Sunday, January 22, 2017

Health Care in Society and the Demise of Obamacare

The Affordable Care Act is due to disappear. The incoming administration and Congress are working on making it so. This is the culmination of a long dream of politicians and pundits on the conservative side of the political spectrum. Now, they'll get their wish.

But what is it a wish for? Is it really a wish for wasteful, costly health care with millions of Americans uninsured? Do Republicans really want to go back to a time when people showed up in the ER for routine care, and then stuck the hospital with the bill? Are they aiming for a return to medical bankruptcies? I doubt it.

The ACA was a compromise among the many, moneyed, players in health care: hospitals, pharmaceutical manufacturers, insurance companies, and doctors. Smaller--and less well-heeled--players also participated to some extent: citizens, nurses, consumer advocates, and social welfare organizations such as churches did have their voices heard. The product was the ACA, a law which essentially reformed the insurance marketplace, and a law which gave every player something they wanted, and also placed demands on every player. It wasn't perfect, but it was a step.

The Republican Party and groups of conservative citizens fought it from the moment it passed. "Obamacare" became a slur, like "communism", despite the fact that the ACA was a market-based solution to our insurance market problem, and despite the fact that the major elements of it were essentially based on a policy solution originally proposed by the conservative Heritage Foundation.

Now this is my blog, so in addition to sharing evidence and facts, I also get to share my opinion. I argue that there were two main reasons the ACA became a focus of Republican and conservative rancor. In the former case, the Republican Party, it was pure politics. First, I think it galled the party that Democrats managed to do their thing--create a market-based solution to a social and economic problem, a solution that had the potential to be popular (think: keeping your kids on your policy until they're 26, getting insurance coverage for pre-existing medical conditions).

Second, Republicans saw a political opportunity, and this is related to the latter case, "conservatives". Here I'm talking about less politically-connected, ordinary folks with a particular political point of view. The "tea party" types who saw the ACA as a government intrusion, who saw it as an erosion of their freedom to go without insurance, I guess. Fact is, I have more respect for these folks. I don't agree with them. I think that as our society evolves it is inevitable that we'll have to trade some of our "old rights" for new ones. But hey, I get it. It's a political philosophy, a point of view.

My view is that Republicans saw this disaffected minority (and they have been a minority) as a potential addition to their voting base, a way to seize control of hundreds of local congressional districts. That's just cynical, and I hold them in the lowest esteem for it. If Obama and the Democrats had somehow managed to pass a law greatly expanding Medicare--a "public option" for everyone--and Republicans wanted a market-based solution instead, they'd have a case. But this? This was just political calculation.

Criticisms of Obamacare abound, but what's not much talked about is that any massive legislative act has to be amended and tweaked to work. Unintended consequences happen. This law could have--should have--been adjusted several times in the 6 years since it passed. Republicans, having taken control of the House of Representatives in 2010, could have worked to make that happen. They didn't, because they saw more political opportunity in just obstructing change.

Now, they have their wish, and their "replacement" solutions are sounding either weak or complicated or both. The fact that they need a replacement highlights just how popular the ACA is, now that some 20 million more people have coverage. It's hard to believe that navigating health care insurance could get more complicated, but House Speaker Paul Ryan's current sketch of a plan promises to be just that.

Really? They think that's what Americans want? To have to phone 3 hospitals to see who has the cheapest appendectomy? Changing doctors every year, because every year you have to be on the internet looking for a cheaper option than you currently have? Look, I get the whole "smaller government" thing, but I have to wonder at what point does ardent political philosophy fail the practicality test?

I'm not at all certain about what will happen. Obama was smart. His namesake health care reform isn't perfect, but it showed a large fraction of the voting public a glimpse of a better life. That's not going quietly. Now that Republicans have control, what will they do? Maybe they'll just fix what's wrong with it and give it a new name, like "Patriot Care" or maybe name it after that new president-guy. The essentials will persist but they can take their claim to it, which will make them feel better about their brand.

Or maybe not.

Americans are going through a trial right now. We're arguing with one another about what post-frontier America looks like. This trial began in the turn of the 19th to the 20th century: unions, communism, socialism, environmentalism, the Great Depression, Social Security, Medicare and Medicaid were all being fought over as we left behind the Old World order and tried to figure out what sort of New World order would be fitting for America. Something consonant with our culture but oriented to the challenges of a very different world. Where is that balance?

For about the last 20 years there's been this see-saw between one view of our future and another. Neither is perfect, but both reflect the aspirations of ordinary people, even if those aspirations often get hijacked by politically cynical agents of vested interests.

My view is that health care is a right, and it's a right that materially contributes to both the health of our people and the health of our economy. I know others disagree (but the facts argue in my favor--a blog for another day perhaps). I believe that we all must accept that we can't have (and really don't need) everything we think we do. Some call this rationing, but I just call it rational health care. A relief valve in the form of a free, side market could co-exist, but there's no evidence it would detract from a robust public or hybrid public/non-profit health care system. There's no evidence this would necessarily dumb-down our medical research enterprise--although it might rectify the imbalances imposed by the profiteering which is a troubling feature of our current system (see my blog post from 8/29/16).

Over the coming weeks and months we'll see how Washington's new political leaders tackle this issue. They have to do something, because promises were made, no matter how empty or pointless those promises seem now. Having failed for 6 years to work with the previous leadership on revising Obamacare, Republicans now have to deliver something.

Let's hope it's an improvement.

Monday, January 16, 2017

How Coincidental!

It just so happens that I'm coming off what turned out to be a pretty bad cold. It's funny, because I'm a health care provider, right? I mean, how can we get sick? And when we do, don't we know all the tricks for beating it it quickly?


Ok, yeah, well, some. Normally I'd either drop some professional quality echinacea or eat some raw garlic at the very first hint of symptoms. (If you're trying this at home: it's just one clove of garlic and you have to eat it with something bland.) This time the initial symptoms were really mild for over a day and I thought I'd let it roll.

Well it turned into a whole lot of no fun, but after a couple of days things started to improve and I'll be fine. I have no evidence for this whatsoever, but I believe that every once in a while it's good to give your immune system a proper workout. I think it could prevent worse things later, but like I said, I've got no proof for this.

Beliefs about our health, beliefs about how we can (and can't) control our health abound, and I've found are often really personal. A lot of them are shared. For example, a lot of my female patients of childbearing age dislike the idea of using chemical means of birth control because some can interfere with having menstrual periods. Here in particular I'm talking about oral contraceptives like Seasonale or injections like Depo-Provera. They tell me that it feels strange and somehow unnatural or unclean to halt the process the body has of clearing the lining of the uterus, as happens each month during normal menstrual periods.

I haven't been able to locate any evidence that halting this process, or minimizing it, actually leads to a "buildup" of any toxic substance, or leads to any higher risk of disease...although all of these drugs do lead to potentially higher risks of things like stroke or breast cancer. Presumably that's just due to the drugs themselves.

In regular medicine, we have various recommendations that are said to be based on scientific evidence. Do this. Don't do that. Patients express some frustration to me about how often these recommendations seem to change, and how often they are in conflict with one another. To be fair, there are a few really carefully researched, very specific recommendations that change little over time. For example, don't smoke cigarettes.

But then there are those that are flung about from TV news anchors, Facebook newsfeeds, the daily paper, and pop-up ads on the internet. It's not that all of those recommendations are bad, but it does highlight that there's a spectrum of health recommendations that spans from really sound and worth paying attention to, to those that are nascent and possibly just fleeting static.

In the previous blog I wrote about intention. Intention manifests itself in various ways, from focused, meditative thought designed to influence a specific bodily response or symptom, to mere behaviors, such as declining a sugary snack in order to maintain a health body weight. Intention doesn't exist in a vacuum. It is nested within a matrix of other aspects of our psyche and experience. Critical thinking is another aspect. Combine a strong behavioral intention with an uncritical analysis of your Facebook newsfeed about something like, say, the need for vitamin D, and you might get someone taking gigantic doses of vitamin D daily, for no purpose--and potentially to a bad end.

After all, just because it's a vitamin doesn't mean that taking a truckload is automatically good for you. And some evidence shows it can be bad--but that little caveat doesn't seem to get passed around on Twitter so much.

And don't imagine I'm letting regular medicine off the hook here. For decades doctors pushed women into taking hormone replacement therapy after menopause. Until a large analysis found that this significantly increased risks for strokes! One can argue, the doctors meant well, but I lived through that and found that most doctors were too easily buying the "research" of pharmaceutical companies, and too readily latching onto the notion that "one pill can do it all": prevent heart disease and osteoporosis, treat hot flashes, improve post-menopausal sex life, increase energy, improve sleep, etc. etc.

Hormones were the wonder drugs that worked wonders...until they killed you, apparently.

Intention is more than just wanting to do the "right" thing. It's about intending to do your thing. During my recent bad cold, the latter part came on, that's the part where my nose got really stuffed up. I hate that. I really hate when I want to sleep, because it makes me breathe through my mouth. Now there're drugs for this, and I have those. But I dislike using nasal sprays. They make my throat sore, taste lousy, and my nose easily gets "addicted" to them.

So I do this thing where I can focus on my nasal passages, and see them swollen and red, which I know is due to a normal physiological response to to a virus. Then I sit or lie still, close my eyes, and focus with each breath on reducing the inflammation, sucking out the excess fluids in the tissues, draining them away...

And gradually, my nose starts to open up. This works about 50%--it never gets totally unstuffed--and it works about 75% of the time. It's good enough for me. But what about the times when it doesn't work? What about the fact it doesn't fully resolve the symptom? Is that a failure on my part? Is it underdeveloped mental discipline? Does it even matter?

In the previous article, I highlighted a conflict between intention and responsibility. If we can control what happens to us, then when bad things happen, we have "failed." On the other hand, if we aren't responsible, if intention doesn't "work", then whatever happens to us isn't our fault. It's just bad luck.

Now one could easily argue that the only things that matter are behavioral, and proven by medical science. So if you get lung cancer and you smoked, you did this to yourself. If you got lung cancer and you didn't smoke, you just have bad luck. This is where a lot of health care providers are. It means you can easily sort people into piles, "blameworthy" and "blameless." Now I could further ague that this just makes nurses and doctors sanctimonious twits, but then that wouldn't be a very deep analysis. (Even if it feels true sometimes!)

This analysis suffers from several problems. First, we don't know everything. Look at hormone replacement therapy. Oops. Second, we don't actually know that other forms of intention have an impact on health. Maybe there's more to it than we know now. In my experience a lot of doctors and nurses acknowledge the existence of some mysterious power of the mind, or perhaps the spirit. However, unless they are religious, they often don't know what else to do with that information.

One evening in the ICU I had a student come to me and ask me to explain how a woman could still be alive when her "numbers" on the monitors were "incompatible with life." The woman was dying, and the family had been gathering all day from the places they lived. There was one more person--I think it was a son--who was still traveling to the hospital. I told her, "When the son gets here, she'll die within an hour or so."

I could say this because I'd seen it before. It happened exactly as I predicted. By the way, the woman was never conscious the entire shift we were there, until about 7 PM when she briefly seemed to be conscious. Then she died.

What is "intention"? Is it a coherent thought? Is it a mood? Is it the energetic "work" expressed by the sum of the being's narrative, or "story"? Is it a technique? Or is it something more complicated? Is an "intention" ever really one thing, one direction, one thought, one action? And if it isn't, how can we be so certain of our ourselves as healers? How can we say of a patient (as I have heard many times)? "Oh that guy's evil! He doesn't take his meds. He gives the nurses a hard time!"

Hey, I'm not saying some people aren't evil. I'm not getting that metaphysical. Rather most people aren't "evil", it's just that we either refuse to listen or can't understand their "story", the story they are writing with their life, as if it were our place to judge.

I started out this blog with a simple share about getting a cold. Really, you could say I "allowed" myself to get a cold, perhaps out of a belief about immune health that may or may not be true. What I don't know, and what nobody does, is what would have happened if I had tried to abort it with one of my methods. Would it have worked or not? What does that mean? Was I irresponsible? Was I more responsible than the busy professional who says "I never let myself get a cold"? Or did I actually do the right thing, and sometime down the road I'll be rewarded for it? We can't know this.

To understand intention means to understand that--whether one knows it or not--one is telling a life story. Like all good stories, there will be surprises. Not all endings are happy, and sometimes the unhappiest event in a tale ends up manifesting redemption. We just don't know. We want to know, because we all want to be free of suffering, we want to live long and prosper, we want to know it's going to be okay.

For nurses and doctors and other professionals out there ministering to the sick and injured, it means stepping back from prejudice based on what we think we know. It means withholding judgments. It means not seeing a patient as a subject, but as a storyteller. It means trying to learn from that story even as we are participating in the telling of it. For caregivers, family, and friends it gets a bit more complicated, since they have been more intimately "in" the person's story than any of us healers ever get. But I think it still matters. I heard family say, "Oh why doesn't dad just stop...?" fill in the blank with drinking, smoking, whatever. It doesn't matter, the overall slant is the same. It is painful when loved ones do things that seems to contradict survival, but it is part of the story they are telling. In the end, that's all we are left with anyway.

Until our own story ends.

Monday, January 2, 2017

Intention: Radical Medical Science and Its Consequences

Happy New Year!

There's this thing where people say "Oh man, good riddance to  last year!"

For me, 2016 was a pretty great year. It had its bad moments..., and of course there was the election. That was just a whole lot of unpleasant. Anyway, we ring in the new year, hoping, even intending it to be better than last. We make new year's resolutions, which is a way of saying "I'm going to do better, be better." Intent is what drives new choices. When we aren't honest about our intent, or when we don't fully understand our intent, things may not work out in favor of our resolutions. Our resoluteness seems feckless, and we feel guilty. But if we really understand what we want, we can either accept who and what we are, or work to realign our intentions.

New Year's Eve we had a party, and we were talking about this idea of intention and and behavior change with respect to smoking, and we all agreed that what's really hard about quitting is that smoking is just so great. It's contemplative, these days it's often private (as smokers have gotten pushed outdoors), and it comes with a dopamine hit with every puff.

Get the patch. Use the gum. You still get the dopamine hit..., but you don't get the behavior. It's the act of smoking that makes it so successful. In fact any "addiction" is one part neurochemistry but an equal part behavior. Behavior includes the people you do the habit with, the lifestyle, the "hobby" of it, including all the little gadgets, or brands, or devices that go along with it--whether you're talking about the iconic red and white packaging of Marlboro cigarettes, the craft of marijuana smoking pipes, or one's "works", the syringe and needles of injection drug use.

Yes, I know that many addicts aren't so fancy about such things, but the social aspect (for example, hanging out with other junkies, who may also be your friends) validates my point. Addiction is as much behavioral as it is neurochemical.

Anyway, I'm going to turn my attention to the title of today's blog: radical medical science. I am appropriating this term to mean the medical science advocated by so many thought leaders in what has been called "new age" medicine, in which it is said that the use of intention, directed thinking and belief, creates a new health reality. Self-help guru Anthony Robbins, physician Deepak Chopra, author of guided imagery audio CDs Belleruth Naparstek, and The Intention Experiment's Lynne McTaggart are just a handful of those who argue that nature demonstrates to us that our thoughts can reshape reality.

I'll get to the point here: I happen to think they are right. What I don't know--and no one seems to--is how much we can reshape reality, and how it actually works.

Throughout my recent entries, I have maintained a theme that emphasizes the limits of today's material-based understanding of Nature, and specifically, of our own biological nature and the implications of that for Health and Medicine. In other words, today's science of medicine is based on a model that reduces every aspect of health to a process that can be isolated and understood, and from there we can develop specific therapeutics to fix those processes that are "broken." The problem is, this model doesn't fully explain why some people get sick and others do not. It doesn't fully explain why some people respond well to treatment and others don't.

Environment, genes, and psychological and social stressors do explain, to some extent, some of these differences, but not reliably so. When Tony Robbins urges one to "Change your physiology" he's taking some liberties with the scientific meaning of "physiology" but what he means is essential, since he is arguing that changing the way you think and feel about being physically, mentally, and spiritually in the world will change the way you are in the world.

I've tried this. It mostly works.

My wife had an uncle who was a Hindu monk for many years, and it was told that he developed a tumor in his neck. I was further told that he meditated it away.

Now I've never been able to fully verify this story as medical fact, but it doesn't matter, because there are literally thousands of other stories out there like it. Some people believe that their god will heal them, and he does, or so they believe. Whether it is their belief or not is beside the point, since at its most basic, whether it comes from within or is thought to come from without really rests upon the idea that everything comes from within. To will away a tumor, or to believe that God will do so is, essentially, a belief that there's a force that overcomes the destiny of matter.

I have also seen this not work, plenty of times. There was the Christian Scientist I was asked to see several years ago. CS is a school of religious thought that argues that all failures of the material of our bodies is mere failure of belief. Unwilling to accept any form of "regular" medicine, her home care nurses asked me to see her in her home because they felt that perhaps someone in alternative medicine might be able to accomplish what all the exhortations of the nurses and doctor couldn't. I saw her, tried homeopathy, suggested some simple ways to address the ulcers she was suffering from, yet her belief was firm: God would provide. She died within two months of my seeing her.

Was this a failure of belief or a conflict of beliefs? After all, she could hold a belief in the healing power of God and her belief that she would be received into the afterlife with Him.

In 1978, novelist and essayist Susan Sontag argued that metaphors for illness are unhealthy, and that they impose a kind of guilt trip on the ill person, much in the way that Christian Science implicates the faith (or lack of faith) of the ill. She further argued that to impose such an implication was itself a kind of social punishment: After all, it must be you who failed if despite your will, you died of cancer anyway!

This theme has been repeated by many others writing about their cancer (or other disease) experience. Coincidentally, writer and professor Norman Cousins published Anatomy of an Illness: As Perceived by the Patient, in 1979. After being diagnosed with ankylosing spondylitis (a usually-crippling disease) he fired his doctor and undertook a regimen of vitamin C, healthier eating, and laughter, reportedly checking into a hotel and watching comic movies to improve his mood. He was said to have "laughed his illness away" and outlived his doctor's dire prognosis by more than 2 decades.

In 1992, researcher Lydia Temoshok published The Type C Connection in which she shared her research about the connections between emotional self-repression and risk for cancer development--diametrically opposite to Sontag's attempt to relieve the sick of their "guilt" for having gotten sick in the first place. Research in psychoneuroimmunology has demonstrated that the minds of laboratory animals can be conditioned to make themselves sick, by directly manipulating their immune systems.

A comprehensive review of the research and philosophy surrounding this question is beyond the scope of an online blog. But what I have here is enough to establish a few important points:
  1. The mind definitely influences what happens to the body, whether we mean risk for illness or hope for recovery and cure.
  2. We don't really understand how this works or what its limits are.
  3. Assigning blame to an ill person because of these facts is both unkind and a failure to admit how little we know about consciousness and its influence on health.
It's possible that thought itself may be less controllable than we believe. We are taught that there is the world of the body and the world of the mind. So we have medicine and biology to address the former, and psychology and theology to address the latter. This dualism is, I believe, a fundamental failure of today's medical philosophy.

In homeopathic medicine, the state of imbalance of the "vital force" described by homeopaths itself leads to behavioral abnormalities and disturbances. In short, "mental" illness is both material and energetic and not fully amenable to "self" control. Interestingly this squares with the work of today's neuroscientists, who postulate that those things we believe are our "thoughts" that are under our "control" themselves arise before we could possibly "think" of them. In other words, brain science suggests that volition is illusory: we have a thought before we think we thought the thought!

In nursing science, the late Martha Rogers argued that there was no separation between the body and the mind, that they are co-located in a perceivable body, but also extensive beyond the border defined by the body itself. Nurse researcher Elizabeth Barrett writes about the "simultaneity model" of human existence (and one could ask, of all life forms?) in that what we think, and what we are, materially, in the world, are inseparable, and that a full understanding of human health and disease will elude us until we reconcile ourselves with this fact.

Of course, that makes ordinary medical treatment of our day to day sufferings in The Factory problematic. It also makes our social construction of health and illness difficult for ordinary people to navigate. To say someone "bravely fought" against cancer (and lost), as I read often in the local obituaries could say they didn't "fight" hard enough, or that their aim was untrue, or that they harbored a hidden death wish. But to say that their will doesn't (or didn't) matter seems to contradict our observations and a growing body of scientific research that that suggests it does matter.

How do we understand that? How do we unlock its potential? And how do we do so without condemning those who get sick to guilt and those who do die to posthumous humiliation?

I'll write about this more in upcoming blogs. Happy new year.