Cell 2 Soul: The Humane Health Care Blog

Is Healthcare a Right?

by Atul Gawande
New Yorker, October 2, 2017
Link

This is a timely and informative essay.

Gawande meets with some old friends in Athens, Ohio, where he grew up, to discuss their take on the question. It is kind of a trip down memory lane for him.

The meat of the essay comes about halfway through when he discusses the work of the Oxford political philosopher Henry Shue who postulates that basic rights include physical security, water, shelter, and health care. Meeting these basics is among governments highest purposes and priorities.

I think the goal should be security. No matter how bad things get this shouldn't be what you worry about, namely healthcare.
When people in a society get very different deals on things like healthcare, the pact with the government breaks down. That's what is happened with American healthcare.
The reasons go back to a seemingly innocuous decision made during the Second World War. In that time, the administration permitted increases in health insurance benefits and made them tax-deductible for employers. It didn't seem like a big thing at the time, but ever since we've been trying to figure out how to cover the vast portion of the country that doesn't have employer-based health insurance. Therefore, we had to stitch together different rules and systems for each of these categories and the result is an unholy expensive mess that leaves millions of people un- or under-protected. As a country, where pretty much everyone gets options like K – 12 schooling we've been reluctant to address the Second World War mistake and establish a basic system of healthcare coverage that's open for all. The prospects and costs of healthcare in America very wildly and incomprehensibly according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.
Do we want?

• Medicare for all
• Each state to have its own plan for care
• A nationwide market place where we all choose among a selection of health plans
• Or personal accounts that we can use to pay directly for healthcare?

Any of these could work. Each has been made to work universally somewhere in the world.

As a country, we don't have any of these at this time. Gawande's article is a lucid introduction to this area, and worth reading and studying for healthcare providers, the public, and all students.

Two Poems by Jane Seskin

OFFICE VISIT

At the Doctor’s
they’re quick to put you
in a brightly lit room
without a clock, close the door
so you think you’re next,
but honestly, you’re not.

I’m always cold sitting
on the paper-covered exam table,
wearing the short-sleeved gown,
magazine left outside,
shut away from the hallway action
where the staff is merrily chatting.

For years I’ve sat quietly,
patiently, nervously. Isolated.
But now, now I’m in mode of
older smart ass and I-won’t-follow-
your-rules, so I push open the door
… and yes, at long last I am seen.

GRIEF-WORK

I wrote my Mother
a love letter
on a yellow legal pad
a year after her death.

I described workshops taught,
poems published, trips taken,
friends seen, men dated
and at the end

recounted
the incredible loss I felt,
from her absence
in my life.

Then I burned the four pages
in the bathroom sink,
spooned the ashes
into three baggies,

got on a plane to Florida
and scattered the words of love
behind the condo
where she lived with my Dad,

in the park
of the assisted living complex
where she died
in her sleep,

and down the very middle
of her well-kept grave
where I watered the ashes
with my tears.

 

Bio: Jane Seskin is a clinical social worker and the author of Witness To Resilience: Stories of Intimate Violence. You can follow her on Twitter: @jsauthorshrink

The Fake Freedom of American Health Care

By Anu Partanen
NY Times, March 19, 2017

"The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power.  

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom.

I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures."

Excerpts from an amazing op-ed in the NY Times. It pretty well says it all in a pleasant "nordic" way.

Who Are the Medically Uninsured in the U.S.?

In spite of the Affordable Care Act there are many people in our country without health insurance. "The remaining uninsured are primarily in the South and the Southwest. They tend to be poor. They tend to live in Republican-leaning states. The rates of people without insurance in the Northeast and the upper Midwest have fallen into the single digits since the ACA’s main provisions kicked in. But in many parts of the country, obtaining health insurance is still a problem for many Americans."

See: We Mapped the Uninsured.

The states with the lowest percentage of uninsured tend to be the ones that have expanded Medicaid coverage.  However, it can be difficult for Medicaid patients to obtain health care, especially from specialists.  See: Cherry Picking in the Aina.

It's hard to believe there are still so many health care unequalities.

 

 

Overkill by Atul Gawande

The New Yorker, May 11, 2015  Free Full Text.

This is a long, but invaluable, introduction to the topics of over-diagnosis and over-treatment.  The Lown Institute has impressively addressed this topic for the past three years or so and a cadre of physician scientist and clinicians around the world have been interested in subject as well.  In his polished way, Gawande covers the issue for the lay and professional reader.  He asks:  What can we do about the avalanche of unnecessary medical care that is harming patients physically and financially.

Download Excerpts from Gawande's Overkill

 

Rx: The Quiet Revolution

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
Modern version of Hippocratic Oath

PBS April 2, 2015

In this inspiring 90-minute documentary, filmmaker David Grubin takes his camera across America to focus on the challenges and triumphs in our country’s health care delivery system. The four segments that comprise Rx: The Quiet Revolution introduce us to a diverse group of doctors, nurses, and health care professionals who are transforming the way we receive our medical care: lowering costs by placing the patient at the center of their practice.

Rx: The Quiet Revolution shows us what’s happening from Maine to Mississippi, California to Alaska.  You will see physicians, nurses and other healthcare professionals placing the patient at the center of their practice — transforming the way medical care is delivered while lowering costs and improving outcomes.

Filmmaker David Grubin brings you these compelling stories: 

• In Maine, we meet Dr. David Loxterkamp, who practices family medicine with a team of doctors working to treat patients with chronic illnesses.

• In Mississippi, a state with more diabetes cases than any other, Grubin finds a rural health clinic fighting diabetes with the aid of an electronic communications device that provides greater access to medical care, helping patients take responsibility for managing this devastating chronic disease.

• In San Francisco, Grubin visits a health care facility for seniors called On Lok, dedicated to making it possible for frail, elderly Americans in need of nursing home care to live with dignity in their own homes.
  
  
• In Alaska, the documentary follows Native Alaskans who own and operate their own health system, caring for 65,000 people across 107,000 square miles. In spite of the number of patients and the vast distances between them, they are determined to foster an empathetic relationship between patients and their health care providers.

At 90 minutes, this may seem a daunting investment in time, but Rx: The Quiet Revolution will speak to you in powerful and compelling ways.

Atul Gawande's Reith Lectures

The Reith Lectures were inaugurated in 1948 by the BBC. Bertram Russell gave the first talk.

In  2014, there were four Reith orations by Atul Gawande on The Future of Medicine.  They were presented in Boston, London, Edinburgh, and New Delhi.  All can be listened to or read.  In addition they can be downloaded for free to iTunes and transferred to an iPod for easy listening.  O! Brave New World!

You can gain access to Gawande’s four lectures at the BBC site.  They are:

Why Do Doctors Fail?
1/4 Surgeon and writer Dr Atul Gawande explores the nature of fallibility in medicine.

The Century of the System
2/4 Atul Gawande calls for a radical rethink of medical systems to transform healthcare.

The Problem of Hubris
3/4 Atul Gawande calls for a new approach to the 'great unfixables' - ageing and death.

The Idea of Wellbeing
4/4 Atul Gawande calls for a new focus on systems to ensure doctors work more effectively.

Even if you have read “Being Mortal” you will enjoy these presentations.

 

 

 

 

 

Overdiagnosis and Overtreatment: A Modern Epidemic

Role of Fear in Overdiagnosis and Overtreatment: an essay by Iona Heath

The title says it all regarding this extraordinary essay in the October 24, 2014 British Medical Journal. Here are a few quotations from the article. If you would like a copy of the entire paper, let me know (email DJE )and I will send it to you. I cannot post it online because of copyright issues.

In recent decades, health has become a commodity like any other. The exploitation of sickness, and fears of sickness, for the pursuit of profit has increased recently, underpinned by the rapid commercialization of healthcare.

Montaigne wrote: if you don't know how to die, don't worry: nature will tell you what to do on the spot, fully and adequately. She will do this job perfectly for you; don't bother your head about it.

Every healthcare professional is now required to consider an ever greater array of potential risks to the patient's health, however well patients might be feeling. And every responsible and rational citizen is expected to actively seek out and eliminate all possible risks to their future health and to consume medical technologies in order to achieve this aim.

A great comfort is the unpredictability of the future. No one knows exactly what will happen tomorrow. We know a lot about probability, but probability is a long way from certainty. People do not always get the result predicted by their lifestyle. Not everyone who smokes will die prematurely. Conversely, a good diet and regular exercise do not provide complete protection from random disaster.

Doctors Tell All – And It’s Not Good

by Meghan O’Rourke, The Atlantic, November 2014

Meghan. O’Rourke is a writer and poet who has suffered with an obscure autoimmune disorder for over a decade.  Her reflections on American medicine are important and iinstructive.  This article is available as full free text. 

O'Rourke writes:
This essay is about why it has become so difficult for so many doctors and patients to communicate with each other. Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes "patient–centered care" as a mantra, modern medicine is startlingly inattentive   –  at times actively indifferent – to patients needs. To my surprise, I have now learned that patients aren't alone in feeling that doctors are failing them. Behind the scenes, many doctors feel the same way. A crop of recent books was a fascinating and disturbing ethnographic of the opaque land of medicine, told by participant-observers wearing white coats.

Here are our expanded notes from "Doctors Tell All. Download Doctors Tell All – And It’s Not Good

The Smart Patient

an eBook by Gina Kolata

Americans are inundated with medical information. It comes from every direction -- the media, the Internet, well-meaning friends and acquaintances, and an ever-proliferating collection of journals. In 'The Smart Patient -- Mistakes We Make About Our Health -- And How to Avoid Them,' Gina Kolata of The New York Times provides guidance in sorting through this welter, helping readers to make better decisions for themselves. Kolata, one of the country's most respected medical journalists, tells why anecdotal evidence should be viewed with skepticism, why large random studies are more trustworthy than observational ones, when a second opinion is a must, and what questions you should ask your doctor and -- equally important -- what ones you need to ask yourself.

I saw an ad for The Smart Patient in the NY Times and downloaded it to a Kindle.  It's also available for the Nook.  This is a short book, might take one to two hours to read and there is much for patients, their families and all care givers (including physicians) to ponder over.  It's well worth the $2.99 price.

Here's a short review: Download The Smart Patient

I welcome any thoughts you may have and I will add your comments to this post.