April 8, 2022
Dear Interested Readers,
What We Don’t Recognize or Refuse to Manage Plus What We Did Not Learn or Have Conveniently Forgotten May Be Our Undoing
Flummoxed: flum·moxed
/ˈfləməkst/
adjective
adjective: flummoxed
- bewildered or perplexed.: “he became flummoxed and speechless”.
Flummoxed is a word that I have always used to describe myself to myself and to express my internal frustrations and personal sense of bewilderment when confronted with problems with no answers and implications beyond my conceptual capacity. I think I am partial to the word because it was a word my father frequently used.
My father was an effective speaker, and I think some of his effectiveness was a function of the fact that his speech was peppered with interesting words that were not necessarily obscure, but were infrequently used by most people. My dad’s vocabulary was best appreciated when he was speaking from a pulpit. In his sermons, he could weave those unusual words with literary references and stories that were the foundation for commentaries that were easy for his congregations to follow.
He was media savvy for his day. In the mid-fifties, when central Texas had only one television station, our church’s services were broadcasted every Sunday morning on KCEN, the only television station at the time in Central Texas. As a boy of ten or twelve, it amazed me that the same TV station that brought me Saturday morning cartoons and “I Love Lucy,” “Dragnet,” and the baseball game of the week with Dizzy Dean, also broadcasted our church service.
I am not sure how many people were watching TV in Waco on Sunday in the mid-fifties because even if they had been out on Saturday night to a movie or some local dive to hear some singer like Willie Nelson who lived nearby, they still got up on Sunday morning and went to church. There is always a church nearby in Waco and in the fifties, they were all full on Sunday morning. One interesting product of the pandemic has been that now more than sixty-five years later many churches, mine included, have offered their services over the Internet. Then and now you did not need to be in church to go to church.
I want to emphasize that my dad was not a television evangelist like Pat Robinson, or Jim and Tammy Fay Bakker, but in his own way, he used media effectively. In retrospect, he was a performance artist. He never took a note into the pulpit. He looked like an extemporaneous speaker who might have been good at improvisation, but that was an illusion. The sermons were written out, memorized, and practiced like a theatrical part. His method allowed him to deliver sermons like Shakespearian soliloquies. He preached his last sermon when he was ninety-four. That sermon is on a DVD.
In the eighties and nineties, after he retired, he could not give up speaking. He never wanted to stop doing what he loved and felt that he was “called” to do. To remain active doing what he loved to do, he served as an “interim minister” for many churches, about eighteen, for stretches up to six months in the Carolinas and Georgia. He enjoyed doing the interims for almost twenty-five years until he had to devote all of his attention to my mother whose health was failing. He would take a little time off between “gigs.”
By the eighties, some of these churches would record the Sunday service on cassette tapes for the benefit of their “shut-ins.” For several decades I have had a couple of boxes full of those cassette tapes of church services that were given to me by my mother. Perhaps she thought that if I listened to him preach again my interest in religion would be revitalized. She was partially right because I am interested in religion although many doubts persist. I doubt that she thought a quarter-century would pass before I exercised the option to listen to the tapes. Recently, I began to worry that the tapes might be deteriorating and that I needed to digitize them. So, with the apprehension that I might have waited too late, I finally began to listen to them. For the past two months, I have been transferring a few tapes each week into MP3s and have shared them with interested family members by means of Dropbox. Ironically, I realized that I had rarely heard him speak over the last fifty years of his life.
The process has been a joy. It is great to hear my father’s voice again and marvel at his use of language. It has been great to appreciate how he used his voice like a fine instrument. As I have listened to his sermons, I have wondered about what he would say about Russia’s war against the Ukrainian people. I would love to get his take on the violent weather that most of us believe is a manifestation of global warming, and a few may think could be God’s wrath. The list of our concerns is long, but somewhere in the answers to my questions, I am almost certain that he would use the word “flummoxed” as a description of how we must feel. He believed in God’s love for us and often preached about how God understood and cared about our bewilderment, sense of loss, frustration, and confusion in our lives. He was sure that God could be a great help if we would ask for help when we were bewildered by all the uncertainties of life.
If you read these notes with any regularity, you probably are aware of my fascination with the acronym, VUCA. Yes, I am often flummoxed by the volatility, uncertainty, complexity, and ambiguity of our world that can be a daily challenge to our sense of justice and reason. It is even worse if you are paying attention and hoping for a world of peace and universal opportunity.
The title of this discourse, “What We Don’t Recognize or Refuse to Manage Plus What We Did Not Learn or Have Conveniently Forgotten May Be Our Undoing” is tediously long and cumbersome by design. It evolved as an attempt at humor from my sense that we are “collectively flummoxed” because we are collectively inattentive to what really matters. Some of our distress may be traced to paying more attention to individual interests rather than to our collective best interest. I admit to a bias toward the sense that we “wait and see” long past the time when we could mitigate our future grief by early intervention. The most charitable assessment is that we are flummoxed and paralyzed by the complexity and interrelatedness of the multiple problems that challenge us. It is so hard to know what to do that we do nothing. Perhaps, our mutual bewilderment and the perplexed state that we share arises from our inability to pay attention to the clues around us. It is also possible that we fail to act collectively when that collective action has an immediate personal cost. We just don’t seem to ever learn that waiting to act often leads to a greater cost and many unnecessary losses.
I read three articles this week that I want to bring to your attention. Each one felt important to me. Each one seems to be germane to the theme of being flummoxed or acting ineffectively. My hope is that listening to the messages in the three pieces might make us a little less flummoxed by the rapidity of change in our environment. The articles are “Putin Had No Clue How Many of Us Would Be Watching” in the New York Times by Thomas Friedman, “Ten Years of Choosing Wisely to Reduce Low-Value Care” in the New England Journal of Medicine by Elizabeth Rourke, and “The End of the Covid Emergency Could Mean a Huge Loss of Health Insurance” in the New York Times by Elisabeth Rosenthal.
Of all the commentators that I have read on the Russian aggression against Ukraine, Tom Friedman has been the one writer who has left me feeling less flummoxed. In “Putin Had No Clue How Many of Us Would Be Watching” Friedman advances the idea that we are already experiencing a new World War. That insight arises from the way world markets are impacted, and the way the world is using the Internet and social media to follow every new event in ways that were never possible before.
The hands of the West are tied by the fear that we might provoke World War III. We may not be fending off “nukes” from Russia yet, but the whole world is impacted by this war and will be for a very long time to come. What has happened can’t be put back in a box. Russia will be a “pariah state” as long as Putin is in power. It is difficult to imagine a negotiated peace after seeing the horrors of Bucha. Could we negotiate a peace that leads to Russia returning Crimea and the Donbas region to Ukraine? Will Russia willingly pay the hundreds of billions of dollars, if not trillions, to repair the damage they have done? Would Putin ever willingly submit to a war crimes trial? The world has a problem it can’t neglect or easily resolve. We are collectively flummoxed and it is scary. Friedman writes:
Almost six weeks into the war between Russia and Ukraine, I’m beginning to wonder if this conflict isn’t our first true world war — much more than World War I or World War II ever was. In this war, which I think of as World War Wired, virtually everyone on the planet can either observe the fighting at a granular level, participate in some way or be affected economically — no matter where they live.
…This has quickly turned into “the big battle” between the two most dominant political systems in the world today: free-market, “rule-of-law democracy versus authoritarian kleptocracy,” the Swedish expert on the Russian economy Anders Aslund remarked to me.
Those thoughts should trigger an “ah-hah” response. Up till now most of us have found it very easy to emotionally support the brave people of Ukraine in their David v. Goliath encounter with Russia, but what most of us have not fully understood or entertained as an idea is that we are critically engaged in the struggle and have a lot to potentially lose.
Friedman has much to say, but in the end, his point is that we all have much more at stake in the war in Ukraine than most of us realize. The Ukrainians are fighting for all of us, and the cost of the war will be born by all of us whether we are shot in a street in Bucha with our hands tied behind our back or whether our pain will be an economic cost spread over years to come in an unstable world. Friedman seems to suggest that besides the economic burdens created by the war that we will all bear for a long time, our responsibility is to be witnesses to the atrocities. We all have a lot to lose if Putin prevails.
To be sure, Ukraine’s democracy is frail and the country has had its own serious issues with oligarchs and corruption. Kyiv’s burning aspiration, though, was not to join NATO but to join the European Union, and it was in the process of cleaning itself up to do just that.
That’s what really triggered this war. Putin was never going to let a Slavic Ukraine become a successful free-market democracy in the E.U. next door to his stagnating Slavic Russian kleptocracy. The contrast would have been intolerable for him, and that is why he is trying to erase Ukraine.
But Putin, it turns out, had no clue what world he was living in, no clue about the frailties of his own system, no clue how much the whole free, democratic world could and would join the fight against him in Ukraine, and no clue, most of all, about how many people would be watching.
It has been inspiring to watch President Zalensky rally the brave Ukrainian people. We do care, but I don’t think we really appreciate that like it or not we are at war. We may not be shot with our hands tied behind our back, but we will all pay a price. It may be time to do more than have fundraisers and increase sanctions.
When the American Board of Internal Medicine announced its “Choosing Wisely” campaign in 2012, I was ecstatic. The campaign was constructed on the concept that we wasted billions of dollars every year doing tests and procedures that added no value. I wholeheartedly embraced the idea since that was exactly what Dr. Ebert thought when Harvard Community Health Plan was created in 1969. I had been practicing in a “choosing wisely” environment since I joined the practice in 1975. It’s hard to believe that we are ten years into the experiment. It is time to see if anything has been accomplished. That was the intent of the “Perspectives” article entitled “Ten Years of Choosing Wisely to Reduce Low-Value Care” that was published this week by Dr. Elizabeth Rourke in the New England Journal. Dr. Rouke begins her article with a confession that I should also make.
Let me say at the outset that in my primary care clinic I practice low-value care. Not every day, but often enough. Probably every week. For example, when patients show up with a list of tests that need to be done before they can get their cataracts fixed, I do them. I want them to be able to see. Similarly, I’m well aware that imaging for acute, no-red-flag low-back pain is not recommended before 6 weeks, but there are times when I am unable to convince suffering patients to wait, and I order a lumbar spine plain film or MRI.
She goes on to give a brief history of “Choosing Wisely.”
…The effort launched with lists from 9 societies and has since grown to include more than 80 societies and lists, comprising more than 600 items. In addition, the program has spread beyond U.S. borders to 25 other countries, including Canada, the United Kingdom, Germany, and Japan.
Choosing Wisely was an immediate public relations win for the medical profession in 2012, demonstrating that doctors were stepping up to address low value and high costs in medicine. Ten years later, however, it’s clear that making lists and publicizing them are not sufficient to reduce low-value care. Medical services that do not improve patients’ health continue to account for an estimated 10 to 20% of health care provided in the United States, costing $75 billion to $101 billion per year.
I am not sure what happened that caused “Choosing Wisely” to fail to meet our expectations, and I am not convinced that Dr. Rourke knows for sure either, but what is clear is that despite the good intentions of many doctors to manage the tension between just doing tests to mollify the anxieties of our patients and responsibly managing the resources of the entire community, we have not changed our behavior enough to make a real difference in the cost of care. She adds some perspective:
In retrospect, it seems obvious that merely labeling certain common practices as low-value was unlikely to result in their elimination. It’s worth noting that the stated goal of the Choosing Wisely campaign was not to reduce low-value care, but instead to promote professionalism in medicine and encourage conversations between doctors and patients. It’s part of the political genius of Choosing Wisely that these outcomes are not readily measured. Who can prove that conversations are happening? Who can quantify professionalism?
But the political compromises that have allowed Choosing Wisely to flourish have also rendered it toothless.
Her next observation connects the disappointments of “Choosing Wisely” to the troubles of the ACA.
The program is a manifestation of a belief that also animated the accountable care movement endorsed by the 2010 Affordable Care Act (ACA): the belief that by eliminating low-value care, health systems can achieve cost savings without reducing quality. The bruising political battle over the ACA, however, drove Choosing Wisely away from anything that might smack of rationing…In short, Choosing Wisely has allowed doctors (and medical societies) to look like they are addressing low-value care without actually being forced to make any substantive changes.
The failure of “Choosing Wisely” and some of the disappointments in the ability of the ACA to lower the cost of care do make a difference because healthcare is such an important part of our economy and because wasteful care is a big part of the income of so many people. There is a tendency to protect any practice that generates income even if some of the income represents an unnecessary expense. She notes:
…From an economic standpoint, health care is the tent pole of the American postindustrial service economy, and any significant reduction in the amount of care provided would result in financial and job losses.
Dr. Rourke has significant concerns about how the program has affected the relationships between doctors and patients. I fear that the failures that Dr. Rourke discusses add up to another example of my theme, “What We Don’t Recognize or Refuse to Manage Plus What We Did Not Learn or Have Conveniently Forgotten May Be Our Undoing.” She continues:
In short, …patients — and I — want more of the conversations that the ABIM set out to promote in 2012. But after 10 years, it’s hard to see how Choosing Wisely in its current guise is ever going to get us closer to this goal. Given its limitations, the program is in danger of recapitulating the qualities of the low-value care it highlights, offering little benefit and possibly causing harm.
Dr. Rourke is not giving up easily. She finishes her essay with some hope, but she suggests that if there is to be any progress there must be some change.
Choosing Wisely could make the transition from feel-good gesture and highly imperfect tool to catalyst for meaningful change in the postpandemic world. Though it’s unlikely that low-value care can ever be extirpated completely from medicine, we can unquestionably do better. I’d love to live in a world in which this program is actually a part of that change. I’d love to live in a world in which my patients and I are truly choosing wisely.
The final article from my reading this week that suggests that we are flummoxed and that “What We Don’t Recognize or Refuse to Manage Plus What We Did Not Learn or Have Conveniently Forgotten May Be Our Undoing” comes in the form of a guest essay in the New York Times by Dr. Elisabeth Rosenthal. Dr. Rosenthal was once one of the most prolific healthcare reporters for the Times while she was an ER doc in New York City. She is now the Editor-in-Chief of Kaiser Health News. She is also the author of AN AMERICAN SICKNESS: How Healthcare Became Big Business and How You Can Take It Back which I consider to be one of the best books ever about why the business of health should change.
In her essay, The End of the Covid Emergency Could Mean a Huge Loss of Health Insurance, Dr. Rosenthal is giving us a warning. If we heed her words we may avoid failing to recognize a problem we should manage before it leads to the undoing of healthcare coverage for many vulnerable Americans. We should heed her warning. She writes:
If there has been a silver lining to this terrible Covid-19 pandemic, it is that the rate of Americans without health insurance dropped to a near historic low, thanks to various federal initiatives connected to the government-declared public health emergency.
Now, with the pandemic’s acute phase seemingly drawing to an end, millions of low-income and middle-income Americans are at risk of losing health insurance. The United States might see one of the steepest increases in the country’s uninsured rate in years.
When the federal Covid-19 public health emergency ends — as it is currently scheduled to on April 15, though it is likely to be extended — so will many of its associated insurance protections. That includes a rule that forbade states to kick anyone off Medicaid while Covid-19 was raging, and that came along with a 6.2 percentage point increase in federal Medicaid funding to keep these most vulnerable patients insured.
She points out that before the pandemic many states would regularly review their Medicaid recipients and kick many of them off the program. In my non-profit work with the poor in my community, I have met several people who lost their Medicaid coverage before COVID and as a result, had their medication expenses increased by many multiples. Dr. Rosenthal predicts a change that for many vulnerable people could be a much bigger inflationary problem than gasoline at $5.00 a gallon.
When those enhanced subsidies expire, many lower-income Americans could be left with the prospect of paying double for health coverage…
The Build Back Better Bill, which passed the House in November, would have extended the more generous subsidies for purchasing A.C.A. health plans. But the bill was declared “dead” by Senator Joe Manchin of West Virginia, this year, who refused to support it. Now Democratic leaders are hoping to negotiate a slimmed-down version, but it’s unclear whether a bill will materialize with the provision in it.
Thank you, Senator Manchin. Isn’t it ironic that many residents of West Virginia, one of our poorest states, will suffer great harm because their senator wanted to protect fossil fuels more than his constituents?
I am indeed flummoxed by so much of what I see around me. We do live in a very complex world where some of the connections between problems are hidden, and it is indeed true that what we don’t recognize or refuse to manage in foreign affairs and in healthcare plus what we did not learn or have conveniently forgotten about both may be our undoing, and that reality leaves me flummoxed.
Visible Changes Give Evidence of Spring and Great Things To Come
The ice is out! The Red Sox opened against the Yankees at one o’clock this afternoon, and during the fifth inning (2:30 PM), we saw one of our loons for the first time this season! It was about fifty yards offshore. My wife took the picture below with her trusty Nikon just in time to get it into this letter. Loons and baseball at the same time must mean that spring is here!
Nothing announces spring like a field that is being prepared for planting. One of the joys of living in a small New England town is that there are farms nearby that are the scenery you pass during your daily travels. What might be a more delightful spring scene than the one captured in the header of this post?
What you can’t see in the picture is that this farm lies just a quarter-mile from “downtown” New London. Across the road that is out of sight on the left is a neighborhood and the New London Historical Society which has a collection of buildings from the nineteenth century that give a visitor some idea of what life was like in those times. The juxtaposition of the rural with the urban and the past with the present is not easily captured in one photograph.
What was captured is the beauty of the day and the field that is beginning the long journey toward a harvest. What I look forward to is stopping by the farm stand down the road toward town (Spring Ledge Farm) and buying some of the fresh produce that those fields will soon produce. Just across the street from the farm stand is the New London Barn Playhouse which is getting ready for a summer of great theatrical productions. I hope you take advantage of viewing the pictures presented in the links in this paragraph. Who knows? Maybe you will plan a visit to see me and my lovely little town this summer!
I hope spring is getting your juices flowing!
Be well,
Gene
