Monday, August 29, 2011

OUR HEALTHCARE SYSTEM AND THE JAPANESE IMPERIAL COURT


The August 25 edition of the NYTimes Well Blog (http://well.blogs.nytimes.com/2011/08/25/an-insurance-maze-for-u-s-doctors/) relates a study showing how much American doctors spend just trying to get compensated by insurance carriers.

The study, published in today's edition of Health Affairs (http://content.healthaffairs.org/content/30/8/1443.abstract) estimates that while Ontario, Canada, physicians spend an annual average $22,205 interacting with Canada’s single-payer agency, their American counterparts spend $82,975. American physicians' office staffs spend  20.6 hours weekly interacting with health plans—nearly ten times that of their Ontario counterparts. If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year. 

How to account for our persistence with such an obviously wasteful strategy? I don't believe we Americans are masochistic, just poorly informed. If we looked seriously at our own experiences in this system, we'd scream for reform.

For example, I recently saw my own doctor just to get a prescription refill. Ours is an older community, so most of his patients are on Medicare, which reluctantly but continually reduces physician payments. This leaves him earning less than some on his staff, so he's limited his participation in Medicare. That means that I needed to pay cash for my visit, assured that I'd somehow be reimbursed. Sure enough, a check arrived a few weeks later from somewhere in Georgia that paid me for half the visit. And a month after that, his office sent me a check paying most of the remainder, along with an explanatory letter. I wondered, then, how much it cost simply to reimburse me.

American healthcare's financial "system" is as complex as seventeenth-century Japanese imperial court manners--and even worse, it's riddled with unnecessary middle people who bleed it without adding value.

Again, I urge you to see the video "Health, Fear & Money" at www.ourailinghealthcare.com, a gloriously clear explanation of our Gordian healthcare knot.

Friday, August 26, 2011

ANOTHER SYNDROME BITES THE DUST


Every day we hear about a new medical breakthrough, but how many remain on the stage two months later?

Well, I came across a genunine one today, destined for permanence. The lead article in this month's Journal of Questionable Diseases, it's entitled "Finally! Help for the Dreaded Bad Manners Syndrome," and I reprint it here.

Five-year-old Timmy Castelfiore-Padilla (not his real name) skitters around the examining room like ball lightning, colliding ferociously with walls, furniture, and people. 
       
"Look out, loser!" he screams at his mother, lingering long enough to kick her shin. Ms. Castelfiore-Padilla cries out and falls to the floor in agony, hissing between clenched teeth, "You see, Doctor? He's always like that."
       
But don't jump to conclusions, for Timmy is not a hideous monster. Along with thousands of other unfortunate children, he suffers from Bad Manners Syndrome, or "BMS."
       
Timmy’s doctor, O. Dayton Splint, MD, is a world-renowned BMS authority. Thanks to dedicated scientists like him, we've come a long way toward understanding this scourge. Dr. Splint outlines the history of BMS. "It's hard to believe," he explains, "that until a few years ago these were 'nasty' children, and we treated them accordingly. Of course, we persecuted adults in those days who later turned out to suffer Ethical Deficit Syndrome, Corporate Greed Disorder, and other chemical imbalances we didn’t recognize at the time. 


       
"Through research, we learned that these kids are actually victims of their own physiology. Finally the government took notice and began a crash program to find the cause and cure."
       
Ignoring Dr. Splint, little Timmy has made his way into the clinic's backyard, where he's found a hatchet and has begun to hack apart a wooden fence. 
       
Undaunted, Dr. Splint continues. "Suddenly, these kids were no longer criminals, but healthcare consumers. Institutions everywhere got grants to treat Bad Manners Syndrome with a variety of drugs. But since most patients went on to state prisons regardless of treatment, we figured we'd better look into it further."
       
A nurse finds Timmy in the backyard and says something to him. He turns toward her, a carnivorous expression on his face, and, hatchet in hand, gleefuly advances.
       
Dr. Splint continues, "We eventually discovered that Bad Manners Syndrome results from an abnormality in a particular protein, called 'obnoxin.' Its molecules, which are normally tightly coiled, begin to unwind in these children, and that's when demonic behavior begins." 
       
In the backyard, a determined Timmy takes craftsmanlike swipes at the nurse. Obviously an old hand at such play, she grabs Timmy's wrist, disarms him, and tosses him onto his back. 
His filthy epithets penetrate the clinic's thick plate windows.
       
"Knowing the cause," says Dr. Splint, "we've gone on to develop an effective treatment: we simply re-compact the uncoiled obnoxin. Compaction must be done rather forcefully, and in an area where a good deal of it is stored."
       
The nurse has comfortably seated herself and placed little Timmy face-down across her legs. With a strong right arm, she begins to compact the errant obnoxin in his buttocks. Whap! Whap! Whap! His yells announce another successful treatment. The molecules are compacting just right. 
       
Concludes a satisfied Dr. Splint, "It's the most dramatic cure since penicillin."

Thursday, August 18, 2011

"HEALTH, MONEY AND FEAR"


I recently saw a terrific video about healthcare reform, "Health, Money and Fear." Produced by emergency physician Paul Hochfeld of Corvallis, OR, it comprehensibly addresses the obscenely high cost-to-benefit ratio of our healthcare quasi-system by tracing it to its guiding values, our notions about self-image, lifestyle and responsibility. You can view it free online and purchase it, if you like, at www.ourailinghealthcare.com.

When I mentioned to a friend that I'd bought a copy, she told me she had one, too. Turns out there are several in this community, owned by excited fans who, like me, want to show it to others.

Maybe we're drawn to it because it heralds a shift in the argument. Until now, discussions have been limited de facto to the economic realm, reform as who's-going-to-pay-for-what. This supplies the media with no end of side debates about rationing, entitlements, malpractice suits, and "socialized" medicine, slowly convoluting the issue into a Gordian knot. "Health, Money and Fear" is a deep slice through complexity to the problem's core, the values that drive healthcare's economics. The people interviewed in Hochfeld's film--like Dr. John Kitzhaber, emergency physician and former Governor of Oregon--know what they're talking about, both medically and civicly.

This is heartening progress. I plan to show the film locally, publicly, along with friends who agree it's a document whose time has come. If you see the film, please let me know what you think. 

Tuesday, August 9, 2011

NEW-AGERS ENLIGHTEN HOSPITAL PRACTICES


If you read this blog and get worked up--either about my subjects or my rant style--and need to cool your adrenals, here's something a little different. 

Those of us who wonder whether "alternative" modalities will eventually integrate with mainstream medicine need wonder no more after reading the below, from the current issue of the new-age magazine PARADIGM!

Two years ago, James Dancing Rainbow would not have held his current job. In fact, hardly anyone would even have imagined its existence. Rainbow shows funnyvideotapes to hospitalized patients to make them laugh—which is to say help them heal.
       
Many hospitals now accept the notion, first popularized by former Saturday Review editor Norman Cousins, that laughter is an invaluable healing tool. Rainbow's hospital, St. Vitus General in Mill Valley, California, founded its Humor Therapy Department in 1989. It stocked its library with tapes of the Marx Brothers, Candid Camera, Woody Allen, and Dan Quayle, and hired James Dancing Rainbow--formerly James T. Limpet--as its Senior Humor Technician.
       
“I guess I like it,” concedes Rainbow, pushing VCR buttons for a patient. “What the heck, it's a job.”
       
The patient, a man blooming with tubes like a modern Medusa, watches the Three Stooges on his screen. They make silly faces, throw pies, take pratfalls. The patient remains stone-faced.
       
“I'm coming back in an hour to get the machine,” Rainbow advises. “That tape's on for you to laugh at, Turkey, so don't make me feel like I wasted my time, y'hear?” And James Dancing Rainbow moves on to his next patient.
       
Wide acceptance of humor therapy has brought additional “new-age” techniques into mainstream medical practice. At another bedside in the same hospital, Transition Counselor Summerfall Winterspring notices on her clipboard that her patient is terminal.    
       
“So tell me, Ms. Dwuff,” she asks, “have you gone through the bargaining stage yet, or are you still in denial? No use burying your head in the sand about dying, you know.”
       
Ms. Dwuff, a crusty critter despite her years, springs upright. “Dying?! I'm not dying any more than you are, you impudent whelp! I'm just lying here!”
       
“Aha!” responds Ms. Winterspring confidently, tapping her pencil on her lower lip. “You're in the anger stage. I'll send you our Anger Specialist, Ms. Clearlight.”
       
Exhausted, the patient drops back onto her pillow. She moans, “I’m too tired to argue. Just bring me that Dan Quayle video, will you? All I really need is a laugh.”
       
In the cafeteria three floors below, Certified Caring Technician Rhonda Crystalwater is taking her coffee-and-cigarette break. “Rough day today,” she explains, blowing smoke pyramids. “Twenty-eight biorhythms and three more aura readings to do, one reiki, two fleiki, and Christ, the elevator's kaput.” She indicates her copious belly. “Can't climb stairs. Chemical imbalance.”
 
These innovative healing methods have so won over St. Vitus General’s patients that all its departments have found some new-age approach. The obstetrical ward was converted into a home-style delivery suite, complete with kerosene lighting and underwater deliveries in the department’s hot tub, all to an endless-loop tape of Pachelbel’s Canon in D. The Surgery Department replaced its antiquated green gowns with bright tie-dyes. Through the public address system comes not the standard metallic voice paging doctors, but that of Shirley MacLaine reading the Course in Miracles. In-house psychiatrists now channel Freud and Jung. And St. Vitus General bubbled to the top of the new-age column when it recently introduced play therapy into its Intensive Care Unit, renamed the “Peekaboo I.C.U.”
       
The hospital even tried to change its name to “St. Vitus Holistic,” but snagged on a lawsuit brought by the McDonald's Corporation, which patented the word “holistic” in 1975. According to a leak from the hospital's Board of Directors, a second choice may be “St. Vitus Biodegradable.”

Friday, August 5, 2011

DON'T LISTEN TO THE WORDS. LISTEN TO THE MUSIC

Hats off to one of my medical school psychiatry professors, Dr. Werner Mendel. Every week he performed a fascinating practice before a rotating audience of students. When my turn came, an inpatient, Mr. S, was shown into the room and introduced to us. The next ten minutes, Dr. Mendel engaged the man in small talk: how are you doing? Is the food okay? Have you had visitors? Then the patient returned to the ward.

Dr. Mendel began. "Mr. S was born in Appalachia but moved as a teenager to New Orleans. He entered the Navy at the outbreak of the war, and served in the Pacific. He was captured and spent time in a Japanese POW camp. He was married but now divorced. He's a longtime heavy smoker…"

He backed up each point in his biography of Mr. S with an observation. "Of course, you noticed his anchor tattoo, the slight bow when he entered the room, the pale band around his fourth finger…" We students had been clued into Dr. Mendel's act, so we'd sat at the edge of our chairs, almost painfully attentive, yet we missed ninety percent of what he had noticed. Afterward, the ward's psychiatrist read to us from Mr. S's chart; needless to say, the stories matched.

Astonished that so much valuable information might universally hide in plain view, I coveted his skill. Afterward, I cornered him in the corridor. "Please, please," I begged, "tell me the secret."

I wasn't the first to ask. He told me what he told everyone: "Don't listen to the words. Listen to the music."

(An interesting aside: Dr. Mendel once performed a study in which trained psychoanalysts treated one group of patients, and hospital employees with no formal training treated a second group. Guess which group showed the most and least improvement. Right! Understandably, Dr. Mendel was startled by the results and repeated the experiment, with the same outcome.)

Decades later, Dr. Mendel's advice became clear: words can lie, but the body always tells our truth, inevitably expresses our mind.

Yet we maintain a myth that body and mind are separate: I "have" a body and I "have" a mind, and hardly ever do the twain meet. I don't know why we assume this; whatever Darwinian advantage it has eludes me. We so deeply believe body and mind are two unconnected entities that we act astounded when we learn that an event involving one affects the other. Unmanaged stress causes insomnia? Well, I'll be. Cancer can cause anxiety? Knock me over with a feather.

It takes our finest scientific minds, then, to reveal that, as I reported yesterday, negative events in our personal histories predispose us toward illness. Today I read its obverse: a better life is more likely to be longer. According to research published in May by the American Psychological Association (http://psycnet.apa.org/journals/hea/30/3/268/), a positive social atmosphere in the workplace confers longevity. In this study, employees who enjoyed collegial support and positive social interactions were less likely to die over a twenty-year period than those who reported a less friendly work environment. Well, as I live and breathe! What'll they think of next?

If we're to move toward a healthcare style in which people matter, we'll need to leave the duality behind. When we honestly see that body and mind are one, then preventive medicine is no longer just a search for incipient disease. It's living, moment to moment, as enjoyably as we can. 

Wednesday, August 3, 2011

TREMENDOUS DISCOVERY: TRAUMA CAN SICKEN US

Recent research is making it obvious that much of disease originates with traumatic experiences. A landmark study done by Kaiser San Diego (http://www.cdc.gov/ace/index.htm) demonstrates how closely adverse childhood experiences ("ACEs") correlate with health problems in adulthood. Now two articles in this week's Journal of the American Medical Association (find both at http://jama.ama-assn.org/content/current) further validate not only that relationship, but suggest an approach to treatment.

One article, from Australia, shows that women who were raped or sexually abused tend to suffer a lifetime of mental disorder and psychosocial disability, including impaired quality of life, overall disability and increased suicide attempts.

In the same issue, a study of over a thousand former child soldiers in northern Uganda who suffered from post-traumatic stress disorder were helped most by simple narrative therapy--that is, talking about their experiences with trained nonprofessional counselors.

Wait a minute. Let's back up a bit. Isn't it already obvious that sexual abuse can confer lifelong problems, or that a child soldier will be prone to PTSD? You'd think we wouldn't have to prove this through scientific research, yet there's something in our culture that declines to make the reasonable link. It's expressed in that non-advice, "Get it behind you." It wasn't pleasant, but it's over now, so get on with your life. People with cancer often tell stories about such "encouragement" from well-meaning friends.

But we don't get over it. These experiences change who we are. In order to understand what we've been through and thus our current existential location, we need to talk about it. Matter of fact, that's all most psychotherapy is. But it needn't even be called psychotherapy, as the Ugandan "counselors" were nonprofessionals. It could equally be part of friendship, people caring deeply enough about one another to ask the right questions. Hopefully this will become a popular skill as we renovate healthcare as though people matter.