7 December 2018
Dear Interested Readers,
A Potpourri of Feelings and Observations
Some weeks it is beyond my ability to finally decide on one subject for these notes. It occurs to me that most weeks this letter to you does not live up to its billing as “musings;” it has often become an argument or presentation of a point of view, an attempt at persuasion, or even dare I say, an attempt to “sell” you on an idea. For whatever reason, perhaps Tuesday’s presentation about “Medicare for all” and the intermediate step of reconsidering “a public option,” I have no need to make a sale and would prefer to just pass on a little of the “chatter” in my head that I have been listening to for the past few days.
I am sure that some of my mood is an extension of my reflections about my father who would have been 98 on Monday had he not faded into the hereafter in the early morning hours of September 27. Add to that the death of George H.W. Bush, our forty first president last Friday evening, November 30. President Bush’s passing initiated a flood of tributes and interesting reminders of the period from 1960 to 1992 when he was active in politics. His funeral services were moving experiences and a reminder of what once was considered the appropriate attitude and behavior of the individual who is head of government, commander of our armed forces, and our head of state, the personified representation of who we are as a nation. Sarah Glasser of The New Yorker put the event into the context of the moment as well as any commentator that I have read or heard. I recommend that you read her article.
I never voted for the forty first president. I often had an opposing point of view, but I never worried about the future of our democracy at home or America’s place as an international example and sponsor of human rights and the leader of progress toward a more just and safe world while George H. W. Bush was president. It was great to be reminded by President Bush’s son that he hated broccoli and had a lousy “short game” when playing golf. That made him human. It was inspiring to be reminded that he was a champion of the civil rights of the disabled, supported and signed legislation to promote clean air, and led the world’s peaceful response to the fall of Soviet communism. As I thought about what he had accomplished, I had to reexamine why I paid more attention to the parodies of his clunky style by Dana Carvey on “Saturday Night Live” than by the substance of his performance in office. Shame on me.
It has been a while since we have seen Senator Alan Simpson, the giant man and intellect from Wyoming, but he offered us the best quote of all in his eulogy of his friend.
“Those that travel the high road of humility in Washington are not bothered by heavy traffic.”
David Blumenthal and James Morone note in their 2008 book, The Heart of Power: Health and Politics in the Oval Office that George H.W. Bush was famous for his foreign policy expertise, but was equally well known for his disinterest in domestic affairs. Perhaps it was the unlikely adequacy of his “one thousand points of light” to be all that we needed to address the needs of the underserved that laid the groundwork for his defeat by Bill Clinton. Historians focus on the fact that he reneged on his “no new taxes” promise as the reason he lost. The fact is that he was forced to renege on his promise because of the failures of the Reagan tax cuts to generate the revenue that was promised. The Medicare coverage for catastrophic conditions passed during the late Reagan years were repealed under Bush. It is possible to forgive his lack of healthcare accomplishments or expertise when his record is reviewed fairly with other one term presidents like Jimmy Carter who also faced financial challenges to the economy. Let’s face it, when the economy is under pressure or when wars and other foreign challenges are the most pressing issues, healthcare is moved to the back burner. It is a subject that gets deferred. I think that fact is one to remember, and explains in part why healthcare reform has been an uncompleted task stretching over more than a century.
Perhaps it is interesting to note that today is the seventy seventh anniversary of the attack on Pearl Harbor that forced us into to World War II after trying to avoid it for over two years. WWII was the first opportunity that George Bush had to serve his country. It is remarkable that he went from high school at Andover Academy to being a Navy fighter pilot who served with distinction before he even went to college . We are losing our WWII veterans at a rapid pace. If you were 18 in 1941 you are 95 today. My father always carried some personal guilt because he spent the war in the seminary while his older brother was a paratrooper in the 507th Regiment of the 82nd Airborne. He was decorated for his valor in the Battle for the Merderet on D Day and later at the Battle of the Bulge. Dad’s guilt was such that he explored becoming a military chaplain during the Korean conflict.
While I was thinking about George Bush, World War II and my Dad this week I happen to notice a startling report on the experience of the elderly in long term care hospitals (LTCHs). Twenty one percent of Medicare patients have adverse events in LTCHs, and many are fatal. There is a link in the summary if you want to download the whole report of more than sixty pages. Over the years there have been other similar reports on SNFs and other facilities. I must admit that like George Bush’s preference to focus on the issues of foreign policy over domestic issues like healthcare, I have focused my attention more on healthcare coverage and the delivery of ambulatory care than on the specific issues that the frail elderly face when they need long term nursing care and support. Once again my father’s experience may be atypical but it is informative.
Dad had access to spectacularly appointed facilities. I felt good about his comfort when he was a “rehab” patient. There was a substantial change when it became obvious that despite heroic efforts to get better, he was deteriorating. I visited him many times as a “rehab” patient and as a patient requiring custodial care. At first I thought that the only change would be a bed transfer around the corner to another wing of the same “state of the art” building, but I was wrong. The room was exactly the same layout and was equally well appointed, but that is where the similarity ended. The defining difference was staffing. Logically one would imagine that patients who were weaker, more often confused, and less capable of self care would have more help available, especially since the expense exceeded $10,000 a month. Not so, though.
There were many wonderful nursing aides and nurses, and many of the therapists who had tried to no avail to help him get back on his feet and be capable of self care would come by for short visits, but there were long periods of time when it was difficult for him to get help when he needed it, even when a family member was present. The problem was primarily staffing and not apathy, although it was easy to sense that as staff became tired and overwhelmed their patience would wear thin. Errors were made. Falls occurred. Respectful interchanges were replaced by frustration laced admonitions that had lost all sense of respect and were poorly disguised expressions of frustration. Sometimes the body language conveyed more of a sense of “Why aren’t you dead yet?” rather than, “What can I do to make you comfortable?” Each time I saw an image of George Bush being pushed in his wheelchair I was transported back to my father’s final months. I will admit that I was also projected into the uncertainty of my own future. My dad had money. He had a respected position in his community. He was in a facility with fabulous appointments. None of that makes much difference when you end up on the floor after falling out of bed because no one came when you called, or if you were drugged to the point that you would not be a problem and yet could still arise from the induced coma to confusion.
On several occasions in the moment, and on many occasions on reflection over the past two months, I have wondered what if he had not had his privileges, community status, and family who were speaking up to try to mobilize the help he needed? I think that the majority of the debilitated elderly face much more jeopardy, and have less support. The data seems to support that observation that our experience raises as a concern. You and I should think more about these things since like George Bush and Harold Lindsey we will all move from being young, strong, blessed, and capable of helping others to being older, broken, vulnerable, and in need of the help of others.
As a nation we face more than finance problems in healthcare. We have nursing shortages in rural and chronic care environments, and are at risk of developing nursing shortages, even in our most respected academic institutions and larger suburban hospitals. As was noted in an article in the New York Times last year, we are increasingly dependent on the importation of doctors. Rural practices are very dependent on foreign trained doctors, and almost 20% of doctors in academic centers are immigrants. In Newt Gingrich’s old Congressional district in the northern suburbs of greater Atlanta my mother’s cardiologist was from Nigeria and her gastroenterologist was from Pakistan. The author of the NYT article, Aaron Carroll, a physician at Indiana University Medical School, describes part of the picture:
…we are reliant on physicians trained outside the country to fill the gap. A 2015 study found that almost a quarter of residents across all fields, and more than a third of residents in subspecialist programs, were foreign medical graduates.
Leaving training aside, foreign medical graduates are also responsible for a considerable share of physicians practicing independently today. About a quarter of all doctors in the United States are foreign medical graduates.
The United States trains far too few physicians to care for all the patients who need them. As in many other fields, foreign medical graduates work in many of the areas that other doctors find less appealing. More than 40 percent of the American primary care work force is made up of people who trained in other countries but moved here. More than half of all the people who focus on caring for older people are foreign medical graduates as well.
Importing foreign doctors fills the gap now, but may not be a sustainable strategy especially for rural America and the underserved who get their care at Federally Qualified Health Centers. By the way, Dr. Carroll points out that we are competing with other developed nations for well trained physicians.
The United States is not the only country that relies on doctors trained or educated in other countries. We’re not even the country with the highest percentage of such physicians. According to data from the Organization for Economic Cooperation and Development, almost 58 percent of physicians practicing in Israel are foreign medical graduates. About 40 percent of the doctors in New Zealand and Ireland were trained outside those countries.
As we debate issues like the need for work requirements in the expansion of Medicaid in many states that were initially reluctant to accept the Medicaid expansion of the ACA, as was my state of New Hampshire, should we also not be paying some attention to looming workforce issues? It is becoming increasingly obvious that personal experience sharpens the vision and moves the theoretical issues we debate from something that is a problem in general to be dealt with when there is time and the fiscal climate is improved and may be more conducive. Later the same issues that are deferable now will feel acute and critical.
I will leave you with one more thought. How are “burnout” and “professional fulfillment” similar and different? That question occurred to me when I realized that the burnout researchers at Stanford are tracking rates of both burnout and professional fulfillment. I have reported that I did experience symptoms of burnout from time to time during the forty six years that I was in training and practice. Working every other night for eleven months of my internship (one month was every third night) left me with a blur of fatigue and the aftermath of a year of a constant fear of failure. Jonathan Haidt and Greg Lukianoff in their new book, The Coddling of the American Mind: How Good Intentions and Bad Ideas Are Setting Up a Generation For Failure, talk about “anti-fragility,” the “untruth” of emotional feelings, and the “us” versus “them” mentality of modern life. In retrospect I see all of those realities operating in my experience and feelings about practice and realize that I was fortunate to avoid the personal disasters that were the reality for many who were not blessed with the opportunity to practice in an environment where stress was always part of the weather, but so was the satisfaction of practice with talented colleagues for patients who had needs and were frequently quite vocal about how grateful they were for our efforts to improve their their health and the experience of their care.
Here Comes the Sun
We have come to that time of year when most people, especially those in healthcare, travel to work in the dark and return home long after the sun has set. That’s just the reality when sunrise is after 7 AM and sunset is around 4 PM. I know that this time of year is tough. It feels like we have entered a long, dark, cold tunnel with no evidence of when we will reach the other end, since it keeps getting darker and colder.
There was a time when by 7 AM I was behind my desk almost every morning or in a meeting, and it was the rare day in any season that I was home before 9 PM. These days the sun has always been up for an hour or two before I get up. As my wife says, “When you are retired everyday is Saturday!” It is also true that these days I am usually at home sitting in an easy chair in front of a fire or finishing up my afternoon walk when the sun goes down.
The problem for the past few weeks has been that no matter the time of day there was no sun to see! I love the bright midday sun of a chilly winter day. Twilight all day long is even an issue for retirees. Over the last few weeks it has seemed that day after day we trudged on through impending doom and a falling stock market without any sign of the sun, even at noon! The perpetual darkness certainly adds to the gloom leading up to the longest night of the year, but now the gloom has cleared! We have had several days of clear skies with an observable yellow orb from the time I get up until twilight this week, and as I look at the long range outlook the trend should continue for at least another week! Unfortunately, it appears that what we gain in sunshine will be undermined by what we lose on the thermometer. The predicted high for the coming week will be a balmy 31 next Thursday, the day before the next predicted snow this time next week. I could care less about the cold temp because I will just put on another layer as I enjoy the clear skies that we are predicted to have on those cold days next week.
I am trying to get out everyday for a minimum of four and an occasional six mile walk. I love walking in the sunshine when I do not need a headlamp and a yellow reflective chest strap with a blinking red light on the back. One of the major joys of walking at twilight is watching the sky change when there are just a few wispy clouds to reflect and enhance the colors of the setting sun. I have enjoyed the scene at twilight this week and hope the show continues next week. Just to illustrate what I mean I lifted another beautiful screenshot from my neighbor’s drone video entitled “Four Seasons On Little Lake Sunapee.” I have offered it before and would suggest that it is worth your viewing if you have not done so yet.
I guess that I am addicted to scenery and outdoor exercise. Before the skies cleared last weekend I accepted the invitation of a friend to walk with him on the indoor track at Colby-Sawyer College. It takes ten laps to make a mile and our conversation stretched over sixty laps, but it just was not the same as the six miles we usually walk around Pleasant Lake over on his side of town. I was pleased to discover an article in the New York Times by Jane Brody the next day, “The Secret to Good Health May Be a Walk in the Park,” that verifies the wisdom of my preferences. She writes:
Even though I was heading to a highly coveted job at The New York Times in 1965, I was heartbroken to leave Minneapolis, where I had begun my journalistic career two years earlier.
Minneapolis was then, and still is, a slice of heaven for anyone who enjoys the great outdoors. According to an ambitious project of the Trust for Public Land, Minneapolis leads the nation’s metropolitan areas in providing the best overall access for the most people to well-equipped and serviced public parks and recreation. Its neighbor, St. Paul, is a close second.
Not surprising, then, is the fact that Minneapolis-St. Paul is also ranked the healthiest urban region in the country. And no, their residents are not preserved by the cold! If anything, they are out there enjoying it — ice skating, cross-country skiing, sledding, cycling, running, walking, you name it.
Sometimes it is good to find facts that substantiate your bias, or preferences in life. She writes later in the article:
“Parks are the key to good public health and to the environmental health of cities,” Mr. Benepe said. Hanaa A. Hamdi, the trust’s public health director, says research has shown that community green spaces can reduce violent crime; counter stress and social isolation, especially for older adults; improve concentration for children with attention deficit disorder; enhance relaxation; and promote self-esteem and resilience.
I love big public parks like Forest Park in Portland Oregon, Cameron Park in Waco,Texas, the “Emerald Necklace” in Boston, the Brook Path in Wellesley, and Prospect Park in Brooklyn. I’ve enjoyed them all and would encourage you to take advantage of a park near where you live this weekend, no matter what the temperature is! Gyms are great, but my bias is for the outdoor life, and now there is a public health database to support my preference.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
