April 12, 2024

Dear Interested Readers,

 

I Don’t Understand Why Healthcare Isn’t A Top Political Issue

 

My adventures in healthcare continued this week with my much-anticipated first post-op appointment with my surgeon at Dartmouth which was three weeks and a day after my surgery. My stitches were uncomfortable, and I knew that if nothing else good happened, I would be free of them. My biggest concern was that the pain and the numbness in my right foot persisted, and I could not dorsiflex the foot which meant that walking with my walker took extra effort to avoid dragging my toes and tumbling forward. 

 

The visit began with X-rays. The appearance of my spine after repair surprised me. As you can see in the picture below, I expected to see the hardware, the screws, and the rods, but I had imagined that after surgery I would look a little straighter.

 

 

The explanation for my persistent curvature was the combination of my previously unappreciated congenital lumbar scoliosis and the fracture of my third lumbar vertebra. I had sustained the fracture in an accident and fall over a year ago when I tried to take my snowblower out of my truck single-handedly and ended up on my back with the snowblower on top of me. I have always been a risk taker, and as an old man I forget that some of the things I could once do are no longer possible for me to pull off. 

 

From a technical and professional perspective, I had no qualms with my visit. I was just disappointed with my progress and surprised by the appearance of the X-ray. The orthopedic resident was quite thorough and my surgeon was in to see me as soon as the resident had completed his exam. Both seemed quite sympathetic with my persistent symptoms and long-range concerns about the foot drop and the ongoing disability that it would cause. There were positive realities. Much of my preop pain was gone. Preop, I had substantial discomfort in my lower back, right hip, right lower leg, ankle, and foot. I had numbness over most of my lower leg and foot. The foot drop had developed over three or four weeks before my surgery. I had hoped that it would be gone after surgery, but to my disappointment, although my back, hip, and upper leg discomfort had improved, foot discomfort that caused deep pain when I tried to walk had persisted and even seemed worse. 

 

Most of my pain post-op has been with the effort to do things. My pain overall has improved enough that every night is not an adventure in pharmacology and pillow arrangement. One of my greatest sources of discomfort has been psychological and precipitated by my ruminating over how I had responded to my patients with similar pain during my long years of practice. I had some retroactive guilt because on reflection I fear that i had not been appropriately sympathetic to their discomfort. I have no doubt that I was perceived as empathetic with the patients who had pain, but I wondered if I had been deeply empathetic with the pain they felt. Now years later I was hoping to get the empathy and action from my providers that perhaps I had been unable to feel or provide for my own patients. 

 

Over more than thirty years, I had managed hundreds of patients who had cardiac surgery as well as many others who had spinal disease and injuries that were not much different than I was currently experiencing. As I look back on those years and all of those patients, I wondered if I had just tried to appear “as if” I had true empathy when the best I could do was a “concerned sympathy.” I don’t think I felt their pain. Although I could offer sound advice and provide some effective pain management strategies, the moment I left their bedside and returned to the process of seeing the next person on the list I did not own or carry any of their pain with me.

 

Was it realistic that now J was hoping that my providers would help me with the burden of my current discomfort in ways that I doubt I was ever able to offer my patients? Do we ever really see the world through the eyes of others? We can’t really walk a mile in their shoes. Perhaps professional distance is necessary for objectivity, but now I am on the other side of the sheet. I have abruptly become quite aware of how alone we are in our pain and other symptoms even when surrounded by those who try their best to steer our care and are blessed with friends and family members who love and care about us. 

 

Part of my surprise associated with the X-ray stemmed from the fact that ten years ago my wife had a similar fusion with screws, rods, and bone grafts, and in her post-op films she had looked very “straight.” It took a while for me to reason that the difference in our pictures was because I went into surgery with scoliosis and a vertebral fracture.  I felt somewhat better and hopeful when at the end of his exam my doctor told me to return in two weeks. I knew his schedule was packed for months into the future, and a return in two weeks meant he cared enough to find a way to squeeze me in. I left with the hope that my symptoms might still improve as the healing continued. One definite positive from the visit was that my surgeon told me that I could carefully begin to use my Peloton again. I have not been able to exercise since mid-January. Two months of inactivity has cost me a lot of muscle tone and stamina. I hoped that regaining some lost strength and flexibility might make a big difference.

 

My visit with the doctor had been on Tuesday afternoon. Things changed at 4:30 AM on Wednesday. I woke up with significant new pain in my left inner thigh and upper calf. When I ran my hand over the area of discomfort, I could feel a lumpy cord. I applied a heating pad and waited for the morning to come so that I could call the office of my surgeon. The nurse was very helpful and called the New London Hospital ER to tell them to expect me. 

 

The New London Hospital is a huge asset for our community. It sports a beautiful building and there are outpatient offices in a new building across the parking lot. Most diagnostic services are available, and there is an urgent care area as well as a traditional emergency room. A helicopter is available to transfer patients who need more intense care to Dartmouth which is thirty miles north of us. At 9 AM I was the only patient in the ER. The staff was courteous and efficient. In a matter of minutes, Dr. Galvin appeared ready to help me. I believe that many people, myself included, often are apprehensive about whether what they are feeling represents a real problem or is some misappreciation of a normal functional discomfort. Dr. Galvin was quick to share my concern that I had an extensive area of phlebitis in my saphenous vein. We both wondered whether I also had a deep vein thrombus that could result in a pulmonary embolism.

 

I had been relieved when Dr. Galvin’s fingers landed on “the cord” and palpated it from my mid thigh to upper calf. Superficial phlebitis does not carry the same risk of precipitating a pulmonary embolism as does a thrombus in a deep vein. There is some variation in the treatment of superficial phlebitis. With localized phlebitis, heat may be an adequate treatment. If there is the possibility that the clotting might extend to the deeper veins then anticoagulation should be considered. To evaluate the extent of my problem and to rule out a deep vein problem, Dr. Galvin ordered an ultrasound of my veins.

 

Within a few minutes, the ultrasound technician rolled her machine next to the gurney where I was resting and began the test. The good news was that my deep veins were clear, but the clot in the saphenous system was extensive. Because of the size of the thrombus and its relationship to the femoral vein, treatment with an anticoagulant was indicated. We were soon on our way while a prescription for Xarelto was sent electronically to our local pharmacy. I was not surprised when I learned that the co-pay for a month’s prescription was $72. The retail price of a month’s supply of Xarelto is about $600. There is a lot of uncovered expense in our care system.

 

After I have bored you with my tale, you might wonder what my point might be. My personal experience gives me much to celebrate and also leaves me with many concerns. First the positives. 

 

The most significant positives are the wonderful professionals that I have encountered as I have worked my way through this difficult period. My PCP, Dr. Katrina Klaus, has been terrific. She is very responsive to my questions and concerns with prompt responses through the My Chart app in the Epic Medical Record. My neurologist at the Chelmsford offices of Atrius, Dr. Kara Chisholm, gave me good advice and her staff worked with Dr. Klaus to help me get a prompt referral to the Dartmouth Pain and Spine Service.

 

A problem is that “prompt” is about two weeks versus six or more weeks for less acute issues. I was told by one of the referral service support specialists at Dartmouth that “playing the MD card” took several weeks off of my wait time. I was glad to get the benefit, but does that represent healthcare equity? 

 

All of the staff at Dartmouth have been very supportive, responsive, and ideally patient-centric, but they work in a stressed system. One scheduler admitted that there were systems problems, and then he gave me the secrets that I needed to employ to expedite my appointments. It seems sad to me that access problems get pushed on to staff to resolve through makeshift workarounds and system patches that require doctors and nurses to expand their schedules taking time either from other responsibilities or accepting an encroachment on their personal time. That reality reveals both workforce issues and resource shortages. 

 

The Dartmouth staff does work in an environment that is very adequately supplied with the benefits of the latest science and medical technology. It may seem remarkable that there are systems issues in a well-appointed medical facility staffed with top-tier professionals, but those inconsistencies do exist. If it takes a lot of “extra advantage” to get access that is still too slow but better than for most, then we have a problem of inequity that touches everyone. Great facilities with the most up-to-date technology and talented professionals do not guarantee a care system that offers timely access to care across the entire population. 

 

Perhaps one of the most important things that I learned in my years leading a healthcare practice was that the most difficult and limiting issues were likely to have an external origin. Another learning was that the social determinants of health that can’t be resolved by the care system alone are often the defining reality in outcomes. The care system must be re-engineered if it is to deliver better results. Dr. Paul Batalden, an emeritus professor at Dartmouth and one of the founders along with Don Berwick of the Institute For Healthcare Improvement (IHI), is one of several individuals credited with asserting that:

 

“Every system is perfectly designed to get the results it gets.”

 

If your system’s results are disappointing, it needs to be improved. I think the hope arising from this observation is that redesign or processes of continuous improvement can make a difference in a closed system. I also think that because of the power of external forces internal improvement and redesign will never completely create a system with adequate access and equity across all of the domains of quality and safety. If we are to enjoy a system that serves everyone, not just retired doctors, the internal and external challenges to the system must be eliminated through redesigned with direct involvement of the public through our political system. Conservative individuals with a faith in a mixture of the “invisible hand of capitalism” and the primacy of states’ rights, would vigorously disagree with me. My response to them is that what we have been doing isn’t working for many people and our efforts need to be thoughtfully changed.  

 

It is sad for me to contemplate that the sort of collaborative congressional participation required if we are to see improvements in our system or care and more equity in the social determinants of health is not possible with our current deep political divisions. It would seem that the idea of better health for everyone would logically mean a better country and would be a powerful enough objective to lift the conversation beyond the limits of the status quo, but we know from the difficult process running up to the passage of the ACA that a bipartisan search for a better system of care is precluded by many pockets of self-interest. The turn onto the road to better care through bipartisan redesign still lies a long way down the road we are currently traveling. 

 

I had written most of this letter before I started reading my local newspaper around noon yesterday. Our paper has a traditional editorial page five days a week, Tuesday through Saturday. I have said before that one thing I like about the paper is that a large percentage of its editorials are republished from papers like the LA Times, the Washington Post, and the Chicago Tribune as well as from other sources like Bloomberg Opinion.  Yesterday’s editorial was from Bloomberg Opinion and was entitled “Health care is still too costly in America.” It was originally published on April 4 by Bloomberg. The editorial starts fast:

 

America’s approach to health care is an outlier among the world’s rich countries, and not in a good way. Extraordinarily complex and hideously expensive, it still manages to leave some 26 million people without coverage. The Affordable Care Act of 2010 made notable progress, but failed to solve the pressing problems of high costs and less-than-universal access.

 

The authors know what they are talking about and continue to describe the problem and offer a possible solution, the revival of the idea of a public option:

 

The ACA fell short partly because legislators dropped the so-called public option. This idea should be revived. The dysfunction in Washington makes such innovation difficult at the federal level, but states have been trying variants. These experiments are worth watching. The need for more reform is clear. The US spends about 17% of gross domestic product on health care, half as much again as comparable countries — yet on many metrics, including life expectancy, US outcomes are worse. The system’s enormous cost is partly hidden because most Americans are insured through their employers: The premiums suppress wages, so the true hit to families’ finances is disguised. Even covered employees can be on the hook for additional charges, enough in some cases to pay for a small car.

Workers fear that losing their jobs will mean they lose their insurance too. More than half of the 20 million who’ve signed up for Obamacare in 2024 complain of high monthly costs and out-of-pocket spending. And despite the ACA, roughly 10% of Americans still have no coverage at all.

 

Those brief words are a pretty accurate review of our current state viewed from a very high level. My previous personal narrative is meant to demonstrate that there are failures to fear and endure even for those of us who are extremely privileged with more resources than over 95% of all Americans. Is anyone really safe? My answer is no. Some of us may feel safe but that is often because we have not needed to use the system. Like COVID, the least fortunate among us are more likely to be harmed, but no one is without some risk of suffering from our overly expensive and self-serving system. 

 

The editorial continues by showcasing a public option being offered by Colorado to it citizens, and I suggest that you read about it. It finishes on a crescendo that reinforces the idea that we are at risk together and that the work will be difficult. We have a lot to gain by finding some way to work together. Perhaps the best place to start is with a public option which would once again give the champions of competition and conservative business principles a chance to show that they really can participate in a solution that leaves no one out and where success is defined by progress toward the Triple Aim and healthcare equity. 

 

However conceived, public options will face setbacks. Health care reform is administratively demanding and politically fraught. Absent rules compelling participation, hospitals and providers could refuse to see patients if reimbursement rates fall too low, leaving areas with less coverage and weaker competition. Nobody says this will be easy.

Yet the existing system is undeniably failing. In poll after poll, Americans say rising health care costs are a top concern. States should keep on trying new approaches to see what works. And Washington should put the Medicare-based public option — perhaps the most promising way to solve the system’s biggest problems — back on the agenda.

 

I guess that I am lucky. I am sure to improve because I did get the benefit of the best the system can currently offer. Quality health care should not be a function of status or luck. Equity in access and outcomes in pursuit of the Triple Aim should be the new rigorous objective toward which we work. I fear that any success toward that goal in the next five years will be determined by the elections coming up this fall. Better healthcare needs to be on the ballot. 

 

A Septuagenarian Party Just Outside the “Path of Totality”

 

I’ll admit that the header for this post is not typical. At first glance, you may have thought that it was a weird scene from some sort of nursing home event. If you look closely you might notice me in the middle of the picture. My walker is in the foreground. My wife is sitting to my right. I am banging on a drum as the lady to my left bangs on her drum and sings songs to the developing eclipse that we are facing. We all have the prescribed glasses.

 

My wife and I were delighted when my companion drummer invited us to share the eclipse from the front porch of her recently completed new home which is about 400 yards down the shoreline from our home and over half a mile by the road. New London experienced 98% of the totality of the eclipse. To get the full 100% we could have easily hopped on I-89 and driven together with another few hundred thousand people the 145 miles to Burlington, Vermont. Our friends who took that route said that the trip up was pretty easy, but they were hours and hours coming back through a traffic jam. Of interest, one of my boyhood homes, Waco, Texas, was also in the path of totality. 

 

The view that we had was pretty good. All but a faint crescent of the sun was obscured at the peak. The air became dramatically colder, but even at 98% of totality it was not much darker than a late spring evening which suggests to me that 2% of the sun’s light is still pretty powerful. If I am around in 2044 when the next nearby eclipse occurs, I will be 99. I look forward to that day. Twenty years ago was 2004. George Bush was president and David Ortiz was leading the Red Sox toward their first World Series win in over 80 years. 2004 is like yesterday, so 2044 must be just like tomorrow. I will be ready for totality the next time around.

 

We had great weather through Tuesday. Since Tuesday, it has been another washout. Our “prognosis” is for rain through Saturday followed by a chilly, dreary, and overcast Sunday. I hope wherever you are you will enjoy a beautiful spring weekend. 

Be well,

Gene