January 6, 2023
Dear Interested Readers,
Thoughts About the New Year
Last week I advertised that I was going to review 2022 and then look forward to 2023. It is easy to talk about “what has been” and much more difficult to anticipate “what will be.” At the end of the essay I wrote:
Much of what happens this year will be a function of four things 1) the war in Ukraine, 2) the decision the Justice Department and the Attorneys General in Georgia and New York make about prosecuting Donald Trump for his many crimes, 3) the continuing struggle to control COVID, and 4) actions taken by our Supreme Court. I am concerned about the uncertainties at our borders and how the conservative majority on the Supreme Court has once again gotten the issue wrong…. [That was in reference to the court reinstating “title 42” which limits immigration until the case is heard sometime in the next few months.]
I continued:
I am not an authority on issues of immigration, but I am moved by the footage I see of the suffering at our borders. I believe that we have both the wealth and the need for an expanded labor force to make it advantageous for us to offer many many more families and individuals a chance to be Americans. To incorporate millions more into our society will require changes to child care, housing, food security, education, and healthcare infrastructure that would be a step forward for all of us. Do I expect that we will make progress on immigration and infrastructure issues in 2023? No, but I hope I am wrong.
The last paragraph was clearly a “punt.”
It is pointless for me to try to anticipate more about what lies ahead in 2023. I am making my list of resolutions for personal growth, metaphorically buckling my seat belt, putting on a crash helmet, saying a prayer, and crossing my fingers as I wish us all luck in the coming 12 months! It is still true that in an uncertain world, it’s good to have a plan and direction, but it is even better when those aspirations are coupled with grace and good fortune!
It took less than a week for it to be clear that my list of four concerns was woefully inadequate. I will stand by my first four things to watch, but I want to add more concerns to the list. Last week’s list was:
1) the war in Ukraine
2) the decision the Justice Department and the Attorneys General in Georgia and New York make about prosecuting Donald Trump for his many crimes,
3) the continuing struggle to control COVID
4) actions that will be taken by our Supreme Court.
What was I thinking? The list should contain many more issues that I omitted. Another week of violent weather coming across the country is a vote for global warming. More precisely I should say that the concern should be “What are we going to do about global warming?” I wish global warming was the only omission from my list of certainties for 2023, but I also erred when I failed to mention the fact that since we have not done anything that can be relied on to diminish access to assault rifles or other high-caliber guns, we will continue to have mass shootings. We should all be embarrassed that we live in a country where firearms are the number one cause of death in children. One big lump of concerns that I am sure will be the source of headlines in 2023 is the feeble attempts we are making to address the social determinants of health.
If you are a “lumper” you can summarize the whole discussion by calling it poverty. I prefer to think of myself as a splitter so housing, access to food, access to child care, education, access to adequate healthcare, and meaningful employment are all separate concerns. As is true for most problems, the concern is multiplied when the affected individuals are from a minority.
Over the last few years, I have been waffling when it comes to where I want to focus my attention. When I began writing in 2008 my focus was on optimizing the delivery of care by employing systems improvement engineering principles to the practice of medicine. I did not focus on dualism or biases as being background contributors to the problems I wanted to address. Like many doctors, I take great pride in our scientific achievements and our professional desire to apply the benefits of our rapidly expanding knowledge to everyone who might benefit from “cutting-edge practice” and a focus on quality while eliminating waste. I overlooked what we now know to be true: We tolerate huge inequities in the care we provide. We become very defensive whenever we are presented with data that demonstrates the shortcomings of our system of care compared to other developed nations. My prediction is that with divided government, and the workforce stresses that exist with our dispersed system of care there will be little or no improvement in our quest to be better in 2023. The objectives of the Triple Aim seem to be as distant now as they were in 2007.
I don’t practice anymore and I have given up my positions on the boards of Guthrie Health and The Boston University Medical Group. The only direct contact I have with any practice is my service on the President’s Advisory Council of the Whittier Street Health Center in Boston, but I have frequent interactions with our system of care with my own care, the care of family members, and the questions and concerns that people bring to me because I was “once a doctor.”
A frequent point of observation is through the eyes of former patients, friends, or family members who ask me for my interpretation of their tests, symptoms, and suggested treatments. I begin the conversation with disclaimers. I am retired. I no longer have an active license to practice medicine. Medicine has moved forward a long way since I last practiced. I tell them that they should not substitute me for their “real” providers. With those disclaimers understood, I am delighted to listen to their concerns. Usually, they are eager to send me EKGs, echo reports, stress tests, cath reports, and lab tests.
The good news is that almost always the testing suggests to me that the evaluations were thorough. I do frequently see evidence of unnecessary testing, but almost always the workup has been adequate and there is evidence that the workup was done by a clinician who was following standard practice and was “thinking.” The problem is usually that there was a failure to communicate between the provider and the patient who has called me for help. I am delighted to reassure them that they are in “good hands” and that they can trust the advice they have been given. In the conversation, I frequently learn that the person who called me did not think they had access to the time they needed to have their questions and concerns adequately addressed. Sometimes the problem is even worse because it has been very difficult for them to get an appointment with any provider who is willing to give them the time and attention they need in order to be comfortable with a difficult decision.
In the last week, I have had two cases that are worth considering for what they have to teach us. In the first situation, I was called by a friend who wanted me to go to our local hospital and talk with a young man we both know. I was surprised to hear that there was a problem since I had always imagined the fellow to be a healthy guy who enjoyed outdoor activities. He has no PCP, so he presented to an urgent care unit with the complaint of a month of progressive fatigue, shortness of breath, and weight gain. He had gotten one COVID vaccine dose but failed to complete the series. Earlier this year, he had a moderately symptomatic episode of COVID that did not require hospitalization, but he has not felt “good” since then. He has returned to work, but it is hard for him to get through his tasks.
In the urgent care office, he was found to be markedly hypertensive and edematous. His chest x-ray showed cardiomegaly and vascular redistribution. When I dropped by to talk with him as was requested, I was pleased to learn that he was waiting to be transferred to Dartmouth Medical Center. He had already had a diuresis of nine pounds overnight. He told me that an echocardiogram had shown that his heart was large and did not work well.
After his transfer, his diuresis continued for another fifteen pounds for a total of twenty-four pounds or three gallons! His cath showed an ejection fraction of 20%, normal valves, and no coronary artery disease. It is possible that he has post-COVID cardiomyopathy. He was discharged on meds with the advice not to exert himself much over the next six months while his heart is recovering. I hope it does, but I am concerned for his future.
It is possible that in time his LV function will improve whether this is a post-COVID cardiomyopathy or some other idiopathic process. Again, the care was excellent, and the young man did not need me to be anything other than a sympathetic friend. What disturbed me was that he has no health insurance. In this country, he is not alone.
His job does not offer health insurance because he is “not full-time.” His income has been just a little too high for Medicaid, and for practical purposes either too low to buy insurance through the ACA or the barriers too complicated for him to negotiate. I don’t know him very well, but would not be surprised to learn that his self-image is such that “taking welfare” would not be an option he would embrace.
I think that his problem is not his care, but rather his lack of coverage. He spent five days in the hospital and had a cardiac cath. He already has a large bill that will probably exceed his annual income and will exhaust any savings that he might have. I doubt coverage would be an issue in his care if he lived in a European country. We are a “purple state” with a social safety net that has some big holes. Would he be better off if he lived in Vermont, New York, California, or Massachusetts? I am sure that he would be in even more financial trouble if he lived in Florida, Texas, Tennessee, or in any of our “red states” that have not accepted the Medicaid extension of the ACA. I doubt things will change over the next year or over the next several years. I can imagine that if this man was a member of a minority things would be even worse.
The other case that came to me this week was from South Carolina, a “red state.” It underlines another issue that needs correcting but I doubt will get much attention in the coming months. It will probably get worse. The patient is the father-in-law of an old friend. He is a seventy-eight-year-old retired man who has been having chest pains that are difficult to relate to exertion. As best I can understand, he has Medicare C (Medicare Advantage) coverage. He has a PCP, and he has been seen by a cardiologist.
He made a mistake that many people make. He drove himself to an emergency room when he had chest pain. After he told the intake person that he had chest pain, he was told to take a seat. Six hours later after never being evaluated, he walked out. His PCP did see him sometime in the next few days and ordered a nuclear stress test that showed an ejection fraction in the thirties, areas consistent with old infarctions, and areas of ischemic myocardium.
His PCP arranged for him to go to a university center about an hour away from where he lived to have a cath. Before he arrived, the cath was canceled because “of insurance issues.” My guess is that the university center was “out of network” for the Medicare C plan that he had. Whatever the explanation, his coverage did not give him easy access to the care he needed. His problem, based on the nuclear study is probably three-vessel coronary disease and prior undiagnosed myocardial infarctions with unstable angina and a damaged ventricle. These are the sort of issues that should be addressed promptly, and care should not be delayed for fear that the system won’t get paid. Finance should not trump care.
This case upsets me more than the first case because in the first case Dartmouth provided the care and the finances will be a follow-up problem for social services and the billing office. In the case of the man with chest pain, the system was not prepared to help him when he went to an emergency room, presumably because of workforce issues, or when he needed the diagnostic cath that would be the first step in care that could be life-saving because finance and coverage were more important than his medical safety. Both are examples of how the system can fail us lethally.
I know that COVID greatly stressed our system of care and that hospitals, clinicians, outpatient practices, and chronic care facilities have not recovered and continue to be stressed in ways that I could hardly imagine when I was trying to lead a medical group toward the objectives of the Triple Aim. Then we were improving slowly. Now, it seems that many of the gains have been lost, improvement skills have been discarded, and the mission has been forgotten.
It is hard to know at what rate our system of care is deteriorating, and two cases present no statistical significance, but I must believe that across the country in many places cost, quality, and access to care are not improving. Expenses are rising as a function of worsening workforce shortages.
I know that there are many patients who feel unheard when they try to get help. They often assume that the doctor is uncaring. Sometimes they imagine that the doctor is trying to see more patients just to make more money. When I hear someone complain about the profession’s inability to adequately “hear” and “see” patients my first thought is that there is a healthcare provider who is in trouble. The inattention the patient experiences is more likely to be derivative of the stress that caregivers are experiencing than a lack of caring or a desire to see more patients and make more money. I do believe that as a profession we have failed to make the improvements in systems that would protect both patients and caregivers, and for that omission we are culpable.
I don’t know what the answer is, but I ask you, do you? Do you expect that care delivery, quality, and healthcare finance will improve in 2023? If you don’t think things are likely to get better soon, do you plan to do anything? Are you sure that you, your family, and your friends are safe from experiencing some failure of care? A flawed system ultimately can become an equal opportunity disaster. 2023 will be a challenging year.
Gray Skies: Reality and Metaphor
It has been a dark week from both meteorological and metaphorical perspectives. I have tried not to remember that today is the second anniversary of the debacle at the Capital. At a literal level, the scene in the header for today’s letter is pretty typical of what I have seen each time I have looked out my window this week. At the metaphorical level, the darkness became most intense when Matt Gaetz nominated Donald Trump to be Speaker of the House. Was it a joke? Gaetz was the only person who took the move seriously since no one but Gaetz voted for the former president.
The picture in the header was taken midmorning last Tuesday, and not late in the afternoon just before sunset. Today, it is snowing and that means that the dull beige snow that persisted through the warmer weather of this past week will get a nice new topcoat of new white pristine beauty. The picture below was taken at about 11 AM today as I was reviewing this post for errors. It is almost exactly the same view that you see in the header, but now the ice on the lake is covered with snow. Maybe when the storm passes the sun will come out for the weekend.
After the fiasco in the House this week as Kevin McCarthy has tried to get elected as speaker, I am tempted to say that the gray skies and blah landscape of the header picture could be a metaphor for what we might expect during the next two years of divided government. I am comforted by the thought and certain knowledge that within a few days or at most a couple of weeks the sun will shine again in New London even if Washington continues in the drab darkness of a political winter.
Given what I have observed as I have watched thirteen attempts to elect a new Speaker of the House, it is possible that it will be a lot longer before the sun shines (metaphorically) on the Capital again. Does “never” Kevin mean never Kevin? What I think we can conclude is that McCarthy will eventually win, but what has he given to the very far right for his empty victory? Our government is divided in two ways. There is a deep division between Republicans and Democrats, but there is an even more dysfunctional division between various factions in the Republican Party. It seems that the only thing that unites Republicans is their distaste for progressive thoughts. When they get an opportunity to lead, they battle one another. I guess that it is possible, though unlikely that the circus of continuing rounds of voting will still be going on by the time I write to you again next week. What is more likely is that McCarthy and his cronies will be busy harassing president Biden and his administration while we all lose.
I have watched the whole thing, and it has been an educational experience. Normally, I would not have devoted so much time to a process that has earned the proverbial comparison to watching grass grow. My excuse is that I slipped on the icy stone steps to my deck on New Year’s Eve and came down pretty hard on my back. It was my second fall in two weeks. Since my second fall, I have been parked in my recliner trying to get relief from a couple of heating pads and large amounts of ibuprofen.
I welcome the entertainment I get from listening to various Republicans as they try to explain just how Kevin will win in the end, and together (those for and against Kevin) they will save the vast majority of Americans who placed their trust in the Republican party to make things right just like Ronald Reagan promised. It has been a small consolation to see McCarthy squirm. If Groucho Marx was still around, the “word of the day” would definitely be “schadenfreude.”
I joke because the whole fiasco makes me sad. I fear that 57 million voters got upset over the cost of gasoline and turned over the possibility of progress on the social determinants of health to a party that is divided against itself. The irony is only those who want a dysfunctional government will be “winners” in this unfortunate farce. There are those on the far right who believe that the best government is the one that does nothing. It is strange to consider getting nothing done as a measure of success.
Maybe we will be rescued by a miracle. The possibility is worth a few desperate prayers. I can deal with a few overcast days because experience reassures me that the sun will return soon, maybe tomorrow. The idea of two years of political darkness listening to voices from the far right tell us about how their objective is to save America by doing nothing to upset business is a stress that is difficult to contemplate. 2024 can’t come too soon.
Be well,
Gene
