….and there was a problem.  The de-leveraging process began, and the bathtub water went draining out.

While the liquidity was being drained from the system, the asset values of everything began to fall – quickly and dramatically. Fundamentals meant absolutely nothing. As we all know, there are many of methods to measure the value of equities: discounted value of earnings, discounted cash flows, Enterprise Value / EBITDA, Market Cap / Revenues, Price/ Earnings.  They all meant nothing – all at the same time.  That was scary.

Even the stocks that we felt were very inexpensive – got a LOT more inexpensive.

Fortunately, that period is over, as is the party for RWR. Their victory laps are over, their music has stopped. During an appearance on Fast Money in December, the panel was openly hostile to Rosenberg’s continued thesis of problems, problems, problems. To paraphrase, “No, the economy hasn’t turned, and things haven’t become better”. Listening to RWR meant that you missed a 50% upswing in the market. Of course, that’s the problem with structural economists – they see the mountain, but they can’t see through the valley to the other side.

Yesterday, the “W” of RWR slashed her earnings estimates for Goldman Sachs. The market said, “Yawn”.

What happens now? Well, over the last 9 months, those asset values that were falling precipitously have once again begun to increase. Fundamentals didn’t mean much again over these last several months as everything increased.

This year, we expect fundamentals to mean something. Everything won’t increase indiscriminately. There have been some clear winners in this movement upwards, as companies like Apple (AAPL) have seen very strong increases in their market valuation and market multiples.

No doubt here – 2010 will be a stock pickers market, and our list of favorites (both long and short) has been refined.

Over the weekend, I exchanged emails with a trusted friend who is the head of oncology at a large hospital in the greater Chicago area. She was quite emphatic that we take her God-daughter to the pediatric orthopedic surgeon.

So we did.

Very nice doctor, and very personable with my daughter.

His PA had set up the two x-rays while she did the initial assessment. When the doctor came into the room, he introduced himself, examined my daughter’s finger, and then walked right over to the x-rays, took one look at them, sat beside my daughter and began to trace out the bones on her finger with his ink pen. With this drawing, he showed my daughter where the little bone chip was located, and then instructed to her that she stop wearing the splint so that she can begin moving the finger. Within a couple of weeks, the increased mobility will eliminate the pain she currently feels.

Done. X-Ray viewed. Diagnosis given. Comfort provided. Treatment given. Visit over.

It was the best $50 (co-pay) I had spent in a long time. Too bad that we had to include a second visit to the pediatric doctor.

Cha-ching to the healthcare industry.

To me, this episode represents a microcosm of why the US absolutely needs a single payer public option. The current system may get to good health, but it does NOT represent the best path to good health.

About 3 weeks ago, my oldest daughter broke her left index finger while playing basketball. The nurse at the school told her that it was just a sprain, so she didn’t bother notifying us (the parents). No note, no nothing.

Having played contact sports my entire life, and having had my share of boo-boos, I could immediately tell once I saw her finger – and based on the swelling, the bruising, and the inability to move/bend her finger – that it was broken. So, we took her to the pediatrician’s office the next day. We paid the deductible, and were told that it was probably broken, so the doctor sent us to the radiology clinic for an x-ray.

Cha-ching to the health care system.

When you read this story, you might come to the conclusion that the doctors involved were disinterested (at best), or incompetent (at worst). I wouldn’t go that far in my assessment. We have been taking our children to this practice for three years, and all previous interactions have been simple and uneventful. The pediatricians seemed friendly and knowledgeable, though they can’t seem to figure out the scheduling thing (an appointment at 3pm should mean an appointment at 3 pm, not 4pm).

After several hours, the doctor’s office called us (not the doctor, but a nurse), and in my head, I began to channel “Gomer Pyle, USMC” : “Surprise!, Surprise!, Surprise!”. Indeed, it was broken.

We asked the nurse where the break was. She had no idea – she was a nurse. Moreover, the only thing that the radiology clinic sent (sorry, faxed over), was a text assessment of the x-ray, they didn’t send over (sorry, courier over) a copy of the x-ray. (This story gets better since the radiology clinic uses a digital x-ray machine which captures a digital image that can be easily sent over to the doctor’s office – but isn’t).

…..Excuse me?

That’s right, no x-ray image. Just text – which read, “Findings – appropriate views of the left second digit were performed. A minuscule volar avulsive fracture is seen, adjacent to the epiphysis of the left second middle phalanx.

Impression – Undisplaced miniscule avulsion fracture from the volar surface of the base of the left second middle phalanx.

The doctor, …sorry, the nurse, explained to us that the treatment recommended by the doctor was to place the finger in a splint for three weeks, and then begin taping it to the next finger so it would regain its mobility.

Three weeks pass by, the finger still hurts, and is painful to bend.

Back to the doctor’s office. As there are three doctors in this pediatric practice, we get to see the senior doctor this time. She examines the finger, and suggests that we need to re-visit the radiology office for another x-ray. We pay the doctor’s deductible. We go to the radiology office, and pay for the x-ray.

Once again, cha-ching to the health care system.

We get phone call from the doctor, sorry, nurse, to tell us that, yes, indeed-y do, the finger is still broken. Unfortunately, this nurse didn’t know that we already had an x-ray three weeks previously, so we would need just a little more information from them beyond, “yes, the finger is broken”. I correct the nurse, “still broken”, and “we would need to speak to the doctor”.

The doctor actually phones at 530pm. Yes, indeed-y do, the finger is still broken, and we should probably speak to an orthopedic surgeon for a second opinion (third opinion now, but who is counting when I’m paying for it).

I ask her, “what does x-ray suggest?” “Is the bone fractured, or does the lack of proper fusing/healing over the last three weeks suggest another problem,…. or is there a chip in there which is causing the lack of healing.”

She doesn’t know, she hasn’t seen the x-ray.

….excuse me?

Based on the description from the radiologist’s office (suspect small avulsive fracture at the base of the middle phalanx of index finger), it’s probably a chip, but it could also be the result of ligament damage which would imply surgery.

…excuse me? You think what….???

“Nope, haven’t seen the x-ray”, the result from the radiology office reads:

Findings – appropriate views of the left index finger were preformed. A very subtle thin sliver of bone density is seen at the volar and lateral aspect of the proximal interphalangeal. This is concerning for a small avulsive fracture fragment.

Impression – Suspect small avulsive fracture at the base of the middle phalanx of index finger.

…Are you kidding me?

When did doctors stop reading x-rays?

Obviously I’m old. When I had to visit doctors with possible broken bones, they would take the x-ray, and then they would actually look at the x-ray. Now get ready for this part…..but those doctors would actually SHOW ME the x-ray, and SHOW ME what was wrong.

Therefore, when did the current crop of doctors stop reading x-rays, and more importantly, when did they abdicate their responsibility to their patients to provide healthcare based on their understanding and experience in medicine?

I didn’t ask the that question, but I sure thought about asking the question.

Did someone repeal the old adage that a picture is worth a thousand words? All we got from the radiology office was 54 words. Actually, it was only 14 words. I had to ask for the nurse to dictate the actual result from the report to get the other 40 words.

I called three orthopedic offices to make a single appointment. One of the orthopedic offices suggested that we would have to bring a copy of the x-rays with us, otherwise we would have to sign a waiver.

A waiver? For what?

A waiver that we would have to pay for a new x-ray.

Are you kidding me? Cha-ching!

So I drove to the radiology office to pick up a copy of the x-ray. When I called to let them know I was coming, they asked whether I wanted a copy of the film, or a copy of the x-ray on dvd.

Hmmm. Interesting. In other words, the doctor’s office could EASILY get a copy of the digital x-ray file transmitted over the Internet to their office – and have a look at the picture themselves.

Thank you Al Gore for inventing the Internet!!!!

…but my pediatrician’s office didn’t get a copy of the picture. They got the text which reads….broken finger.

I retrieved the x-ray images from the radiology office. Now, I can look at a picture as well as anyone. So, I Iooked at the pictures.

Voila!!! A tiny bone fragment on the palm side of the finger, at the base of the second finger bone. A very tiny fragment of bone was causing this pain.

….but here’s the bigger issue. I’m not a doctor, nor a radiologist….but once you see this picture, any idiot can see the tiny bone fragment.

See it? It’s the one that the arrow is pointing to.

Question: why didn’t the pediatrician look at the image the three weeks ago, and suggest… at… that…. time…. that we should see an orthopedic surgeon since the bone fragment is not like a simple fracture where the bone can fuse together as it heals. A fragment like this was going to need additional treatment.

Three lost weeks, and additional expense. Cha-ching, cha-ching.

In other words, we are paying for the process of health care, wrong decision points and all, as we get to the outcome. Shouldn’t we be paying for the outcome? Shouldn’t doctors be paid based on the outcome rather than on an à la carte system where they still get paid when they are wrong?

We haven’t yet seen the orthopedic surgeon yet, so there will likely be more to this story. However, this little episode is a pretty telling data point.

Today, I made three appointments to orthopedic offices, and then canceled two. One of the appointments that I canceled was the orthopedic office that the pediatrician recommended. I guess I made the wrong choice because I got a call from the pediatrician this afternoon….TELLING ME (I might add)….that the reason that they recommended that specific orthopedic office was because that orthopedic office was a PEDIATRIC orthopedic office…(you moron, dad).

I told the good doctor that I went to the website of the orthopedic office that they recommended, reviewed the bios of the doctors, and found that everyone specialized in children’s scoliosis issues.

Now…..I’m not a doctor, …..but it seems to me that a finger break is slightly different from a congenital scoliosis issue.

As a result, I looked at the other orthopedic offices in town, and found surgeons that specialize in hand surgeries. Bingo!….or so I thought.

The doctor I chose for my child was a member of a very large orthopedic practice.

Oooops.

Earlier in the day, the nurse from the pediatrician’s office seemed dismissive when I mentioned the name of that larger practice. I guess I hit a nerve because the actual pediatrician felt compelled to call me and explain why they were recommending that we see the orthopedic practice that they recommended.

…”it’s a practice that focuses on pediatrics…not adults”, she said.

“But, they specialize in scoliosis issues, not fingers”, I replied.

“Yes”, she added, “the bones of growing children are different from the bones of adults, so the treatment will be different.”

….I guess she is protecting pediatrician’s turf. Heaven forbid that someone who has done 4 years of residency in orthopedics, and specializes in hands, would infringe on the turf of the pediatric orthopedic surgeon that specializes in ….scoliosis.

I also took the opportunity to express my frustration to the good doctor regarding this “process”, and asked her about reading x-rays.

I was appropriately stunned to hear her describe that she would never feel competent to read an x-ray since she didn’t do four years of residency reading x-rays, like a radiologist does.

“When did you abdicate your responsibility to appropriately treat your patients based on your judgment and experience in medicine, let alone pediatric medicine?”

….I didn’t actually ask this question, …but I sure thought of that question.

Look at the x-ray. It’s pretty obvious that there is a bone fragment floating around the base of the finger.

Any idiot can see it.

So, why didn’t my pediatrician look at the x-ray picture, and suggest to us, three weeks ago, that we should see an orthopedic surgeon?

Single payer public option, baby!

It can’t be any worse than the current system of groping to the outcome, and having me pay for each and every step – regardless of whether the good doctor knows what she is doing, …….or not.

It’s time to change the health care system – for the better!