Unconventional Wisdom 3

Epidemiology

“If one is going to study the effect on human health of a phenomenon thought to be dangerous, it has to be done after the fact, right Curmudge?”

“It’s called epidemiology, Julie, and that’s what we will talk about today.  As in the two previous postings, information will come from Hiserodt’s book, which we may occasionally quote or paraphrase.  Original references are found in chapter 16.  An early study by Abbott (1983) of 4,000 nuclear workers, exposed in the workplace to an average of 7 cGy (about 20 years of additional annual background radiation), revealed that their cancer mortality was less than that of the population of Ontario.”

“But, Curmudge, those workers had to be healthier than the average citizen even to be hired.  No wonder their cancer mortality was less.”

“That’s called the healthy worker effect, Julie.  Abbott corrected for this by including a cohort of non-nuclear workers drawn from the same population as the nuclear workers.  The cancer mortality of the non-nuclear workers was right up there with the general population; for the nuclear workers it was much lower.  Another study in Canada, by Gribbin et al., compared leukemia mortality of unexposed Atomic Energy of Canada workers to their colleagues who were exposed to an average of 4.9 cSv.  The exposed workers had about half the leukemia mortality of the controls.”

“Curmudge, even a reckless old buzzard like you should be afraid of plutonium dust.  Plutonium emits alpha particles; they don’t go far, but I’ve always envisioned their making big holes—sort of like Swiss cheese—in one’s lungs.”

“Hiserodt described the fate of 26 males exposed to plutonium dust and fumes during atomic bomb development in 1944-45.  Their health was checked every five years starting in 1952.  By 1986-87, 22 of the subjects were still alive at an average age of 66.  Two had died of heart attacks, one in an auto accident, and one—a pack-a-day smoker—died of lung cancer at the age of 72.”

“Someone has calculated—Hiserodt didn’t say who—that eight of the atomic bomb workers (living at the end of 1987) had received a dose of more than 2 times 10 to the 15^th power alpha particles.  Curmudge, I think I’ll have to revise my mental picture of what alpha particles do inside lungs.”

“Don’t close the book yet, Julie.  In chapter 19 Hiserodt describes what might have been the definitive low-level radiation study.  In 1991 the U.S. Dept. of Energy contracted with Johns Hopkins University to study ‘Health Effects of Low-Level Radiation in Shipyard Workers.’  Workers were divided into three groups: (1) The Control group of 33,352 workers whose duties did not involve radiation.  (2) The Low group of 10,462 workers whose cumulative exposure was less than 500 mrem.  (3) The High group of 28,542 workers whose cumulative exposure was equal to or greater than 500 mrem.  Results were reported as standardized mortality ratio (SMR), which compares the death rate of a group in question with that of an age-adjusted population of peers.  The control group had an SMR of 1.00 for death by all causes, which corresponds with that of the general population.”

“That certainly sounds rigorous, Old Guy.  Tell me what those academic statisticians found.”

“With one exception, the SMRs for both exposed groups were lower (better) than those of the control group.  The exception was mesothelioma, which is known to be caused by amphibole asbestos.  For all causes of death, the difference between the exposed groups and the controls was statistically significant.  For cancers other than mesothelioma (leukemia, lymphoma and hematopoietic cancers, and lung cancer), the SMRs were lower than the controls but not significantly lower.  A reviewer (Prof. John Cameron of UW-Madison) has stated that, ‘This study is probably the best scientific evidence…to show that low levels of ionizing radiation are without health hazard.’ “

“Wow, Curmudge!  I certainly feel better after reading that last sentence.  It is especially interesting that this study was initiated to show the adverse effects of low-level gamma radiation and ended up showing no adverse effect.  It’s another nail in the LNT theory’s coffin.  But why, after so many years, hasn’t the Department of Energy issued a formal report on this work?”

“We can only speculate, Julie, and we will in a later posting.”

“I hope you haven’t forgotten, Senescent Senior, about the unintentional epidemiological event in Taiwan (1).  In 1982 several radioactive cobalt-60 orphan sources were inadvertently recycled into 20,000 tons of steel, some of which was used to construct apartment buildings housing 10,000 people.”

“It wasn’t forgotten, Julie; it was only a ‘senior moment.’  The average cumulative dose for the exposed residents was about 50 mSv.  Twenty years later, only seven fatal cancers were observed where 232 were expected.”

“Do you suppose, Curmudge, that the tenants’ rent was raised to reflect the benefits of radiation hormesis?”

“My guess is that the tenants were evicted and the buildings razed.  It was probably government policy to protect the residents from further exposure to radiation, whether it was good or bad for them.”

Kaizen Curmudgeon

(1)  Sanders, C.L.  Dose-Response 10, p.615 (2012).

Unconventional Wisdom 2

Mice in the Laboratory

“I’m not surprised that it’s hard to find humans to be the subjects of radiation research.  Although mice are ideal for this kind of work, I sometimes feel sorry for the little critters.”

“It’s not all that bad, Julie.  They get three squares a day, and they don’t have to worry about snakes in the grass, owls in the trees, and traps with cheese.  Sometimes they get to participate in reproduction studies, and they even have a 50-50 chance of being in an experiment’s control group.”

“Funny that you should say that, Curmudge, because we’re going to discuss chapter 14 of Ed Hiserodt’s book (see previous posting) in which the control mice usually got the short end of the stick.”

“Let’s look at some of the data:

Maisin, et al. (1988): 1,000 mice per data point were exposed to a single dose of gamma radiation from 20 to 600 cGy.  At 200 cGy, the LNT theory predicted a 60% increase in leukemia while the actual data showed a 35% decrease.

Ullrich, et al. (1979):  400 female mice per data point were exposed to 10, 25, 50, and 100 cGy.  At 25 cGy, cancer mortality was decreased by the following percentages: pituitary (20%), ovarian (20%), mammary (46%), and uterine (13%).

Sacher and Grahn  (1964):  About 100 mice per data point were exposed to cobalt-60 gamma radiation until they died.  Those exposed at about 0.5 and 5 cGy per day lived longer than the unexposed controls.”

“It would appear, Curmudge, that the little rodents died for a good cause, i.e., disproving the LNT theory and supporting radiation hormesis.”

“Here, Julie, is an interesting observation by Yonezawa (1990).  Mice were irradiated with a low dose of x-rays (50 cGy) two weeks before receiving a potentially lethal dose (740 cGy).  The survival rate 24 days after receiving the second dose was higher (80% survived) for the mice that had received the preliminary dose than for the controls that had received no preliminary radiation (11% survived).”

“That certainly resembles vaccination.  The authors called it ‘radioresistance’.  These findings have certainly changed my attitude toward mice, Curmudge.  The next time I see a mouse I won’t whack him with a broom; I’ll salute him.”

Kaizen Curmudgeon 

Unconventional Wisdom 1

A continuation of Conventional Wisdom posted August 8, 2011.

“Listen up, Julie.  I’m going to teach you that exposure to small amounts of radiation won’t hurt you.  In fact, it may even be good for you, even at the levels used for diagnostic purposes such as computed tomography (CT) scans.  Recent research has shown that living in a radiation-deficient environment stunted the growth of a protozoan.  And living in a radiation background that is several times our present level should improve our health and longevity. (Google Sir Samurai T. D. Luckey.)”

“Get off it, Curmudge!  I’ve been taught since I was a child that all radiation is dangerous.  Old men are supposed to dream dreams (Acts 2:17), but isn’t this one pushing the envelope?  And besides, blogs are too brief to teach anything.  The most they can do is inspire the reader to learn more.”

“Right as usual, Julie.  Our teaching—I mean exposure—to this topic began over a year ago (August 8, 2011) in our posting on Conventional Wisdom.  At that time we still had a sponsor and had to tread softly on controversial topics.”

“Hooray! Vive l’indépendence!  Now we can tackle controversial issues head-on.”

“Whoa, Ms. Enthusiasm.  As I said, we introduced today’s topic, the linear no-threshold (LNT) concept, in 2011. To avoid repeating everything, let’s all go back and read the Conventional Wisdom posting.”

[Blog delayed 10 minutes for Jaded Julie and readers to read old posting.]

“Now I remember, Curmudge.  According to the linear no-threshold theory a plot of cancer occurrence vs. exposure, based on high levels of exposure to radiation, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect.”

“That’s it, all right.  But extensive research has shown the LNT theory to be invalid.  We cited some of it in our earlier posting, and we’ll list more books and papers today.  If our readers study the documents that we cite, most should agree that the LNT theory has become outmoded.  However, there will likely be some who will cling to the LNT dogma.”

“Also in our Conventional Wisdom posting there were references suggesting that exposure to low-level radiation imparted a protective effect against cancer.  Will we discuss that also?”

“We surely will, Julie, but it may require more than a single posting.  There’s so much information on these topics that we’ll only have room in the blog to mention authors and brief summaries.  Complete references are in Hiserodt’s book, discussed below.  And to examine these documents critically, a reader will need to become familiar with the units used to measure radiation, which we don’t have space to cover.”

“But Curmudge, we’ll need to use some numbers, and readers will require a few units to even gain a seat-of-the-pants understanding of our story.”

“Good observation, Julie.  Here are some common abbreviations and units:

Abbreviations: m = milli or 1/1000; c = centi or 1/100.

Rem is effective dose in U.S. units; sievert (Sv) [gray (Gy) is equivalent] is effective dose in international units.  1 Sv = 100 rem.  1 cSv =  1,000 mrem.”

“How about providing a frame of reference?”

“Here are some ballpark values:

Typical background radiation (cosmic, terrestrial, radon, medical) in the U.S. = 300 mrem (0.3 cSv) per year.  Background in Denver = 600 mrem (0.6 cSv).

Maximum permissible exposure for a nuclear worker = 5,000 mrem (5 cSv) per year.

Acute exposure (1-2 days) to cause radiation sickness = 100,000 mrem (100 cSv).”

A single computed tomography (CT) scan = 1,000-5,000 mrem (1-5 cSv).”

“Thanks, Old Guy.  Now we all should be on the same page.  Shall we begin our discussion by mentioning the books on this subject that are available?”

“To easily obtain the most information at a reasonable price ($5.91 from Amazon), I recommend Ed Hiserodt’s Underexposed (subtitled What if radiation is actually good for you?) (2005).  Despite its easy-reading appearance, the scientist or nonscientist will likely agree that much of the story is there, and that it is supported by a comprehensive Amazon review by Jay Lehr.  Books with more detail and a much higher price include Radiation Hormesis by T. D. Luckey (1991) and Radiation Hormesis and the Linear-No-Threshold Assumption by Charles L. Sanders (2009).  These books are well documented with peer-reviewed literature.  Luckey’s two books—an earlier one was published in 1981—contain over 2,00 citations.”

“Well Curmudge, I can guess which book a very familiar tightwad bought.  Prof. Luckey is revered in Japan, where they accorded him the honorary title of Samurai.  This can be confirmed by ‘googling’ Sir Samurai T. D. Luckey, where many of the teachings of this blog are also supported.  By the way, I noticed that the books by Luckey and Sanders have hormesis in their titles.  Perhaps you can tell us what hormesis means.”

“It’s the protective effect mentioned by Tubiana in Conventional Wisdom.  And more generally, it’s the phenomenon where something that is harmful at high doses is helpful at low doses.  Examples are many trace metals, vitamins, and even water.  So to proceed, in addition to the papers cited in our Conventional Wisdom posting (those by Vaiserman, Tubiana et al., and Scott et al.) the following tend to refute the LNT theory and support the radiation hormesis concept.  We’ll start with the early observations, made mostly by Japanese scientists, on survivors of the atomic bomb attacks on Hiroshima and Nagasaki.”

“Chapter 15 in Hiserodt shows plots of cancer deaths vs. exposure.  Because plots are hard to show in this blog, I trust, Old Guy, that you can describe them.” 

“A ‘hockey stick’ plot of effect vs. exposure (with blade to the left coinciding with data on unexposed controls) would have refuted the LNT theory.  These plots were shaped like field hockey sticks with blades drooping below controls, thus demonstrating radiation hormesis (fewer deaths than controls) below around 10 cGy.”

“Curmudge, with those exciting findings published in Health Physics and seemingly ignored since 1987, let’s take a few days to search the books further and find some more data.  Sayonara.”

Kaizen Curmudgeon                                               

The Ordeal 3--Summary

“Cancer patient, Jay, and his devoted wife, Ann, have begun six days of in-patient chemotherapy in a different hospital.  Hopefully, they will not be subjected to any hospital screw-ups that we’ll want to discuss.”

“So we’re done for the day?  I’m outta’ here.”

“Nicht so schnell, Julie!  We’ve still got work to do.”

“Based on the tone of your voice, Curmudge, I perceive that you just said ’Not so fast’ (in German).”

“Right as usual.  As we promised last week, we’ll summarize what we learned from Jay and Ann’s ordeal.  In addition, we’ll provide some unsolicited suggestions that the original hospital (which will remain anonymous) needs to consider.  Let’s start this way: Julie, if a hospital said that they were providing patient-centered care—and most of them say that—what would you, as a patient, expect?”

“First of all, if I were in severe pain, I would expect the hospital to do everything feasible to alleviate it.  Nothing else matters to one experiencing intractable pain.  If I had nausea or constipation or other physical discomforts, I’d expect help there too.  Also, I would consider a noisy environment to be a physical discomfort.  Finally (but definitely not least), the hospital should minimize the patient’s and family’s emotional stress.  Not knowing, waiting, or poor communication in general would be almost as bad as pain.  Things often not known would include one‘s diagnosis, when the next test will be and when its results will be available, and when one will be able to eat.  If a hospital can’t communicate with its patients, its supporting elements like clinics and pharmacies, and within itself, it might as well be a cottage industry in Kyrgyzstan.”

“Well put, Julie.  And at some point during Jay and Ann’s ordeal, they experienced each of the above.  The biggest issues at the first hospital were emotional stress and communication problems, which started with the computer hang-up in getting Jay admitted.  Then there were the almost non-existent communications between the hospital and pharmacy.”

“I was really concerned about Jay’s having to wait a day—in pain—for a CT scan and then overnight for the result.  CTs are run 24 hours a day in most hospitals, and there are services that read them overnight.  Of course, Jay, Ann, or nurses in the hospital should have stayed abreast of the constipation problem before it became serious.  Most everyone knows that narcotic painkillers cause constipation.”

“On the other side of the ledger, I was impressed by the on-call oncologists who answer the phone at 2:30 a.m.  It’s amazing that they can be alert and give sage advice to someone who might not even be their patient.”

“So, Curmudge, what’s the bottom line?  The original hospital seems to have a peck of systemic problems.”

“Julie, my one-word answer is the same as it has been for the past six years.  Lean! The hospital needs a Lean transformation.  Anyone who is not acquainted with Lean can start with the first Kaizen Curmudgeon posting in May of 2007 and read the next 240.  In a nutshell, the hospital needs to empower the employees to map their processes, find the root causes of problems, and then use plan, do, study, act cycles to implement continuous improvements.  They need to find the waste and inefficiencies in their systems and get rid of them.  And finally, the hospital must do this with the full support and leadership of management at every level.  If Jay and Ann’s first hospital has already started a Lean journey, it needs more attention.”

“That was a pretty concise rant, Curmudge.  If a hospital can get its systems in order, they should be well on their way to providing patient-centered care.  So what kind of problem will we illuminate—but not resolve—next?”

 

“We’ll take a break for a couple of weeks, read some books, and then present some stuff about a little-known issue that a few readers might not believe.”

“Sounds interesting.  I’m with you, Old Guy.”

Kaizen Curmudgeon

The Ordeal 2

Another tough week, but are screw-ups subsiding?

“Curmudge, a newby who just surfed into this posting would have no idea what we are talking about.”

“That’s the way it is in blogs and in life, Julie.  It’s difficult to put today into context without knowing what went on yesterday, or last week.  But we can’t wait for stragglers.  Time to proceed onward.”

“I understand, Old Guy, that Ann became a ‘frequent flyer’ at the local pharmacy.  Quoted below are some of her comments:

‘Needed several new medications. Local pharmacies do not carry some of the specialized ones; they have to be ordered.  One special one to prevent infection would have cost $3,200!  We did not get it filled.  It had to be ordered from somewhere.  I called the clinic early this afternoon to learn if there is an alternative but have not heard back yet.  Having to run to the pharmacy daily is frustrating—especially with back orders, meds not in stock, or unusual drugs.  Wish there were a better system for cancer patients. The clinic does not stock samples of drugs.  Some days it's multiple trips to the same pharmacy.’

‘Jay had a strong drug reaction that lasted an hour during an outpatient chemo infusion that took 8 hrs last Thursday, and a Neulasta injection that produced severe flu-like aching—very painful. Plus other painful side effects: mouth sores, bad stinging and pain in jaws and throat. Incredible fatigue.’

‘I asked the pharmacy to call as soon as they got the Vicodin order (for pain), and they called us back to say it was ready. Then they also texted Jay's phone.  Nice.  I made friends with the pharmacist today; told them all I'd be a "frequent flier" and that Jay was enduring aggressive chemo. I think they will be ready-on-the-spot now since they know we need help. They were great about the Vicodin—usually that one can't be called in.’ “

“The situation at the pharmacy end of the system seems better, Julie, but things are still messed up at the hospital end.  This is what Ann wrote:

‘Any e-filing or phoning of prescriptions from the hospital side to our pharmacy has not worked.  I asked where the disconnect is occurring, but I’m not sure I got an answer.  I called the clinic to get a prescription, and they said I had to talk to the hospital medical unit.  After four phone calls to the hospital last Friday afternoon, the clinic finally just did the Rx—and phoned it in. The hospital never did do it in spite of three calls from me to the 3rd floor medical unit (they promised it was done, each time I called) and two calls from the clinic to the medical floor!  The clinic staff told me the staff on the hospital floors don’t like to phone in prescriptions.  Nice, huh?  Then why don't they just hand me a written script then?’ “

“Wow, Curmudge!  As in the Book of Job, it seems that trouble keeps coming:  

‘It’s 6 a.m. and Jay was up all night throwing up.  At 2:30 am I called the on-call doc. She said to come right into the clinic at 8 a.m. What a long night.  No sleep again for Jay. It may be a bowel obstruction.’

‘It’s 11:30 am, and he still feels crappy; blocked up. The x-ray showed a mass in Jay’s abdomen. He must have a CAT scan for a better view.  Jay will be an inpatient for the day and tonight.’

‘The CAT scan—where is it?  It was ordered at 11:30 am.  Jay is not able to have any food or water due to the blockage, and he's extremely uncomfortable with nausea. The RNs gave him meds that helped. But the doctor still doesn't know what the problem is.’

‘Jay waited all afternoon; but by 5 pm, still no scan.  Where's the CAT scan? Then we will have to wait for a radiologist to read it.  Now the business day is over, and Jay has a serious blockage that hasn’t been identified.’

‘My patience is wearing thin with delays at the hospital.  Jay has been through hell. The clinic staff and on-call folks have been wonderful—responsive, caring, and attentive, but there seem to be snags at the hospital diagnostic level again.  Where's the urgency with a cancer patient?’

‘Jay just sent a text: He just got back from the CAT scan at 5:45 pm.—6 hours late. He said the CT folks were swamped with ER cases today.  As expected, results will not be available until tomorrow.’

‘Next day: The CAT scan showed that the mass is severe constipation from the GI system’s shutting down due to electrolytes being out of balance.  Electrolytes via IV are starting to wake up Jay’s GI system.’ “

“Curmudge, might some of those ‘urgent’ scans in the CT backlog have been defensive medicine?  And I’m surprised that there wasn’t a radiologist on call.”

“With a name like yours, Jaded Julie, I would not be shocked by your having suspicions.”

“So where do we go from here, Professor?”

“It depends, chère étudiante.  If delays and screw-ups have really subsided, next week we’ll summarize what we’ve learned.  And you and I, who probably aren’t qualified to make recommendations, might make some anyway.”

Kaizen Curmudgeon

The Ordeal 1

The First Week—Further Diagnosis and Follow-Up

“Prepare, Jaded Julie, to be dismayed, disgusted, and disheartened by today’s discussion.  Every cancer patient’s experience is an ordeal; some are quite tolerable, but some are horrible.  We are going to discuss one that started out in the horrible category.”

“Curmudge, I sense that you are in a black mood that can only be assuaged by feeding it to the computer, pressing the ‘save’ button, and ultimately posting it on our Kaizen Curmudgeon blog (http://kaizencurmudgeon.blogspot.com).  So how are you and I going to tackle this?”

“To maintain our focus on Lean management systems in health care, we will pluck the organization’s systemic problems from the patient’s experience.  Most of these first- and second-order ‘screw-ups’ will be described by quoting the patient’s spouse.”

“Screw-ups, Curmudge!  Those are harsh words coming from an ancient but dignified professor.  We know that hospitals work hard to avoid ‘never’ events, wrong site surgeries, surgical site infections, and medication errors, but it’s the seemingly minor and more frequent screw-ups, as you describe them, that make life miserable for patients and their families.”

“Patient-focused care doesn’t always happen, Julie.  Here’s the story.  My close friend, Jay (not his real name), was diagnosed with Burkitts lymphoma quite recently.  In fact, the full extent of the disease has not yet been determined.  In any case, it will be treated quite aggressively beginning with a week as an inpatient in a hospital outside the immediate Fox Valley.  Jay’s wife, Ann (not her name either), has been providing daily updates to friends and family.  Quoted below with her permission (and with some editing) is how she described Friday:       

‘Jay is finally an inpatient after a snafu that took all day.  The morning began with a PET scan.  Then at noon we got lots of our questions answered at the oncology clinic.  The PET scan results were not what we hoped.  There is mall lymph involvement in Jay’s chest—only 1 cm more than normal but still there in two little places.  The spinal test still has to come back.’

‘We then walked over to Inpatient, but there were no orders, not even an order for food. Poor starving Jay; he has had nothing to eat since yesterday.  Our hope was to get a jump-start on treatment today.  The orders got lost between the oncology clinic and the hospital, which incidentally are in the same building!  Orders had to be re-done—followed by lots of apologies.  Apparently the problem was the staff’s unfamiliarity with their new computer system.  But we still lost a day of treatment.   Jay is just now getting settled in at 7 p.m.  We were there all day!’ “

“Now I understand your blue funk, Curmudge.  What a horrible way to treat the patient and his family who are already under a level of stress that neither of us can fully appreciate.  It was unconscionable!  So how might a hospital avoid these situations?”

“Every hospital knows its own system best, and some may have their screw-ups under control.  Those that do not will need a person or persons with strength to walk through the hospital’s silo walls and the stature to be heard when he or she speaks.  It’s critical that these problems be nipped in the bud, so patients will need to know whom to contact when things appear to be going awry.”

“So what do you foresee in Ann’s next report, Curmudge?”

“It’s time for some good news, Julie, so I remain hopeful.  Many years ago Jay and Ann and I hiked together in the Rockies, and I want to do it again.”

Kaizen Curmudgeon

Bloggers--Affiliated or Independent

“Hey, Curmudge, with respect to both kinds of bloggers, we’ve been there and done that.  We spent most of five years affiliated with an organization, and it has been several months since the old man’s cubicle was dismantled and we became independent.  But why should anyone be interested in the life and times of a blogger?  To most readers, a blog posting is simply a few paragraphs of either valuable or useless information written under someone’s real name or nom de plume.”

“The biggest reason, Julie, is because we are different.  Most blog writers are real people practicing real professions who write declarative sentences.  You and I are fictional people, and our author is a senior citizen writing conversational

sentences in an old folks home.  And we’re an excellent example of symbiosis; the old man does the thinking and we do the talking.”

“Sounds as if we might have a story.  Let’s start by describing how an affiliated or institutional blogger differs from someone in the marketing department.  Although they are both producing copy viewed as representing the organization, the work of the marketing person is directed at customers while the blogger’s postings are directed at anyone willing to read them.  The blogger’s post is signed (sort of), while marketing stuff simply emanates from the department.”

“Here, Julie, is another way to describe an affiliated blogger.  He or she might be regarded as similar to a columnist on the editorial page of a publication.  The columnist provides research and observations to support an article, but the tenor or the piece must not violate the publication’s mission statement.  And speaking of research, the blogger can study and summarize topics of interest to colleagues and to the organization.  A librarian tells ‘where it is,’ and the blogger tells ‘what it says.’ “

“And finally, Curmudge, like any material written for public consumption, the draft postings of an affiliated blogger should be edited for content, grammar, and to assure conformity with corporate policy.  That should not be difficult, because blog postings are usually not over two pages long.”

“You know, Julie, we both had a great time being affiliated bloggers.  And our 200 postings on Lean, leadership, and health care are out there in the blogosphere for anyone to read.”

“So what’s different about being independent, Curmudge?  I suspect that your answer will be ‘everything.’ “

“A big difference is that we don’t have formal or implied constraints.  That was and still is not a practical issue, because the old man continues to insist that we use good taste in what we discuss.  Now, however, we don’t hesitate to tackle a controversial topic or mention a good publication written by what used to be a competitor.”

“What about the venue where the work is done, or ‘gemba’ in Lean parlance?  It used to be a cubicle in a big room in an office building.  Now the old man’s office is in his bedroom in an apartment.”

“Well Julie, the old man’s ‘cube’ wasn’t too bad unless a neighbor was on the phone.  Otherwise, the room’s background noise was just a low hubbub—fairly conducive to reading, thinking, and writing.  He was used to that after 60 years working with people either in a classroom, lab, or office.  Now, although the apartment is everything one would want, it is as quiet as a tomb.  Although most people would like a little peace and quiet for writing, this is extreme.  Of course, there can be no camaraderie or exchange of ideas in a solitary workplace.  But the old man is getting used to it.”

“I suspect that there are other practical disadvantages for a blogger in isolation.  Being ‘out of touch’ means that local concerns and issues can’t be addressed in the blog.  An independent blogger would be unable to function without the Internet, but then again, there wouldn’t be web logs without the web.  So, Curmudge, what will the old man do in the future, and what will happen to us?”

“I suspect that we will look farther afield for topics to discuss, and the old man will do what we discussed on June 3, 2012.  He will remain an inveterate teacher and will ‘keep on a-keepin’ on’.“

Kaizen Curmudgeon