Boreal B[l]og

A while back, my wife got a call from an ultrasound tech, who was shaking, she was so upset.  A young individual, in their 20s, who recently had an uncomplicated appendectomy, had presented with abdominal pain.  There was gas in the liver and no portal vein was visible on the ultrasound.

CT was not performed with contrast, due to the elevated creatinine.  But another “old fashioned study,” a contrast BE, had shown, on separate days, nearly no movement of contrast except through a tiny lumen, suggestive of an intussusception.  I was interested in the fact that high tech studies, with high costs and high radiation doses, didn’t make the diagnosis in this woman, but controlling imaging studies and radiation in medicine appears to be another issue where I speak out alone.

The young person died.  Yes, people die here in Arizona from appendicitis and uncomplicated appendectomies.  I appear to speak out alone when I ask why we aren’t learning from these cases.  We should drive the mortality rate from appendicitis to zero.

This person did not live in Saddlebrooke, Cobblestone, one of the country clubs, and have a seven figure income or an eight figure net worth.  I am not sure who is going to pay for the costs of care, which were limited by the early death.  But how do the young and uninsured, who have appendectomies, or even mesenteric adenitis, pay for the costs of an ED visit with a CT scan?  Many are young, gorgeous, and broke, to quote Suze Orman.

I will ask my colleagues again where the money is coming from to pay for care for all Americans, since the young, who think they will live forever, won’t, and they can have catastrophic medical issues, including bad motor vehicle accidents.  We have pretty much tried to say vaccines are bad, radiation good, evolution didn’t happen, the Earth is a few thousand years old.  I am waiting for the concept that young people don’t get sick and the rest of us don’t really die.  I once reviewed a paper for a right-wing medical journal (volunteer, of course), that purported the FDA killed 10,000 people a year by not allowing drugs on the market.  The statistics in the paper were awful.  And I still remember thalidomide.

As a matter of fact, I wonder what will happen if we do away with social security and Medicare.  My wife and I will survive, so long as we don’t have a catastrophic illness, but when insurance companies will have premiums high enough to cover their overhead (read: eight figure salaries), we may become old, not so gorgeous, miserably ill, and broke.

Most people who live to ninety have some degree of dementia.  It is a fallacy to think we will live to a ripe old age, and then, just before bad things happen, quietly die in our sleep.  Visit a few nursing homes if you wish.  Heck, there is a life at any cost group that will keep me alive even if my wife doesn’t want me to suffer.  Or keep her alive, when I don’t want her to suffer.

The facts are these:  most women over 85 are widowed, and a lot fewer men.  Let’s look at the women.  Most are not living at La Paloma having nice dinners with their friends at 85.  Most are trying to get by, not clear what the bills mean, are subject to scams, can’t get around well, and fear for their safety.  Maybe they have children, maybe they don’t.  The children have lives of their own.  Come on, we all know the picture here.

Suicide by poverty will join suicide by cop as the new America.  We aren’t as fortunate as the African Dik-dik, who dies, when his/her mate dies.  Some of us just keep on going.  That’s fine, until we need to stop keeping on going.  I know what that is for me, and I have it in my living will, so clear that even somebody who lives in Arizona can understand it.

But I have left my point:  how do we figure out a way to care for people who have catastrophic needs at any age?  Is spending $400 billion a year on war (defense is such a nicer word, but it was once–and still should be–the Department of War) really appropriate?  After 9/11, I said that we needed covert operations, which would be far more effective, to deal with terrorism.  Two wars and a decade later, a small, brave group of men killed Osama bin Laden.  He could have been dispatched without the money and lives lost in either war.

In these pages, I have offered a host of solutions, not one of which has been adopted.  That is unfortunate, not because I didn’t get the credit, but because those who were in power have not solved the problem.  We can and will, as soon as we say, “We can care for everybody in America appropriately, and we can pay for it.”

Then it will fall upon us to figure out a way to do it.  Once we make up our mind it will happen, we will find a solution.  Heck, I might even come out of retirement to offer a few thoughts of my own.  Ten, twenty, and thirty years ago, they were ignored.  Maybe now they won’t be.

Many years ago, as a hospital medical director, I attended a meeting we had with one of our payers.   I remained quiet throughout most of the meeting, and when the time was right, I spoke.  I process slowly, but I process well.

When I spoke, the mood in the room was tense.  I summarized the payer’s points, asking whether I was correct.  I wasn’t, so I continued summarizing until they agreed that I had understood them.  The tension went out of the room like air out of a balloon.  I don’t remember who “won,” but I learned something that day.

During my tenure as medical director, I received many complaints about the hospital and doctors, and I handled them the same way.  Rather than defending, I summarized the complainant’s points, discovering that I could hear tension go out of a telephone conversation, too.  People were amazed that somebody was listening to them.  Sometimes, that’s all people want.  Try it with your spouse some time.

I was asked to debate climate change.  I try to do things that will make a difference, and my debating climate change is not going to change policy.  Debating requires good public speaking skills, which I have, but only when I teach.  I doubt I will teach anybody anything in a debate.  Debating also requires fast processing skills, which I do not have.  That is why I am a writer.

Debates also have other problems, too.  They have winners and losers, and winning and losing have become toxic.  The desire to win has overshadowed the desire to look for new solutions.  Steve Jobs was deeply flawed, but he had the ability to move people to find solutions to problems that they thought impossible to solve.  We need that sort of approach in medicine.  Debates don’t offer it.

In medicine, we would have done well to have first studied the efficacy of  CABG, CEA, angioplasty, stents and EC-IC bypass.  Had we, millions of people would have been helped or not harmed.  Of the five, only EC-IC bypass was properly studied, and we found it didn’t help.  The scientific method is more helpful than the often screaming debates I heard, sometimes directed at me in the case of CEA.

In the past 15 years, national discourse on many topics, at one time bipartisan, disappeared. There are several reasons, but it is a fact that many issues that are scientifically based, and should be treated that way, have become politicized. Such polarization is toxic, and it can be transmitted.  I caught it.

The idea of seek first to understand, then to be understood, Covey’s Fifth Step, is one of the most powerful.  It goes with “if you want to influence people, you must first allow yourself to be influenced.”

I’ve also been guilty of misuse of the language, using such words as “most”, rather than “many”; adjectives and adverbs I chose might have been better.  Words matter.  I am deeply concerned about Internet anonymity and the loss of critical thinking skills; lessening of emphasis on science and math education might be the cause.  Apple outsourced to China in part because we didn’t have the engineers here.  We have far too much name calling, prejudice–not just in the racial or religious sense–but politically.  For those like me, who process very slowly, this fast-paced prejudice puts me at an disadvantage, for if I process, often the conversation is over without my participation, and if I don’t process, I risk saying something I later regret.

I’m often glad I’m pushing 65.  It isn’t always fun, and with each passing year, like the great tight end Jerry Rice, I have to work harder and harder to do the things I have done all my life, knowing at some point, I will have to hang those things up.

But I am glad I won’t be alive in a world that will be people rich and resource poor.  Wilderness will disappear.  Quiet is disappearing, too, along with our great heritage of dark skies.  I do not want to live in a crowded world, where I can no longer find solitude in the wilderness and feel more comfortable there than with a lot of people.  The first thing I notice in Europe and Asia is the pushing and shoving.   The second thing I notice is the smoking.  The third thing is the relative lack of obesity, the fourth the number of solar panels in a latitude 20 degrees further north than the one I live in.  Europe has wonderful public transportation, polyglots, downtowns that work, and good use of the available space, which is not a lot.

There are many softer words in our language; we would do well to use them more often, in hope that maybe others will catch on.  We need to discuss medical care in this society, not debate it.  I don’t know what the right system will be, but many of us think it needs to be changed.  The irony is that not all of us are doctors or payers, but all of us are patients at one time or another.  That gives us something in common.  How should patients be treated?  How do we pay for it?  How do we do what is necessary and avoid what is not?  How do we die, when it is time?  When and how do we deny care, because we simply can’t afford it?

It is easy to criticize.  It is far more difficult, but far more rewarding, to first ask “Let me see if I can summarize what you said, for it is very important I do so correctly.  Please correct me if I make any mistakes.”

I hope I am not mistaken when I say that hopefully we still have time.  But not much.