Monday, March 29, 2010

THE BOILING FROG SYNDROME


Here’s a comment by Donald Kaye of Santa Fe, NM, on my March 25 piece, “Gadgets”:

I read a comment by you saying that trust was necessary in a patient/doctor relationship. Have you figured out how to develop that trust in the usual ten minutes that most primary care docs give (sell) to a patient?

I'm sure there are exceptions but the only doctors I have met who aren't in a hurry are on a government or foundation salary. That includes military and VA doctors and all of those who work for Mayo or Cleveland Clinic and some faculty docs at universities.

That tells me something about fee for service.


Donald’s gone to the heart of the matter. Any benefit that might emerge from the examining room depends on the relationship between the patient and practitioner. (I say “practitioner” because more and more, it’s not a physician, but a physician’s assistant or nurse practitioner.) And what kind of relationship can you nurture in ten minutes? Did I say ten minutes? Blimey, the national average is now seven minutes.

There’s more at play here than fee-for-service, though. Thirty years ago I hired on as a salaried doc in the general medical clinic of a prepaid system. It soon became evident, though, that we were working under a quota: even though management denied it, I was to see four patients per hour, period. It struck me as scandalous! How much can one learn about a stranger in fifeen minutes? I gave it a decent try, but had to check out after just a few weeks. The incentive for me to rush patients came from the company, which suffered the same conflict of interest that medical insurance carriers do: the more money it takes in and the less care it dispenses, the greater its profit.

These ridiculously short visits result from greed not on the part of physicians, but the entities that pull their financial strings. The docs I know yearn for more time with each patient, but they seem caught in the Boiling Frog Syndrome. I hope you’re familiar with BFS since it’s widely applicable these days. Put a frog in a pot of water, apply high heat, and the frog will jump out. But apply low heat, and the frog will accommodate to each rising degree until it calmly lets itself boil.

Private insurance carriers, Medicare, and Medicaid have incrementally decreased their payments to doctors for as long as I can remember. For their part, doctors, not generally known for political activism, responded by seeing more patients in shorter visits. Even though they sped up their turnstile, their incomes still plummeted. (When one of my kids considered going to medical school, she pencilled out the possibilities: “...let’s see, medical education costs…hmmm, my student loan… and I’ll earn, hmmm…wait a minute…am I crazy, or what?” In sum, she’s not in medical school.) Today, at last, some docs are beginning to feel the heat and reach for the edge of the pot. When Medicare reimbursements were recently cut a further 21%, my e-mailbox filled with medical howls.

The Mayo Clinic is indeed a healthier model, and thank goodness for that. Valuing patient individuality and a healing environment, people routinely leave there feeling better, no matter what was done medically. The VA and military medical services are just that—services—so profit is not a consideration.

Donald asked whether I’d figured out a way to develop trust between practitioner and patient in ten minutes. Maybe Buddha can, but I can’t. That’s one reason I drone ad nauseam that authentic healthcare reform can’t happen in an exclusively economic discussion. If we’re actually to alter healthcare to make it worthy of its name, we need a decentralized national conversation about its most basic elements.

Thursday, March 25, 2010

GADGETS

The Panasonic Corporation recently announced it’s developed a medical robot that dispenses drugs to patients.

It will join its cousins, used increasingly in testing, diagnostic procedures, and surgery and other treatments. These machines can be miraculously useful, like the ones that perform thousands of blood tests in the time it would take a lab tech to check a single sample.

Sometimes, though, they tend toward the scary. Imagine a wheeled contraption that turns up at your bedside. (I’m not talking science fiction here; this actually occurs now in a few places.) This robot doesn’t look like a person except maybe for the physican’s face on the television screen, mounted where a head would be. The physician might not be in the hospital, though; she could be thousands of miles away. A camera in the robot transmits pictures of you to her. She operates controls to probe you here and there and perhaps zoom in on a lesion. She offers you encouragement, and then directs the robot to the next patient.

My neck hairs stand up when I learn of such stuff, I suppose, because I harbor a particular value that just won’t go away: human contact is a necessary and major component of healthcare. All else equal, the more contact, the better the healthcare. For the cost of a single drug-dispensing robot, a hospital could afford to hire several human beings to do the same work.

I’m indirectly involved with a breast cancer support program for women in northern California who live too rurally to participate in facilitated support groups. This program aggregates them into virtual groups with closed-circuit television. This arrangement is better than no participation at all, but one wonders: if technology didn’t breathe down our necks so fiercely, maybe we’d train local rural people to facilitate groups face-to-face. Nothing, nothing takes the place of actual contact.

The use of technology is a choice. Certainly we’re free to choose otherwise, but we are, after all, a technophilic society: we love gadgets. We’ve come to believe they’re more accurate, precise, objective, and, well, more glamorous than people are.

Contrast that with their job competitors, human beings, who are notoriously messy and unreliable. They get distracted, don’t show up, take breaks, need training, demand benefits, and make mistakes. (We downplay the fact that machines, having been designed and programmed by fallible humans, make mistakes, too, and they, like humans, need maintenance and eventually break down.)

I’m not sure whether I’ve become the curmudgeon I laughed at in my youth or whether healthcare actually is devolving. I’ve joked that the way things are going, eventually we’ll get our healthcare from vending machines, but these days I’m not laughing. The man who coined the term “virtual reality” a couple of decades ago, Jaron Lanier, has just published a book, You Are Not A Gadget: A Manifesto, in which he describes an ominous turn in the way we see ourselves. Young people, accustomed to flowing seamlessly between on-screen and actual realities, have “…a reduced expectation of what a person can be, and who each person might become.”

Is healthcare a kind of video game where one wins by diagnosing and treating according to the rules, or are greater, albeit invisible stakes involved? My spirits plummet when I see practitioners who turn their backs on patients in order to relate to medical records in their computer, and who don’t bat an eye at bedside robots. On the other hand, my spirits soar when I hear patients demand compassionate, personal treatment, knowing in their bones that gadgets are only gadgets, and that healing must flow from the human reservoir.

Monday, March 22, 2010

A BIT OF PROGRESS


Apparently Congress is going to enact some degree of healthcare reform this week.

Looking back, it’s surprising we had the system we had till now, since it featured two glaring errors.

One was our neglect of the fact that healthcare insurance corporations exist to make profits, period. They aren’t in the business of providing healthcare. Quite the contrary: since their profits arithmetically equal the money they take in minus what they pay out, they serve their stockholders best by denying and delaying payments. The sooner we remove their ladle from the money stream, the better.

The second error, which continues to thrive, is that we still have no meaningful handle on costs. No matter who pays, healthcare’s expense will continue to rise. In the 1960s one dollar of every twelve spent for anything in the United States went toward healthcare. Today it’s almost one in five, and counting.

Why is American heathcare so expensive? Having been examined more thoroughly than any patient ever was, it’s coughed up this conclusion: we simply use too much. Surgeon-writer Atul Gawande explained this elegantly in an article in the June 1, 2009 issue of the New Yorker. I’m told this piece is required reading for White House staff.

There are a couple reasons we overuse healthcare. One is that we tend to medicalize problems that arise from lifestyle. Too many of us suffer the effects of terrible diet, toxin exposure, poor relationships, and inadequate exercise, and then, instead of changing the way we live, ask doctors to fix us. Obesity, type two diabetes, diet-related high cholesterol, and a host of other diagnoses can be treated effectively with lifestyle change, but we somehow find it more attractive to request expensive, side-effect-rich medications and surgeries.

Another pressure toward overuse is plain old marketing. There’s hardly any illness for which some smart cookie can’t invent a high-tech diagnostic or treatment gadget which healthcare facilities snap up in order to compete for patients. There’s an apocryphal story about a computer geek who heard that a local medical center was offering free digital exams. Just the thing for him, he thought, so he rushed there only to discover “digital” also means “finger.”

Despite this week’s move toward heathcare reform, we’re still stuck with a cultural conundrum. Can we persuade ourselves to back off the often-illusory promises of medical technology long enough to take a good look at how we choose to lead our lives?

Saturday, March 20, 2010

SPIRITUALITY, TAKE TWO

My colleague, Dr. Ruth Bolletino (see Kindred Souls, bottom of page), sent me this comment on my March 17 posting, “Spirituality”:
There are different ways to construe reality, and we use different ones at different times. Let's say that spirituality is indeed a perspective, maybe even a perception, a way of seeing oneself as being connected with others and the universe. That's a marvelous way of looking at things (even though, personally, I confess, there are a lot of people and things I can think of that I would strongly prefer not to see myself as being connected to.)
While that perspective surely lessens our fears about mortality, we're alive now. In the moments that we are able to see our experience in that unified way, what will we do with that perspective? Surely spirituality is, as you say, about more than making us feel good with an expanded self-image.The philosopher Jacob Needleman once pointed out that "real spiritual development calls for action." In other words, it has an ethical element, a way not just of seeing, but of being and acting that demonstrates our connectedness with the people around us.
In every culture we know, people have believed that we human beings have a dimension that cannot be accounted for in physical, intellectual or psychological terms alone. And every major spiritual movement we know about includes a conviction of concern for others.
There's an immediate pay-off. Check it out. Google some phrase like "how helping others is good for health," and you'll read about studies showing that concerned action is good for us, mentally and physically.
- Ruth Bolletino, www.cancerasaturningpoint.org

(By the way, Ruth published a terrific book last year, How to Talk with Family Caregivers About Cancer.)
 
It’s remarkable that Ruth and I are talking sense about spirituality here without having used the word “religion.” A good many people have been turned off by organized religion, but I know very, very few—including adamant atheists—who don’t express some sense of spirituality.

To paraphrase Carl Jung, "Summoned or not, spirituality is present." It begins to make its appearance when my life-threatening illness indelibly confirms that my days are numbered. (They always were numbered, but until now I found that fact convenient to ignore.) I finally know for sure that I can’t spin my wheels indefinitely. Since every moment counts now, how do I use each most effectively? 

This raises magnificent questions: what am I supposed to be doing, anyway? Why am I here in the first place? Soon I find myself reviewing my daily life, my values, my relationships with others, and my perceived place in the universe. Before my diagnosis, my attention was dominated by American Idol and the price of asparagus. Now my horizon's dramatically expanded, as though this illness has cranked open lifelong blinders.

Thursday, March 18, 2010

THE EXHAUSTED PHYSICIAN


Snippets in the news suggest that the issue of resident physician exhaustion is on the rise again.

Imagine that as you awake from your coma in the ICU, the young physician who’s adjusting your IV drip is heading into a coma of his own. On the job twenty-four hours now, his brain consists of tired neurons connected by strands of caffeine. If it weren't for that tube in your mouth, you’d yell for help.

This question of resident overwork pops up like clockwork in our media every ten years, like a cicada cycle. “OMG,” we text one another, “have you heard about this?” We write letters to editors. We call for Congressional hearings. Outrage blooms in headlines. Then the issue burrows underground again for a decade. University committees that study the problem eventually recommend limited work hours.

And very little changes. When I put on my anthropologist hat to question this inertia, I identify a couple of suspicious factors. One involves the intent of young doctors themselves. A few years ago I attended a meeting at a midwestern medical school in which the faculty announced new rules to resident physicians. Shifts were to be limited to twelve hours. Overtime work would not be permitted. Residents were to take two consecutive days off every two weeks. This still sounded like a lot of work to my slacker ears, but several residents responded as though they were being laid off.

“This is a teaching hospital,” one complained. “How am I going to learn with such abbreviated hours?”

Another protested, “You’re telling us to go into our board exams against the residents at St. Elsewhere who’re getting a hundred hours of training a week.”

No one said, “Gosh, thanks. Maybe I’ll be able to lead a humane life now, and give my patients more mindful care.”

So part of the resident exhaustion syndrome stems from rat-race mentality. But part, I think, comes from our cultural view of healing as a metaphoric transfusion from the caregiver to the sick person. We tend to see healing as a zero-sum game: the patient’s improvement will be roughly equivalent to the healer’s depletion. This is especially visible in lay caregivers. It’s not uncommon for relatives of sick people to work themselves into sickness.

When I recommend that we begin healthcare reform not with its economics, but its most fundamental principles, this is one item worth discussion. Do we actually believe caregivers—including professionals—need to be drained by their work, or can we imagine a system in which all players feel better for their efforts?

Wednesday, March 17, 2010

SPIRITUALITY

A member of our cancer support group asked, “Why is it we never talk about spirituality?”

Actually, we talk about whatever members bring up. Some are reluctant to speak of spirituality because they suspect it would be unwelcome in a secular hospital. Some assume that spirituality is necessarily different for everyone, and so hardly discussable. Some fear offending others, or being offended.

Still, it’s naggingly present, especially amid life-and-death experiences. A few years ago I was asked by our local hospice—a first-rate organization—to help out in a training session. For one exercise participants were divided up, and I facilitated a group of eight. We were asked to complete a written survey about our own religious views. One question was, “To what degree does your religion affect your daily life?” I crossed out “religion,” wrote in “spirituality,” and completed my survey. Afterward, in discussion, it turned out that everyone in our group had done exactly the same thing. Their spirituality, whatever that meant, trumped their religion.

What, then, is spirituality, and what does it have to do with sickness and healing?

Twenty years ago I experienced a spine-threatening illness. At any moment I could’ve become a C2 quadriplegic. It got my attention, believe me. My doctor friends insisted on immediate surgery. I wasn’t opposed to that, but wished first to try something less invasive. So for a couple of weeks I flopped around, doing research one hour and screaming at the universe the next. Friends offered help in the form of books, dietary suggestions, prayers, crystals, and talismans that began to form a sizeable pile beside my bed. I was grateful for their sentiments, but none of it helped much…until a friend sent me a curious poem.

The poem, written two thousand years ago by a Taoist monk, related the pains of his aging. Actually, he was disintegrating. Line after line lamented his losses. His faculties were failing, organs were falling away, but the final line said this: “On the other hand, what does this have to do with me?”

That got my attention as much as the illness had. What a remarkable accomplishment, I thought, a self-image that ultimately transcends disease and death. This monk wasn’t alone in that skill. Ram Dass tells of when his guru was dying of cancer. His students, gathered around him, wept. One cried, “Please, Master, don’t leave us.” The old man replied, “Leave you? Where would I go?”

These people aren’t kidding around. That’s actually the way they see the world. Imagine what that perspective does to fear, for one thing, but also to one’s relationships with others and with the universe. Now, that’s spirituality.

Apparently it’s about expanding self-image. Say I see myself mainly as a guy, comprised of my job and my masculine role. If I get prostate cancer, the consequent loss of work and post-op incontinence and impotence will devastate me totally. But a wider view is also available. For example, I’m a father, a son, brother, friend, raconteur, gourmet, reader, coin collector. Or wider: I’m a human being. Or wider yet: I’m a sentient entity. I’m a grape on the vine of consciousness, a child of God, a Dharmic agent, an eternal spirit. A common greeting among yogis is the Sanskrit “Namaste” (pronounced na-ma-stay). Translated literally as “you-me-it,” it expresses the recognition that there are no boundaries. You don't need to be a yogi: parallel concepts exist in every religious tradition.

Sounds fine, right? But how do we get there? Like every other endeavor, one step at a time. It begins by wondering, today: am I possibly slightly greater than I’ve believed up until now?

Monday, March 15, 2010

NO ONE SHOULD BE ALLOWED TO TREAT A DISEASE THEY HAVEN’T HAD THEMSELVES


There was a fine piece in the NY Times last week about when doctors become patients. You can find it at http://well.blogs.nytimes.com/2008/02/08/when-doctors-become-patients/?pagemode=print.

Here’s the issue: patients and doctors live in two different worlds.

In the late 1970s I taught a community college course called “Philosophy of Health.” One session was spent role playing. People paired off, and for five minutes one of the pair played “patient” and one played “doctor.” Then they switched roles. Finally, we discussed what they'd experienced. Virtually everyone, every time we did it, commented on the polar difference in roles.

A typical response was, “When I was a patient I felt relatively helpless, ignorant and dependent. When I played doctor I felt I needed to look intelligent, competent, and in control. Neither role felt comfortable.”

If such observations surfaced after only ten minutes of play, consider how thoroughly these roles are internalized after they’re enacted dozens of times as a real patient, and over decades as a physician. We become the roles we play, forgetting that this isn’t actually who we are.

I viewed a videotape shot a few years ago, in which actual oncologists role-played patients in a support group to an audience of their colleagues and staff. The only coaching they’d been given was the assignment of a diagnosis. Their play was in three acts. In the first act, the “patients” ad libbed about what it was like to have cancer. After a short intermission they returned to their places, but now in makeup: bald, pale and bruised, pushing IV poles, they expressed the tribulations of treatment. After another intermission they returned again, surprised to find one seat empty. In this third act they spoke about death and dying.

Considering the complaints I hear about how some doctor was cold or impersonal or uncaring, this video startled me: these oncologists played patients with nuances professional actors would have missed.

When we doctors seem dispassionate, then, it’s not because we haven’t noticed suffering. The fact is that we’ve noticed it in detail, but we’re not practiced at dealing with it because we suffer a particular occupational hazard, expressive aphasia. What’s that? We unconsiously but obsessively respect our profession’s taboo against expressing feelings. In short, emotion isn’t germane to science. Though the human condition is probably comprised more of emotion than intellect, medical training coerces us to believe it’s an either-or game. Doc, you better keep your white coat between you and all that messy patient emotion.

The task, though, is impossible. If you make your living sticking your fingers into people’s orefices, you’re emotionally involved with them, period. When you daily wade in suffering, you’re absorbing it like butter into hot toast. Suffering is the given. The question is what do we do with it? Well, repression is one time-honored strategy, but over the long run it's a prime cause of physicians' suboptimal health statistics. As a member of one of our support groups said, “Buried suffering is always buried alive.”

This is why being a doctor is poor preparation for being a patient. Over the years, I’ve known a half-dozen doctors who attended cancer support groups as patients. Every one of them told me the switch in roles blew their minds. The ones I knew in practice were fine physicans, competent and kindly, yet still were shocked by how much they had failed to notice in their patients before they themselves got sick.  The gap between the world of the patient and that of the physician is so striking and so central to genuine healthcare (that is, health “care”) that I’m astonished it’s so under-addressed in medical training. 

I’ve related here before the comment that arises occasionally in our cancer support group, “No one ought to be allowed to treat a disease they haven’t had themselves.” Funny though this strikes us, it actually describes the “wounded healer,” the archetype at the heart of the Hippocratic tradition.

Treatment that doesn’t connect hearts is just plain mechanics. I love mechanics; it works, and it does us good. And it’s exactly half of what we need.

P.S....
I'll be on a radio show tomorrow, March 16, 9-10AM PDT. It’ll be on a community station in Mendocino, California, available live online at www.KZYX.org. I'll be discussing healthcare reform with Dr. James Morone, Chair of the Political Science Department at Brown University, and Dr. Richard Louis Miller, noted psychologist and agent provocateur.

Thursday, March 11, 2010

YOU DON’T KNOW TILL YOU ASK

A week ago I met a man who has esophageal cancer. He seemed remarkably tranquil and accepting. “I’ve had a good life,” he said. “I’m not sure I’m going to take any treatment.”

I asked him to tell me about his good life. The first thing out of his mouth was that his dog had died last October. He burst into tears. “He was my best friend. He meant the world to me.” This man is divorced, with no close relatives and little social contact. He is truly suffering more from the death of his dog than from his cancer.

Another example. A woman recently attended our support group for the first time. When it was her turn to speak, she said, “I’ve been listening to all of you and wondering whether I ought to leave. You’ve been talking about your cancers, which is understandable, I guess, this being a cancer support group. But I don’t want to talk about my cancer. I’ve talked about it enough. It’s dominated me too much. I want to talk about my life—what’s happened, what’s happening now, and what my future might be. I’ve accepted that I’m mortal. But I’ll be damned if I’m going to spend the rest of my life in doctors’ offices. What I’d rather talk about is how I see myself, psychologically and spiritually.”

I feel relieved when someone says something like this. Restricting the conversation to cancer and treatment seems too physical, too mechanical a direction. Tumors, after all, are just errant unconscious tissues. But stories about our dog’s death, our spiritual views, about anything we’re invested in, are rich in healing potential.

More...

We're still having some software problems with comments, so here's one I received by e-mail March 16:



The question I want my health care providers & specialists to ask is “What do your life to be like?” for the present time, near future, and further on and “What are you hoping to avoid?”  I also want to have an honest conversation about the types of treatments and activities I’m willing to try. Don’t waste my time lecturing about treatments or procedures that will not significantly improve my quality of life. I don’t want to be a lab rat or research project. I’ve accepted I’m gonna kick it, so get on board with me and quit trying to figure out a way to make me one of your success stories. Remember, this is about me & my experience. As long as I’m still alive, I want to call the shots. If you won’t walk beside me, refer me to a provider who will.  –Thanks!

Wednesday, March 10, 2010

POSITIVE VIBES ONLY


“I need to keep positivity around me,” said a woman with stage four lung cancer.

Toward that end she’d hung a sign on her front door requiring “Positive Vibes Only.” She insisted that her family and friends speak only optimistically. Her husband, her two grown children, and visiting friends wore fixed smiles. Hand-lettered aphorisms hung everywhere: “You’re never a loser till you quit trying.” “Perseverance is many short races one after another.” "An optimist sees the opportunity in every difficulty.

Her home’s positivity was tangibly artificial. When I left, I felt less uplifted than stifled, as though I’d been drawn into a vortex of denial gone stale. 

Not that I have anything against denial per se; in psychological circles denial’s a “defense,” and a terrific defense it is. When some prospect’s too hot to swallow, we delay until it’s cooled off a bit.

Maybe I’ve written this story here before, but it’s worth repeating. A support group member with aggressive metastatic cancer decided she was going to live as though her disease didn’t exist. She re-opened her law practice, and she took dancing lessons as often as her waning energy permitted.

One afternoon another group member asked her, “Aren’t you in denial?”

She answered, “Of course I am. It’s the only medicine that works for me these days.”

Hats off to her! It’s impossible to tell if her denial bought her time, but it definitely bought her quality. Still, it wore out with use. Sooner or later denial becomes impossible to maintain.

Manufactured positivity is common in Cancerland, probably as an understandable reaction to our traditional—and actually obsolete—notion of cancer as implacable doom. Even though it’s time-limited, though, it’s still more useful than its yin-yang twin, pessimism, which, as studies have repeatedly confirmed, adversely affects the immune system.

Fortunately, our attitudinal choices aren’t limited to forced grins or gratuitous gloom. How about simply recognizing one’s current reality without projecting anything—“positive” or “negative”—into the future? Sure, that’s not an easy skill, but the fact is that we really don’t know what’s going to happen over the short run. The older I get, the more regularly I’m surprised. In regard to the woman who demanded positivity around her, there are only four things I know with certainty:

1. She has stage four lung cancer.
2. She will die one day.
3. At the moment, she’s unquestionably alive.
4. My own feelings in response to being with her.

If I, as a caregiver, can nurture those facts in my mind, I’m more likely to act therapeutically.

Friday, March 5, 2010

WHO’S SUFFERING, AND FROM WHAT?


A local seventy-eight-year-old woman with breast cancer seems to be coping with it admirably. She suffers some moderate side effects from her meds, but emotionally she’s relatively at peace.

Her two adult sons, who accompany her to every medical visit, sit on the edge of their chairs asking innumerable, repetitious questions. 

They’re fried.

But their emotional suffering isn’t addressed directly because they’re not “the patient.” Every day we see caregivers having a harder time than the identified patient, proving that cancer and other serious illnesses are socially contagious. One person bears the tumor, but everyone around them suffers their version of it, and they all need to be treated. Still, the hurried pace of current medical practice too often limits treatment exclusively to the patient.

To avoid that, ask yourself this question amid the patient’s circle: who’s suffering here, right now, and what are they suffering from?

Tuesday, March 2, 2010

PLEASE TELL ME, MR. PFIZER: SHOULD I TAKE A DRUG?

As long as we’re talking about people mattering in healthcare, what’s my involvement in my own personal health?

I ask that because I’ve noticed an ominous parallel. As healthcare insidiously became more remote and industrial, which is to say less humane, patients' individual self-images tended in a similar direction.

We’ve largely come to believe, for example, that any discomfort in our life is evidence of a treatable disease. We can thank relentless marketing for that, especially the marketing of pharmaceuticals. Open a popular mag like Newsweek or People and you’ll find a number of two-page drug ads. The first page depicts someone in the horrid grip of the latest Silent Epidemic—depression, insomnia, shyness. “Omigod,” you say to yourself, “that’s me!” The ad, having already guessed your response, suggests you ask your doctor if this medication is right for you. The second page is a torrent of finely printed details, including the drug’s numerous side effects. If BigPharma had its way, this second side wouldn’t be there at all.

Pharmaceutical companies have reaped stunning success from advertising this way for a quarter-century now. Sure, they’re selling more drugs than ever, and at higher prices than ever. But they’ve accomplished even more: they’ve gradually persuaded us that drugs are the preferred response to discomfort, period.

We physicians get this sales pitch in spades. Our licenses require us to obtain so many hours of continuing medical education annually. We can get them via courses, but most of us find it convenient to attend the CME lunches at our local hospital. Many hospitals, though, particularly rural ones, can’t afford a regular CME calendar, so guess who fills in: a prominent medical professor from the University of Pharma. And when drug companies hire eminent physicians to lecture their peers, you can bet that certain brand-name drugs are mentioned.

So Pfizer throws a lunch this week; the rest of the month features GlaxoSmithKline, Merck, and Aventis. Since every drug company has the opportunity to take its turn, this may sound fair. But there’s one outfit that never gets invited: attention to one’s life. Little wonder, then, that as docs absorb these talks over years and decades, many say “drug” after you say “sickness.”

Pharmaceuticals are only a single slice of our hi-tech gadgetry. It seems there’s nothing we can do ourselves that some intricate, God-awful-expensive machine can’t do more accurately. “It's a lot like exploring outer space,” wrote David Callahan, director of Hastings Center, a bioethics think-tank near New York. “The capacity of medicine to provide ever-advanced technologies is endless. No matter how much you spend, you can always spend more.” By the way, he wrote that observation almost twenty years ago.

We’re further along technologically today, but are we commensurately healthier? Many healthcare reform advocates emphasize the breathtaking disparity between our astronomic healthcare expenditure (highest per capita in the world) and our dismal results among all nations.

If there’s any “healthcare crisis,” it’s this: we’re caught in a technology-dependency cycle. It begins when we don’t feel right. Then, ignoring any meaningful connection between, say, our overeating, our obesity, and our type two diabetes, we consult a practitioner, who gives us a prescription for a product that might offer us some relief and possibly side effects as well, but in any case re-convinces us that both our suffering and relief come from outside us.

I half-stole this blog’s title from E.F. Schumacher, author of Small Is Beautiful: Economics as if People Mattered. One of Schumacher’s prime values was what he called “appropriate technology,” the right tool for the job. Sometimes we need fiber-optic surgery, sometimes a touch. If I begin to consider how thoroughly my entire life influences my health, I’ll develop a more acute sense of which technology suits me now and what I need to do for myself.