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.

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?

Nope.

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.

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.

"Pinning"

Friday, the semester ended for me, and for the Class of 2016--our accelerated "second degree" nursing students. In 16 months 27 people from backgrounds in biology, English literature, accounting, political science, and other fields managed to master the enormous amount of complex material and clinical skills to become Registered Nurses.

Pinning is a nursing tradition. At the end of nursing school, many programs hold a ceremony to celebrate the students' rite of passage from unschooled novices to competent nurses. Ceremonies vary in their content and style, but most contain a group recitation of the Nightingale Pledge. The original pledge spoke to the Victorian mores of the time: probity and forbearance from "mischief", faithfulness and purity were emphasized, no doubt reflecting the way society thought women should behave. The nurses should "aid the physician in his work" (emphasis mine), reflecting the place of both women and nurses with respect to both men and physicians at the time (from Lystra Gretter's 1893 version of the pledge).

The Gretter pledge also had the graduates pledging before God, which of course makes sense in light of the time. Most people were nominally of the Judeo-Christian traditions that underpinned European and American societies, and the then- and formerly-colonial regions to which they had spread, such as South America and much of Africa.

I do prefer more contemporary versions--even though they don't have the long tradition--because they recognize that not everyone believes in "God", much less a one-size-fits-all god, and because although part of what we do is to aid physicians, we also aid other professions.

Moreover, in "aiding" other professions--including medicine--to do their work, we more often than not coordinate everyone's efforts, physicians included. That doesn't even get into our own discipline's body of knowledge about health, healing, and humanity that form the core of Nursing as a medical art both of and distinctly different from Medicine. It is the similarity of our work to the work of Medicine that makes Nursing amplify the healing art. And yet it is our distinctiveness that also serves as a counterpoise to Medicine. One can routinely observe this in the clinic: The nurse humanizes the fraught work of the medical man. Medicine, by its very nature, can become the grotesque creator of monsters artfully depicted by Mary Shelly's Dr. Frankenstein. Nursing, by its very nature, acts as Medicine's conscience.

The importance of this emerges during training, and we instructors emphasize this role as counterpoise to the physician. But we're partners too. We observe, report, and execute the regimen. They have the deep knowledge of anatomy, physiology, and medicines that solve the medical problems. They save lives, but then so do we, both in their absence as we monitor patients through dark nights, but also in their presence, when hubris, fatigue, or just plain orneriness threaten the poor fellow lying in that hospital bed.

The Factory, which I have written about here before, has created a new alliance between Nursing and Medicine, in my view. Once, we were as much at odds as we were allied, nurses and doctors. That's still true to a great extent, and as I have argued here, not an altogether bad thing. But The Factory has emerged as a new player, a new force with its own agenda. Some agents of The Factory are explicitly for profit. The looming harm of this is, to me, obvious. It's less obvious when examining the non-profit agents of The Factory. Who is making the money? What's the real goal? Is it to make the system efficient and humane? Or is it to enrich the operators of the enterprise?

I gave the closing remarks at our pinning ceremony on Friday. I wanted to keep things short and light, but I could also see the potential in the room, and urged the students to make things better. That's really hard when you're a nurse: the organization often pits your own good morals against prerogatives that seem anything but humane and compassionate. It will be hard for them. I hope we prepared them adequately for that struggle in the short time we had to prepare them.

What is Science, Really?

This past week I've been getting pop-ups asking for donations when I go to Wikipedia. The last couple of years I've clicked on the Donate box and sent them a few bucks. I figured it's a community resource of sorts, non-profit and volunteer-run. Why not?

This past year I went to Wikipedia at one point to read the entry on homeopathy. It was really long, and it was heavily slanted toward the notion that homeopathy is a pseudoscience, and that the bases of homeopathy are founded on corrupt, disproven principles (such as "molecular memory"). The preponderance of primary research studies cited as "evidence" of homeopathy's lack of efficacy are cherry-picked from the available body of data.

I couldn't edit the page because it is "locked" to prevent "vandalism." I took a stab at trying to learn how I could become a part of the accepted body of editors, but it proved to be a bit of a chore so I let it go.

Recently I took another stab at it. I have a bit of time now that the semester is winding down. I ranged across the hyperlinks that discuss the various things that would bear on my task: the different locking "levels", how to become an editor of locked pages, and the categories of articles displayed on Wikipedia. I clicked on a link that discussed "pseudoscience" in the context of editing, I saw a long list of things that the community editors think of as "false science", including homeopathy, osteopathic manipulative therapy (OMT), and chiropractic (all of which have evolved as clinical practices, and all of which have empirical data to suggest their efficacy--however chiropractic and OMT are beyond the scope of today's article).

As I read further, clicking over to the entries discussed in the previous paragraph as well as others, I began to discern a pattern. Now I will grant that many of the things on their list are historical fancies (e.g., "ancient astronauts" or "moon landing conspiracy theories") or metaphysicial pursuits (astrology, creationism, channeling) that lack hard evidence and/or are not otherwise subject to Karl Popper's scientific falsifiability. The list is also very long and includes things that may lack hard evidentiary support, nevertheless may offer plausible hypotheses that could one day explain certain natural phenomena.

Pseudoscience is, I suppose, a real thing. It's reasonable to argue that some domains of theory and practice ought to be best left to the believers, with the hope that good things will follow. For example, my wife, a musician, has been studying sound healing. Part of this has been to reintroduce her to "chakras"--which are presumed to be seven loci of energy flow in the human body. Often depicted as foci of colored energy, there are various systems of chakra patterns that stem form various ancient and modern beliefs.

She knows that no one has "proven" the existence of these chakras, and yet she feels their presence when she gets work from people doing Reiki, or when she works with her singing bowls. Does this make it pseudoscience? Metaphysics? Or is it simply a framework for integrating intellect and spirituality that applies to specific moments posed by the subject of the work?

I occasionally perform Therapeutic Touch on patients. When I do, it's coincidental to the rest of the more medical purpose of the visit. I don't charge extra money for it. I don't know if something is happening, but I feel it, and often the patients do as well. I don't claim to know what's happening or why people feel better afterward, and I can accept that the effects may stem wholly from mindfulness, quiet, and taking a few minutes to reduce the general emotional arousal in the room.

It might also be mysterious energy. Who knows?

So then why must the critics scornfully call this "false" science? Scorn should be reserved for mendacious con-men whose only aim is to separate fools from their money. Scorn should be reserved for those who would impose their metaphysical peculiarities on the rest of us in a civil society. Scorn should not be aimed at earnest people who mean well and largely cause no harm. Ask their patients: if they feel wronged, they will say so. Mostly, they feel cared for. (I know because I bother to ask.)

Carl Sagan correctly acknowledged that for something to be subject to proof, it must exist, and there must be some way of verifying or falsifying the thing's existence. Philosopher Paul Feyeraband suggested that scientific "anarchism"--freeing our science from the constraints imposed by socially-mediated sets of rules--would free our minds to explore. Some things will pan out. Others won't. Philosopher Larry Laudan argues that "pseudoscience" has no meaning, and is mainly a term of emotion. To this I can testify: I've had plenty of conversations with smart but unimaginative blow-hards who like to spew bile and spittle against people practicing arts that may seem to their practitioners as scientific, and seem to the spewer as "pseudoscientific claptrap!"

I think it's a bunch of self-righteous nonsense.

I've practiced homeopathy for 20 years. Save for the first few, in which I felt the rush of hope and light of the "true believer", I've been a skeptic of sorts. I've kept up with the literature surrounding homeopathy and I've found myself alternately pleased and despondent about it. Klaus Linde's 1997 meta-analysis of clinical trials of homeopathy hesitantly suggested that the technique's effects could not be accounted for by the placebo effect. Translated: Yikes, this weird thing we can't explain may actually work!

British researcher Edzard Ernst has made it his life's work to debunk homeopathy (after briefly training in it) and in a 2002 meta-analysis concluded that homeopathy doesn't work. Lancet published an editorial in 2005, "The End of Homeopathy", based on the work of Aijing Shang's team, in which they compared 110 trials of homeopathy and 110 matched trials of regular medicine. The team claimed that homeopathy performed no better than placebo (and interestingly, that regular medicine barely did!).

I have to say that this had left me feeling for a while like maybe I've been barking up the wrong tree. And if I really am a scientist, I have to admit that maybe it's time to hang up my repertory. I can live with that. (That's what a scientist does.)

I dug deeper. Recently, I completed a study in my own practice, a simple chart review. I'll withhold the specific results, pending publication. But it's enough to say that the results are intriguing. I'm not sure if they are the result of homeopathy, or my awesome bedside manner, but it is unlikely the results are solely caused by chance. In preparing the article I dived into the literature again.

Robert Mathie is a homeopath and researcher--so he has a point of view--but I found his team's 2014 meta-analysis of homeopathy to be enlightening. He concludes that homeopathy appears to work. So how is it that some meta-analytic studies find it does work, and others find it doesn't? The answer appears to lie in methodology, and methodology appears to be driven in part by one's point of view.

I found an article by Robert Hahn, an anesthesiologist with Linkoping University in Sweden. This guy isn't a homeopath, and he hasn't made his name as a crusader against "psuedoscience." He's just someone with a curious, open and discerning mind. His literature review of the studies touted by mainstream medicine as evidence of the ineffectiveness of homeopathy found that authors were guilty of a number of methodological malfeasances. He states:

Clinical trials of homeopathic remedies show that they are most often superior to placebo. Researchers claiming the opposite rely on extensive invalidation of studies, adoption of virtual data, or on inappropriate statistical methods...One way to reduce future emotional-driven distortion of evidence by investigators and skeptics would be to separate the evidence-seeking process from the formulation of clinical guidelines more clearly. (1)

And remember, this was before Mathie's group published their analysis in 2014.

I might suggest to those who would apply the label pseudoscience without careful pause, that they themselves are "pseudoskeptics." Pseudoskepticism is a habit that substitutes an emotional certainty of disbelief for real skepticism. Real skepticism admits the tenuousness of scientific theory, withholds certainty, and leaves emotion where it belongs--outside the lab. A real skeptic would admit that homeopathy doesn't fit in with our current physical, chemical, and medical theories, but would admit that both the clinical evidence and empirical evidence do show that something is happening. Actual clinical use of homeopathy is a choice between deciding to wait until more information is forthcoming, or plowing ahead with what we do know, aiming for as much care and safety as we can.

Part of what makes the skeptics--or, er, the pseudoskeptics--crazy, is this issue of care and safety. I'll be the first to admit that there are a bunch of people out there utilizing this method in unsafe, unethical ways (see my previous article). But medicine itself relies on clinical experimentation. Without it, patients will suffer and die while science patiently--and slowly--advances. Clinical experimentation with alternative therapies can be performed ethically (2)...and in the process, maybe we will help a few more folks than we would have otherwise. The results may puzzle us, but should inspire us to investigate further.

References
1. Hahn, R.G. (2013). Homeopathy: meta-analysis of pooled clinical data. Forschende Komplementarmedizin, 2013;20:376–381 doi: 10.1159/000355916.

2. Adams, K.E., Cohen, M.H., Eisenberg, D., & Jonsen, A.R. (2002). Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Annals of Internal Medicine, 137:660-664.

FDA Alert...on Homeopathy

The FDA released an alert in September of this year. Homeopathic "Teething tablets and gels" are to be avoided by consumers and unused portions discarded because of reports of weakness, flushing, difficulty breathing, and seizures, in a few children who have received the problem-specific, combination remedy from Hyland's. The company has voluntarily recalled the product.

The online news source, Vox.com, reports that "The US government is finally telling people that homeopathy is a sham". Golly, I hate online news. Simmer down.

No. The FDA reported on exactly what one would expect to see when millions of people use a medicine unsupervised, a medicine that comes from a system, a philosophy that is completely different from the thing we all use a reference point for understanding medicine, health, and healing: "Western technological biomedicine" --WTB.

In homeopathic circles there has been an argument among many different philosophical perspectives. I practice "classical" homeopathy, the origin-story of homeopathic medicine. Therapeutic homeopathy, is a more European practice, and one frequently used by naturopaths and chiropractors (however this is by no means the case among all NDs and DCs). It's fairly straightforward and easier to prescribe, and certainly enables the practitioner to see more patients in less time. There are other variations, but I needn't digress. It's enough to add that one related homeopathic prescribing philosophy is that if you throw a bunch of remedies together in a mixture, only the "right" one will act: "combination remedies".

Many remedies are made from toxins, poisonous plants, and venoms. If "like cures like", and if the proving* data of Hahnemann are to be believed, then it follows that the wrong remedy could, in susceptible individuals, be enough to trigger a bad outcome.

I tell my students, if it's strong enough to cure you, it's strong enough to kill you. That may be a bit of an overstatement for some therapies (e.g., Reiki), but the harm will be proportional in any case. Nature doesn't give any free lunches.

I've also shared that things like Zicam Intranasal Spray should be avoided because it can cause the loss of sense of smell. It's "homeopathic"--that is the company legally uses a loophole in the FDA regulations concerning homeopathic remedies. The law provides that all the remedies in the Homeopathic Pharmacopea of the United States automatically can be marketed. By potentizing even a small part of a product it can be labeled "homeopathic" and marketed for specific indications (colds, teething, etc.).

Both the homeopathic pharmaceutical industry and the allopathic industry are each using homeopathy in a way in which it was not conceived and cannot be.

The whole premise of the art is that each person is, at some moment, in some state of imbalance. Think of it as an imbalanced manifestation of some unifying field. The practitioner must understand the field in that moment and prescribe (or not) on that basis alone. When used as a "specific" agent to treat a communal diagnosis (the "name" of the "disease" in WTB) it ought to fail much of the time. In fact studies of the remedy Arnica montana for bruises and sprains--its homeopathic indication--fails about have the time and performs no better than placebo.

For my part, I'm surprised that it has taken so long for this phenomenon to emerge. How could it not? If we develop the picture of symptoms statistically associated with a verum (real) remedy in a homeopathic proving trial (see again note * below), then it follows that if people randomly take remedies on a regular basis using an allopathic model (or at best a weak homeopathic model) some are going to start to show symptoms of some remedies.

Ok, ok. I'm getting into the weeds here. Let me just say that WTB is a great thing. It does some things that only it can do, and it does a lot of things fairly well. I mean, if I (or one of my patients) has pneumonia, I might take a remedy, but I'll certainly have some antibiotics on stand by! The antibiotics will not be without harm, but it beats dying, and medicine--of any sort--is never perfect.

But the pursuit of perfection, practice, doesn't come without an ethics. In the case of homeopathic medicine, sound judgement prevents poor outcomes, and when done well, at least the homeopath listens, even cares. In the opposite case I would argue that allopathic practitioners also care, but their care is constrained by the necessarily industrial, high throughput model I detailed in the previous entry.

I would argue that WTB is also more motivated for profit than anything homeopathy can muster. Homeopathic medicine is a "weak force" medicine. Before interpreting that as self-deprecation, recall that the "weak nuclear force" is one of the building blocks of the Standard Model of physics. It's necessary, critical, but only to a point. Thus, don't ever expect homeopaths to rake it in using classical methodology.

Although it will hurt the industry's revenue, I can't argue against the FDA. Homeopaths will have to come to terms with their "weak" science--that is, a weak-force medical technique that nevertheless can have profound effects on the organism. The "science" of that: you have to thoroughly understand the possibilities and constraints imposed by an alternative medical system. Allopaths will have to accept hypothetical models other than what they are used to in order to properly judge whether or not homeopathy is "a sham", as Vox.com put it.

Other have tried to put homeopathy in the grave. Even I have my doubts. However there are enough studies that leave tantalizing loose ends--genuine effects--that it remains unburied. However homeopaths will have to revisit their philosophical origins in order to determine not only if the basic system is really effective, but how these other, admittedly more efficient, systems have a place, and if so how the whole thing should be regulated. Right now, every homeopath is his own captain.

I have advised families who have members not under my treatment** that they can try things like Hyland's Teething Remedy. On balance many fewer are harmed in this way than by regular medicine. In recent years, since the Zicam incident, I am a bit less free with this, and half the time warn people away from these combination remedies and faux-homeopathics. I don't know the details of these incidents reported by the FDA. It isn't many I'm sure, but it urges caution in the use of these combinations.

I am certain that in low potencies I've never seen a reaction that was truly grave, and I am also certain that in high remedy potencies there lies hazard in careless prescribing--how could it not? This is consistent with homeopathic--and natural--theory: there's no free lunch. I have the clinical experience to confirm this. But larger systematic studies of this effect in the community are lacking. I would like to come up with a way to evaluate this system on the system's terms (there are a few clinical trials but results and quality vary).

I am certain that I have seen clinical improvements that are not satisfactorily explained away by "placebo effects" or the "clinical encounter" and similar psychosomatic phenomena. Not that I haven't seen those too--every doctor has! However, homeopaths are humble in the face of placebo effects; allopaths (physicians and pundits) aren't, viewing them as a confounder in most cases and a "miracle" in others. Yes, people do get better just because they would anyway. We recognize that. The best of us recognizes all of these phenomena. Hahnemann did! Surely allopaths have the right set of intellectual tools to do consider homeopathy on its own terms: rigorous scientific philosophy accepts the twin pillars of hypothesis and falsifiability. Sometimes opponents seem weak on the first part and too-quickly convinced on the latter part.

Homeopaths aren't anti- or psuedoscientific (ok, some are), rather we just choose to offer people something we have a method for evaluating the effectiveness of, and take on some faith that the effects are real, even if we don't understand the mechanism. When the method is properly applied, I've seen some pretty amazing things happen. And it's all happened safely.

And safety is why I am glad that the FDA is forcing homeopathic medicine to come to terms with its own philosophy.


------------------------------------------------- * -------------------------------------------------
Notes:
* Hahnemann's original drug testing in which subjects received the real remedy or a placebo, and after several homeopathic-strength doses, would report on symptoms (or lack of) which would be recorded. These are considered the first systematic drug tests.

 ** Under my treatment, patients are not to use any other remedies under any circumstances unless I direct. The reason is beyond the scope here; maybe I'll write about that later. But it makes sense: why interfere with such a subtle and poorly-understood process? If they need some support, there's drugs, herbs, nutritionals and so on.

Tales of the Profession, part 2

The good news is, I didn't get hit by a truck! Life goes on.

It's been a while since my last entry--the semester seems to overbear everything else. In the fall I and another instructor are responsible for supervising the graduating seniors in their final clinical rotations. Unlike their earlier education (a mere two weeks before they begin again in late August) these experiences are not directly supervised by faculty.

Students are assigned to RN mentors, we call them "preceptors", who work in the various agencies to which they are assigned. Each student has two sites, a "regular" hospital site, and a specialty site. The regular site is what we call medical/surgical or "med-surg", and it's the typical thing you'd see on TV, or have experienced if you've been in a hospital for a routine surgery, or some illness. The specialty site can be pretty varied and includes intensive care, emergency, labor and delivery, inpatient rehabilitation, school nursing, community nursing, and so on.

At 360 hours total, it is the most extensive clinical rotation of any nursing school in the state.

There's a lot I can write about this clinical course and what I observe, but today I'll just begin with how students transform from the idealized world in which we train them up, to the real world in which they will practice.

In the first group of students we ever enrolled in the accelerated second degree program, now some five years past, we all got together at University Park, at the nursing college, and held a day-long orientation. I helped to lead an exercise intended to tease out their preconceptions of nursing and health care, and they were to draw something on the whiteboard that they thought about the profession, health care, or something related to the journey they were soon to undertake.

So this one guy draws a factory on the board, with little stick figure patients going in one side and coming out the other. Although I have thought for many years now that the wonder of the modern hospital isn't its technical wizardry, but its amazing throughput, I was surprised that he saw it the same way--rather cynical, for a young guy. But I thought he was dead-on.

American health care is very expensive, and this is for a variety of reasons. Being able to move a lot of people through quickly saves a bit of money. There are lots of moving parts. Nurses and doctors to be sure, but also respiratory, speech, and physical therapists, nurse aides, maintenance workers, food service, pastoral care (of several faiths), pharmacists, security personnel, tech specialists, bioengineers, lab workers, and even sub-specialists in all these specialties, such as IV nurses, and pharmacists that design certain drug protocols for cancer and heart disease. There are supply chains for drugs, food, medical supplies, and technology. There are layers of administrators, MBAs, lawyers, risk managers, and community advisers.

It probably does feel like one is a chassis on a factory assembly line, when you're going through it.

Throughout the fall semester, my colleague and I visit as many of our students' sites as we can fit in, and we do so while the students are on duty with their assigned nurse-mentors. It's a great experience for the students because they begin to transition into the real world with the help of an assigned person who sticks with them throughout their time on a given unit. It's great for the agencies because they get an "extended interview" experience with a potential hire.

I see a strong difference between the early visits and those scheduled later, near the time we are at now at Thanksgiving. In the beginning, the students are anxious, excited, intimidated, and keen to best the challenge of operating with less faculty supervision. They quickly become attuned to the culture of a unit or community agency; they learn the language and expectations of anyone who would enter the fold as it were.

Later, they begin to assess the discrepancies between the ideals they have been taught in their regular schooling, and the real-world pressures faced by their preceptors as working nurses. My colleague and I read the structured journals they are to submit for review each week. We witness the disturbing events the students have experienced, sometimes it's prejudice, sometimes it's inappropriate care, sometimes it's the futile efforts to save someone that should be allowed to pass unmolested from this life.

But I can see them also becoming a part of the thing that they hope to join--including some of the less than ideal attitudes and behaviors. The stress of clinical work among the very ill, injured, and hopeless often brings out the best in them, but it can also reinforce the negatives. We, the faculty, continually try to reinforce the best in them, to get them to see things in more subtle and complex ways. It is one thing to "put on a smile" when faced with an angry, difficult patient who just seems mean! It is another, higher-level thing to get beyond that and determine what is beneath that anger. Is it a growing neurological reaction to a new medication? Is it despondency? Is it a youth trying to control just one thing in his world? And then what? How do you break through and build a therapeutic moment from that?

It's pretty high level thinking, that. And it's very easy to let that be the unachieved thing during a day of call bells and tests and medication passes and anxious family with questions and doctors' orders (which are sometimes in conflict with each other!) and on and on...

And then the RN clocks out. Tomorrow it will happen again. And so it goes every day until the nurse changes positions or finds a comfortable way to retire early (and these are both quite common in nursing). Maintaining a high level of enthusiasm in The Factory is difficult. One recent study found that nursing's high turnover is often directly related to declining levels of intellectual challenge and sense of control over one's practice, two features of the profession that are being systematically eliminated in favor of throughput and productivity, uniformity of experience (from the patient's perspective), and "quality control."

My RNs tell me that hospital practice is highly regulated, and to my view it seems more highly regulated than when I started out in the hospital. Arguably care is safer and more efficient, although the evidence is conflicting. "Evidence-based practice" is the catchphrase everyone uses now, so much that it starts to sound like Dilbert-esque corporate gobbledygook, it starts to sound like a joke. Nurses still solve problems, and practice still poses intellectual puzzles to challenge the practitioner. But my survey of the field convinces me that a lot of my newly minted colleagues might not stay in the profession very long if they continue to be treated like factory workers.

Evidence-based practice may be a means to reducing unnecessary health care costs, but it won't be the only way, since some of the cost drivers are unregulated drug costs, unnecessary equipment, redundant testing, defensive medical practice, and an emphasis on "customer satisfaction" in a setting in which it's kind of normal to be unsatisfied. I see EBP as having another side: a way to convince practitioners and patients alike that one size of health care fits all. Hardly the art of Medicine or Nursing.

On Why We Do What We Do

I read this morning that Junko Tabei died in Japan. Tabei was the first woman to conquer the "Seven Summits", the tallest peaks on each of the seven continents around the world. Her long career in mountain climbing occurred over the last 40+ years. She died, at 77, of cancer. She kept up some mountaineering while undergoing treatment.

After I read that, I lingered in bed awhile, thinking about a life worth remembering. I started thinking about my own lifespan, and my parents'. I thought that if I die at 77, then I have about 22 years left. I thought about what happened in my life, what I did and didn't do, over the last 22 years. My mom is 78, and she's still alive. Ok, maybe I get 23. My dad's 81, so maybe I could last 26 more years. My wife has survived cancer and she's 59; her father died of cancer at 68, but her mother--living with multiple sclerosis for over 50 years--didn't die until she was 91...

Or maybe I get hit by a truck tomorrow! You never know.

Don't imagine that I was looking back (or forward) with regret for what I've done and haven't done. Granted, we all have things we regret, but for the most part, I let go of that some time ago. I feel like I'm doing what I want to do and what I should do. I goof off, too, but that's part of life's fun, isn't it?

No, this isn't a retrospective on my life or anyone's, and it's not a wet-eyed missive on the importance of "living life to the fullest." Rather, it made me think about why we--in this business of healing and health care--do what we do.

People get into this business for a variety of reasons: a stable job, intellectual challenge, a love of others, and a wish to relieve suffering. The highest aim, though, is sung by The Fray's Isaac Slade: "to save a life." This is what I was thinking about, "saving" life. From this spun a web of other things.

I'm a homeopath. I'm also a scientist. As a scientist I know that science may one day decidedly judge that homeopathic medicine isn't a thing. The remedies are sugar pills. The improvements are illusions, accidents, and placebo effects. And my career of treating patients with this method was a waste of effort. The materialist model of treatment was correct all along.

Or, I could be right. Science may show that everything we have observed and theorized about homeopathy since Hahnemann coined the term is pretty close to the truth, and we, the crackpots, were on the leading edge.

If I'm wrong, was my life wasted? If I'm right, was it justified?

Hahnemann left the "regular" medicine of his time because he felt it caused more suffering than good. In Aphorism 1 of the Organon he states that the physician's highest calling is to make the sick healthy. His conception of this strange new medicine, this "homeopathic" medicine, was that it should make healing genuine, that it should extend, or save, a life. He differed with his "regular" colleagues in what saving a life looks like, but the result is the same: more time.

More time to do what?

That's when it occurred to me that more life and better life are not especially relevant to framing these questions of duration and value. I've seen cases in which a baby dying in childbirth caused a tectonic change for good in the life of a family. A very short life that changed the lives of others.

Nothing we do will last. No life we save will be saved forever. Lives we save may not change. In the end, there is only The End. Then why do we do it?

It was then I thought of what I have observed in my practice. I am not always successful, and sometimes when I am successful, I later learn that the person died anyway, of that problem or of something else, either spectacular or mundane. I connect this to others--doctors, nurses, therapists--and it is the same. No matter what we do, the victory will be fleeting.

So we all say, it's not how long you lived, it's what you did with your life. But how do I, or any of us, contextualize this then?

It was then I thought that Hahnemann was right for his time, but not right for all time. The highest calling for any of us is to relieve the suffering of others. And that's a calling that demands more than any medicine we can deliver with all our technologies, homeopathic, allopathic, or otherwise.

When I began this journey, I hoped that I had found a way of cheating Death. As a child I feared disease. Hospitals scared me. My precocious head was filled with fears of brain tumors and leukemia, and more exotic fears like scleroderma and myasthenia gravis. In nursing school--a school I entered because I sought a portable, well-paying job while on my way to earning a living in the arts--I learned about so many more diseases, injuries, catastrophes that beset us at every turn.

After I graduated I began to explore alternative medicine because I found it interesting. I was attracted to the rococo beauty of things like traditional Chinese medicine. Homeopathy, however, seemed above the other things I was learning about, so tiny, so subtle, and most of all it appeared to me to be a link to some medical magic that could forestall the seeming random assault of these many diseases.

In homeopathic medical school, I met a former student, a young physician, who was said by our teacher to be something of a genius at the art. He was what the rest of us aspired to be. He also had colon cancer, and in his 30s, he died of this disease, despite homeopathy and everything else. I've seen similar things among those who diet and exercise and eat only organic foods and practice yoga and don't smoke and don't drink alcohol and pray every day--and those who climb mountains.

So it seems the only "magic" is in us, not the wands we wave or the potions we carry. And that magic is limited to relief, to kindness, to creating a space for hope. That's it. That's all we get. So I guess I'm making the best of that, whether I have a few more days or 30 more years.

Private Health: American Individualism and the Tyranny of Evidence

I've criticized the two main sides in the vaccine "debate"  previously. One of the things I made clear concerned the personal nature of health care decisions in American culture. Not that other cultures don't share some similar values, such as avoiding harm, doing good, and confidentiality. They do. But many state-run or "single payer" systems are operated on the premises that health care is a right of the citizenry and that therefore all citizens must contribute to the general welfare.

This basically means that the people as a society make sure that everyone has health care. In the US, this has often been interpreted as everyone has terrible health care, which is rationed and miserable. However, most Britons and Canadians like their systems. You get sick. You go to the doctor. You get treated, and you leave better. Simple.

There are problems, but they aren't as bad as they're made out to be. Yes, sometimes people wait for elective procedures. The systems can be overburdened. Like any public enterprise, these things go through good times and bad. Political neglect can lead to actual neglect and poor service or shortages or mismanagement. These systems may be closed (Canada) or open (Britain), meaning there may or may not be a legal cash system outside of the national health service. I'm really simplifying this a bit, so bear with me. But this does describe the essentials, and many countries operate this way.

We here in America have criticized ourselves soundly for our failure to pick up these habits of advanced societies. Of course, by a lot of metrics we do have some pretty bad stats--higher infant mortality, lower life expectancy, much higher costs, and so on. But still, are we that bad?

America is "the land of opportunity." We value the frontier. Although that frontier has become less physical and more metaphorical: we pursue the edge of things, space, medicine, technology. It makes sense that ours is a "free market medicine" opening the doors to creativity and innovation.

These other societies that have centralized their health care delivery and payment streams have managed to achieve remarkable gains in health and longevity. That is true. But perhaps ours is a different metric. Perhaps we measure health as much by our perceptions as we do by our statistics.

I hear a lot of complaints about doctors, medicine, hospitals--but that happens everywhere. Sick people aren't at their best, and to the sick the world can seem a sour place. And mistakes and misadventures happen in all systems of health care delivery, regardless of who's paying the bills. So it also makes sense that our system, despite its obvious faults, "works" in that it imbues us with a sense that the impossible is possible.

I support single payer health care. It's parsimonious and efficient, and it can be humane and expeditious, if supported properly. But I do begin to understand why it's so hard for many in our culture to accept that communitarian health care is to be rejected as a policy change. It robs us of our power, although arguably there's no evidence that Britons feel "robbed" of anything. It is possible here to pay for anything. It is harder in Britain--they make choices that to Americans feel like a defeat. If everything can be done it should be done, regardless of the cost, although held in check somewhat when the "everything" is painful, tortuous, and causes it's own suffering when the benefit really is small.

Recently I helped a family member navigate a new health problem that had all the earmarks of "going bad"--and by this I mean an ever-growing list of tests that obscure more than they reveal, and would expose this family member to an ever-growing list of potential side effects, medical misadventures, and puzzling-but-likely-inconsequential findings that would require "further investigation" but lead to nothing.

This, I have seen before.

The thing that brought me into the picture was the cost of a special type of MRI that the insurance wouldn't cover. This was not because the insurance company is mean, but because experts there know that risks would exceed the benefits at moment in the diagnostic process, and they would pay for a different kind of test--one I might add that is a bit painful for the patient!--but one that would yield more useful diagnostic data in the process. My relative didn't want to pay for her daughter's uncovered special MRI if there was no good reason to do so, but she was a bit peeved at the insurance company.

This is how people experience the "tyranny" of evidence: the evidence pointed to not pursuing the testing that my relative intuitively felt would be more useful to sorting out her daughter's problem. This is understandable, and in my view it's also the reason why Americans instinctively turn away from the possibility of single-payer health care.

In short, we don't want a system that uses evidence to guide health care decision-making because we fear we won't get the care we think we need. We are willing to suffer the inefficiencies and excess costs of our current system because each of us wants what we feel is the "very best."

There's a wrinkle in this argument, and it's similar to the wrinkle in my family member's health care adventure.

If the original operators who evaluated her had done a careful history and thorough physical exam perhaps they'd have found what I did, that the "problem" which seemed on its face so dire was really a less serious problem, nothing that would require extensive, expensive, and painful testing, and nothing that would require the specialists to whom she had been referred.

So, it's not the means of delivery, but the means of execution of our health care that perhaps we ought to be concerned with. I'm not proposing that every clinician needs the clinical acumen of TV's Dr. Gregory House. But heck, I'm just a nurse practitioner and I figured it out!

I propose that the problem is not how we pay for health care, nor who controls the delivery, whether it's insurance companies or a government agency. The problem is that clinicians have become mentally lazy. Listening with empathy, hearing the patient's story while mentally framing that story with basic principles from anatomy, physiology, and pathology, and doing a careful, attentive examination would save more money, deliver more effective care, and produce more healthy, satisfied patients, than anything else we could do with system organization.

I started this blog entry over a week ago. The event I described happened just a week ago--so it closes out the theme in the title in a way I didn't initially expect. It's not about who will pay for health care, nor how it will be paid for. Ultimately, we as a society have to figure out how much waste and inefficiency we will tolerate, and how much control we will cede to others (whether it's an insurance company or a government is merely a matter of aesthetics!).

If I sound a bit sour toward my colleagues in health care, it's on this deeper point concerning the actual clinical encounter. My family member's health concern was treated by decent people, I'm sure. But those same people (one, a specialist) got all tied up in fruitless speculation and punted to exotic tests without good cause. I realize the pressure to order tests that clinicians are under. But I have universally found that simply explaining one's reasoning process and the potential hazards and inconveniences of excess testing soothes people. It's not that you're being stingy, you're acting in their interest.

And by the way, my family member's doing fine. It seems all will be well at this point. It just took a bit of thought and kind, non-technical explanation.

Zika...and Dementia?

The British online Mirror reported late last month on a study that appeared in Cell: Stem Cell by Hongda Li and colleagues at the LaJolla Institute of Allergy and Infectious Diseases. We already know that Zika can affect the brain development of the fetus, leading to microcephaly (small brain) in babies. The Mirror reports that the LaJolla study's authors suggest that Zika can infect and affect the brains of adult mammals as well...and may lead to dementia.

I read the study, which is available online, and indeed the mice they studied did show evidence of damage to special parts of the little mouse brains that are responsible for growing new brain cells. For a long time we thought that nerve cells were the only cells that didn't grow more after birth. Indeed, even our skeletons are entirely replaced--cell by cell--over the course of a decade. It turns out that nerve cells can also be and are being replaced, at least in our brains, and that they grow new connections when stimulated. This is the basis of the so-called "brain games" that have become popular: challenge your brain and grow new cells and connections. Get smarter--or at least preserve what you have.

Although the authors' conclusions in the published study are justifiably cautious and include careful scientific disclaimers about the some of the dissimilarities between mouse and human brains, they acknowledge that implications include the possibility that Zika virus infection in humans may contribute to various brain-based problems like memory loss, learning problems, and other neurological issues.

Let me stress that this is very early research. No scientist has linked Zika to actual human adult brain damage!

Part of what makes this interesting to me is the fact that the article in the Mirror pushes this preliminary finding--from a mouse brain model--out to the general public. It seems a bit glib, but scaring people into believing Zika might also cause adult-onset dementia must surely get "clicks."

Another part I find interesting is because I am a homeopath.

The researchers published their findings, and it's evident that they, like most scientists, view biology as a set of intricately interacting, but ultimately understandable, connections of tiny chemical structures interacting in a completely mechanistic way. It's clear in this model that all those chemical interactions are deterministic, except to the extent that chance encounters could also influence their ultimate expression. Put another way, we are the sum of millions of tiny chemical interactions, that if known would mean we can fully predict the development and treatment of disease. The only wild card would be random environmental interactions such as trauma, toxins, and radiation. Add to that an element of really random luck in how genes express themselves (which may or may not be true), and it's thought we can someday explain the whole thing.

In some systems of medical philosophy, like homeopathy, it is believed that ways in which this mechanistic model of biology attempts to account for everything that can happen (and thus how we can fix it all) lacks a certain piece. That piece is the subject of a lot of speculation, but what is not in doubt is that weird, unexplainable things do happen. The speculation is over why.

In Eastern Asian systems of medicine we talk about qi ("chi" or "chee"). In homeopathy, Hahnemann names it the "vital force" or dynamis (Aphorism 9). In other systems it goes by other names: energy field, dynamic field, organismic "vibration", and so on. This is a widespread idea, but could still be dismissed as the pervasiveness of mystical or magical thinking around the world and present in many cultures. Scientists of a materialist philosophical bent could be right. We just haven't figured out quite how all the parts work in synchrony and in disturbance.

Or, they could be wrong.

Granted, these "fields" or qi or whatever could be all wrong, but I doubt it. I think we just haven't quite gotten to a philosophy or technology that allows us to see what's really going on. That's my bias, and I'll own that. But that doesn't mean I'm wrong.

If life is governed by some sort of unifying field, it may be possible to manipulate that field, or at least understand how it becomes disturbed and causes organisms to sicken, suffer, and die. If it were so, and we already had some means of influencing that governing force, wouldn't that be worth exploring?

This week, as I do every week, I saw several people suffering from things seemingly unresponsive to regular medicine, things that seemed to "just happen". Some of them were new to me, and I'll have to wait and see if this thing called homeopathy works for them. Others were familiar, and we were following up to examine the effects of this supposedly "quack" medicine. The follow-ups were satisfying for the most part, examples of a system invented by a German crank 200 years ago because he took the time to really pay attention to what was going on with his patients. We don't fix everyone, and indeed some problems are better repaired by the materialism of regular medicine and surgery. But we fixed some people who were at their wits end.

If Zika does infect and affect human brains, is it possible that we already have at least some means to make people more resistant to it, or cure potentially disastrous effects? I haven't seen any verifiable cases of Zika yet at this latitude, but stay tuned.