A Socratic dialog on health care reform (VIII)

While on his way to barter for health insurance through the Athenian health care exchange in the Agora, the philosopher Socrates has a chance encounter with Hippocrates, the father of medicine.

Hippocrates: Socrates, my dear fellow! Good day to you. But to what business are you hastening at such an early hour? And, I might add, with such a limp?

Socrates: Good morning, Hippocrates. Were it not for your timely greeting, I might have passed you by. I make haste to join the line of my fellow citizens who stand outside the newly formed healthcare exchange in the Agora. Finally, after years of waiting, we can sign up for affordable health insurance! I can hardly wait to compare the options, for alas! — as of late I have been plagued by this painful hip and fear the need of an artificial replacement.

Hippo: Ah, good Socrates, how sorry I am to hear of your woes! And yet, I fear that your painful hip may be the least of your worries in this healthcare debacle.

Soc: Whatever do you mean, Hippocrates? Are there not enough willing surgeons to go around?

Hippo: Of surgeons there are plenty, Socrates.

Soc: What then? Do you refer to the lack of affordable plans in the healthcare exchange?

Hippo: No, Socrates. A review shows that there are plenty of plans from which to choose. Moreover, with the increased competition, the premiums have dropped appreciably.

Soc: This is good news indeed! But tell me, Hippocrates, what are these concerns which you harbor in your heart?

Hippo: Have you not heard the latest news from the Senate floor, Hippocrates? There are those in the Congress who have plotted to derail the Affordable Care Act. If they have their way, the entire enterprise could come undone.

Soc: But what is this? Tell me more, Hippocrates!

Hippo: A small select group of representatives from the more conservative quarters have vowed to postpone the implementation of the Affordable Care Act for at least another year.

Soc: How can they orchestrate such a thing? Is the ACA not now the law of the land?

Hippo: To be sure, good Socrates, it is. But this select group has tied the postponement of the ACA to the budget bill now before the Senate. Because of their ridiculous amendment the Senate has refused to pass the legislation required to fund the government, the result of which being that all non-essential governmental employees are to be furloughed without pay indefinitely.

Soc: What? To jettison the funding of the Athenian government merely to undercut the implementation of a law on the books! But that is an outrage!

Hippo: (sadly nodding his head) To be sure, to be sure, good Socrates. But I am told that there is little which can be done to remedy the situation. The conservative party has closed ranks, despite the fact that there are many among its members who lament this action.

Soc: Such behavior is outrageous and unbecoming of statesmen!

Hippo: Alas, Socrates, there are few statesmen left in our time. Plato has informed me that this plot has been years in the making, for no other reason than to discredit the president and his program.

Soc: It would appear that politics is alive and well in our Athenian economy.

Hippo: Indeed, the Athenian Times reports that the current budget brinkmanship is just the latest development in a well-financed, broad-based assault on the health law. It gives one pause to wonder at the extent to which our politicians will go to rescind it, even if that means not funding the government and refusing to raise the debt ceiling, which would all but ensure a global Athenian default.

Soc: How small the problem of pain in my hip appears in comparison! Perhaps the mad hatters in the party of tea should consider hemlock.

The new norm

I’ve known this mother for a long time. Far from wet behind the ears, she’s raised four other children, mostly on her own after her divorce several years ago. She’s never been one to run to the office for every sneeze and sniffle. If she brings one of her children in to be evaluated, it’s usually for a good reason. more»

Interested readers can peruse my latest JAAPA Musings blog post, newly published in the Journal of the American Academy of Physician Assistants.

Humane Medicine — Just passing through

I watch them go — a new family I will most likely never see again. They’ve played by the rules, but got burned by the system. Lose your job, lose your health insurance, lose your doctor. more»

Interested readers can now access my latest Humane Medicine columnTransitional Medicine: Patients who are just passing through — recently published in the Journal of the American Academy of Physician Assistants.

“Notes from a Healer” — Frustrated

These are the days of pediatric practice that try clinicians’ souls.  more»

My latest installment of Notes from a Healer — Frustrated — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.

A Socratic dialog on health care reform (VII)

Socrates pays Hippocrates another visit to discuss the latest political rumblings concerning the health care reform legislation.

Hippocrates: Good day, Socrates. I see that you walk with the step of a healthy man these days. I trust the former injury to your foot is now well healed.

Socrates: To be sure, my good friend and physician. Once again I find myself healed well, if not well-heeled. (chuckles to himself) But tell me, Hippocrates, what do you make of the recent resurgence of heated political debate in the Senate concerning our newly passed health care law?

Hippo: Ah, my good Socrates, know you not that the opposition has sworn to dismantle the law even before it is enacted? For they have sworn an oath to have it annulled before the legislative session is brought to a close.

Soc: By whose authority?

Hippo: By the mandate of the voters in the mid-term elections of last fall. The opposition is claiming victory on the basis of the mandate for change.

Soc: But I was of the understanding that the law contained many desirable provisions to enhance the coverage of health care for the citizens of Athens—forbidding third-party payers to deny coverage for preexisting conditions, guaranteeing the portability of coverage, removing the provision for lifetime caps on payments for care, and so on.

Hippo: What you say is true, my friend. But those of the opposition argue that the law is unconstitutional because it mandates coverage for all citizens—

Soc: (breaking in) Excuse me, Hippocrates, but is that not a good and desirable thing, to have coverage for all our citizens?

Hippo: To be sure, it is—but in this instance the law mandates that coverage be purchased by individual citizens if they have no provision for coverage from their employer.

Soc: I was under the impression that universal coverage was to be enacted as a right of every Athenian citizen.

Hippo: Alas, the single payer option was defeated in the preliminary debate. The lobbyists for the health insurance industry made certain of that through the influence of much silver coin in the pockets of the politicians. Likewise, the sorcerers bought their influence to insure that the price of pharmaceuticals could not be negotiated in the Agora.

Soc: It seems as though that which began as a good and noble idea has been degraded through bribes, trickery and quiet whisperings behind the scenes.

Hippo: Legislation is crafted much in the same way as sausage, good Socrates. In each instance the process is best left undisclosed to prevent a sudden surge of nausea and queasiness of the stomach.

Soc: Tell me, Hippocrates; is there no way to retain the noble points of the law while discarding the undesirable tenets?

Hippo: Undesirable to whom, Socrates? To those with influence and power? They will see the entire piece of legislation rescinded before compromising on these points. In the end we live in an era where the winner takes all in politics.

Soc: But our Athenian government is based on the premise of democratic rule. Ultimately, the people decide their common weal.

Hippo: Have you not heard that our supreme court has ruled that the multimillion drachmae corporations must be considered as bona fide entities having a political voice? A fist full of drachmae speaks louder than the jingle of pennies in a purse.

Soc: Then our democracy—

Hippo: Is but an oligarchy, my dear Socrates. Or better stated, a plutocracy in which the great wealth of the few controls the destiny of the many.

Soc: And what of the middle class, those of the artesian guilds and such?

Hippo: Alas, Socrates, they continue to disappear from the Athenian social strata. The gap has widened between those who have and those who have not.

Soc: What! Is there no political solution to this dilemma, Hippocrates?

Hippo: Perhaps, Socrates. You should pose that question to your old student and politico, Plato. He might be able to offer a feasible plan. I’m told he spends his days engaged in drafting a treatise that deals with such issues. He calls it The Republic.

Soc: Indeed, he has written “the price of apathy towards public affairs is to be ruled by evil men.”

In and out of medical practice

At the age of 46, disillusioned with modern medical practice, Dr. Margaret Kozel decided to end her 17-year-career in primary care pediatrics. She cites some of her reasons in her blog post, Confessions of a worn-out pediatrician.

“Our system of paying for health care and the stresses on today’s families were pitting my best medical judgment for the child against all the other worries and desires of the parents,” Dr. Kozel writes. “The economics of health care trickled down into my exam room, into the conversation between doctor and patient, distorting the relationship.”

High on her list of complaints are the inequalities inherent in our American healthcare system. Those who need pediatric care the most—poor and underinsured children—are the least likely to access it. And in those cases where health care is available, third-party payers dictate standard of care, sometimes with substandard results.

“Private insurance companies decide who gets paid for what, so pediatricians treat serious mental illness with little psychiatric training, use nebulous tools to diagnose attention deficit disorders, and valiantly tilt at the windmill of childhood obesity not because we can do this most effectively, but because we are the only professionals who can get paid to do so.”

“At the other end of the treatment spectrum, free market forces often urge us to over-intervene with minor illness, where less really would be more.”

“Clinical truth has only grown more obscure since my medical school days,” Dr. Kozel muses in a separate NYT Well blog post. “Today, as we take on the hard work of health care reform, doctors continue to work under an avalanche of pharmaceutical marketing, malpractice threats and shortsighted health insurance strategies.”

“In an age when public health issues like obesity are what pose the greatest threats to our children, pediatricians will need to move out of the confines of the fee-for-service exam room to advocate for effective healthcare policy in the wider community.”

Dr. Kozel has fleshed out her career in and out of medicine in her book, The Color of Atmosphere. Interested readers can glean much of her sentiments from an online video interview here.

Despite her misgivings, Dr. Kozel maintains a positive outlook for the role of pediatric healthcare in the future.

“I believe our society will eventually see the economic sense and moral imperative of universal health care coverage, paving the way for healthcare to be designed by health professionals, and to be viewed as a right and a responsibility, rather than a commodity to be purchased. I believe that pediatrics can evolve, too, in a way that will truly meet our society’s health needs.”

Follow Dr. Kozel’s opinions on these and related issues at Barkingdoc’s Blog.

Memes and the evolution of medical practice

A meme is “a postulated unit of cultural ideas, symbols or practices, which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena.” The British evolutionary biologist Richard Dawkins postulated this concept in his 1976 book The Selfish Gene to explain the spread of ideas and cultural phenomena in evolutionary terms. Susan Blackmore, the British psycho-theorist, further developed Dawkins’ theory and believes that we are moving toward a new form of meme, the teme, which is spread by the technology we’ve created.

If we consider for the moment that memes do indeed exist (and their existence is far from certain), we could postulate that medical memes propagate through the medical community via medical journals, lectures and mentors. Published research eventually generates new approaches to the diagnosis and treatment of disease. Much contemporary medical research in the U.S.A. is underwritten by the pharmaceutical industry.

Nowadays, children routinely take medication for chronic conditions such as allergic disease, asthma, ADHD, depression, diabetes, gastroesophageal reflux and hypercholesterolemia. A spate of recent articles documents that 1 in 4 children covered by health insurance took some form of prescription medication in 2009. Annual spending for prescription drugs in children increased by 10.8 percent the same year, and the price of branded prescription drugs increased by 9.2 percent. Clearly, someone besides the patient is benefiting enormously from these trends in medical practice.

As a clinician who has worked on the front lines in ambulatory pediatrics for 30 years, I can vouch that these statistics seem to be supported by what I have observed over the past decade. The sheer number of children who take daily prescription medication for chronic conditions is astounding; and in my opinion these numbers will only escalate exponentially.

What drives these trends? Are clinicians becoming more astute at recognizing and diagnosing these conditions in children? Are the conditions themselves growing at an alarming rate secondary to cultural influences such as high fat diets, readily accessible food, over consumption of calories, unlimited access to TV and video games? Are parents themselves at fault, seemingly unable or unavailable to rear children with their best interests in mind?

Although any or all of these factors could potentially contribute to these disturbing trends, might medical memes—those ideas which seem to infiltrate medical practice and become acceptable norms—also play a role here? Are we clinicians too quick to reach for the prescription pad at the expense of taking time to offer wise counsel to our patients?

Some memes may replicate effectively even when they prove detrimental to the welfare of their hosts. According to Dawkins, “systems of self-replicating ideas can quickly accumulate their own agenda and behaviors,” which ultimately might prove to be good or ill for society, culture and the population at large.

Perhaps the medical profession needs to examine itself and take a closer look at what drives contemporary medical practice. In the meme, that might be a good thing.

When the soul breaks

I read Joan Savitsky’s recent New York Times piece with profound empathy for the author—and for a good friend of mine, both of whom are physicians.

Dr. Savitsky narrates what it was like living through four years under the threat of an impeding law suit for purported malpractice.  A young woman under her care had succumbed to an aggressive cancer, and the family elected to sue Dr. Savitsky for “malicious, willful, wanton or reckless” conduct.  According to the wording of the complaint, she had acted “negligently, carelessly and without regard” for her patient’s health.

Reading through the piece, I readily identified Dr. Savitsky’s feelings as very similar to what my friend experienced when he found himself in a similar situation.  Legal action was brought against him by the grieving parents of a child he had cared for in the newborn period.  Despite timely diagnosis and intervention, the child succumbed to an overwhelming infection.

In both cases the litigation process dragged out over an extended period of time.  Dr. Savitsky’s was eventually dropped (the plantiffs’ attorneys felt they were unlikely to prevail); my friend’s case went to court and the jury acquitted him of any wrong doing.  From the standpoint of these physicians, although both cases had favorable outcomes, a certain damage had been done.

Dr. Savitsky divulges that she left her primary care practice after almost thirty years.  She writes: “I can’t say it was because of being sued, but I can’t say it was irrelevant either.”  After his courtroom debacle my friend retired from medical practice for nearly a year.

My friend comments that “a lawsuit is a life changing experience, perhaps similar in scope to losing a loved one.  I suppose it involves losing that part of yourself that was ‘secure.’”  In short, it breaks your soul.

While unfortunately there are those physicians who seem to care little for their patients, the majority of doctors do desire to provide those entrusted to their care with the best they can offer.  When the outcome sours, it is not only the patient or the patient’s family who suffers.  When the patient elects to sue, the physician experiences feelings of betrayal.

In the face of failure, most clinicians grieve privately in their own way.  They examine the facts of the case; they ask themselves if there were anything they could have done differently to alter the outcome.  Many times the answer is no.

The sad fact is that, when all is said and done, physicians who have been sued are changed people.  Many of them are resilient and return to medical practice—with a healthy dose of mistrust and a touch of paranoia.  Others elect to leave the profession entirely.  Those who continue to practice remain vigilant, ever mindful that at some point they can be sued again.

Broken souls take time to mend; some never heal entirely.

“Medicine in the time of the EMR” posted in YJHM

The EMR, we are told, will help cut healthcare costs.  When medical records are converted into digital format, data will be instantaneously available to all providers caring for the patient.  Clinicians will have carte blanche access to previous laboratory and radiological studies, thus insuring that such investigations are not performed repeatedly or needlessly.  Data will be collated and scrutinized to insure that standards of care are met and that medical errors are eliminated.  Electronic billing will become the norm.  One day patients might even be able to schedule their own appointments online.  Somehow all this will serve to lower costs and improve the efficiency and quality of healthcare delivery.

Indeed it might.  But in my mind healthcare delivery is something different than the practice of medicine….>>more

My latest essay, Medicine in the time of the EMR, is now posted at the Yale Journal for Humanities in Medicine blog, a companion blog for the Yale Journal for Humanities in Medicine.

A Socratic dialog on health care reform (VI)

Toward the evening of a long day of discussions with Aeschylus, Plato, Aesculapius, Apothos, and Litigius, the philosopher Socrates makes his way to the home of Hippocrates, the father of medicine.

Socrates:  Hail, Hippocrates!  Are you at home?

Hippocrates:  Socrates, good fellow, welcome!  Come in, come in.  But I perceive that you walk with a limp.  What ails you, my friend?

Socrates:  An infection on the sole of my foot, Hippocrates.  I consulted Aesculapius, who cleaned and dressed the wound; then purchased an antibiotic potion from Apothos.  The rubor and dolor have already begun to subside.  But enough of my woes.  I came to consult you on a related matter:  that of the state of contemporary medical practice in Athens.  I desire your opinion on our health care system, as there is much discussion in the Agora and the Senate.

Hippo:  Ah, yes; as of late I’ve had my ear attuned to these myriad discussions myself.  Truly, they have become intricate and arduous, a snare to all who dare to enter into the fray.

Soc:  Fair Hippocrates, if you, the father of medicine, find these discussions convoluted, can the rest of us hope to make any meaningful sense of them?

Hippo:  I dare say that it would be difficult.  But I shall endeavor to enlighten you as best I can, Socrates.  Ask away, and I shall mix you a bowl of wine in the meantime.

Soc:  I appreciate your hospitality and willingness to dialog with me, Hippocrates.  Now tell me, what is your opinion of the system of health care delivery in Athens?

Hippo:  In a word, broken; although it pains me to say it.  The system has devolved from what I had originally envisioned it to be into a massive and complex enterprise of business.  All relationships are now contractual, defined by the solicitors and their ilk.  Products and services are bought and sold in the medical marketplace like milk and meat in the Agora.  All participants profit at the expense of the citizenry.  The cost of care escalates, and from what I read, the system will soon be unsustainable.

Soc:  How did all of this happen?

Hippo:  It is the fate of mankind, Socrates.  All men want just one thing:  a little more than they already have.  More silver, more material things, more pleasure—and longer lives to enjoy it all in.  Health care is no exception.  The more we create, the more we consume.

Soc:  But speak to me of the health of our citizens, Hippocrates.  Is it not vastly superior than it had been when you first formulated the tenets of medical practice?

Hippo:  In some aspects, yes.  We have managed to lengthen the average lifespan of our people through improved housing and sanitation services.  Overall, we enjoy a more healthful diet.  And when it comes to intricate technology, we lead the entire Mediterranean world in procedures such as open heart surgery, organ transplantation, and artificial joint replacement.  Yet this has come at an enormous price to our society.  Many of our citizens are still unable to obtain basic health care.  It grieves me deeply to read of the numbers of children who fail to receive their immunizations and in some instances proper nutrition.  At its inception I had envisioned that the system would care for all of our citizens, not just those who were well off.

Soc:  I perceive a certain sadness in your words, Hippocrates.  There is much wrong with the system, and yet much is to be admired as well.  Certainly you have strived to elevate ethical practice in the healing arts.  Why, look at the oath that you and your students have drafted—an example of high ideals and excellence of care.

Hippo:  True, perhaps; but I fear that the system corrupts many of those who elect to practice the art.  And many of those it does not corrupt experience burnout and choose to depart the ranks of the profession.  You see, Socrates, we have amassed a great deal of knowledge that has allowed us to immensely improve the health and longevity of our citizens.  But what we lack, what we truly lack, is the wisdom to guide us in meting out the resources of care.

Soc:  I understand that 4 out of every 10 Athenian healthcare drachmae are spent on caring for the old and the infirm at the end of their lives.  Is that true, and if it is, can you enlighten me as to how this came to be the case?

Hippo:  Indeed, it is true.  Many families desire that every effort be made to prolong the lives of their elders, even though the situation is hopeless in many cases.  A good deal of silver is spent shunting patients back and forth from assisted living facilities to hospitals, where procedures of questionable merit are performed, instead of allowing nature to take its course.

Soc:  But surely we can not stand by and allow our elderly to die when we have the means to restore them to health!

Hippo:  Restore them to health, or merely prolong their existence?  I need not remind you, my dear Socrates, that unlike the gods, we humans are mortal.  At some point our bodies will wear out and pass away.  Death, merely the last stage of life, will eventually hush us along.

Soc:  I perceive now that your title of father of medicine is one well bestowed, Hippocrates.  You are not only a healer, but a philosopher as well.  But, to return to our previous line of thought, where can we procure the wisdom to guide us in formulating a more just and equitable system of health care delivery?

Hippo:  You, the wisest of all men in Athens, ask that of me, Socrates?  It is I who should be asking that of you.

Soc:  But in truth, Hippocrates, I recognize that I know not the answer to this dilemma.

Hippo:  As you well know, Socrates, admission of ignorance is the wisest place to begin a rational dialog.  If we can come to an agreement on the problems, perhaps then we can hope to ameliorate at least some of them.

Soc:  If we should find a remedy to this medical morass, I must remember to ask Crito to sacrifice a cock to Asclepius.