Wednesday, August 9, 2017

Fundaments II: The Societal Importance of Healthcare

I hadn't even put my soapbox away from the other day and now I find another use for it.. It's too tempting to climb onto it and make one more pronouncement.

The most frequent question asked about Healthcare today (and by "Healthcare" I mean access to and insurance for) is whether it is a right or a privilege. Without staking out either side of the proverbial aisle or commenting (for now) on the means of providing healthcare, I will state that this debate misses another definition, probably the most important one. 

There is no question that Healthcare is a responsibility.

From a societal standpoint, it is not a matter of whether we can afford to pay for access to proper medical care, including both preventive and responsive treatment. It is whether we can afford not to.
Uninsured medical care is a huge burden on the financial well-being of this country. The mere fact that you don't have insurance does not protect you from medical calamities. Accidents and illness must be treated whether they can be paid for or not. Our society in its civilized state has quite rightly accepted this as fact. But even if you believe insurance is "fake money" the resources used to care for the sick and the injured are very real. Real instrumentation, real medicines, real space and real manpower are utilized. The money to pay comes out of taxes, charity funds and federal grants-in-aid. In other words everybody pays when patients are uninsured.

Beyond the financial issues though are the rather terrifying public health ones. There are few areas of the country where people can truly retire from the world. Some folks may have cabins in the woods or yurts in the dessert. But the vast majority of Americans, even in rural parts, live in defined municipalities. Most have some shared water source, shared public space (schools, church, stores) and some need to interact on a regular basis with other citizens.

Can you imagine a country where medical care is unavailable or ignored? A country where infectious disease is untreated despite continued social interaction? Where the contamination from illness is left uncleaned and unmanaged? You don't need to have too vivid an imagination to see the results. It has happened in this country. Google the Spanish Influenza of 1919 or the Polio Epidemics of the '30s and '40s. Imagine what SARS might have been or Ebola without proper healthcare and containment.

These are horror stories but not scare tactics, unless you are one of the growing number of young and healthy folks that is convinced that they will remain healthy and immune forever. Only if you can promise that you will never get meningitis or hepatitis, never fall and have a head injury, never be struck by a car or a falling object, then you need not buy into the societal protection that is insurance. But only in those remote shacks or distant huts can you assure that you will never burden a community with the detritus of your health issues. Even then, the mountain, forest and desert are interconnected ecosystems. They can be poisoned by death and disease as surely as a village, town or a city.

Not having insurance when you can is a personal choice but a uniquely selfish one. Not providing the means of access to healthcare to large portions of the population is a cruel and dangerous mistake.

Thursday, July 27, 2017

We Are All Charlie Gard

In medicine, less frequent than in politics or entertainment, there are cases which rage in the public imagination. Most often they are about end of life decisions, usually of a younger individual for whom the treatment options have run out and the decision to “pull the plug” is fought vehemently in the wards, the courts and the press.

It is rare, thank mercy, for such a case to involve a newborn. But the tragic situation that unfolds in London with Baby Charlie Gard is one of those rare and horrific occurrences. The child is dying, born with a syndrome that rapidly degrades DNA in the energy supplying portions of his cells. His family wished to pursue experimental therapy in the hopes of survival but the medical establishment and the courts would not allow them to do so.

It is easy to side with Charlie’s parents. I cannot imagine the horror that the young couple is living with, knowing that their little child is terminally ill without hope of rescue or cure.  Like everyone else, I pray for the miracle that will allow the small boy to survive while knowing that such a miracle does not exist.

But this is not a case where there are good guys and bad guys, despite how it is often portrayed in the inflammatory headlines of the press and social media. I wrote that it is easy to take the parent’s side, but that is tempered with the fact that the parent’s side is neither realistic nor necessarily kind. There is no cure for Charlie’s condition. Even if the therapy were to work the best hope would be stabilization. But no one, not even the expert in New York who offered treatment, can predict Charlie’s condition in the future or his prognosis. No one can estimate the cost and effort that will be required to keep him alive or what his quality of life might be. My heart cheers that his family has said they would do whatever it takes to keep him with them, but no one should have to face such an unimaginable and indefinite burden.

Nobody wants Charlie to die. There is a tendency for lay people to use terms like “The doctor gives him six weeks to live,” or “the doctor says he will never walk again,” as if the provider is condemning the patient to his doom. Perhaps doctors are at fault because we explain prognosis in such a detached manner that it is easy for us to seem remote or callous. But doctors don’t choose the outcome. We merely predict and facilitate. No one, beyond the family itself of course, would be happier if Charlie were to survive and thrive than the doctors at Great Ormond Hospital who had to make the decision to remove care.

But there is a side that is not represented in the discussion, and that is Charlie’s. The parents should have the right to make decisions for their child but those decisions should be based on what might be best for him and what the best medical information reveals about his disease course. It cannot be enough to say they want to keep him alive and will love him through whatever life gives him. Charlie, were he to survive, would have no ability to report pain or hunger or thirst. He would have limited independent movement. He would probably never develop speech. If he could see, he would be unable to interpret images beyond the flashing of lights. And he would most likely die at a very young age.

Charlie’s parents have been put in an impossible position. The ethics committees, the doctors and the courts have provided a support for them to make the unimaginable choice, to allow their child to pass away. They, and all of us who are engaged by this case, must look at all the resources and think what is best for the small and voiceless soul that is Charlie's.

Wednesday, June 28, 2017

Fundaments I: The Essence of Healthcare

In general, I steer clear of overt political statements. This in itself is a political stance in a time of hyperpolarizaion. Politics is not what this post is about.

The problem with Healthcare (capital H) is that the term has been politicized to the point that you almost have to shade the word red or blue whenever you write it. Like many words today ("liberal" and "conservative" being two obvious ones in this context) it has lost its meaning in the jumble of policy and polemic that usually accompanies discussion. Talking about the Dread Healthcare means taking a stand for or against one administration or the other; one law or another; one belief system or another.

None of this could be further from the fundamental definition of healthcare. There is nothing political about giving or receiving medical or wellness assistance - it is a normal human activity and in all probability has always been so. Ancient Egyptian mummies show signs of medical intervention and even earlier human remains show that the species has always tried to fix what was physically wrong.

Skull from Early Dynasty Egyptian tomb showing cranial trepanation during life.

In point of fact, the actual act of providing health care is no different now than it was in past centuries. An ailing soul presents to an individual who has some interest (if not expertise) in medical care. The provider assesses, diagnoses and lays on hands in an effort to cure. The laying on may be surgical or prescriptive or acupunctural or spiritual. The essence is the same.

The controversy is not about how the care is done or whether it is done at all. It lies in who can access the care and how it will be paid for. I'm quite sure our earliest ancestors felt the same way as we do, arguing about how long they had to wait in a drafty cave and how many bird eggs the shaman demanded in payment for the intervention. Humans always will question value.

But to lose the essence of medical care as we are now doing in the convolution of policy and economics is both short sighted and dangerous. Any law or any regulation should be written for the express purpose of facilitating the basic practice of medicine. Any law or regulation that interferes with this process or makes it harder to attain the care needed must be discarded.

Tuesday, June 20, 2017

Singing A New Song

About a year ago, my wife accepted a new position in Dallas, TX. It was an academic dream job for her. Once it was apparent that Dallas was a great city to live, there was no hesitation in supporting her career and making the move.

As with any major change, the move brought me to a branching point in my career. Would I open up another solo practice? Would I try to join one of the many established groups in my new city? Or would I take the leap into a different career focus - one of consulting on practice implementation and teaching on healthcare?

Several important factors led to my decision to follow the latter path. First, I am not quite the ingénue I used to be. Pediatric specialties require a long start up time. One needs to earn the trust of the community and of the parents before a practice is seasoned and established. At my age, I wasn't sure I would have time to devote myself to a building process, not to mention for the long-standing attachments that inevitably develop.

Another factor is Dallas's saturation with excellent pediatric orthopaedists. I know them all well and can unfailingly recommend them all. Although I flatter myself to think I would have been welcomed in their numbers, I could hear them say, "But where will you find your patients?"

The final and probably most compelling factor was an opportunity to embrace the role of teacher and mentor. I have always been academic at heart and the siren song of instructing was too great to ignore.

So here I am - same voice but singing a different song.

My consulting service is focused on returning providers of all stripes to the joy that they once had in working in healthcare. I can safely and boldly say that I loved every minute of my clinical practice. and I believe that everyone who chooses to enter the service of medical care feels that or felt that way at one point. Now, in an age of noise and uncertainty, politics and polemics, it is difficult to remember. Why did we choose to become doctors? Nurses? Therapists? Surely it was not to satisfy some policy written by a remote and monolithic government. It was to reach out and help others. As corny and as idealistic as that sounds, it is nevertheless the truth. What other reason would anyone have to devote so much time and sacrifice to such a difficult undertaking.

I am happy to have a platform to give voice to my ideas, even if only a few are listening. I have the opportunity to talk with providers and patients and policy makers - to learn and teach what medical care is all about. As such, this blog has been revitalized to serve as a place to record what I've learned. And hopefully a place to engage in dialogue with others.

Welcome back to my blog. I hope you enjoy the song.

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