So Much for Stirring the Pot

The problem, of course, with trying to stir up controversy is that you need mindless gullible folks who think with their emotions, respond from their gut with kneejerk vehemence in order to do it right. To the best of my knowledge, I don't have any readers like that and, if I do, they don't generally show up in my comments.

Since my readers are overwhelmingly intelligent and thoughtful, they gave courteous considered answers that made sense, which, although not adding to the controversy, does make for a much more pleasant conversation.

Now, the Mother and I spoke of many other things regarding healthcare reform. I'm going to include many of them and I won't be making a distinction between ideas she had and ones I had. That's not entirely fair to her, of course, so I encourage you to assume the ideas you like are hers and the ones you don't are mine. That ought to even things out nicely. That and she is encouraged to jump in if I've misrepresented her views in any way.

The Mother and I address this problem from different directions. I don't know that we are looking for different results (though I suspect we have different levels of confidence that anything appreciable will be done to address it any time soon), but we are seeing it from different sides. I am looking as a patient, as a citizen, where prices appear ungodly high and, though I have good insurance that reduces it drastically (a) the costs are still very high for a quite healthy family - aside from the high cost of the insurance itself - and (b) I know personally half a dozen families devastated by the high cost of medical care for a loved one. And that's aside from the millions in this country who have no protection. Not only are they not cared for in a way that could preclude serious maladies, because they have no insurance, medical care when they have serious conditions are much more costly and still fall on us to pay - in medical costs for those costs absorbed by hospitals (and higher insurance premiums and copays as a result) and in higher taxes.

The Mother (paraphrasing from our conversations) doesn't see a way to reduce costs without making some serious changes to how we do things. Cost reduction must include (some of these are mine):

• Reducing outlay for the care of those who have no chance of survival and no quality of life - to what degree, well, there's a debate (as I discussed yesterday). This includes limiting care for those who will not help themselves.
  
• Tort reform to limit malpractice to a reasonable level and assure that cases are not tried that are not based on solid fact. Malpractice insurance, even for successful doctors, is outrageous and, believe me, that increases the cost for all of us. Don't think that the fact that we have the highest healthcare costs is completely unrelated to our rampant litigiousness. Even clearly baseless lawsuits can be expensive because the one suing is not held responsible for the costs (something I'm all behind).
  
• Administrative costs. Most doctor's offices have more staff to deal with (often fight with) insurance companies/medicare/medicaid and submit 18 kagillion different forms in triplicate to get reimbursement often months later. Money spent on administration goes into fees for service and money not spent on nurses or other medical support.
• Doing something about the high cost of medical education. Most doctors don't get to practice until they're practically in their thirties. That's a long time to live without a viable income aside from what can be hundreds of thousands of student loans. Doctors are a huge boon to any society, but the exigencies of becoming a doctor forces a certain level of greed on them just to survive and recover. It makes sense to provide some sort of subsidization, especially to encourage doctors to go into some of the less lucrative but undermanned subprofessions.
  

Now, the Mother is scared to death that a public option will be like Medicare, which, in her (and other doctors she knows' opinion) starves doctors for fees, reduces fees willy nilly whenever funds are cut without rhyme or reason. Clearly, there are other doctors who agree and, at least a handful who do not. I don't know what it's really like, whether it's an inherent problem with the system, whether the recent privatization is a factor, whether this is a side effect of having a vehemently anti-medicare faction in the government (either dominating Congress or the White House or both) since 1980 (with the exception of 2 years). Possibly, it is a factor of all three, but what I can say is that there is a significant potential for a public option to be mismanaged due to the political winds that blow and suck in Washington, because of factions that actively want it to fail will work to ensure it's failure, because a long term program is always struggling in an environment that changes the budgetary rules every year.

But, here's the thing, there are powers that very much want to have a viable healthcare system, one that doesn't leave huge swathes of the populace at a disadvantage, powers that want the right healthcare for everyone. They know very well that an option that doesn't work is more hindrance than a help toward their goal. It is very much in their interest (and surely the rest of our interest) to find an option that works because I believe very much that it's possible. The industrialized world beyond our borders is proof positive in my opinion that it can exist (and I find it every bit as compelling as the evidence of vaccination's great good).

In healthcare reform, in my opinion, involves several medical things and several nonmedical things. It's about reducing cost, preferably by removing as much from the equation as possible that isn't medical (and yes, that can include health insurance, but also administrative costs, protection against unreasonable lawsuits), while (a) improving care by reducing unnecessary errors (I'm of course for electronic records) and penalties for excessive secondary infections or surgical botching, and (b) providing care to everyone in a reasonable way, which, in my opinion, would also reduce costs associated with nonemergency medical care in an emergency setting, and reducing the burden of preventable disease. The cost of a mammogram is far less than the cost of treating stage 4 breast cancer, but people without insurance are going to end up with the latter if they can't afford the former.

It is about reducing the overall cost, but I don't see it, if it can be done intelligently, reducing the burden on the citizens because we're already paying for all those that don't care until its too late, by those who can't afford it, and, of course, for billions of dollars in profit to the health insurance "industry". Big pharma is a whole other topic, of course. I want to see a big change in where the money's going: to doctors and medical practicioners instead of lawyers and insurance companies - if we can do it, doctors won't go broke and we'll pay less than we did before. For better care.

Tomorrow, I'm going to postulate one way I could see doing it. So, if you feel like arguing, get ready. Or practice on this post. :)

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What Kind of Patient I Am

A week or so ago, I wrote a post about what I look for in a doctor. I used an article from the New York Times about a rather extreme example of what I was talking about and referenced a movie I liked. What I look for is a doctor that will explain what they want to do and why, that will listen when I have questions or issues. Someone who works with me rather than just "on" me. Someone who treats me with respect and dignity. Someone who is genuinely intent on my health. I maintain that's the kind of doctor I look for, what I think a doctor should be.

I should probably admit that effectively a professional skeptic, that I make my living questioning experts, challenging decisions, validating assumptions. Not because I don't respect experts, but because (a) everyone makes mistakes - the closer you are to something, the more easily you can mislead yourself (It's why I so treasure my novel reviewers.), and (b) if you're doing the right thing, you should be able to demonstrate why - which is really part of the scientific process, being able to hold up to scrutiny. In my world, an amazing (even frightening) proportion of decisions involve something called "engineering judgment" - like the "fact" that the foam impact couldn't have damaged the tile sufficiently to be dangerous on STS-107 (Columbia).

My father was a biologist. If there's one thing he taught me, it's that absolutes in biology are few and far between, so judgment is part of it. That doesn't mean that doctors aren't experts, who worked long and hard (amazingly so) at great expense in both money and time to get where they are. They absolutely are. It's just that people are amazing diverse critters and a jillion things that don't fit neatly with what's gone before.

When I wrote that post, the Mother, who is a doctor, pointed out that expecting to convince every patient of the right thing to do just wasn't feasible in many cases since many people were incapable of listening to reason or appreciating evidence no matter how compelling. And that a great deal of time can be wasted trying to do so. Almost immediately, on my other blog, Ask Me Anything, someone asked about the repercussions to other children of unvaccinated children. She could not have asked for a more excellent example for vaccinations are something that, for study after study, have been proven unconnected with autism, that have changed drastically the survival of children all over the world by protecting them from once ubiquitous disease, that still are seen as a bogeymen by people who should know better. She also pointed out this excellent rebuttal to the article I cited which, I might add, I agree with.

I have to concede the point.

So, I'll expand on my description of what I want in a doctor by what kind of patient one needs to be to make the partnership work. Because it's not a partnership if both aren't pulling their weight.

• You have to respect their expertise. I question experts, but I shut up if I they have a solid story and I don't challenge them unless I have cold hard facts on my side or uncover a pretty sizeable hole on their part. If they got the data or a reasonable explanation, I thank them and move on. I never assume they're wrong and the same is true of doctors. If I get to the part where I find myself doing so (i.e. many screw-ups), it's time I looked for a second opinion or a new doctor.
• I do my homework. I'm much more likely to ask worthwhile questions of a doctor (or an expert) if I know my symptoms, what my body's done before, my family history, did some information searching at reputable medical sites and took the time to get educated. If I've done so, they can save themselves the trouble of explaining the obvious and we'll both use our time more effectively. If I do have to question something, it will be for a valid reason.
• I listen too. This kind of ties in with the first one, but it's worth noting. A treatment, no matter how well explained, is useless if I don't follow it. If I've come determined that I know more than the doctor, all of their knowledge and science won't do any good. If I refuse to hear what they tell me, I'm wasting both of our time. And I'm not doing my part of the partnership. I have to not be a moron.
  
• I have to do my part. The appropriate treatment might actually be instructions for me to take to fix my own problem (lose weight, stop smoking, walk around once in a while, cut the salt); whether I like it or not, it's likely to help me help myself. They can't wave a magic wand and undo all the damage I do to myself. If I go into the doctor 80 pounds overweight, it's not the doctor's fault I'm short of breath or prediabetic or have elevated blood pressure. And they can't write a script to make that all better. I'm going to have to take steps to fix it or the end result is no one's fault but my own.
• I have to speak up. Knowing I'm allergic to sulfa or that my daughter's already had shingles isn't going to make any difference to the doctor if they don't know it. It might be buried somewhere in my chart (my pediatrician's have been digital for years), but the doctor has dozens if not hundred of patients to keep track of and a limited time in which to do so. I, on the other hand, have first hand knowledge that won't help the doctor if I haven't fully shared it. If I'm prescribed an antibiotic I don't recognize for the ear infection, I should make sure it doesn't have sulfa in it (which has happened to me). They are experts, but they're only human. They have a mob of patients to look out for. I only have me and my closest family.
• I have to be realistic. There's a limit to what they can do. If my father doesn't find out he has colin cancer until it's at stage four, I can't blame the doctors if he doesn't. He might, sure, but I need to appreciate that, in order attempt it, he's going to go through hell, it's going to be expensive and dangerous and uncomfortable. It's going to be a major factor in his life...and it still might not work. Or work indefinitely. If my baby is born weighing less than 19 oz, odds are good she won't survive and, in order to try to keep her alive, she'll spend months, maybe years, in intensive care, that it will be lonely and painful and miserable, a rough way to live your first year. If she survives, she'll likely to developmentally challenged and struggle all her life. And all that effort still might not be successful. Sometimes, when the situation isn't nearly that extreme, things happen and, despite our best efforts, someone dies. That's biology. There's an element of crapshoot despite all our modern medicine.

I still believe in a doctor who respects me, but I can't get there without respecting the doctor as well.

P.S., I read an interesting article in the New York Times today about getting support from others, even if you have something obscure, through the information superhighway.

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More on Health

I try to catch up, but it just isn't working. Ended up working until late at night for WORK so I'm just now starting my blog. Which means I doubt I'll get it all up before the night's out. Whew!

I mentioned some speculation about unforeseen consequences for our pill-poppin' tendencies in my last blog. But I kind of would like to continue that line of thinking with regards to the whole health care industry. Now, let me preface my opinions with an assurance that I know many health care professionals are dedicated and devoted. I don't intend to imply that problems I've seen are a condemnation of the whole medical profession.

However, there are some serious problems out there, whether they result from insurance issues or financial pressures or laziness - a tendency that exists in most professionals to find an "obvious" answer and then leave there without looking deeper. In certain professions, like space safety, that kind of laziness can get people killed (or at least spacecraft lost). This is also true for the medical profession.

Too often, in my opinion, an obvious answer is addressed without digging for the real cause. Treat a symptom without realizing what the real problem is.

Case in point, my mother-in-law, for instance, has been battling mini-heart attacks since she was thirty-seven (little less than a decade, by the way - yes, my husband's younger). She's gone into the emergency room multiple times. She's fought multiple bladder and other abdominal infections and pains that no one's taken seriously. So, two weeks ago, she went into the emergency room and someone suspected a gall bladder problem and gave her a simple blood test. There it was. Her gall bladder was 19 cm in diameter (instead of the normal 3) and filled to (literally!) bursting with 37 gall stones. And, yeah, the doctor thinks it's been a problem for ten years but no one ever checked.

Now, this is one person, anecdotal evidence at it's best, but can you honestly say you don't know a story like this? Someone calling in to the doctor with their four month baby's coughing but never able to get an appointment, but getting prescription medicine over the phone, only to force the issue and find out the baby now has pneumonia because she'd been given the wrong medicine? When she told me I'd made my baby sick because I'd given her the wrong medicine (that she'd prescribed), I vowed never to go back to that doctor. And I didn't.

A relative's son had surgery for an in-grown toenail. He ended up with a fever that the doctor repeated dismissed over the phone. Fortunately for mymy relative's son, my relative took her son to the emergency room when his temperature topped 103. But not, unfortunately, before he ended up with an infection in his bones that made for three very scary days in the hospital and took six months of IV antibiotics to overcome.

My poor mother-in-law has had a number of doctors that have not ever seemed to delve to her real problems. But I learned something listening to her struggles. I believe most doctors do their best, but, even under the best circumstances, they aren't going to understand your body as well as you do. They're going to know how many people react to certain medicines, but they don't know how you have responded or will respond. When it comes to your health and the health of your family, you had better be an informed consumer and know what's happening and what isn't going like it should.

People don't come with warranties and you can't just toss 'em if they break down. And, for all the uncertainties and unknowns that come with chemistry and physics, it's just a drop in the bucket to what we don't know about biology.

Just sayin'.

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