Monday, August 27, 2012

THE GLOBAL HEALTHCARE CUL DE SAC


I’ve written here ad nauseam that no matter what healthcare policy the U.S. pursues—the the Affordable Care Act (“Obamacare”), old-fashioned fee-for-service, national single-payer, or the mishmash we currently suffer under—healthcare costs will eventually bankrupt us.

When we take a disciplined, knowledgable look at why healthcare is so grotesquely expensive, the usual suspects—doctors’ incomes, hospital billing practices, malpractice issues, nonpaying patients—fall by the wayside. Sure, they exact some cost, but are dwarfed by a single megaproblem: we grossly overuse medical technology...and there’s new hi-tech coming down the pike daily, with ever greater price tags.

We hear about growing lines of patients awaiting services in the U.K. and Canada, and now the same sort of news is emanating from Cuba and China. Check out http://news.yahoo.com/cuba-campaign-takes-free-health-care-142839515.html?_esi=1 and http://news.yahoo.com/chinas-chaotic-health-care-drives-patient-attacks-131133300.html?_esi=1.

Cuba’s system is entirely socialist, meaning the government owns the facilities and employs the practitioners. Besieged by increasing costs, Cuba's health sector has already endured millions of dollars in budget cuts and tens of thousands of layoffs, and it became clear this month that Raul Castro is looking for more ways to save. A media campaign is now discouraging what it terms “frivolous” medical visits. Its theme, on posters in clinics and ads on state TV is, “Your health care is free, but how much does it cost?”

China’s system is, surprisingly, more and more market oriented, with patients covered by private insurance. Demand has so grossly expanded that facilities are insanely overcrowded, doctors glaringly overworked, and patients infuriated to the point that several have murdered their doctors. Said Yanzhong Huang, an expert on China's health reforms at the Council on Foreign Relations, “The supply cannot catch up with demand, you have long waiting times, doctors on average spend five minutes with patients and don't have time to communicate well with their patients, and that creates problems." Does that sound familiar here?

According to an expert at the World Health Organization, much of dissatisfaction with healthcare occurs when “…people don't know the limitations of medical care and they expect that if they pay, the cure will come.” That should also sound familiar.

I don’t see any way out of this dead end except stopping, quieting down, and redesigning healthcare after publicly exploring its most basic questions: what is healthcare about, anyway? What do we mean by “illness,” “treatment,” “suffering,” “healing,” and “cure?” How are body and mind related? How are lifestyle and illness related? What’s the doctor’s responsibility? The patient’s? The caregiver’s? What happens when they meet, and what should happen? When is it okay to die? What level of care do we owe one another?

Thursday, August 23, 2012

THE MEDICAL OFFICE


I’m hearing stories about wonderful doctors whose offices are less than wonderful, actually reminiscent of the stiff 1950s. My friend Miriam told me,

“Last time I visited my doctor, the receptionist didn’t say a thing to me, just pushed a sign-in sheet across the counter. Soon a woman called me in from the waiting room. Walking ahead of me, she asked how I was—a nice touch, but really, she wasn't even looking at me. And who was she, anyway? A nurse? Another patient? For all I knew, she could’ve been someone who’d wandered in off the street. Am I supposed to ask? Is it up to me to teach manners to grownups? She weighed me, took my temperature, and left the examining room. In a few minutes, Dr. D came in. Now, him I love. Right away he lifted my mood. Afterward, he walked me out, hugged me, and moved on to his next patient. The woman behind the desk said, 'We don't take Medicare anymore. Today's visit is seventy-seven dollars.' She was like a clerk selling me chewing gum, take it or leave it. She handed me a bill with my name on it, misspelled.

“I know Dr. D cares about me. I'm lucky he's my doctor. But his office staff acts like their customers might be burglars. If they were any more negative, they’d assault patients. Wouldn't they enjoy their work more if they were friendly? How can Dr. D not notice how anti-healing his staff’s low morale is?”

Imagine you work in a medical office, dealing with patients who can be out of sorts, demanding, even intimidating. You hear them wail in the examining rooms, and your daily office buzz includes saddening details of their miseries. You spend hours with insurance company phone robots, careening through algorithms in search of the dubious prize, an argument with a live representative. All this can harden you—to patients, to your work, and to your own feelings. Little wonder medical office workers’ morale can decline to the point that they treat their customers coldly.

If a medical office were selling widgets instead of conducting healthcare, the staff might be forgiven its emotional distance with the traditional apology, “Business is business. Don’t take it personally.” But healthcare isn’t about widgets. It’s about people in their deepest pain and need, who are suffering, defenseless, pushed to their edge. If they’re to matter in healthcare, we who work in it need to feel and act from a deeper humanity.

I recommend this more from a medical sense than a moral one. It can’t be emphasized enough that patients need comforting. They need to leave the medical appointment feeling better than when they came in. Toward that end, arguably the most important person on the staff is the receptionist, who sets the visit’s emotional tone. Every member of the staff is potentially a placebo, able to make the patient feel better. An ideal visit is one where the patient is already half-treated before even seeing the doctor.

I could offer suggestions touching on office design, staff behavior, traffic flow, and other features, but every office is different. Instead, I suggest trying this: when business is slow, how about a staff member pretending to be a patient, going through each procedure that a patient would, and afterward writing a paragraph or two about how it felt? When everyone’s done it, you can all go out for pizza and beers (at office expense) and talk about changes you might like to make.

Wednesday, August 22, 2012

REP. AKIN AND MENTAL HEALTH


By now everyone’s heard about Rep. Todd Akin’s (R-MO) comment that women only rarely get pregnant from “legitimate” rape. Aside from his view being erroneous and brutish, it’s an example of increasingly endemic poor mental health.

Unless some alien force had captured his tongue and ventriloquized him, what he said was what he believed. His claim that he “misspoke” amounts to flatly dishonest groveling; misspeaking occurs on the level of single-word choices and typos, and this was a complete idea. Believing that “legitimately” raped women rarely get pregnant, he probably harbors a slew of other off-the-wall opinions he takes to be fact.

It seems more Americans are doing similarly, believing that climate change is a tree-hugger hoax, the 9/11 attack came from Iraq, the world was created in one week six thousand years ago, and Obama’s a Kenya-born Muslim. Never mind evidence, science, and logic—we’ll believe anything we damn please.

Obviously, this is no way to run a democracy. But it’ll get even worse unless we push for regular reality testing. It’s not enough to demand that Mr. Akin withdraw from the Senate race. We need to let him and the millions of others who operate from hermetic wishful thinking know they’re not only flat-out wrong, but actually circling the sanity drain.

Saturday, August 18, 2012

THE CAUTIONARY PRINCIPLE


As I recently slurped a Yoplait yogurt, I wondered whether its milk came from cows given bovine growth hormone. I emailed the customer service department, and got my answer the same day: “There’s no evidence to show rBST is harmful to humans.”

I took that to be a yes. I don’t know if rBST is a curse or a blessing, for that matter, but I don’t see any need to ingest even a homeopathic dose of it. Exercising my sacred American consumer Right of Choice, I scratched Yoplait off my shopping list.

Bovine growth hormone has cleared the bar of the Food and Drug Administration. It’s a low bar: the FDA admits into the marketplace thousands of untested chemicals it lumps together as GRAS, or “Generally Recognized As Safe.” GRAS isn’t cautionary; it’s more like, as kids say, whatever. In the cautionary view, questionable chemicals aren’t citizens (at least not until the Supreme Court meets) so they don’t have the right to be considered innocent until proven guilty beyond a doubt.

In Canada, the Cautionary Principle happens to be the law. We visited a relative in an Ottawa suburb, and learned it’s hard to buy Roundup there. If you’re absolutely determined, you can get it, but only if you post a sign in front of your home saying you’re using it. To your greener neighbors, your sign may as well say, “I Whip My Children.”

Read the ingredients on the back of your shampoo bottle. How many of them would remain there if the U.S. were to adopt the Cautionary Principle? (By the way, have you ever wondered how those who make shampoo choose its 141 ingredients?) Of course, we’re talking more than shampoo. It’s time we did something to end the relentless contamination of our food, household agents, building materials, personal products, and even medications.

Much of this pollution resides in stuff I don’t need anyway. Browsing in Safeway, I peeked at a sandwich’s ingredients list. Why does a turkey sandwich need three different artificial coloring agents? Somehow my life will limp along without Yoplait and Safeway sandwiches.

Don’t hold your breath waiting for Congress to fix this. The folks who make this stuff will wail that the Cautionary Principle will wreck their business. Hundreds of thousands will lose jobs. The national economy, now only derailed, will tumble over the precipice. The beginning of the end of civilization as we know it. In other words, the usual. And Congress won’t pass any law that threatens the end of civilization as we know it.

But here’s the good news: we don’t need Congress. All we have to do is enact the C.P. ourselves. All the time. Every act, including every purchase, is a vote. To paraphrase Arlo Guthrie, if only one person stopped buying Yoplait, he or she would be called an eccentric. If two stopped, we’d called it an emerging cult. Three, though, is a conspiracy, and when four do it, corporations begin taking notice.

Johnson & Johnson, for example, plans to remove potentially dangerous chemicals from nearly all its adult toiletries and cosmetic products worldwide by 2015. Its announcement didn’t call them hazardous, only "chemicals of concern." Fine. That’s the Cautionary Principle at work. We don’t have to revive Congress or rely on Friends of the Earth and Physicians for Social Responsibility. All we have to do is to buy exactly what we want and not to buy what we don’t want.