so there was no extra shuttle bus ride to the lot. It was a five-minute walk from the baggage claim. We missed out on a Fiat 500 rental by one customer at the Hertz #1 counter-damn–and were offered a Ford Focus.
“No thanks, ” I said. “What is available in the next size up?’
We took a Volvo 860 sedan and were assured it could handle dirt roads. Only later did we find out that in rural Idaho there pretty much are only dirt and gravel roads. Perhaps it was a premonition, but next I did something I almost never do when renting a car––I elected to accept, and not decline, the CDW (collision damage waiver). I didn’t want to be stranded off some highway in a gulch or worse, with a banged bumper and be liable.
“Yes,” the rental car guy told me. “You won’t be liable for any damage with this and you will have roadside assistance anywhere 24/7. Only later did I realize how useless the latter was, since most of the 129-mile ride from Boise to Stanley was outside of cell phone range.
Getting out of Boise was a snap. The rental guy had given us written directions to Stanley which in retrospect, I should have ignored––more on that later. My plan was to stop at an Albertson’s food store, to get more water and food for later, but as it had already been a long day, we decided to just “go for it.” Although the state capital, Boise is pretty small as US cities go, and the airport was close to Idaho-21, which we would take all the way to Stanley. Within a few minutes we started to wind our way northeast and the topography changed. The cityscape yielded to rolling hills dotted with sagebrush and pine trees. Interspersed were huge reddish sand plateaus largely devoid of vegetation. They reminded me of the mammoth formations I’d seen in southern Utah while hiking there ten years ago. My mind started to wander and I could almost envisioned Shoshone Indians on horseback peering out for the “white man.” Since Lewis & Clark had explored much of this area, it wasn’t that impossible¬––but 200 years earlier.
Nearly dry creek beds bent along with the road, and piles of gravel and small rocks marked the shoulders, indicative of constant gravitational pulls on the rocky cliffs. The radio had been pre-set to KISS-some # country music––I turned it off. Gradually leaving the 85 degrees of Boise, we started to climb and the temperature fell to the point where the A/C was gladly turned off and the windows opened with cool fresh mountain air. As we ascended, the number of mountain road switchbacks increased. Slowly the landscape changed as well from sand and sagebrush to dense forests of pine, interrupted by ever-deeper river gorges and streams with audible rapids.
Denise commented that every place we had traveled she could remember the smell. (This must be an artist-right brain phenomenon.) Jackson Hole, Wyoming smelled like sage. Alaska had smelled like salt-water and ice. Florida, which she detests, smelled like mold, mildew, and dirt. She pronounced Idaho to smell like pine and sage and some as yet unidentified fruit. Only later would we discover that the Idaho state fruit was Huckleberry. It grows on low shrubs all over the state, but more in the north. They look like blueberries but are more tart, and cannot be cultivated. The peak season is July-August.
Winding our way more north and east, the contrasts of the state struck me. There was so much land, trees, valleys and meadows, yet so few cities and people. One national forest after enough flashed by us. I was later told by our fly-fishing guide, Mary Ann Dozier, that per square mile of state land, there were more national forests in Idaho then any other lower 48 state.
Passing through the Idaho forests and cliffs, I couldn’t even see one grocery store next to the highway. Traffic was minimal and from small town to small town, the road was largely deserted. Scenic overlooks appeared and after about and hour and half we stopped to stretch our legs. With the higher altitude and low humidity, we were both drinking a lot of water and almost out. I envisioned driving off a cliff into a gorge with no food, water, or cell phone. We would only be found days later––half dead and dehydrated.
Compared to Florida, the contrasts were striking. We might have well been on a different planet. As the forests became denser, I started to notice towering Redwood pine trees, which I had mistakenly thought only grew along the Pacific coast in northern California, Oregon, and Washington. Some were hundreds of feet tall and likely centuries old.
The mile markers flew by and then suddenly everything stopped. A short line of cars was being held up by what at first appeared to be road construction. Only later did I hear that that morning there had been a mudslide and only now the road was re-opening.
“Crap,” I said to myself silently.
“Maybe we shouldn’t have listened to the rental car guy’s directions,” I uttered.
Relax,” said Denise. “We will be there so enough.” We both exited the car to stretch again and breathe in fresh, arid mountain air with pine scent everywhere. It smelled like Christmas. After about 15 minutes, the eastbound line of cars was let through. I say cars, but there were probably only about a dozen backed up.
About an hour west of Stanley I finally spotted a country store and gas station, set back from the road on the north side of Highway 21. I pulled in to park in the gravel lot. The first thing I saw on the door and windows were pro-gun stickers, like “GUNS ARE WELCOME ON PREMMISES,” “Please keep all weapons holstered unless need arises. In such case, judicious marksmanship is appreciated.” And “WE SUPPORT IDAHO CARRY OPEN AND CONCEALED.” If I hadn’t known before, I now knew I was in the west.
Inside a tall blond woman in her 50’s was behind the register and was soon joined by a shorter man with longish gray hair, beard and handle-bar moustache. True to the signs, he had a 45-caliber sidearm holstered to his belt. I got some bottles of water; Gatorade, few apples and trail mix bars.
“You’re eating healthy,” the man commented.
“Yes, but I had beer for breakfast,” I joked. He barely cracked a smile.
“How far are we from Stanley?” I asked.
“Only about one hour and the road gets better,” the woman said.
We told them where we were from and she said she was originally from Sarasota, Florida––small world indeed. I didn’t ask how she got to the middle of nowhere Idaho from there, but was glad to see humans and know our destination was close.
Around mile marker 130, the countryside changed again. Rising out of the east were huge jagged cliffs with snow still on top. I knew from pictures we were almost there.
“There is the Sawtooth Mountain range,” I said to Denise. We both hooted with joy. Beneath the mountains were miles upon miles of meadows with zigzag worn gray wooden fences to keep cattle and horses in place. Minutes later we saw the sign and shouted, “Welcome to Stanley.”
We were too tired to explore the town, which indeed was only composed of a few dirt roads. However, Stanley lies at the end of Idaho-21 where in t-bones into Idaho-75. A quick left at the stop sign took us parallel to the Salmon River and 1/2 mile later the Riverside Motel on the right. In the office we met the owners Frank and Patti Wright. Frank was originally from Princeton, NJ, and was an ardent Philadelphia sports fan. A bit chubby and middle-aged, he and Patti welcomed us, and gave us the room keys.
“Where’s a good place for dinner?” I asked. They suggested The Bridge Street Grill in lower Stanley. I wasn’t sure I had heard him correctly.
“Excuse me, did you say lower Stanley?”
“Yes,” he answered. “We are in upper Stanley. Lower Stanley in about one mile north on 75.”
It was amusing to hear that a town of 63 people was divided into two parts but tired, travel-weary, and hungry, I chose not to debate the irony any further.
After dumping luggage in our room, we quickly looked out on the porch. The view was spectacular. The Salmon River ran past us with gentle rapids and breath-taking views of the mountains and meadows behind it. Cattle grazed lazily behind the Z-shaped fence on the far side of the river. We snapped pictures and headed off to the restaurant.
If Stanley was small, lower Stanley was even smaller. The Bridge Street Grill sat on the river edge, and was so named for a bridge that had washed away years ago in a flood and then rebuilt with concrete. We asked to sit outside and enjoyed a local craft beer and more water. We then discovered the daily Stanley weather phenomena. As the sun was starting to set, the temperature began to drop. In fact, we would soon find out that the temperature swings were 30-40 degrees daily. We both ordered Ruby Red grilled Idaho trout with lemon caper sauce, and of course a baked Idaho potato. The trout was fabulous and the breezy night air bathed us in sensual luxury. We passed on coffee and dessert and headed back to the motel. We showered, unpacked, then quickly passed out.

August 22, 2014

FIVE DAYS IN STANLEY

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FIVE DAYS IN STANLEY

THE BACK STORY:

“Guess where the coldest place in the country was yesterday?” I asked.
She of course knew the answer, having heard the question many times before; many times, as in every morning for the past five years.
“Uh, Stanley, Idaho?” She replied.
“Yup,” I would say. “Thirty six degrees.”
This being the middle of June in Florida, where heat and humidity could wring sweat out of a corpse, thirty-six degrees was something to be coveted, almost worshipped. For at least the next three months, sweat and outside were synonymous. Even a trip to the mailbox could cause beads of perspiration to envelop the skin.
“You know…” I started to say.
“Don’t say it,” she interrupted. “We should go visit Stanley someday, right?”
“Yes. We could rent an RV and drive cross country and…”
“Forget it,” she interjected again, “You know I don’t do road trips.”

I had practiced medicine for over 35 years, most of it in Florida, and was on the cusp of retirement. One of my goals was to travel more, but my wife, Denise’s profession as an art teacher would at least over the short run, damper that somewhat. She and her daughters had carefully planned a retirement party for me on June 28, 2014. I never expected what ensued.
As music, drinks, and food flowed, my youngest daughter, Emily, tapped a spoon on a glass to get the crowd’s attention. My praises were spoken and then Denise presented me with a colorful folder. She briefly gave the inside story we shared daily about Stanley, and inside the pamphlet were beautiful color pictures of the tiny town with the Sawtooth Mountains in the background. I laughed as I flipped page after page filled with pictures and fun facts, 2010 population 63, elevation 6253′ above sea level, and no stop lights.
“We’re loosing the audience here,” I complained. “I think they got the joke already.”
“Keep turning,” she insisted.
Taking a deep breath, I finally got it. On about page five or six, was a series of reservation numbers for flights, (in and out of Boise, Idaho) and car rentals. She had recently been painting furiously and had made enough money to pay for our “dream vacation.”
What had a first been a “groundhog day” type joke, was now an imminent reality. The crowed laughed and our combined five daughters giggled at my shock and surprise.
Having grown up in rural New York State, I was familiar with small towns. However, Middletown, NY, (pop. ~20,000) was a bustling metropolis compared to Stanley. I had been a boy scout and camped in the woods, cooked my own food over an open fire, washed my mess kit in a stream and even got up at 4 AM to watch beavers build a dam. But since then I have lived in large cities, Cleveland, San Diego, Houston, and now St. Petersburg. My travel was less tent and RV, but upscale hotels, B&B’s and fine restaurants. Was I now ready for almost a week in town with six dirt roads in the middle of a national forest?

PLANNING:

The only part of the trip Denise had left to me was lodging. Tapping in hotels for Stanley in Google, yielded eight choices, (not including cabins and guest ranches). Some were even reviewed on Tripadvisor! After a few phone calls, a pattern emerged. The weekend of our trip someone was planning a wedding and most rooms were booked. With sixty-three residents I assumed this was most likely a “destination wedding,” From where? Boise? I finally got room at the Sawtooth Hotel that looked lovely, but there was no TV. The Riverside Motel had vacancies but after two days we would have to relocate from a riverside unit because of the wedding. The temptation to fish off my front porch directly into the Salmon River was irresistible. Reservation made.
My neice in Ann Arbor’s boyfriend knew someone who they said had grown up in Stanley––really. She contacted her and she wrote back to say alas no she hadn’t been born or grown up there, but had spent time there with family and gave up some useful tips. Everyone seemed to mention McCoy’s Bait and Tackle shop and after emailing them we got a reservation with a fly fishing guide Mary Ann Dozier. So we booked her for Sunday August 17, my birthday.
I nervously monitored the temperatures in Stanley daily and saw they were having a “heat wave.” To us however this was wintertime Florida weather with highs in the 80’s and lows in the 40’s. The key was the humidity was less than 40% so no worries.
“I think we should get a Go-Pro for our trip,” Denise said.
“No,” I said. I’m not wearing that thing on my head and besides my small Canon Powershot will be fine. I’d rather spend $300 on fishing then another electronic device.” In truth part of me wanted to do this and then I found out a friend’s son owned one. Could we borrow it? Yes. Eureka!

 

July 7, 2014

NAVIGATING THE MEDICARE BENEFIT OPTIONS MAZE

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NAVIGATING THE MEDICARE BENEFITS OPTION MAZE

Having just retired on July1, my medical group’s commercial health insurance policy is no longer available to me. However, being past 65, I started a year ago applying for Medicare benefits. Despite my knowledge in this field, I had assumed this would be a snap. I also had assumed that my Medicare patients who enrolled in a Medicare HMO (Medicare Advantage), did so for purely economic reasons. My experience has been nothing short of an eye-opener. I should have of course known better, embarking on any venture with a government agency. I signed up on-line for Medicare Part A, but Part B was more challenging since I didn’t want to start collecting Social Security at the same time and the computer program didn’t like this.

There is of course Medicare Part A, which covers hospital bills, and Medicare Part B that covers other medical and physician service. Then there is Part D that is the drug prescription plan. Medicare HMO’s combine A, B and D for one set fee and are known as Medicare Part C, or Medicare Advantage. However, hospital, physician, and drug choices are severely limited when signing up for Part C, no matter what the insurance company’s marketing advertises. “Medigap” plans can be purchased to fill in the many holes which A and B do not cover, for another premium. This is also called Medicare Part F. Are you still with me?

Now there is also Medicare Parts E, G, H, I, J, K and L. But let’s skip those for now. By late spring of this year, my head was spinning. I threw in the towel and used an insurance expert to help me navigate this alphabetical morass. Within the past two months, hardly a day would pass without some document arriving form Medicare, Social Security, or United Healthcare, the private insurance company that I had chosen for my Part D and F plans. Thankfully, they have an almost 24/7 telephone help line. I was told in writing no less than three times that my Medicare Part B would be higher than normal due to my “high” previous year’s income. I was asked in writing to verify, in writing, why I hadn’t applied for Medicare Part D benefits from the start of the year, etc.

My epiphany was that many of my former patients probably chose Medicare Part C or HMO plans, not just to save money, but also not to have to deal with this endless maze of paperwork and redundancy. This system is so cumbersome, arbitrary, and difficult to understand that only another government agency, the IRS, can make it look simple.

I have come to the conclusion that navigating all of these arms of the Medicare tendrils is almost a full time job. I have a much better appreciation for what my patients have had to endure all these years while I was simply trying to diagnose and treat their heart disease. It is no wonder our Medicare system is such a mess.

May 25, 2014

How the VAH Scandal Applies to All of Us

HOW THE VA HOSPITAL SCANDAL APPLIES TO ALL OF US

Whether you are a veteran of not, the recent report of “waiting lists”, and possibly preventable deaths of veterans, has implications for all citizens. There is no large health system which functions perfectly. But I would say that the efficiency of any given system is inversely related to its size. If this is true, then the VAH system is, and has always been, a bureaucratic and wasteful mess. Like most physicians trained in this country, I rotated through many VA hospitals, from Cleveland, to San Diego to Houston.
Many veterans receive important and good care at these facilities. However, many are shorted good care not for lack of funding, but due to layers upon layers of bureaucratic rules, regulations, and officials. Long before there were diagnostic-related groups, or DRG’s, for private hospitals, the VA health system was famous for extraordinarily long lengths of stay. So long in fact, that when I was a house officer at the La Jolla VAH outside San Diego, we had our own admitting diagnosis-IFTW, (in for the winter). Veterans came from the north and Midwest, got admitted for something, and stayed hospitalized for months.

Now the pendulum has swung to the other extreme and patients have a hard time getting admitted and staying long enough to be stabilized. (This is not unique to the VA system and affects private medicine as well.) I have recent first-hand experience with this. A friend of mine, who is a Vietnam War veteran, had to wait nine months for hernia surgery. Admittedly this is not a lethal condition but the story of my father-in-law was. A wounded WWII veteran, he was an insulin-dependent diabetic for over 30 years. He had already lost one leg due to the disease. In his eighties, his diabetes became increasingly brittle. It was not uncommon for the ambulance to appear several times a week at his ALF, for symptomatic blood sugars of 50 to over 500. He was repeatedly “stabilized” in the local VAH ER, and then sent home. Finally, I told my wife to tell the ER staff that she was not leaving the ER, unless her dad was admitted. That worked––at least for three days.

His blood sugar was no better after discharge and two days later EMS was again summoned to his residence for hypoglycemia and syncope. He was readmitted and at this point I intervened. I spent over 30 minutes on the phone arguing with a hospitalist about how he needed an endocrinology consult before discharge. Ultimately she relented. Later I found out that his clinic endocrinologist did not even see him, but only an “endocrinology PA” visited and did a consult prior to discharge.

I called his doctor and asked about an insulin pump. I was told he was “too old.” Later at a nursing home his other leg developed gangrene and he refused more surgery. He and the family chose hospice care, where he quickly died. I have often wondered if his last few years would have been different in a private hospital.

I doubt that ACA will make this any better for non-veteran patients. Simply insuring millions of patients with a Medicaid-like product does not guarantee access to care. In fact, a recent survey of thousands of doctors estimates a least one-half will not accept patients in the future with Medicaid or ACA-insurance. Wait times for potentially life saving care will become the norm and unnecessary deaths a reality.

Do I believe that there were secret “wait-lists” at VA hospitals. I’m not sure, but I wouldn’t be surprised. Surely Washington administrators and executives had to have known. And if they did not, then they should be fired. In fact, I have longed argued that the government could save billions, and veterans could receive better care, by simply giving health insurance vouchers for their care in the private system, instead of a VA hospital or clinic. Do I think this will ever happen? No.

It is unrealistic to expect a monumental bureaucracy like the VAH to deliver timely and efficient medical care routinely. It is laden with career government employees who sadly care more about their jobs than good care for our veterans. At the bottom are wonderful and giving nurses and other staff, but at the top are people whose only goal is to preserve the status quo and keep their job until retirement and secure a government pension. Efficient care is an anathema to such a system.

I predict we are headed for a two-tiered system of healthcare in our country––those who wait for care, and those who don’t. And in this respect, what happens in the VA health system has implications for all of us.

January 18, 2014

The Death of the Progress Note

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THE DEATH OF THE PHYSICIAN’S PROGRESS NOTE

I am not sure of the date or time of death. However, I am reasonably certain of the cause. Death was by electronic data and formatting. The victim was the time-honored physician’s progress note. To be sure, these notes, even the now “ancient” written ones, were far from perfect. Shortcuts such as “as above” or AVSS (All Vital Signs Stable) littered the pages of the now nearly extinct hospital chart. Yet, what now replaces it more resembles “computer vomit” than anything readable or coherent. The EHR is drowning in data excess where the truly pertinent information is at best lost is a sea of cut and paste gobbledygook, and at worst, repetitive false information.

The designers of the EHR sowed the seeds of this mess. Initially computerized health records were created to more accurately bill medical procedures, CPT codes, and hospital services. Clinical information was added out of necessity, but layered on a framework of billing and coding, making a very imperfect marriage as the final product. Having used our office EHR now for ten years, and learned four different hospital systems over the past few. Thus, I have seen more than my share of this landscape, and trust me, it isn’t pretty.

I have worked with IT personnel to try and make my notes more readable and coherent, and have used everything from larger fonts, to SOAP formats. But in order to comply with coding requirements for mid-level and higher coding, I am forced by Medicare to throw in stuff that is redundant and clinically useless. For example, “No change in PMH/FH/SH/ROS.” (Translation: Past Medical History, Family History, Social History and Review of Systems.) Since it is unlikely that my patient with CHF or atrial fibrillation will remember a new symptom, or discover a family member had a stroke, between day one and two of his hospitalization, this exercise is a waste of time, but required by CMS if you want to be reimbursed for a complex visit.

I review my patients’ medication administration record, (or MAR), daily. However, if I document those medications in the record, the end result may be a morass of unorganized and scattered drugs. The worse offender here is the Meditech system used by HCA hospitals. When incorporated into the progress note, the list is neither alphabetical, by date or route of administration. In other words, it is a disorganized mess. This quirk has been pointed out to the Meditech IT staff, and they say they have forwarded the doctors’ “concerns” to the programmers, who say they are “working on it.”

The other issue with the electronic progress notes is the “carry forward” features. The Meditech physical exam auto-fills from the previous day, unless you specifically change it. This is nice for the time pressed doctor, but leads to false and inaccurate documentation. I have seen patients who days following extubation still have noted an ETT in the mouth. In order to keep the physician “honest,” you must fill in “General Appearance” daily, but the rest can be an all too easily repeated. Ditto for the Impression and Plan. Again I have noted plans like, “For bypass surgery” a day after the procedure was completed. In its defense, you can free text anywhere, but that takes work and typing skills, and many older doctors simply are lacking here. And the local HCA hospitals have refused to install voice recognition software to make the docs’ jobs easier.

Other hospital systems force the doctor to refill the H&P daily, but there are auto-click buttons, which when repeated daily are obvious cookbook catch phrases. You can free text for sure, but again that takes more time. Local Baycare hospitals have thankfully installed proprietary voice recognition software to accommodate the “keyboard-challenged” physicians.

The end result is often a misleading and unhelpful recording of the day-to-day patient’s progress. There seems to be more than enough information in the notes, it’s just that the “forest in lost inside all of the trees.”

I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.

There must better information systems around. Unless we can free ourselves from being reimbursed by the number of words in a note, I fear the valuable physician progress note will continue to drown in mountains of data and illiteracy.

October 23, 2013

Guess What Might Just Save Healthcare

Filed under: Uncategorized — Tags: , , , , — admin @ 2:30 pm

GUESS WHAT MIGHT JUST SAVE HEALTHCARE COSTS

If you are like millions of Americans, at some point in your adult life, your doctor will order you to have a CT or MRI scan. Quick, easy, and painless, (unless you have claustrophobia), these invaluable imaging tests provide a vast amount and array of diagnostic information about illnesses, and direct treatment paths. However, the real pain usually begins when you receive the bill. It is not uncommon for the charges, including radiological interpretation, to run into the thousands of dollars. However, as those of us in the medical field know, “charges” do not = “costs.” So what exactly is the cost of these tests? Good question.

It is not uncommon for a MRI, (Magnetic Resonance Imaging), to cost $2,000-$5,000, depending upon where it is done. So how about charging just $275 for the test? Sound like a myth or joke? It isn’t, if you go to Affordable Medical Imaging, (http://affordablemedicalimaging.com/). So here’s the catch: they do not accept insurance or fill out insurance forms. Neither do they wait for payment. The patient pays the bill at the time of service, and the company gives the interpretation results and billing information to the patient. The patient may then submit it to his or her insurance company for payment.

How can they do that and still make money? The answer is easy. Without having to bill insurance companies and wait for authorizations and payments, the supplier to consumer short cut saves thousands of dollars in overhead costs. It may come as a shock to many, but health insurance is in large part the problem, and not the solution, to not only skyrocketing health care costs, but also access to care in this country. Insurance sets the rates of payment, including Medicare, (which by the way is the worst offender), and thereby increases overhead for hospitals and doctors. Since Medicare “rules the roost” over how providers get paid, and how much, they have no competition. One of the immutable laws of economics is that no competition=increased costs. This is true whether you are selling hamburgers or imaging tests.

One of the problems with health insurance in the US is by its history and very nature; it functions like no other insurance product. Imagine if your automobile insurance was forced to pay for preventive maintenance and oil changes. Or your homeowner’s policy covered a couple of shingles knocked off a roof in a storm. If they did, then how affordable to you think those policies would be? Every time insurance is excluded form the equation in medicine; prices go down––think LASIK and plastic surgery. Insurance, by its very nature, is meant to cover episodic large, often unpredictable, events; not everyday minor problems.

The difference however between health insurance, and others, is the implicit belief that everyone, no matter how rich or poor, is entitled to basic coverage for illness and accidents. Although still somewhat controversial, it is this essential belief that makes that coverage either very expensive, or not accessible, as in rationing. Unless this paradigm changes, and I doubt it will, medical insurance will continue to escalate and health care more difficult to access.

To be sure, not everyone can afford high deductible health insurance plans. Although the Affordable Care Act, (a.k.a., Obamacare), will reduce premiums for some, it will raise them for many more. Yet, if the truly free market were permitted to grow in health care, prices could only come down for everyone. Imaging is the easiest place to have price competition as Affordable Medical Imaging demonstrates. But there is absolutely no reason why it couldn’t be done in other medical and surgical fields as well.

Medicare, as an arm of the government, changes reimbursements for often arbitrary and political reasons. As an example, up until a few years ago, there were 100’s of freestanding cardiac catheterization labs across the US. That was until Medicare decided to reduce payments to these labs below the actual level of costs. No matter that most labs could do a heart cath, charge between $1,000-2,000, (including facility fees and professional charges), and still make a profit. Instead, and due solely to favored payments, outpatient heart caths went back to the hospitals where charges for the same procedure are typically between $5,000-$10,000. That is an example of how preferential pricing can be a major driver of health care costs.

The roadblocks are substantial. The medical insurance and hospital industries have vested interests in keeping costs high. And as long as we view the holy grail of medical care being equated with having similar insurance for all, costs will never become significantly lower, and access will be come more two-tiered. Sometimes the simplest solutions are the best ones.

October 19, 2013

You might want to be a doctor if

Filed under: Uncategorized — admin @ 7:00 am

A CAREER IN MEDICINE MIGHT BE RIGHT FOR YOU

You are young and bright and starting to think about a career. Maybe you are graduating from high school or in college, or floundering around part-time in some tech job. Here are 10 questions to ask your self:

1. Do you love spending lots of time everyday on a computer, Smartphone, or tablet?
2. Do you have a high level of frustration?
3. Do you enjoy making life and death decisions, but also don’t mind having them reviewed by a bureaucrat or regulating body?
4. Can you excel at multi-tasking and don’t mind being interrupted dozens of times a day?
5. Are you flexible enough to learn new rules and regulations at work daily?
6. Can you type or keyboard really fast, (say like at least 50 WPM)?
7. Can you handle someone else telling you how long you can spend with a customer? Whoops, I meant patient.
8. Are you challenged by a lifetime of perpetual course taking for re-certification of things you already know and do well?
9. Do you consider it a challenge to learn an EMR designed by a non-clinical programmer?
10. Do you consider it stimulating to diagnosis and cure disease but at the same time try to avoid a malpractice suit in case you are wrong or err?

If you answered yes to most of these questions, then I’ve got the career for you, young man or woman––become a doctor. Yes, some of the above is tongue-in-cheek, but my observations of the present state of medicine, tells me it is not too far from the truth. I have the advantage of the long view, having graduated from medical school in 1974 and been in private practice since 1979. A lot has changed––some for the better, and lot of it not.

What I do see is many of the doctors my age are choosing to retire early out of sheer frustration. The younger doctors don’t know any better, and seem to accept many of these roadblocks to good patient care as “normal.” They even seem to enjoy the challenge. But herein lies the paradox. As a general rule, many of us chose medicine because it offered autonomy and the satisfaction to heal the sick. Yes, it has paid well, but we delayed entry into the labor force by 10-15 years. And the salaries are only headed downward.

Sadly now a typical physician spends more time on a computer than talking to, or examining, a patient. Ditto for the nurses. The trend in public policy is to expand healthcare coverage to more people, which is a lofty goal indeed. However, within the thousands of pages of ACA (Affordable Care Act, AKA, Obamacare) are no provisions for increasing the number of doctors to care for new patients who sign up. (That is assuming the Health & Human Services actually creates a functional website.) What I foresee is a perfect storm for shortages in healthcare providers.
Older physicians, like myself, will give up in disgust, and less young people will choose this profession. More care will be provided by “physician-extenders”, like nurse practitioners or physician assistants. More hospitals will sponsor marginal quality “teaching programs” with questionable community doctors as the instructors, so the hospital can rake in millions of federal Medicare money. In October of 2014, ICD 10 will be implemented making a coding nightmare for doctors and their office staff. As an example, envision 12 ways to code for infections of the hand. Solo and small group offices will be forced to close, collapsing under the weight of bureaucratic and regulatory rules gone wild.

I would like to be more optimistic, and hope that I am wrong. After all, peers, my family, and I will need more, not less care as we age. However, unless something fundamental changes, we are headed to a homogenous and less available system of health care in this country. Increasing the number of medically insured does not guarantee increasing their access to care.

August 19, 2013

The Schizophrenia of Hospital Discharges

THE SCHIZOPHRENIA OF HOSPITAL DISCHARGES

A long time ago, in a bygone era, hospital discharges were simple. As a physician, you decided when to admit and discharge a patient from the hospital. Unfortunately, this process was often inefficient, costly, and subject to the whims of doctor and patient. Medicare, and other third-party payers, ultimately realized that this format made little sense and motivated keeping patients in the hospital too long. Many unethical doctors gamed the system by ordering questionable consults, insuring excessive lengths of stay, (LOS). As an attending physician, the longer the LOS, the more money they made for daily hospital visits. Sadly, to some extent, this practice still exists today. In the early 1980’s, Medicare instituted its Diagnostic Related Group, or DRG payment method, which capped hospital reimbursements by a given diagnosis, rather than upon a per diem basis. So the longer the patient stayed in the hospital, the more money the hospital lost. Conversely, the shorter the stay, the more money they reaped. Doctors, except for surgeons who did an operation, were excluded. Thus doctors and hospitals became entrenched on polar ends of the incentive equation.

This misalignment of financial incentives was a major factor in the birth and popularity of the new Hospitalist specialty. Of inpatient Medicare claims for internists, the proportion handled by hospitalists jumped from about 9 percent in 1995 to about 37 percent in 2006. The percentage today is much higher. Often employed by the hospital, the latter now had the muscle to hurry the patient out of the in-patient setting, which increased the facility’s profits. Alternatively a hospital group could be contracted for services by a hospital. If it’s LOS profile was less than satisfactory, the contract was not renewed or voided. But the hospitals faced another thorny issue. That was how to get the majority, if not all, of their in-patients admitted to the hospitalist’s service, and not that of a community physician. To mandate this would be in direct violation of many medical staff bylaws or rules and regulations. Some have done so by so-called “economic credentialing”, pressuring credentials and Medical Executive committees, to not renew admitting privileges of “over-utilizers.”

Others, like one local hospital, simply ignored the medical staff’s rules and regulations, and instituted a policy of all “unattached” emergency room patients needing to be admitted by a hospitalist. Faced with declining hospital reimbursements for visits, may family doctors quickly figured out they could make more money by seeing office patients and reluctantly, or gladly, relinquished admitting duties to the hospitalist. As a result, patient care has not always improved, and in others, actually suffered.

Studies found that although the hospitals saved money with hospitalists in charge, Medicare didn’t. Often hurried out of the hospital before stabilized, re-admission rates began to climb. This “revolving door” consequence cost Medicare, and other insurers more, but increased the hospital’s profit. You see, even if a patient was discharged, and re-admitted one day later, the meter would be reset and a new DRG payment to the hospital was initiated. Perhaps slow and inept, Medicare is not completely dumb. On October 1, 2012, they started to financially penalize hospitals for “excessive” readmissions. The penalties involved are not small. If the readmission rates go above a certain percentage, the fine can be in millions of dollars. And the readmissions are for anything and anywhere. So if a patient in Miami is discharged from a hospital with congestive heart failure, and then is admitted in Michigan within 30 days of discharge with pneumonia, the Miami hospital is dinged. The actual rules of Medicare’s Hospital Readmission Reduction Program, which was birthed as part of ACA or Obamacare, are too complex to detail in this blog.

However, suffice it to say that now the “shove them out the door” policy perfected by hospitalists may backfire, and cost the institution more money than it saves. This schizophrenia of hospital discharging gets even more complicated when you consider that realistic fears of litigation drive many ER physicians to err on the side of admitting, rather than discharging patients. In answer to this, some hospitals are now experimenting with utilizing hospitalists in the emergency room

This has left a muddy picture for patients, and their families, caught in the middle of what is in essence more of a monetary, than quality of care, battle. Ultra-short, or long, hospital stays are often not in a patient’s best interest. Sadly, we may have replaced a costly and at times inefficient system, with one driven purely by the “best reimbursement profile” of the day. Ideally, it would be great if third party payers supported and preferentially directed its patients to centers of excellence, where patient discharges are neither too early not late, and can prove good clinical outcomes. How to measure and evaluate this will not be easy, but it is certainly not impossible with today’s metrics and wealth of health outcome data.

July 27, 2013

Another French Paradox

Filed under: Uncategorized — admin @ 10:06 am

ANOTHER FRENCH PARADOX

The French Paradox is the observation that French people suffer a relatively low incidence of coronary artery disease (CAD) despite having a diet relatively rich in saturated fats and cholesterol The term French Paradox was coined by Dr. Serge Renaud, a scientist in France and made popular when described on the CBS news show “60 Minutes” in 1991. The theory goes that the French people’s large consumption of red wine helps to decrease the incidence of CAD by as much as 44% compared to other Western countries, in particular the United States. Other theories such as low genetic predisposition to CAD in the population and generous consumption of fresh fruits and vegetables were largely ignored. Also not mentioned was the leading cause of death in adult French males––cirrhosis of the liver.

But this is a curious topic for another time. I have recently observed something else about the French while my wife and I traveled for two weeks in Europe. We were in five countries: Germany, Switzerland, France, Belgium, and the Netherlands.
My wife made the interesting observation that most of the obese people we saw were Americans and not the natives. Our friends, who live in Amsterdam, also said many were Eastern Europeans. Nonetheless, I too was struck by the relative slimmer size of the Western European people. As a cardiologist, I started to ponder the paradox. Here were people who lived on bratwurst, beer, pretzels, chocolates, and pastries, and yet compared to pot-bellied Americans, you would think they were all Vegans.

Maybe it was because so many of them smoked I mused. Then I envisioned all of my obese patients who were smokers, and tossed that theory out. Next was the portion theory. Sure our portions are huge here, but what we ate at restaurants in Europe was far from tiny. There were some other clues. Here in the states, I suffer, as many adults do, with lactose intolerance. Yet, in France, I ate cheese, butter, and cream with little indigestion or flatus––yet another puzzle.

My wife, the artist, has a theory. She is convinced that food additives and preservatives are the culprit. Indeed a quick Internet search revealed that there are over 1,400 man-made chemicals added to the American food supply today. There are “natural sweeteners” as in high fructose-corn syrup, artificial sweeteners’, and “natural flavorings”, meaning annatto or guar gum, etc. A whole cottage industry of “chemical cuisine” has taken over much of our foodstuffs today. In my mind, the health impact and contribution to our obesity epidemic is unknown, undefined, and suspect.

So as we made our way through a veritable gustatory journey of overtly high fat and high caloric food, my thoughts turned toward my waistline. Since age forty I have added about a pound a year, and my self-image as a “slim” person has been in jeopardy. I weighed myself before leaving for Europe and two weeks later upon return.

Despite sinful indulgences such as pretzels, beer, Belgian French fries, (or pom frites, minus their traditional mayonnaise), French bread, pastries, and hot chocolate so thick you could stand a spoon up in the cup, I was stunned at my weigh-in. I had gained only one pound!

I don’t think I’m any closer to an answer about this paradox than I was before our trip. However, I am starting to agree with my wife––the food industry is poisoning us. I can’t back this up with science but my anecdotal travel experience has me concerned that something seriously wrong is happening with our food supply on this side of the pond.

So now I read labels like a detective, shunning anything that is packaged with more than five ingredients. And if you think that is easy to do, then just try grocery shopping sometime and reading all of the food labels. It will be a real eye-opener. In the meantime, we will continue to shop at Farmer’s markets, grow veggies out back in our Earth Boxes, and eat out as little as possible. I don’t care if it is high fat, lo carb, no fat, etc. What might be more important is and how and where our foods are produced than anything else.

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