I've spent considerable time the last two days mulling over the choices for the next steps in treatment.  I e-mailed Dr. Vanveldhuizen yesterday, and though he is usually prompt in answering, he hasn't replied yet.  Perhaps he hasn't had a chance to confer the Dr. Holzbeierlein (is it a bad sign that both doctors' names have 13 letters?), who would do the surgery if we choose to go that route.  My next appointment with Dr. Van is scheduled for Dec. 10th, and it's just for blood work.  I suggested that if we're seriously considering surgery to remove the tumor in my kidney, we should probably meet with Dr. Holz before then. 

My current feeling is that since the surgery wouldn't extend my life, I'm not inclined to do it: it's an invasive operation, and I don't think the possible complications and the time spent in recovery are worth any possible benefits.  But I don't really have enough information without consulting the surgeon to make a final decision.  As for ablation of the tumor, that sounds considerably less invasive, but again, it wouldn't affect my long-term survival, and at a couple of points in our consultation on Monday, I think that Dr. Van implied that the tumor was too big for ablation.  (It's amazing that no matter how attentive I think I am, there's so much stress and I'm so exhausted by the time we get to the consultation that I miss or mishear or forget parts of what the doctor says.) 

The other decision we need to make is whether to change the chemo regime.  On this score, I think I'll just follow Dr. Van's advice.  My analogy (which some of you have heard in e-mails) is that if Dr. Van asked me which William Faulkner novel he should read first, I'd hope that he would trust my informed advice.  Although I've read about Sutent (the most likely alternative to Votrient), the side effects seem about the same as with Votrient and the survival rates are also similar; I really can't make an informed decision on my own.  Dr. Van has spent his life in oncology; his opinion is much more trustworthy than anything I could come up with.  I'm not very enthusiastic, however, about participating in an experimental trial where I'd get Votrient combined with either a new drug or with a placebo.  I feel somewhat selfish about feeling that way, since this kind of trial might help others down the line.  But the trials would involve more monitoring, hence more trips for tests, and all that seems rather too onerous.

Switching subjects: just when I said that we get no political advertising in Kansas (still true for national and state-wide races), we're bombarded with ads for and against two Democratic incumbents at the state senate level.  Surprisingly, the ads for the Democrats seem more sophisticated.  One Republican ad, however, drives me over the edge.  It's sponsored by the Kansas Chamber of Commerce (didn't chambers of commerce used to be rather bland pro-business organizations?).  It contains two claims, both patent lies, about the Democratic incumbent.  The first is that he voted to restore $600K to the Kansas public employment retirement fund and doesn't just imply, but actually says, that all that money went to line his own pockets.  The second claim is that he voted for Obamacare.  He's a state senator.  Does no one even monitor what PACs say in their ads?  Are there no regulations (Romney would like that) of what the PACs can say?

What we do have are plenty of ads from the insurance companies, since this is the period when Medicare recipients (like me) can change plans.  My bet is that few people actually change, since there's simply too much information to process.  Still, there are parts of Medicare that work very well.  For one thing, we all get a booklet from the government that explains as clearly as possible the alternatives and will provide for Part D (drug expenses) a program into which you can plug the list of drugs you take and receive a recommendation for the most cost-effective plan.  An even simpler guide is that for each alternative, there's a clear percentage figure for the plan's customer satisfaction.  Another efficiency that has surprised me is that I'm not deluged with confusing bills.   I've never received a single bill from a doctor or a hospital.  Instead, I get three monthly statements (that are actually comprehensible).  BCBS sends me a statement of what they have paid to supplement my Medicare coverage.  I get two monthly statements about my drug coverage, and they're not only clear, but I can see exactly where I am in the four stages of Part D coverage.  (In my case, it doesn't take long to move right past the "donut hole" and into the catastrophic phase.)  I get all but the Votrient from my neighborhood pharmacy, but the chemo, because of its expense, is mailed from an out-of-state pharmacy.  Because of electronic record keeping, this is all coordinated, and the statements reflect both sets of prescriptions.  Instead of being swamped with paperwork (I never have to save the numerous receipts from pharmacy visits), I just have my three sets of monthly statements, and that's that.

Let's say that Mitt Romney had the courage of his convictions (two oxymorons in just one phrase) and proposed that his health care plan (as much as we know about it at any given moment) would start immediately, not just for those 55 or younger.  Does anyone think that he'd get a single vote from people 65 or older?  And now that he's backed away from Ryan's ridiculous voucher program so that Medicare recipients would have a choice, does anyone think that having two separate systems would make Medicare more efficient and less bureaucratic? 

I'm certainly not arguing that Medicare is perfect or that Obamacare, while phasing in distinct improvements in health care coverage, is ideal.  There's a lot of work still to do, especially in controlling costs.  But much works surprisingly well--and should, step-by-step and frustratingly slowly, continue to make health care better, especially for those of us who are over 65 and are having much more experience with doctors, hospitals, pharmacies, and insurance companies than we would like.