Category Archives: medicine

The Dry Cat Food Paradox

So close, yet so far...the Tetons

So close, yet so far…the Tetons

I’ve recently had the privilege of attending a continuing education conference in Jackson, Wyoming. As a climber who thinks of himself as primarily an alpinist headed to the Tetons, I should have felt like the proverbial cat who ate the canary. Instead, I left my gear in the basement. It wouldn’t have fit in the car with all the ski equipment and clothes anyway (the whole family of four was signed up for the trip). It wouldn’t have done me any good even if it did fit. Four months out of the year, those mountains are shut down due to a horrendous snowpack. When conditions allow, the climbing is still high up and far back.

It turns out that it is almost as hard for a climber to subsist on Teton routes as it is for a cat to live on hunted birds. Signs of compensation for these difficulties were everywhere in Jackson. Right around the corner from the conference center, was a sign for the “Teton Ice Park”. When the first morning of lectures ended, I walked up to take a look. What I saw was the result of  a noble effort, but one obviously born of desperation. An enterprising guide service had run a few hoses over a 40 ft. retaining wall to produce about five, moderately-angled chunks of ice. The ice park rented gear, but I decided to utilize a different compensatory facility – the climbing gym just outside of town. It turned out to be quite nice.

CIMG4000

Back in the conference center that evening, I was mulling over the dissonance of indoor climbing in the Tetons when the next set of lectures began. Maybe I should have been paying better attention to the speakers. However, it was a series about nutrition, and though the subject is interesting, the hard science behind it could be covered in about fifteen minutes rather than the three hours allotted  As I considered my Teton climbing experience, I kept coming back to the viewpoint which kept me in the Black Hills for all these years: alpine climbing is more about training than actually climbing. Adaptation to harder routes in the mountains paradoxically required less time climbing mountains. Living in a place like Jackson resulted in strong legs and weak skills. Unless a climber availed himself of  an artificial training facility, the volume of technical climbing needed to improve was just not accessible, at least to anyone with a job. My mind wandered back to the lecturer. He was talking about the Paleo Diet and I found it strangely relevant to the contradictions involved in trying to be a good alpine climber.

Guide service storefront.

Guide service storefront.

This diet is supposed represent our nutritional heritage. It encompasses the type and mix of foodstuffs our hunter-gatherer ancestors adapted to eat. Therefore, runs the logic of the diet’s proponents, it is the mix of foods that we ought to eat to  maximize our health and longevity. On the menu is lots of meat and a few plants. Grains and legumes are out. We should eat more like cats than cows, the speaker admonished. To back up his assertion, he flashed a slide on the screen with a picture of a cat at the top and a chart favorably comparing the body compositions of hunter-gatherers with those of cats.

The picture looked a little like my cat, but my cat thrives on dry cat food. I say “thrives”, because I have a dietary comparison-state for her. She was a stray who showed up in our garage when the weather got cold. Before coming to live in our house, she had, in fact, been subsisting on the cat version of the Paleo Diet – fresh, free-range mouse and bird meat. She wasn’t doing so well. She was thin and listless. After a few weeks living inside and dining on kibbles, however, she was tearing around the house like a maniac, destroying rolls of toilet paper and climbing the curtains.

Here are the first four ingredients listed on her cat food label: chicken by-product meal, corn grits, chicken fat, tuna, brewer’s rice. One would expect a wild cat to catch birds, but I doubt one ever took down a tuna, much less an ear of corn or rice. Still, a cat’s ability to live a long and active life eating nothing but rock-hard brown morsels shouldn’t surprise us. Evolution makes the most  of things, not necessarily the best of things. Wild cats developed the capacity to survive on mice and birds. Cats are therefore well suited to that diet. That doesn’t mean that there isn’t a diet better suited to cats. Perhaps humans are much the same.

A subsequent  slide showed a Kung! tribesman butchering an antelope with a stone tool, and then a chart with cholesterol levels and heart disease rates demonstrating the sterling health of various modern hunter-gatherers. Unfortunately, the health data for the Tarahumara, a group of indigenous people living in Mexico and renowned for their feats of long-distance running, look just as good. The Tarahumara subsist primarily on corn, beans, chiles, and beer.The answer to this dietary conundrum is not found in the diet, but what comes with the diet. Both the Kung! and the Tarahumara are incredibly active, and they do not suffer from surplus. The Paleo diet is not the answer to our health problems. No such simple answer exists.

Of course, there are limits imposed by natural adaptation and on artificial adaptation. Artificial answers are also incomplete. To be a good alpinist, one must climb a certain number of big routes in the mountains. But plate after plate of summits will limit a climber’s potential in the end. Though it isn’t complete in itself, some artifice is required as well. Likewise, when my cat came to live in the house, she didn’t just get dry food, she got a warm, stress-free place to sleep, immunizations, and anti-parasitic medicine. I’m sure she would not be so healthy if we limited our involvement with her to setting out a plate of kibbles on the driveway.

Of the billions of humans alive now, most are suffering from the short-comings of an agricultural, and subsequently an industrial, society and a few are suffering from its excesses. As the most realize the economic, social and technological benefits which drove the move to agriculture in the first place, they no longer get the grace period which the few enjoyed. The harms of excess come right along with the initial development. We can’t simply go back, though. Solutions will require some artifice, and may have an unsatisfying appearance – less like grass-fed beef  and more like a bowl of dry cat food or an indoor climbing gym in the Tetons.

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Cult of the Range-Fed Turtles

When my best childhood friend grew up, he decided to become an archaeologist. During his graduate training, he was in charge of  a dig in the Mississippi river valley which unearthed an odd structure. In the midst of the native people’s dwellings, was found a circular enclosure made of closely spaced wooden posts and containing a large pile of turtle shells. The undergraduates were eager to speculate about the purpose of the structure, but my friend cautioned them against it.

“We can’t be sure of its use,” he said”, and we can’t just guess based on what we might use an enclosure like that for today. We can’t just assume they were running a turtle ranch here. Why would they do that with a river full of turtles just a quarter-mile away? We have to put it in context of the surrounding village and the environment of the time, look for other examples and see if there are any modern structural analogs. Then we can make a guess, but it will still just be a guess.”

The next day the professor in charge of the dig came around on a rare site visit to see how things were proceeding. The students were eager to show him the mysterious ring of posts with its pile of shells.

Upon seeing their find, the professor remarked without hesitation, “Huh, must have been a turtle pen,” and promptly resumed his walking tour of the dig.

I don’t know if archaeology has an excuse for this kind of thinking, but medicine does:

Life is short. The art is long. Experience is difficult.

– Hippocrates

We can be forgiven for resorting to teleological assumptions now and again in medicine. With limited time and incomplete information, we must sometimes act on hypotheses which attribute function to structure and purpose to processes. Lucky for us, there’s plenty of slop in the system, so even if we’re wrong at the start, we usually get a second chance. We are trying to get away from teleology, though. “Evidence based medicine” and “scientific medicine” are the names that we have given that effort.

We are trying to get away from teleology because we have been burned by it. We thought that the body made pus to fight off bacterial infections, so for years, when we saw people with respiratory illness cough up phlegm with pus in it, we gave them antibacterial medications. We were wrong, not just about the purpose of pus, but in attributing a purpose to pus. Again, it was an understandable mistake, given the long history of debate regarding the merits of pus. Was it a good sign, or a bad one? Should we encourage or discourage its formation? It turns out we shouldn’t have been focusing on the pus at all, but on    the outcome of our purposeful intervention in the underlying process that produces the pus.

Purposeful results and final causes apply prospectively to human endeavors alone, and even there it’s often difficult to tell whether, when our actions are associated with the desired result, the outcome is due to our actions or simply due to fortuitous circumstances. Applied retrospectively or to processes and structures beyond our control, teleology is a sure mistake.

When we assign an endpoint to a process, we presume causation and correlation must be proven. Humans are notoriously bad at that. In systems which we can’t duplicate or control, we can always tell a causal story (I’m looking at you evolutionary psychology, intelligent design, cosmological fine tuning). But those stories are just interesting rationalizations, sharing the merits of a fairy tale in that they reveal more about us than the subject matter. Our fairy tales are harmless when they are about the universe, the origin of life, turtle ranches or anything else beyond our control. When we tell teleological stories about processes we do seek to influence (and can) we court tragedy.

The practice of bleeding was based on one such tale: the story of homeostasis. We still tell it today, but we tell it as metaphor instead of fact. The story is based on the simple observation that, when a person becomes ill, they go through a series of changes in their physical state which ultimately ends in either the restoration of their previous state, or death. Having observed other systems, the Greeks thought that the process of illness looked like a disequilibrium. Having observed associated changes in fluids which emanated from the body, they attributed the disequilibrium to an imbalance in those fluids. We can hardly blame them for the limits of their observations. We can’t fault their hypothesis. However, we can fault their method.

They didn’t just postulate an imbalance in the humors as a cause of illness, they presumed a balance of the humors as a state the body sought. The difference in these two points of view is subtle, but crucial. If  the balance of fluids is seen as descriptive  then restoring health by balancing the fluids remains a working hypothesis. It admits that other factors may determine the observed equilibrium. It leaves open the possibility that the observed flux of humors is a secondary phenomenon. Most important, it leaves physiologic equilibrium as a simple description, instead of presuming that it is a purpose with causal powers.

Given a description and a working hypothesis, physicians would look at their efforts to balance a patient’s humors with a critical eye. As a teleological assumption, with equilibrium as a “final cause” under Aristotle’s system, the idea creates an entirely different viewpoint. With  humoral balance rooted in the body’s design, variances in expected observations must be due to inadequate methods or incomplete knowledge of the humors. For this version of the “balancing the humors” hypothesis, failure is not an option.

Now, the ancient Greeks may have weathered this kind of assumption better than their heirs. They loved to fight with each other. In the face of inconsistent outcomes from humor-balancing interventions, they were likely to call Aristotle and Hippocrates idiots or just ignore the under-girding theory of causes altogether in favor of their own pet theory. Definitive statements naturally took a healthy beating in the Greeks’ intellectual environment. The Romans, and the Europeans who came after them, were much more pious.

As a result, no one questioned the teleological assumption, out of reverence for its sources, and the vital fluids persisted in medical thought owing largely to the idea of homeostasis by design. No matter how apparent the flaws in our understanding of the blood, bile and phlegm, they were somehow attached to the homeostatic goal of the body. As long as physicians saw that equilibrium as the body’s goal, they could reconcile any discrepant observations with the over-arching story and persist in practices such as bleeding. It fell to investigators outside of the medical profession to discover the secondary nature of the humors. Only then did the practices aimed at balancing the fluids truly begin to fade.

But long after bleeding and the balance of fluids fell by the wayside, the tale of homeostatic purpose continued to plague medical science. Physicians continued to view physiology as directed toward an end. For example  the heart was seen not to pump blood, but to be a pump. Therefore, medical students were instructed to never administer medications called beta-blockers to patients with heart failure.

Beta-blockers stick to proteins in the membranes of  heart cells called beta receptors, which normally bind adrenaline. Via the beta receptor proteins, adrenaline stimulates the heart to pump faster and with more force. In heart failure, the heart can’t contract forcefully or fast enough to keep up with the volume of blood returning to it from the veins. If the heart is a purpose-built pump, beta blockers should be anathema in the setting of heart failure. But in reality, when given to stabilized heart failure patients, beta blockers reduce long-term mortality by about one-third.

We don’t yet know exactly how these medicines achieve such a feat. We do know why they are not inevitably detrimental in heart failure. It is because the heart pumps, but it is not a purpose-built pump. The heart is instead a group of cells which inhabits a specialized niche in a system of many cells all with complimentary and competing characteristics, existing in a state of equilibrium which, in deference to tradition, we call homeostasis.

Our physiology doesn’t try to maintain homeostasis any more than erosion tries to form a natural arch. The arch forms (rather than crumbling like the sides of a stream-bed) because it is geometrically stable given the geology. The arch persists because it is geometrically stable, and so we frequently see natural arches where the climate and geology allow. Nobody marvels at this, speculating about a conspiracy between sandstone and weather patterns. Then again, few people have an emotional stake in natural arches. The same is true of our physiology, minus the low stakes. There is no overall homeostasis sensor or hormone in the body. There is no homeostasis conspiracy.

So, we have abandoned the notion of purpose in physiology, and that simple maneuver has allowed us to discover things like the survival benefit which beta blockers produce in heart failure. This move is the principle behind the randomized, controlled clinical trial. All along, it wasn’t ignorance holding us back, but the project of rationalizing our knowledge to traditionally understood, teleological models.

Of course, the questions driving evidence based medicine don’t start from nowhere. Scientific medicine asks questions based on the results of previous investigations and hypotheses derived from basic science discoveries regarding the components of physiology and their relationships. Some of these hypotheses are even most easily stated in terms of purpose. But those statements are now understood as metaphor, rather than bare fact.

Beyond the fecundity of this change in method, the move away from teleology finally brings some redemption for poor Hippocrates. Rather than using it as an excuse, we can understand his aphorism, “Life is short. The art is long. Experience is difficult “, properly again – as an admonition about method. Be skeptical. Remember that your viewpoint is limited. Watch out for overarching narratives. Good advice, and not just for medicine, but for all those turtle-ranch theorists out there (I’m looking at you intelligent design, cosmological fine tuning, evolutionary psychology…).

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There’s a Pill for That

While waiting for labs with me in the ER yesterday, a younger colleague made an offhand comment about quitting medicine. She felt frustrated because, instead of helping people get over their health problems and get on with their business, she spent her time treating public health problems in the clinic and emergency room. Even worse, she had begun to feel complicit in the distortion. I didn’t know whether to offer congratulations, condolences, or both. Most medical professionals never get that far. They continue to feel good about encouraging dialysis for blind, depressed diabetics with one remaining limb and prescribing cholesterol-lowering medication to nonagenarians. Thereby, only the superficial dissatisfactions of their jobs remain.

I don’t think that doctors should feel guilty about the public health problems confronting them in clinics. Nobody planned for our society to fail us. We spent so much of our history working so hard to make life easier and more certain that we just didn’t notice when we started working harder and harder to make life easier than we needed. The illusion of increasing certainty helped us zoom past the point of diminishing returns. Once enough surplus accumulated to ensure against starvation, twice the surplus seemed to offer twice the insurance against shortage, but the excess would only mold and spoil the lot. Our surplus is spoiling in us now, clogging our blood vessels and glycosylating our nerve fibers.

A solution to the problem lies beyond the scope of clinical medicine. The only solution may be time and economic dissolution. The furor over limiting soft-drink sizes in New York City does not bode well for self-conscious alternatives. But medical professionals can feel bad about their complicity in the whole scheme, because our business is to tell people that there’s a pill for all that.

We tell the public that we can “treat” and “manage” diabetes, coronary artery disease and heart failure. The proper terms would be “attenuate” and “temporize”. The proper terms would imply a lack of control however, and a sense of control is what we’re selling as much as medication or surgery. We keep the illusion of control on offer in the name of comfort. We want our patients to feel free from anxiety about their health. They should feel empowered, and they do, which is good since they will still be physically ill under treatment, just a bit less so than when they consulted us.

I guess there really is a pill for surplus-mold, at least on a psychological level, but it will cost those who take it a lot of money, and the motive to seek out the roots of their ailment. Besides, it will keep the doctors feeling good about something they shouldn’t be doing. It may appear to buy some time, but it won’t cure anything.

You Eyeballin’ Me?

ATTENTION

ATTENTION

An older gentleman lay on the gurney. His son had brought him in from the ranch suffering from abdominal pain. I pushed on his liver.

“Does that hurt?”, I asked.

“Well,” he replied after a moment’s reflection, “it ain’t sore, but it is a little tender.”

Attention

Attention

Tender, not sore. Twelve years and I still don’t know what the hell that means. A former colleague grew up in Wyoming, and since she habitually spoke more than three words in a day (not including ‘Yep’ and Nope’) I asked her a couple of times to explain it to me. She just looked annoyed and said it didn’t matter. I finally understood that she was right. The difference between sore and tender is clinically irrelevant.

attention

attention

‘Tender’ does not have any distinct denotative value, only a connotative one. It still bothers me not to understand its meaning. I’d like to think language can give me a working knowledge of other people’s thoughts and feelings. My expectation of understanding is not realistic. Symbols and their associated concepts just approximate the sets of unique experiences that constitute our shared mental universe. It’s all a big analogy of me to you, words or no. While imprecise, the analogy has one great advantage: it is durable. I may not be able to compare my experience of tenderness to the rancher’s to any good effect, but I can achieve a dialog with the dogs.

Attn.

Attn.

I can even predict the salamander’s response to me looking at it and it can anticipate my response to it clawing at the glass. All of us know our perceptions of each other are about something, which allows us to form these relationships, however vague and riddled with projection they may be (though the salamander does not beg food from people who are not looking at it or objects moving outside the glass, it does respond to the cat staring at it and she is surely looking in with a different intent than it understands).

Attention

Attention

I’m pretty sure I share an extensive mutual understanding with the mammals in the house, even the ones with ear-buds. I’m less confident about what passes between myself and the slimy monsters in the terrarium, but after a day of contemplating human tenderness with all its consequences and deficiencies, an amphibian’s intentional stare is the most reassuring.

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Carnival of Adverse Selection

A Canadian friend once told me that he did not understand the American political system and asked if I could explain it to him. I told him that it was basically an exercise in pest management. On the one hand you have your smarmy rats (Democratic politicians) and on the other you have your vicious rats (Republican politicians). The first kind you don’t even want near you, the second kind you just want to stomp. Either way you’ve got an intractable rat problem, so mostly you just try to ignore them as best you can and get on with your life.

Sometimes though, they crawl across the kitchen counter in broad daylight and then you have to pay attention to them. That happened to me during the last Presidential debate. I was doing my best to ignore it, but we have a radio in the garage with a power switch stuck in the ‘on’ position and the debate was playing in the background. I had it successfully tuned out until they started talking about health care and Romney, who’s turning out to be a particularly nasty little ankle-biter, came with the crazy talk.

Here’s what he wants to do about health insurance:

  • Block grant Medicaid and other payments to states, limit federal standards and requirements on both private insurance and Medicaid coverage. The state can structure a cost-share program however it wants?  It can still shift costs to the Emergency Rooms of Medicare-participating hospitals and to the Medicaid programs of richer states (a kind of internal ‘self deportation’ which already happens to a limited extent)? I can’t imagine what the states might do? These changes are supposed to lead to innovation, and they will – just more the sort of innovation that financial system deregulation allowed.
  • Unshackle Health Savings Accounts by eliminating the minimum deduction requirement and allowing people to use the account funds to pay premiums. HSA’s are a nice product for a very limited income range. If you make too much money or too little to make the tax savings worthwhile, a HSA makes no sense. The proposed changes won’t change that. So, why make the changes? Hang on a minute, I’ll get to that.
  • Allow consumers to purchase insurance across state lines. Recall this is the now minimally regulated insurance product. Watch the insurance companies gobble each other up as they try to recruit all those newly available good risks. Watch high risk people get filtered out of the broader  insurance pool as the generous benefit plans become increasingly burdened with these individuals, and the prices for those plans go up and up, in turn prompting lower risk people to leave for cheaper, less generous benefit plans. Will Romney & Co. adequately fund a reinsurance plan to keep this from happening? Not to worry, people with chronic problems can still go to the ER, right? People can preemptively accomplish this adverse selection themselves via purchasing pools, right?
  • Medicare will become a premium support program. The premium support and benefit requirements will be fixed at the current levels in Medicare. If costs go up, the market will determine how people make up the difference. And in time, like gravity takes care of shoddy construction projects (who really needs architects or building codes), the market will take care of things by channeling the high risk people into the more generous plans (Medicare), driving those plans’ costs out of sight and eventually, driving those plans and high risk  people out of the market. I can almost hear the invisible hand slapping – see adverse selection and cost shifting above. (It’s actually worse than that – Medicare has a normative effect that goes beyond its simple economic effects but that is a story too long and tangential for the moment.)

So, why make the changes if they entail all these predictable distortions? Free market fundamentalism is the answer. Markets aren’t a highly effective tool for these guys, they are a moral imperative. So in their view, markets must be good for every application. Just set up a market and have faith; it will solve any problem. Regulation and critical analysis aren’t caution, they’re apostacy. I’d usually ignore this crap, like I ignore people praying for rain, but this is more like praying that your kid gets better from leukemia in lieu of consulting an oncologist. I feel like I’ve at least got to say something.

So, for all who wondered what could be worse than Obamacare – it’s this happy horse shit. These two rats are scampering across the counter in broad daylight with this mess, and they need stomping, (metaphorically of course).

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Whatever

The healthcare reform law is still alive and the squabbling surrounding it, too stupid to live yet too overwrought to die, is reanimated. Here I go, unable to resist the smell of brains, shambling back into the scrum with the rest. In my own defense, I work in the non-systematic system this law purports to reform. I also have something more constructive to mumble than “Brains, brains!”.

Just look at the objective of the law. Its primary aim is to finalize the conversion of the health insurance industry to a healthcare financing industry. In other words, to convert it from Lloyd’s of London to GMAC. This objective is very modest, as the industry is already two-thirds of the way there. Kaiser, with its souped-up HMO model, is almost all the way there. By finalizing this transformation for the whole insurance industry, the authors of the law hope to provide universal access to healthcare and control costs. These goals are not so lofty as they first appear. In fact, the second one may not be possible by legislative means at all.

We already have universal access, just not rational universal access. Call 911, and someone will come to help you without checking your credit rating or insurance status. Go to the clinic because you have symptoms of diabetes, and you will not get the same courtesy. You must wait for the ensuing heart attack or coma.

Objections to universal access must start with what we already have, and I think these objections, since they have life and death implications, require some earnest gesture before they get serious consideration. I’d propose an opt out. If you think our polity should not concern itself with the physical well-being of its constituent individuals, please tattoo a Gadsden flag across your forehead. Then we can demand payment up front if we find you bleeding by the roadside or keeled over on the sidewalk, or we can simply choose to pass you by. Until you bear that mark, you won’t be taken seriously.

The legitimate objection regarding universal access relates to efficacy. Giving people financing, and thus access, doesn’t mean they will automatically access healthcare rationally. They will probably do a little better than they do now, but the cost control envisioned in the law depends on people doing a lot better at seeking care rationally. People probably won’t live up to that expectation.

Market forces are the problem. Efficient choices in healthcare are difficult. Even clear-cut problems often require some technical knowledge to allow for good decisions. For ill-defined problems, not even the experts can tell the consumer what he or she is buying. So, the consumer must make purchases based on emotional facts rather than physical facts.

From the perspective of emotional facts, healthcare choices break down into two broad categories: care we care about and care we don’t care about. Care we care about is reassuring care and impressive care. Reassuring care is any care that addresses illness we fear, like cancer. Impressive care is care with visible, immediate, dramatic results, like open heart surgery. Care we don’t care about is public health and chronic care, especially if it is merely preventative.

Among these two sets of choices are tests and treatments that are expensive and effective, cheap and ineffective, expensive and ineffective, and cheap and effective. The market favors care we care about, without regard to those sub-categories. Allowing people to participate in the market alone won’t help control cost, for this reason.

Agency is necessary to sort care rationally, in the light of physical facts. Physicians have been the de facto agents up to this point, but they really haven’t wanted the job and therefore serve the role poorly. A financing company might be able to act as an agent, but would be limited to guiding choices among preexisting options.

The Affordable Care Act contains some elements that gesture in the right direction, like ‘death panels’, ( guidance on end of life care). People don’t like those elements because they seek to rationalize, and thus ration care, which entails a loss of autonomy. People are loath to cede autonomy to any agent, especially a visible yet impersonal one like a panel, real or imagined. Until doctors choose to willingly alter their practice and fully embrace the role of agent, everyone will continue to get expensive and ineffective care we care about, and do without cheap and effective care we don’t care about.

To that end, the recent fights over USPSTF recommendations for cancer screening are the sort of fights we need to be having. We’ll see if the political process will allow those fights to go on and spread. As for the ACA, whatever, it’s a start. At least it doesn’t propose to expand market distortions until care is rationed by price alone or beg for a forehead tat.

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Autonomy

The quest for autonomy should be medicine’s ethical basis. A person afflicted with pain or debilitating illness can do little else but attend to the demands of their malady. Offer that person some relief, and they can better fulfill their potential. Whenever medical interventions achieve that goal, it is a clear win. All too often though, that’s the start of trouble, because winning is seductive, and it easily displaces less dramatic goals. Casinos could not survive otherwise. And when it comes to healthcare, we’re really in a sort of magic casino.

Players come in the door with a stake, but there are no bets and the only game is Blackjack. Rather than betting, we simply get to keep playing until the house wins and then we have to leave. Meanwhile, there’s the best cash bar ever, Cuban cigars – whatever floats your boat. And there’s more. Interventions are available for purchase. A player can buy the game down from  eight decks to one. He or she can spend a little more for the privilege of referring to a strategy chart during play. A little more buys a consultant to count cards for the player. Cards are even for sale. Between the dealer’s hits the house will give or take back a card for a price. All of these changes in the game are analogous to medical interventions in real life, from preventive care to emergency surgery.

The catch is, you can’t win. Sooner or later, the house hits 21 and you have to go. The trick is, remembering that you can’t win and playing to stick around and enjoy the bar and the Cuban cigars while you can. Ignoring your cards doesn’t make sense, but neither does hunching over the table with your card-counter whispering urgently in your ear.

Of course, the house could try to help the players out. It could require the purchase of a single deck game on entry. It could hire a concierge to tap players on the shoulder when they forget what they’re about and start to play to win.

Right now, the house of medicine is satisfied with being an honest shopkeeper. It is loath to get involved with purchase decisions because it mistakenly views those choices as, categorically, an expression of autonomy when they are not. They can lead to an increase in autonomy, but they can  lead to an ultimate loss of autonomy as well. Too many players are fixated on their hands in eight deck games, trying desperately to win, a card counter at their side and no cigar money left. Surely, we could do better.

Marketing a Pig in a Poke

Everyone knows better than to buy a pig in a poke, so selling one ought to be hard. It happens everyday in clinics and hospitals, though. Marketing is the key. The seller just has to convince the buyer that nobody really knows what’s in the bag, and that it might be really good. Fortunately, the task is easy for healthcare providers, because it’s just’ telling the truth. Much of the time, both parties can take a good guess at the bag’s contents. Sometimes neither is certain. In any case, a rational price is difficult to determine.

That’s why our current system uses baseline administrative pricing. There may be equally bad ways of pricing healthcare services, but there probably aren’t any better ways. At least this way, prices are based on an educated guess about what is in each bag.

Market pricing is an alternative method. It would give very good prices for squealing bags with pig-shaped lumps in them – things like Botox treatments and laser vision correction. Prices for bags with more amorphous lumps, containing things like cholesterol medicines, blood pressure medicines and cancer screening tests, not so much. The prices for those bags which, in livestock terms, could hold a pedigreed piglet or a skunk, would vary based on the buyers’ fears, hopes and disposable income. It’s a recipe for very good, cheap Botox treatments, and very good, cheap cardiac bypass surgeries and kidney transplants. It might not result in an efficient allocation of resources, but it would present an excellent marketing opportunity for those willing to prey on others’ hopes and fears.

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Templates

When I was a kid, our family doctor kept my medical record in a card file. He kept everyone’s medical records in a card file, each visit documented on one side of a 3×5 index card. The format gave him about two dozen words to put down the reason for the visit, a few salient physical findings, his conclusions and prescribed treatments. For easy, clear-cut problems, it was plenty of information. For the tough stuff, it was woefully inadequate, and he had to recapitulate the entire history and decision making process with every return visit for those complicated problems.

So, the next generation of doctors moved to dictated medical records. This new tool captured better the details of a patient’s past history and the doctor’s thought process . No return visits needed to be from scratch, the doc. just jumped back into the stream of consciousness where he, or the last treating physician, left off. The problem with the thought-to-paper system only became apparent when our society started to spend ridiculous sums for medical care.

The current pricing and payment system is a modified command system. It’s not optimal for a few elective procedures, like LASIK surgery. But given the practical impossibility of  determining individual value for medical care in all other cases, it is about the best we can do. Payments go with terms, defined processes (whether the type of stitch used or the number of steps in a decision), and sometimes even specific words. To get paid, doctors have to extract the valued information from the stream of consciousness. Or rather, the doctors  need teams of technicians to do the extracting. To compensate, doctors are switching from thought-to-paper to paper-to-thought records, otherwise known as templates.

Templates are forms tailored to individual diagnoses or complaints. Each form has billable terms to check off and short narrative sections for processes that produce a charge. As account sheets, they are wonderful. As a means of communication, they are abysmal. At worst, they are checklists gone bad, outlines for linear thinking. Some doctors even propose using data extracted from digital templates for research and quality control in their practices. Except in very limited circumstances, such endeavours will yield more information about the cognitive/behavioral effects of template usage than anything else.

Still, if doctors can learn to adapt their methods to the use of templates, the forms may help after all. The dictated record has dangers of it own. Because it looks so comprehensive, it encourages passivity. It also codifies miscommunication; it is the doctor’s interpretation of the patient’s words, often set down as from an omniscient narrator(“the patient recalls some chest pain, but was experiencing a number of severe stressors at the time”). A template can convey the reason for a visit, a few physical findings, conclusions and treatments – about two dozen useful words. Templates need intermittent narrative summaries as background, but if doctors can remember to use them like 3×5 cards and are granted the time to do so, we may just be off to a good, fresh start.

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