Monday, December 26, 2011

WHAT’S THIS ALL ABOUT, ANYWAY?

Writing a blog is easy. You just say whatever’s on your mind du jour. You don’t have to be 100% sure of what you’re writing because if you don’t get it exact enough, you can correct it tomorrow. But books, especially paper ones, last longer so are more difficult to set straight. These days, then, as I massage this blog into a book, I need to think more carefully about what I’m writing.

I’ve described here how illness changed during the past half-century. When I was a kid, medical visits were principally for bacterial and viral infections. Now they’re mainly for conditions deriving from pathogenic (disease-causing) lifestyles, including horrendous diet, inadequate exercise, poor stress management, dysfunctional relationships, negative self-image, and exposure to literally a million toxins and carcinogens in our food, air, water, building materials, home products, cosmetics, and even medications. These behaviors predictably lead to obesity, type two diabetes, and much of cancer, hypertension and cardiovascular disease. This notion—that we cause most of our diseases—can be a hard fact to swallow. If you don’t believe it, ask your doctor.

Thinking about this shift critically, I’ve come to realize that pathogenic behavior isn’t intentionally self-destructive. On the contrary, it’s usually an attempt to cope with social demands, some of which can be frankly insane. My friends who began to smoke in their late teens and early twenties did so for peer acceptance; they lit up because their friends did, attracted by cigaret ads touting savoir faire. Alcoholics drink not to bring on cirrhosis, but to anesthetise the pain in their life. A teen doesn’t disappear into the couch-potato video game world aiming to flab his body, but to visit a place where he can win for a change. The compulsive eater doesn’t put away a quart of Ben & Jerry’s in response to a lipid deficit, but because she senses an internal emptiness, a feeling of literal unfulfillment. The employee or spouse who puts up with abuse does so because the prospect of responding to it honestly is even more threatening.


In other words, much current illness arises in unhappiness. Every culture's values inevitably dictate much of its constituents’ behavior. Our culture, leaning massively toward materialism, consumption, and individualism, ultimately breeds feelings of inadequacy, competition and separation. Little wonder, then, that we train our physicians to examine and treat individuals, virtually ignoring the context in which they live. Thus we docs wait in our offices and clinics for patients to show up with the diseases that have finally bloomed from their various unhappinesses, and we repair them enough to return them to their pathogenic lives.


This cycle is obviously ineffectual, not to mention ridiculously costly, but even worse, our treatments perpetuate misery by simply turning down its amplitude. Our patches, our tranquilizers and antidepressants, our BP meds and stents and stomach staplings do little more than numb the pain people have unconsciously chosen to live with. In the most honest light, much of our intervention can be seen as enabling neurotic behavior.


Certainly we should treat the longterm smoker's emphysema and the type two diabetes of the obese, since healthcare without compassion is only engineering. But while we perform those treatments, we need also to exercise commensurate skills in educating, encouraging, and supporting our patients in genuine prevention. Colonoscopies and mammograms have their place, but people need also to awake to the possibility of higher-quality lives, styles that honor their personal value and don’t just clear the lowest bar society offers.

Wednesday, December 14, 2011

SUFFICIENT ATTENTION SYNDROME: The Subtle Crippler

The article below was lifted from the current issue of the Journal of Possible Disorders.

In mid-November of this year, Dr. Kevin Bland of the University of Cleveland School of Medicine described a disorder long thought to exist but never before identified, Sufficient Attention Syndrome.

“SAS may be part of the autism range,” said Dr. Bland. “Its sufferers were previously ignored because they tended to avoid online social networks. They’re identifiable, though, by their requirement of unusually long periods to assess their surroundings. They pause in conversations, evidently to think about what was said and what to say themselves. They are employment-challenged by their inability to multitask; in fact, they often seem proud of being monotaskers. Continually dissatisfied with news headlines, they insist on knowing details, too. They don’t watch television because rapid scene changes nauseate them. They’re often shunned because they’re considered too curious and intense.”

Fortunately, treatments are promising. According to Dr. Bland, “Avarice Pharmaceuticals has developed a new drug, Distractin, designed to scramble neural circuits back to normal. We expect in the near future to welcome SAS patients back into fast-track society.”

Tuesday, December 6, 2011

CONSUMPTION

We’d do well to ask why obesity is so rampant. I mentioned yesterday that healthcare costs resulting from it exceed those associated with both smoking and drinking. Funny: all these pathogenic behaviors involve the mouth.

Hardly anyone would dispute that we’re a nation of consumers. We were once a nation of creators, inventors, initiators, but now we just sit ourselves down and ingest. The trope’s even pervaded healthcare: during the last thirty or forty years, as our model of healthcare shifted from a service to a commercial transaction, patients and doctors became “consumers” and “providers.” When I hear myself referred to as a provider, I’d like to provide the speaker with a sound drubbing. And the term “consumer” conjures for me the image of those train-sized omnivorous worms in Frank Herbert’s Dune.



Why are we such obligate consumers?

I suspect we aim to fill a void we sense in our core, a feeling that we’re existentially empty. I’ve quoted eating-disorder guru Geneen Roth here more than once: “You can’t get enough of what you don’t need.” The emptiness we feel isn’t material. It’s spiritual, a currency in which our society is painfully poor. Oh, yeah, there’s plenty of religion around, but much of that, it seems to me, is plain old creed, pious language betrayed by actual behavior. As a popular country/western song goes,

I’ve driven my whole life on empty
Still, I think I done pretty good
I got two SUVs and a Hummer,
And a home in a walled neighborhood
Got a boat with a thousand-horse outboard
My TV screen takes up a whole wall
I got lots of stuff, but it’s never enough
‘Cause no one sells love at the mall

I bought me an RV to travel
And seek what might comfort my soul
I yearned to be more than a food tube,
An unfillable, bottomless hole
I parked in the lot of a Wal-Mart
And in high hopes I entered the store
Bought an iPod and a drill and a George Foreman grill
But left as empty as I was before.
‘Cause no one sells love at the mall
They don’t deal with affection at all
True love, you can’t get it for cash, check or credit
‘Cause no one sells love at the mall

Consumerism presumes that nothing of much value exists inherently within us. Maybe this is an extension of the western notion of original sin. Until we sit and get quiet and finally see the wondrous beings that we are, we’ll continue consuming without satisfaction.

Monday, December 5, 2011

NO CHILD LEFT WITHOUT A BEHIND

The first article I ever published, in Co-Evolution Quarterly in 1980, was entitled “Insurance and the Abandonment of Responsibility.” It pointed out that all else equal, those who take better care of themselves will subsidize, through medical insurance premiums and taxes, the healthcare of those who don’t. Nothing has changed since then.

A major reason healthcare is so expensive is that we simply use too much of it. Americans engage in a number of pathogenic (disease-causing) behaviors until florid disease erupts, and then ask physicians to repair them. We harbor the notion, reinforced by incessant marketing, that medical science can correct just about anything. I can mistreat my heart all I like because when it finally caves in, I can get a new one.

Arguably our most common pathogenic behavior involves diet, obesity being alarmingly endemic. Three-quarters of Americans are overweight or obese, but what’s more distressing is the kid rate, now estimated to be 15-25%. Obesity leads to type II diabetes, cardiovascular disease and hypertension, not to mention disability associated with carrying around all the extra baggage. It’s estimated that obesity costs our society $117 billion annually, exceeding the healthcare costs associated with both smoking and drinking.  

Obesity’s become part of our accepted social landscape. Clothing catalogs standardly offer women “plus” sizes, and men, “big and tall.” Airlines debate installing larger seats, or charging passengers double if their bulk flows over the armrest. A man recently sued a burger chain because its seats wedged him in too tightly.

Last week I encountered evidence that obesity is no passing fad. Visiting another town where a new hospital is being constructed, we learned its special obesity ward will feature a ceiling fitted with a mechanical lift system since a good number of patients are now too heavy to hoist without industrial machinery; in addition, too many of the hospital staff themselves can barely carry their own estimable bulk, let alone their patients'.

Someone’s bound to cavil that some obesity is genetically programmed. Right: that proportion is about one in five hundred people. The rest comes from what’s eaten, period. Many pathogenic diets are a product of poverty. Try feeding your family a healthy diet on a minimum wage income. Unable to afford fresh organic groceries, you’ll opt instead for processed foods notoriously richer in preservatives than nutrition. These imitations are cheaper than the real thing, by the way, thanks to government subsidies their manufacturers wangled. Consuming these empty calories, you’ll plump out without being nourished. If people mattered as much as corporate profit does, we’d help them find their way to genuine food.

Too many families who can afford decent nutrition opt for the convenience of prepared foods, and children in these families grow up learning no alternative. If you’d like a shock, watch this video,  http://www.youtube.com/watch?v=bGYs4KS_djg&feature=results_video&playnext=1&list=PL35762311C5A7EF37, in which chef Randy Oliver asks a second-grade classroom to identify tomatoes. The poor kids haven't a clue. Maybe they've seen a sliced tomato on a McGutbuster, but never a whole tomato.

I recently related in this blog a report by a prestigious medical board (http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm) about American childhood obesity. The board recommended testing kids for serum cholesterol levels beginning at age nine. It also recommended, between page after page of pharmaceutical interventions, “intense lifestyle management” without spelling out what that might be. Of course, everyone suggests behavioral change along with medications, but in practice that amounts to meds alone. Testing kids and putting them on “corrective” drugs will, of course, keep the wheels of commerce spinning (especially since kids will need additional drugs to deal with side effects), but it won’t do a thing to increase the national health. As a certified curmudgeon, I’m amazed, astonished, and appalled that we evince such impressive expertise in chemical engineering, but are so little interested in a national program to promote personal health responsibility.

Monday, November 28, 2011

HAPPINESS

In the psychiatric rotation of my medical training in 1966, my very first patient lamented, “All I want is to be happy. Is that too much to ask?”

Good question. When we talk about being happy, what exactly do we mean? A terrific film, “Happy,” directed by Roko Belic, who made the equally terrific “Genghis Blues,” seriously examines the subject. You can find it at

Happiness depends on how much time we spend in what psychologist Mihaly Csikszentmihalyi calls “the flow.” We’re in the flow when we are absolutely at one with what we’re doing. It’s a magical realm uncluttered by time or obligation or even, as a matter of fact, mortality itself.

We can literally “lose ourselves” in running or in writing, heart-fluttering love, painting, yoga, sex, music, daydreaming, whatever: it doesn’t matter what the activity is. The opposite, evidently, is remaining “in our heads,” experiencing unengaged distance. Gestalt psychology founder Fritz Perls advised, “Lose your mind and come to your senses.”

If you’ve never experienced this total immersion, you might want to take it on as a quest. Unfortunately, it doesn’t get great press in our culture, as we assign productivity a higher value, and I guarantee that the quest for happiness is decidedly unproductive.

Saturday, November 12, 2011

I KID YOU NOT: CHOLESTEROL SCREENING FOR NINE-YEAR-OLDS

An Associated Press news piece yesterday (http://news.yahoo.com/doctors-test-kids-cholesterol-age-11-203530834.html) announced that we’ll soon be screening kids as young as nine years for high serum cholesterol. The new guidelines emerged from an expert panel appointed by the National Heart, Lung and Blood Institute and endorsed by the American Academy of Pediatrics.
The guidelines are based on facts everyone agrees on:
— By the fourth grade, one of every eight U.S. children has high cholesterol, defined as a score of 200 or more.
— Half of children with high cholesterol will also have it as adults, raising their risk of heart disease.
— One third of U.S. children and teens are obese or overweight, which makes high cholesterol and diabetes more likely.

I agree, too. But why is this happening now? One micro-reason is genes: one out of every five hundred people has high cholesterol because of genetic makeup. All the rest, though, comes from—you guessed it—toxic diet and inadequate exercise.
 
In other words, we’ve discovered we’re developing serious disease earlier and earlier in our lives because of unhealthy behavior. We’re going to identify it by large-scale testing, and treat it, of course, with medications.

I have a few problems with this strategy. First, it redefines voluntary behavior as a medical diagnosis; second, it creates an entire new class of “patients” who will consume expensive medications and endure their side effects; and third, it legitimizes and even enables disease-causing behavior.

What amazes me about these guidelines is the degree to which the medical establishment docilely accepts them. We docs should instead be demanding  effective plans for steering kids into healthier behaviors, emphasizing education and parenting.

Oh, my. I get so worked up about these things. Maybe I'm suffering from Inadequate Idiocy Tolerance Disorder (IITD, the silent killer). I need to calm down. A friend advised that I might increase my patience by remembering that we are the distant ancestors of an advanced civilization.


Thursday, November 10, 2011

TECHNOMANIA

A friend forwarded a NY Times op-ed piece this morning (http://www.nytimes.com/2011/11/10/opinion/our-high-tech-health-care-future.html?_r=1&emc=eta1) that scared my socks off. Its author, Frank Moss, an entrepreneur and hi-tech whiz, is obviously well-meaning, but he’s poorly informed about what actually occurs in healthcare.

Moss recommends juicing our anemic economy with a massive dose of medical technology, on a scale similar to our 1960s man-on-the-moon project. Here are a couple of his suggestions:
It would begin with a “digital nervous system”: inconspicuous wireless sensors worn on your body and placed in your home would continuously monitor your vital signs and track the daily activities that affect your health, counting the number of steps you take and the quantity and quality of food you eat. Wristbands would measure your levels of arousal, attention and anxiety. Bandages would monitor cuts for infection. Your bathroom mirror would calculate your heart rate, blood pressure and oxygen level.
Then you’d get automated advice. Software that could analyze and visually represent this data would enable you to truly understand the impact of your behavior on your health and suggest changes to help prevent illness — by far the most effective way to cut health care costs…
…You might slip a low-cost plastic attachment over your phone display, look into its eyepiece and conduct a cataract exam. The avatar would transmit the results to your human doctor, who would send you a video message explaining the diagnosis and prescribing treatment…
I tend to wax interminably on the threat of healthcare devolving down to a vending machine. Plans like this one come close. They assume illness to be a biomechanical problem fully amenable to technologic intervention. That might be valid if cure were available, but it usually isn’t. The bulk of visits to doctors—especially seniors’ visits—are for chronic (that is, incurable) conditions. Seniors don’t need relentless stabs at cure, then, as much as they need guidance and support in living with their conditions.
Wholly technologic strategies like this don’t recognize the sad fact that a gross proportion of American illness derives from pathogenic behaviors so tenacious (including smoking, alcohol and drug abuse, sedentary lifestyle, poor stress management, toxic exposure, and dysfunctional relationships) that the advice we docs currently know how to offer amounts to water off a duck’s back.
These strategies fail to comprehend the emotional, subjective experience of suffering because it can’t be measured by even the most clever device, so they certainly can't develop any way to address it.
Worst of all, they encourage the abdication of personal responsibility. “Just leave the quality of your life up to us and our machinery,” they say. “Trust us, we’ll treat your suffering; matter of fact, we’re developing a therapeutic texting app even as we speak.”
In the real world, Frank Moss’ suggestion, fascinating though it is, is only more of what doesn’t work now. He’s correct in predicting that expensive technologic bandaids will keep the wheels of commerce spinning, but they won’t materially affect our health or well-being. To quote Dr. John Knowles, the late president of the Rockefeller Foundation and medical director of Massachusetts General Hospital,

The people have been led to believe that national health insurance, more doctors, and greater use of high-cost hospital-based technologies will improve their health.  Unfortunately, none of them will.  The next major advances in the health of the American people will come from the assumption of individual responsibility for one's own health and a necessary change in the life style of a majority of Americans.

Tuesday, November 8, 2011

UNCERTAINTY

What is one to do, now that we’ve learned that early detection of cancer isn’t always as important as we’d thought? Should we get screened or not? Some screening tests, as for cervical and colorectal cancer, reliably lead to effective treatment, but serious questions about others, especially PSAs (for prostate cancer) and mammograms, are emerging.

I’m not writing here about the value of particular tests, though, but about testing per se. Healthcare experts are looking critically at testing itself these days, no doubt because healthcare’s gotten so ridiculously expensive. They’re questioning exactly what’s gained, analyzing cost-benefit ratios. An example is the CT lung-scanning of smokers to screen for cancer. Besides being costly, CT scans, like all tests, are subject to “false positive” results that can encourage unnecessary biopsies and woe. And by the way, they're also subject to false negatives.

Why can’t we have tests without false positives and negatives? We’re far beyond reading chicken entrails at this point, but we’re still not perfect. And you know what? Medical science itself will never be perfect, and not just because we lack some tool. Nobel Prize winners since Werner Heisenberg have reaffirmed that uncertainty isn’t some cosmic condiment, but is, in fact, the only item on the menu.

Recognizing that complete security is a myth, then, how much of it are you willing to buy? In healthcare, will you pay a hundred dollars for an x-ray that carries ninety percent certainty? Or would you prefer the ninety-nine percent certainty of a thousand-dollar CT scan? Or perhaps for two thousand dollars, you’d go for the ninety-nine-point-nine-percent certainty of an MRI. (Whatever your choice, of course, there are no guarantees.)

What’s my preference? My most comfortable approach would be the one that feels, well, most comfortable, after trying a few on. Why not explore your U.Q., your Uncertainty Quotient? People mattering in healthcare includes seriously, responsibly, consciously realizing less our wants and more our needs.

Monday, October 31, 2011

DO WE WANT NICE DOCTORS?

In an essay in today’s NY Times, (http://www.nytimes.com/2011/11/01/health/views/the-downside-of-doctors-who-feel-your-pain.html?ref=health) cardiologist Lisa Rosenbaum asks whether “nice” physicians really provide better care than those who are merely technically competent. In this context, “nice” involves interpersonal relationship skills like physical proximity, eye contact, empathy, acknowledging patient concerns, and asking about feelings. Certainly these skills will make the physician more likeable to most patients, but will it improve their care?

Dr. Rosenbaum observes, “…we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.

This discussion misses what patients yearn for—not so much likeable doctors, but doctors who can ameliorate their suffering while treating their physical disease. Niceness doesn’t treat suffering, and empathy only begins to treat it. Admittedly, both suffering and its effective treatment are objectively unmeasurable, but that’s no reason we physicians shouldn’t either learn how to do it or assign the job to someone who can do it. Instead of teaching medical students how to maintain eye contact or how close to sit, we should be showing them how to listen for elements of suffering in order to draw it out and be comprehended so it can be acted upon. But that’s an art, meaning it takes time, and this sort of profound intervention is not medically reimburseable. 

Wednesday, October 26, 2011

DON’T JUST DO SOMETHING; STAND THERE.

Please excuse the hiatus in posting. I’ve been putting my time into untwisting this blog into a book. I’ll keep you posted on progress.

The NY Times Well Blog, a reliable source of stimulating issues, ran a sparkling post October 20, http://well.blogs.nytimes.com/2011/10/20/when-doing-nothing-is-the-best-medicine/#more-62303

In that post, Dr. Danielle Ofri discusses “clinical inertia,” the medical name for doctors doing nothing instead of doing something. She notes that the term is negative, and I agree. It conjures an image of a hypothyroid physician moving slo-mo, as though wading through Vaseline, despite the indication for immediate action. I wonder what Hippocrates would think of “clinical inertia,” having advised, “When it comes to the sick, do the least.”

We docs are trained in doing, and our culture teaches patients to expect us to do, no matter what. God forbid a patient leave the doc without something in her hand—a prescription, a sheaf of test orders, a packet of sample pills, anything to indicate that a medical transaction has actually occurred. An anthropologist would call her departure baggage a “fetish,” a symbol of conferred power.

The issue’s more complex than that, though. If it’s true—and I believe it is—that the bulk of medical visits are for illnesses generated in lifestyle, then less treatment might actually be therapeutic. Emphysema begins with smoking, cirrhosis with drinking, most type two diabetes from overeating, much hypertension from hypertense lives, and so on. Simply patching those symptoms with medical technology can bring relief and is a kind service, but also enables pathogenic behavior. I’m not for firing patients who live self-torturous lifestyles, but on the other hand I need to recognize that my intervention frankly enables that behavior without diminishing it. A more effective strategy would be to attenuate my intervention while requiring more involvement by the patient. Instead of calling that “clinical inertia,” call it plain old restraint.

Monday, October 17, 2011

PREGNANT MOM DECLINES CHEMO SO BABY CAN LIVE

If you're up for a good cry, read this:
When Stacie Crimm found out that she had finally gotten pregnant at 41, she was overjoyed. So overjoyed that she knew exactly what to do when faced with the decision of whether to save her life or her unborn baby's. After she was diagnosed with neck cancer, Crimm decided to refuse chemotherapy. The heroic mom survived long enough to deliver her 2-pound, 1 ounce daughter, Dottie Mae, and hold the baby in her arms, just once.

“This baby was everything she had in this world," Crimson's brother, Ray Phillips told the news outlet.                                                             

I can’t add a thing.

Tuesday, October 11, 2011

SIMPLE QUESTION GOES LONG WAY

A friend asked me, “Do you think herbs actually do something, or not?”

Sometimes you catch a question that hotwires your mind. I got to thinking: how do we know herbs work? Well, why shouldn’t they? Some of allopathy’s most useful medicines—morphine, aspirin, some anti-cancer drugs—derive from plants. The potency of some herbs, and maybe all, is indisputable.

Since we’re asking, how do we know if pharmaceuticals work? Well, sometimes we feel a dramatic change. Most standard medical drugs are designed to be more forceful than herbs or other alternative meds, so their effects can be readily noticeable. (Did I say “more forceful?” Frankly, we often swat flies with cannons.) Anesthetics, antibiotics and analgesics in particular make an obvious sensory splash.

But with some drugs, the question can’t be answered. Adele, a member of our cancer group, wondered if her chemo was working. “I mean, how can you tell?”

“Well, how do you feel?” someone asked her.

“Are you tired?” asked another.

We yearn for a grip on this issue, some metric handhold.

“Well, when’s your next MRI?”

“Oh yeah, my MRI’s next Thursday. That ought to show whether it’s been working.”

That’s when Alec steps in. “You mean if the tumor’s smaller, then the chemo’s working?”

“Sure.”

“And if the tumor’s bigger, it’s not working?”

“Yeah, why?”

“Well, what if the tumor’s bigger, and if it hadn’t been for the chemo, you’d be dead now? Or say the tumor’s smaller, then how do you know if the chemo did that, or if it was your diet or prayer or zest for life?”

Alec can be a bit frontal, but he’s worth listening to. “You go read studies,” he continued, “and they say it works. Well, that’s reassuring, you say. That’s all well and good, but then you think about it: wait a minute, there’s no treatment that’ll work for everyone, so what if it’s me who gets the short end? And you’re back to your original question, ‘Is it working?’ All the statistics in the world don’t matter boo to individuals, anyway. Another guy in this group years ago said, ‘The only numbers I’m interested in are a hundred and zero. Either I’m here or I’m not.’”

So how do we know if this medicine we take is doing what we want it to do? Alec’s right. In most cases, especially in Cancerland, we don’t know and probably can’t know. Probably the greatest source of anxiety among people with cancer is not-knowing. While a tumor might go unfelt, uncertainty tortures around the clock.

Uncertainty is a far more potent feature of the universe than I am. Compared to forces like that, I am, like Job, dust. The realization that I can’t rearrange reality as I’d like can be really annoying. That can invite me to ask myself why uncertainty, such a pervasive, eternal, and undeniable feature of reality, bothers me. If uncertainty is inherently universal, from quarks up, then why don’t I just learn to live comfortably with it? Would dropping my discomfort be risky or dangerous or taboo or illegal, or what?

Abraham Maslow, a founder of the humanistic psychology movement, was one of the few people to study normality. When we crave mental health, what is it, exactly, that we’re after? Of the hallmark list he developed, the one that fascinates me the most is “comfort with uncertainty.”

OK, sounds good. Where do I sign up? Sorry, this is a blog, not an ashram.
Vaya con Dios.

Monday, October 10, 2011

GENUINE DISCUSSION OF HEALTHCARE REFORM

In this blog I’ve mentioned “Health, Money & Fear,” a film that waxes eloquently on the deeper nature of our healthcare crisis. I and others felt the film is so right-on that we had to share it with our community. If you have forty-seven minutes to spare, check it out online at www.ourailinghealthcare.com. If it impresses you, consider sharing it with your community. One way to do that is embedded in the opinion piece I wrote, below, for our local newspaper...

"No doubt you're aware that health care's current cost can wreck your wallet, but do you also know it eats a growing portion of the national economic pie? 

When I graduated medical school in 1967, America spent about 6 percent of its GDP on healthcare. That means one out of every $16 spent for anything went toward healthcare. Now it claims 16 percent, or one out of every $6. At this rate, we'll eventually live in makeshift shacks and shop in dumpsters, but at least we'll enjoy the most expensive health care in the universe.

As I've watched costs climb over the past several decades, I've read what those who study the subject have to say about it. One thing they agree on is that reducing costs can't be simply rearranging who pays for what. There's much more involved. Health care is astronomically expensive because we hold some painfully contradictory values about it. For example, we want all available medical technology, but we want it cheap, which is like insisting that a round-trip hike be downhill all the way. We demand end-of-life care that too often amounts to incredibly expensive prolongation of suffering. We fly into a litigious rage when doctors — that is, human beings — fail to provide us perfect security. 

Such contradictions persist mainly because we hardly ever discuss them. Imagine my surprise, then, when I came across the film “Health, Money and Fear.” It makes a case for a national single-payer strategy similar to the California proposal now navigating the legislature as SB810. It goes further, however, in examining our costly cultural issues through interviews with experts I've long respected, including former New England Journal of Medicine editor Marcia Angell, MD, and Oregon Gov. John Kitzhaber, MD. 

So I've joined with local medical colleagues who support affordable health care, plus the Nevada County chapter of Health Care for All, to show this film publicly, followed by a town hall-type discussion. A broad swath of Nevada County people, businesses and organizations are co-sponsoring the event. Admission is free and refreshments will be available."

WHEN: Tuesday, Nov. 29, 7PM
WHERE: Nevada Theater

Thursday, October 6, 2011

STEVE JOBS GOT IT RIGHT

In today’s NY Times Well Blog(http://well.blogs.nytimes.com/2011/10/06/so-doc-how-much-time-i-got/#more-61357), Dr. Danielle Ofri writes about the difficulty of informing a patient of his cancer’s lethality. She’s not the only doc who recognizes how hard this can be. 

Part of the problem is that although we adults are aware of our mortality, we deny it most of our lives. On his deathbed, William Saroyan said, “I’ve always known I was going to die, but I thought in my case they might make an exception.”

In my practice, facilitating cancer support groups, new members often ask me if they’re going to die.

I answer, “Of course.” What else can I say?

They respond, “Oh, I know that, but will I die from this?”

Here’s how the kindest oncologist I know answers that question: “I don’t know if you’ll die from this, but I do think you’ll live with it the rest of your life.”

What a positive, creative way to frame bad news! Accentuating “the rest of your life,” it simultaneously affirms finiteness and possibility. In an ideal world, frank acceptance of mortality would be a general cultural value. Whether we’ve been diagnosed or not, the sword continually hangs over our heads, poking us to do what we need to do. I can’t put it any better than now-departed Steve Jobs:

“Remembering that I’ll be dead soon is the most important tool I’ve ever encountered to help me make the big choices in life. Because almost everything—all external expectations, all pride, all fear of embarrassment or failure—these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked.”

Monday, October 3, 2011

HEALING & THE EXXON VALDEZ


"It seems as if we have confused science with restoration, knowledge with healing.”

I’ve written that sentiment here. But this iteration wasn’t from me, and it’s not about healthcare, at least healthcare for humans. It's by Marybeth Holleman, author of a highly regarded book on the 1989 Exxon Valdez oil spill, The Heart of the Sound.


Holleman feels that science, with its considerable expense, has been overused and undereffective in the still-ongoing cleanup. She writes,

The massive $400 million spill-research boom in the [Prince William] Sound brought its own unanticipated injury, through intrusive sampling methods and the swarms of scientists, tent camps, boats and planes now in the Sound much of the year.

“About $500 million (half of the entire natural resource damage settlement) has been allocated for research; some say we could have spent ten percent of this amount and learned as much. Then we could have used more of the settlement funds for habitat protection.”

Holleman insists that relentless scientific investigation amounts only to

“…proof that oil hurts animals. While it’s new information, it doesn’t do any good, isn’t restoration, unless some protective measures come from it.”

So what does this have to do with healthcare as though people matter? Maybe I’m deluded, but I see a compelling parallel in our cultural healthcare strategy, the favoring of science over healing. We don’t lean that way because we’re logic nerds, but because science’s reps—thinktanks and developers and manufacturers—knock persistently on our door and natural healing processes don’t. Thus we physicians get paid oodles for performing invasive, expensive diagnostic and treatment procedures, but zilch for just sitting and listening to patients in order to help relieve their suffering.

I’m beginning to think that the healthcare issues I interminably rant about are just one profile of the way our culture faces every challenge—as a problem to be addressed—no, “attacked”—with a high-tech physical toolkit. Certainly imagination would reveal other responses that are at least as effective, and cheaper and gentler to boot.

Saturday, October 1, 2011

WHO DOESN’T PALLIATE?

“I’ve been treating this sixty-year-old woman for emphysema. She's on some meds, plus oxygen at home. She’s smoked a couple of packs of Camels every day for the past forty years, and you know what? She won’t stop. She takes a drag from her cigaret, then one from her oxygen mask, back and forth. I’m tempted to fire her. I mean, this is ridiculous. She claws back any advantage I can give her. What do you think I should do?”

This was asked of me by a physician friend who’s aware of my interest in medical ethics. What would you do? Me, I’ve learned generally to answer every question with another question.

I said, “Well, you’ve thought of firing her. Why haven’t you?”

“I’d feel awful. She’s doing herself in, but she’s still my patient.”

“What does it mean to you—that she’s your patient?”

“I’m her doctor. I guess that means I’ll stand by her no matter what. This is really beyond what I was trained in, diagnosis and treatment. What I’m doing with her is only palliative.”

Only palliative?”

“I’m not a hospice doctor. I don’t do palliative.”

“You don’t?”

Monday, September 19, 2011

SUDDEN UNEXPECTED NOCTURNAL DEATH SYNDROME

A couple of years ago I was chatting in the corridor of a university medical center with a cardiologist I know. Quite a personable physician, he's an associate professor of medicine, at the top of his craft.
I asked him one of the naïve questions I habitually put to my colleagues. "Tell me," I said, "do you ever think of your patients as soft-hearted or heavy-hearted? Stone-hearted? Heartbroken? That kind of thing?"
"Sure, my patients go through the same kind of social trials and tribulations everyone does."
"What I mean is: do you ever think they're telling a single story, not two? That their cardiomyopathy might express that they've been too big-hearted, or that their heart aches because of a great loss?"
Suddenly he remembered an appointment and marched off, leaving me to guess he was avoiding this conversation. Understandable, since after all, if you're a Catholic priest you don't want to be seen discussing Mormonism in St. Peter's cathedral. 
The September issue of Atlantic magazine reviews a book by Shelley Adler, Sleep Paralysis: Night-mares, Nocebos, and the Mind Body Connection (http://www.theatlantic.com/life/archive/2011/09/the-dark-side-of-the-placebo-effect-when-intense-belief-kills/245065/.) Part of the book describes the death, in their sleep, of 117 Hmong men who'd immigrated to the United States. They were posthumously diagnosed with "Sudden Unexpected Nocturnal Death Syndrome," or SUNDS. Adler concludes,
"It is my contention that in the context of severe and ongoing stress related to cultural disruption and national resettlement (exacerbated by intense feelings of powerlessness about existence in the United States), and from the perspective of a belief system in which evil spirits have the power to kill men who do not fulfill their religious obligations, the solitary Hmong man confronted by the numinous terror of the night-mare (and aware of its murderous intent) can die of SUNDS."
When you die of SUNDS, what exactly is the physiological culprit? No one's sure, but one hypothesis is a cardiac arrhythmia. Whatever the mechanism, though, the question remains: why that, and why in this person, at this time? I'd like to ask my cardiologist friend if these 117 men had troubled hearts before they died
SUNDS sounds like death by voodoo curse, doesn't it? Actually, it's known around the world. In Indonesia, it's called digeunton ("pressed on"). In China, it's bei gui ya ("held by a ghost"). The Hungarians know it as boszorkany-nyomas, "witches' pressure." If this phenomenon isn't exclusively native to the Hmong, it's worth studying not as a supernatural visitation, but as still further evidence that the mind affects the body.
Of course, we already know that. The love of our life enters the room, and our hearts flutter. A stranger is rude, and our blood pressure rises. Nine-year-olds have no trouble discovering this principle on their own, yet it seems totally alien to medical practice. We docs are trained to see human beings as biomechanical devices, organisms driven by genes, diet, hormones, and other physical forces, almost to the exclusion of influences from their inner world. It's as though we studied traffic accidents by taking cars apart, hardly glancing at the driver.   
Believing healthcare to be wholly a "scientific" endeavor, we suspend our common sense, deferring to those who regard only the measurable as worthy of analysis. I suspect we do that so readily because even though lifelong experience tells us that body and mind are inevitably connected, we have trouble entertaining an image of how that works.
Alright, try this. Look in a mirror. See your face carefully, imagining what this person is thinking. Now remember the last time you were angry. You'll see that in your face. In fact, recall anger and try not to display it, however subtly. 
We constantly speak what's called "body language." We can't stop. Try turning it off and a proficient observer will call you on it, saying you're trying not to express yourself, which, of course, is an expression. A simple body-mind model, then, is this: when you look at Willy's physical presence, you're seeing his mind in action. (It gets more complicated when Willy speaks, as the language of the mouth doesn't always coincide with that of the body, but that's for another day's blog.) 
Why not give this model a try for a couple of days? Look more carefully at others while mumbling to yourself the mantra, "Actions speak louder than words." Then report in, eh?