Matula Thoughts, 6 March 2015 

Seeing ourselves, health care, & other thoughts. 

3486 words

1.    By March, winter has pretty much worn out its welcome in Ann Arbor. Strictly speaking it’s officially spring in 15 days, although it hasn’t been feeling that close. Nevertheless, we muster on contending with polar vortices by means of central heating, L.L. Bean fleece, March Madness and comfort food. On this particular day, March 6 in 1943, the Saturday Evening Post published Norman Rockwell’s illustration Freedom from Want. Although the illustration might have seemed more suitable for a Thanksgiving issue, the work was number three in his Four Freedoms series. Rockwell’s oil paintings were inspired by Franklin Delano Roosevelt’s 1941 Four Freedoms State of the Union Address. Rockwell actually started this particular painting in November 1942 depicting his friends and family at their Thanksgiving. The other end of the spectrum from Rockwell’s idyllic scene is the image evoked in a report I saw recently from the Bangweulu Wetlands in Zambia on the unintended use of mosquito nets for fishing where:  Out here on the endless swamps, a harsh truth has been passed down from generation to generation: There is no fear but the fear of hunger.  [Gettleman NYT Jan 25, 2015 p.1]  

2.    Freedom from want is a timely theme. During these cold wintry days, it is discomforting to cross paths with panhandlers on our streets. How do we each respond, knowing that many panhandlers have terrible life stories and are at their wits’ end without resources for the next meal or warm bed? (Yes, many of them are clever enough to make a living on the street and a few actually retreat to their own abodes to sleep at night). It is important to realize that most homeless people are not panhandlers and that not all panhandlers are homeless. Furthermore, mental illness is a pervasive condition among panhandlers and the homeless. Most experts on homelessness agree that handouts to panhandlers are not a good solution for homelessness, hunger, and mental illness; a set of community solutions is vastly preferable. University towns like Ann Arbor provide good environments for panhandlers who can turn streets full of students into their workplaces. Still, many of these people are truly homeless and hungry – so how do you and I face those who confront us directly with their need? It is a personal dilemma. I often point them to the Delonis Center, only a few blocks away as a resource that offers decent food, shelter, and a pathway out of homelessness. Many of us in the community support Delonis, but its capacity is stretched and some who need shelter and services are adverse to it for varied reasons. The failure of our society in the industrialized world of 2015 to provide food, security and decent shelter to all its citizens is troubling. Health care is as basic “a need” as food and shelter and most of those folks on the street are incapable of attending to their basic health needs. One measure of our humanity is the sense of empathy that allows us to see ourselves in the faces of the needy who confront us. The great religions value empathy, our most respected leaders throughout time displayed empathy, and mankind’s greatest thinkers argued for it, notably in my mind Adam Smith in his opening sentence of the Theory of Moral Sentiments. Yet, we must be constantly aware for ourselves as we gain privilege and power, that power diminishes empathy. When we lose the recognition that the homeless and the panhandlers are in a real sense our doppelgängers we lose much of our humanity.

3.    Homelessness and hunger are invisible to us most of the time in our busy lives in clinics and operating rooms, contending with hospital capacity issues, residency education, MiChart, RVUs, regulatory mandatories, grant deadlines, and the rest of the broth of clinical and academic medicine. A recent Lancet editorial [The Lancet 384:478, 2014] and series [Faizel, Geddes, Kushel The Lancet 384:1529, 2014 and Hwang & Burns  384:1541, 2014] dealt with homelessness, noting that on any night in the USA and Europe around 1 million people are homeless (median age is 50 years). And what about the Middle East, South America, Africa, and Asia? In our own Washtenaw County, the federally-mandated count on a cold day this January found 307 sheltered and 80 unsheltered homeless people. Of the 387 that day: 52 were children, 94 had severe mental illness, 44 had chronic substance abuse, and 34 were victims of domestic violence. Chronic homelessness accounted for 71 of the total and 29 of the 387 were military veterans. Homeless people, just like us luckier ones, may suffer from multiple morbidities, infectious and noninfectious, including all of the genitourinary disorders that we urologists manage. Yet, most of the homeless are well outside networks that feed into our health care system. The Affordable Care Act (ACA) made inroads into this underserved (or unserved) population, but better models and systems of health care are needed if we hope to truly mitigate freedom from want and provide basic humanitarian services fairly. At the personal level, it’s unrealistic to expect most of us in academic medicine to volunteer in soup kitchens or hand out blankets and socks on the streets. Clinical work is demanding and our environment heaps on additional burdens such that few of us work less than 80 hours a week. However, our community offers a variety of philanthropic opportunities that can use our dollars and leadership just as handily as direct labor. So if you feel some moral traction when you pass by a panhandler, rather than handing over cash (that may or may not be used well), look further (and point them to) resources in our community that help the homeless, hungry, and uncared for – the Delonis Center, the Packard Clinic, and others. If these resources are inadequate, help make them better.

4.    Steven Brill’s book called America’s Bitter Pill was a follow-up to the focused issue of Time magazine he wrote, and I discussed, 2 years ago in these columns. I read the book word-by-word, including the appendix and footnotes. Brill frames the story well and reasonably fairly. Replete with detail as to the historical background of healthcare economics in the USA, Brill takes the reader from March 2007 when the ACA started to take shape as an idea to a year ago in April 2014 when its implementation was in full swing. Much of American health care is the envy of the world, in terms of medical education, residency training, research, and innovation. Yet we are also rightly and severely faulted (often by ourselves) for failure to provide equitable care, for our costs, and for our results. Brill is a journalist and between his Time issue and his new book he experienced a catastrophic illness that gave greater nuance to his reporting. On April 4, 2014 he underwent repair of an expanding symptomatic aortic aneurysm at Cornell. He praised the doctors and the staff, but disparaged the administration of the hospital. His repair and 8 days in the hospital cost $197,000 – and he says it was worth every penny of it, to him. The politics and sausage-making deals with the hospital industry, insurance industry, pharmaceutical industry, and device industry are not pretty. The sausage, by the way, was pure pork. Effectually absent from the bargaining table (and thus on the menu) were the consumers, health care workers, health care scientists, and the educational community of healthcare. Representing the consumers (that is, the public who otherwise were never at the bargaining tables) was the basic structure of the ACA which was totally modeled on Romney Care and its triple intent. These three legs have been variously stated, but they boil down to these:

a.) expanding healthcare coverage throughout the nation;

b.) continuation of an “insurance-based” system that remains employer-funded, private pay funded, & government-funded; 

c.) abandoning the constraints of pre-existing exclusions & life-long limits of coverage.

Kicked down the road was the matter of cost, which inevitably will rise with expanded coverage, enormous subsidies, and corporate protections (future “give-backs” from industry notwithstanding). It was pure speculation to assume that costs will drop after ACA implementation due to less waste, electronic record implementation, bundling of services, improved safety, better “quality” and the “give-backs” of industry. Just about a year ago the federal exchange, HealthCare.gov, was resurrected (in large part with help from Google experts) after its disastrous initial launch. Given that healthcare has become such a massive part of our economy, no single fix, even as complex as the ACA is likely to solve the main problems. Furthermore in the unlikely event of totally disabling the ACA, the negative impact on health care and the larger economy would be unimaginable at this point. Inexplicably, Congress’s flawed 1997 Sustainable Growth Rate (SGR) law that linked Medicare’s relative value units (RVUs are measures of clinical work) to changes in national gross domestic product (GDP) was not addressed in the ACA. This law has now been “put off” by last-minute Congressional “fixes” 17 times. As for my position on these matters, I am a believer in social objectives of the triple intent that underlies RomneyCare, ObamaCare, the ACA, or whatever label you want to throw at it. Few reasonable people doubt that the pre-existing state of health care was unsustainable. Nevertheless, Brill’s book with its collection of leadership lapses, bungled technology deployment, management failures, turf battles, political grandstanding, closed-door deals, corporate greed, personal tragedies, and more, is not inspiring. The ACA may be ultimately so complex, so flawed, and as yet so indeterminate that it will prove to rival the injustice, personal pain, and unsustainable costs of the pre-existing state of heath care. Time will tell. I’ll give what I think is the bottom line on Brill’s book next month. Meanwhile, I believe the ACA’s main effects are here to stay for a while (we will learn what the Supreme Court thinks about the “four word mistake” in the law), but are not sustainable in the long run. The market, the academic community, and the government will inevitably float new ideas and experiments. Some may even be good.

5.    Ultimately, the idea of funding a nation’s health care mainly on an insurance model is not sensible. Basic health care is a human right; people need health care from before birth until death. Furthermore, universal health care is in the public interest – you don’t want people standing next to you on the street with active TB, influenza, measles, or smallpox. Nor do you want a suicidal driver to crash head-on into your car. We don’t need Emergency Departments overwhelmed by health care crises that could have been pre-empted by good preventative medicine and timely care of routine illnesses. We also need the next generation to be healthy in mind and body so as to improve our world and civilization (and fund social security!). Insurance, however, is a sensible way to fund big ticket and catastrophic expenses – such as ruptured aortic aneurysms, renal failure, liver transplantation, major trauma, or amyotrophic lateral sclerosis care to name a few terrible problems.  One experiment in health care delivery already underway is the Federally Qualified Health Center or FQHC.  We have discussed this in these columns and after a few years of preparation finally implemented involvement of our Department of Urology at the Hamilton FQHC in Flint.

6.    FQHC. In January John Wei held the first urology clinic at the Hamilton FQHC in Flint, in February John Stoffel held the second, and we intend to continue a monthly presence there. Hamilton’s facilities include a new user-friendly multi-specialty building just north of the city. Last year’s Hamilton budget was around $22 million, including its basic federal grant of $3.5 million, and it is very well run under the leadership of Michael Giacalone and Clarence Pierce. The following details may seem arcane, but are worth knowing. FQHC’s operate under the auspices of the Health Resources and Services Administration (HRSA). These grant-funded (330B) Health Centers satisfy the following requirements: they are in high need communities, are governed by community boards, offer comprehensive primary care with supporting services, provide services to everyone (with adjusted fees according to need), and meet government accountability requirements. Nationally in 2013 FQHCs served 21.7 million patients and provided 86 million visits. In addition, HRSA supervises two other types of Health Center programs. One is the non-grant supported “FQHC Look-Alike” that operates under Section 330 of the PHS Act. Washtenaw County was just approved for its first “look-alike” at the Packard Clinic. Look-alikes nationally served 1 million patients in 2013 with 4 million visits. The other alternative outpatient program functions under the Indian Self-Determination Act. Although insurance paradigms currently work well with FQHCs, it is the grant funding that provides the backbone.

7.    The other freedoms that FDR’s State of the Union addressed were: speech, worship, and fear. In that order those Rockwell illustrations were published in 1943 on February 20 and 27, and March 13 each accompanied by a matching essay. The FDR freedoms contrast and compare with the equalities articulated by Danielle Allen in her book Our Declaration, mentioned here last month. Allen makes the point that a just society cannot have freedom without a framework of equality. FDR’s freedoms are in themselves manifestations of equality throughout a society including basic human needs of food, shelter, health, and safety with the political freedoms of worship and speech. It is compelling that the final figure, Freedom from Fear, shows 2 parents concerned about their children’s future. [All paintings are at the Norman Rockwell Museum in Stockbridge, Massachusetts.] The future of our children is not only a fundamental human concern, but it is evident throughout much of the animal kingdom. I recall TV docu-drama years ago dealing with the Cuban missile crisis during the Kennedy presidential administration in which JFK summed up our ultimate mutual long-term interests with the Soviets in a phrase something like this: We all inhabit the same Earth, we breathe the same air, and cherish our children’s future. These sentiments derive from thinking of the Enlightenment, tenets of social justice expressed (although imperfectly) in some modern governments, and emerging belief in the necessity for planetary stewardship. Kennedy’s point: if two conflicting sides recognize the similarity of their human condition and ultimate aspirations, conflict can be mediated. This is the empathy of the doppelgänger. I’ve been unsuccessful so far in learning if this was an actual quote from Kennedy or part of the television script, but the words are good. Of course, as we are learning in the Mideast, barbarity and conflict endure when similarity of the human condition is not mutually recognized such as when one side claims divine advantage.

8.    The future of our children and the future of our planet have been best represented by universities for the past 600 years. Universities have been the only enduring heavy-hitters in the matters of educating our successors and expanding the knowledge base of humanity. To a great extent this mission developed accidentally and is fulfilled inadequately. Far from recognizing this essential role, most modern universities fret about rankings, reputations, endowment races, NIH market shares, applicant/acceptance ratios, athletic programs, profitable products, and so forth. We see few grand educational visions. We see little focus on creating a better planet tomorrow – better citizens, better workforce, better governments,  and better energy sources to allow 8 billion or more people to inhabit the same Earth, breath the same air, and give all children a decent chance for self-determined lives. 

9.   Senses. The idea that we, among many other biologic constructs, have 5 senses goes back to the time of Aristotle if not well before then. Hearing, touch, sight, taste, and smell comprise the classic senses, but the reality is more complex for most creatures with additional senses as proprioception, thirst, hunger, and magneto reception. Humans also have a unique sense of time. The human intellect can integrate and creatively imagine senses, such as when you read, dream, or think. Importantly for our species although perhaps not unique to us, is the sense of compassion as so well articulated by Adam Smith that I want to again bring forward. His book, The Theory of Moral Sentiments, in 1759  begins: How selfish soever man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though he derives nothing from it except the pleasure of seeing it. This sense of philanthropy (love of humanity) is a fundamental part of the human condition that has allowed us to build teams, societies, and civilizations in which we take care of ourselves, including the needy and the vulnerable, as well as to try to create a better tomorrow for our children and their successors. FDR’s Four Freedoms (etched into stone at the FDR monument in Washington, DC) extend Adam Smith’s optimism in mankind’s better nature.

10.   Faces – a big step in the world of surgery. Excluding the rare true doppelgängers, it is our faces that mainly set us apart. [Illustration: Dante Gabriel Rossetti – How They Met Themselves. Watercolor 1864. Fitzwilliam Museum] For higher orders of mammals facial recognition is the key identifying feature. The nuances of human expression are essential to conscious and subconscious communication. Darwin wrote a book on this topic in 1872 called The Expression of the Emotions in Man and Animals. Among all the equalities that modern civilization is built upon, the equality of human recognition is no less essential than any other. Seeing the faces of our fellow members of society is a requisite part of the equality of reciprocity in civilization. Facial expression is essential to full interactive participation in society, to understand intent, acceptance, irony, honesty, displeasure, and all the other nuances necessary to the normal daily give and take of citizens, neighbors, customers, and all stakeholders in modern life. To “lose face” is a basic human shame in the figurative sense, but a horrendous circumstance in the physical sense. Ten years ago the first face transplant was accomplished and a recent Lancet article reviewed the first 28 facial transplants done to date in this new surgical frontier.[Khalifian, Brazio, Mohan, et al. The Lancet 384:2153, 2014]

 The authors wrote:

Facial transplantation is a single operation that can restore aesthetic and functional characteristics of the native face by giving ultimate expression to Sir Harold Gillies’ principle of ‘replacing like with like’ … Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. The possible consequences of life-long immunosuppression in otherwise healthy individuals  – including cancer, metabolic disorders, opportunistic infections and death – must be carefully balanced to minimize risk and maximize benefit. Yet surgical innovation has outpaced the scientific community’s ability to fully address certain immunological and clinical challenges. Here, we review the immunological, neurological, and anatomical principles gleaned from the 9 years since the first facial transplantation with a discussion of ethical considerations, highlighting lessons learned from clinical experience.    

A few comments on this quotation. You see once again how surgical innovation outpaced knowledge in the so-called scientific community. Yet isn’t it a strange belief that the surgical community is “not scientific” – for what is science after all but matters of imagination, methodological experimentation, analysis, and new hypothesis? Gillies, by the way, was one of the great early pioneers of modern plastic surgery. The last phrase lessons learned from clinical experience is the essence of the rational practice of medicine and this applies equally in the unnecessarily separated domains of medicine and surgery. A cynic might argue that the 28 salvaged lives cannot justify the costs and risks involved. Wiser voices would counter while the dozens of steps on the moon hardly justified the costs and risks of the lunar program, the collective spinoffs to knowledge and technology were of immeasurably greater value. In a parallel way face transplants similarly extended the reach of medicine and philosophic understanding of the meaning of a face. What have been the big steps in genitourinary surgery? Cystoscopy, cystolithalopaxy, orchidopexy, hypospadias repair, closure of exstrophy, prostatectomy for benign disease, perineal prostatectomy for cancer, the use of bowel in urinary tract reconstruction, cystectomy and bladder substitution, TURP, renal transplantation, ESWL, the Mitrofanoff principle, minimally invasive urologic surgery, and nerve sparing retropubic prostatectomy come to mind. Certainly there are others and more importantly, there will be more. Some will come from here in Ann Arbor.

A final comment. We will miss Michael Johns, who has been with us for much of the past year providing wisdom and effective leadership for our medical school and health system as Executive Vice President for Medical Affairs. We welcome his successor Marschall Runge.

[ President Mark Schlissel, Special Counsel to President Liz Barry , & Michael Johns]

 Best wishes, and thanks for spending time on “Matula Thoughts.”  David A. Bloom

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 David A. Bloom

Matula Thoughts August 1, 2014: Art & medicine

This is the blog format of the monthly email communication called “What’s New” from the University of Michigan Urology Department.

1.  

My drive home from work in the summer is likely to occur in cheerful sunlight, even when the hour is late. A good piece of this seasonal pleasure still remains for us at the start of August. July 2014 has come to a close and with it the celebration of the Fourth, the Ann Arbor Art Fairs, and the Chang-Duckett-Lapides Lectureships of the Urology Department. Our PGY1s (interns) class of 2019 began at least five years of residency training that may easily extend by several additional years with fellowships that many of our graduates undertake. The lectureships we hold every year around this time add some formality and socialization as the new academic season of residency training commences. Andrew Kirsch of Emory University gave a remarkable Duckett Lecture on his work with magnetic resonance urography (MRU) and Kassa Darge of the Children’s Hospital of Philadelphia produced a superb Lapides Lecture on the wide scope of urologic imaging and his experience with MRU. We had excellent attendance and wonderful discussion. MRU is clearly the new IVP. Yes, it is at present much more costly, but as we saw in the discussions, a careful history and physical exam with high quality GU ultrasonography in the hands of well-trained and experienced clinicians will answer anatomic questions well enough to deal for most problems we see. In complex situations, however, the detailed anatomic and functional information from the MRU is unsurpassed. George Drach of the University of Pennsylvania presented a clear discussion of a muddy topic – the Affordable Care Act. He promised that the topic will get even muddier next year as complex add-on legislation accrues in the year ahead.

[Andrew Kirsch, Duckett Lecturer, with Susan Kirsch]

[Peggy Duckett, George Drach, & Kassa Darge, Lapides Lecturer]

2.    The Chang Lecture on Art and Medicine (our 8^th) was given by James Ravin, a well-known ophthalmologist from Toledo who had trained here in Ann Arbor. I first learned about him through his book, The Artist’s Eyes, which had been sent to me by Steven and Faith Brown, Michigan alumni and strong supporters of Michigan Urology. The lecture was amazing and we can mail you a CD of the lecture if you send us a note. Before Dr. Ravin took the microphone, I asked the audience: Why should a urology department care about the link between art and medicine? My answer was twofold and I’d like to repeat it here. The first reason is simply the matula. This long-standing symbol of the medical profession is the flask used for the macroscopic examination of urine. Not insignificantly that is also the name we selected for this blog. The second reason is that this linkage is hardwired in our species. Genetics and epigenetics demand this attention from us. Maybe this is a presumptive conceit, but most people believe our existence among life forms is unique and that the distinctive human condition we claim is built upon our curiosity, our creativity, and our tendency to reflect upon ourselves as well as our fellows. These traits have led to our ability to solve problems cooperatively and accomplish complex tasks like building cathedrals, performing symphonies, writing encyclopedias, or doing cystectomies and urinary diversions. Art is part of all human performances, most especially the medical arts.

[Hamilton Chang, James Ravin – Chang Lecturer, & Dr. Cheng-Yang Chang]

3.    That the study of art should occur in a university is no surprise, universities are the primary stewards of the future – the human future and the global future. Universities educate tomorrow’s builders, thinkers, and citizens. They and their graduates are the primary sources of tomorrow’s ideas and inventions. No other institution in society has such a broad mandate, much less fulfilled it so well over centuries as universities. Ben Shahn, an American Artist of the second part of the 20^th century, put together an essay in a book called The Shape of Content in 1960, where he specifically addressed the matter of visual art in universities, writing: “What can any artist bring to the general knowledge or theoretical view of art that has not already been fully expounded? What can he say in words that he could not far more skillfully present in pictorial form? Is not the painting rather than the printed page his testament? Will he not only expend his energies without in any way increasing the general enlightenment? And then, what can an audience gain from listening to an artist that it could not apprehend far more readily simply by looking at his pictures?” While Shahn was specific that his comments related to visual art, his point extends more broadly.

4.    Shahn answers his own questions in the essay, developed from lectures at Harvard College and offers two reasons why universities (and by extension medical schools and their departments) should be interested in art. First, the product of universities, educated persons, should have what he called the accomplishment of perceptivity – a necessity for tomorrow’s international citizens. His second reason is that the universities, themselves, are enriched by bringing art, he says, into the circle of humanistic studies. This point anticipates the vision that E.O. Wilson called consilience, the idea of global village of knowledge in which boundaries between fields of study are mere human conceits. Wilson contends that the most important findings for our species will be made at the interfaces and boundary waters among the fields. Shahn expands on this second point in his essay, saying that bringing art into the circle of humanistic studies serves the: “… general objective of unifying the different branches of study toward some kind of a whole culture. I think it is highly desirable that such diverse fields as, let us say, physics or mathematics, come within the purview of the painter, who may amazingly enough find in them impressive visual elements or principles. I think it is equally desirable the physicist or mathematician come to accept into his hierarchy of calculable things, … [the] nonmeasurable and extremely random human element which we commonly associate with poetry or art.” [Shahn p. 9]

5.    Visiting professorships are an important part of academia, bringing the best insights of established thought leaders, as well as the newer voices and controversial ideas of those who challenge the status quo. We do this fairly well at Michigan Urology throughout the year in each of the disciplines within our field. It is equally and especially important for universities to offer periodic public lectures on broad themes such as Ben Shahn provided at Harvard for general audiences on topics that offer important humanistic insights, cut across fields of study, and stimulate conversation and cultural curiosity. We try to fulfill our part with the Chang Lecture and if you missed it this year, consider holding that calendar slot next year on the Thursday of the Art Fairs. Our speaker will be Pierre Mouriquand of Lyon, France. He is an extraordinary pediatric urologist, a deep thinker, and a committed artist who paints nearly every day.

6.    A number of years ago I came across a wonderful statement made by the late and great Michigan faculty member and world-class physiologist, Horace Davenport. A student recalled him telling a medical class that “physicians are the attendants at the service station of life.” Of course, in Dr. Davenport’s days the gas stations were true service stations where someone pumped your gasoline, checked your oil and tires, washed your windows, and actually fixed problems with your automobile. Notwithstanding the dated image of the service station, it is an appealing metaphor. While the current phrase patient-centered care is bandied about as though it were a new idea, the consideration of “what the patient wants” has really never been far from the minds of good physicians. While we all have seen instances of domineering and inconsiderate medical care, the idea of a “patient-centric” approach is hardly revolutionary and new. It is unfortunate, albeit useful, that we need to proclaim that the health care we offer in our organizations is “patient-centric.” As health care has become more complex, specialized, and team-based it is easy to retreat onto islands of our professional turfs and focus on the solutions of isolated clinical problems. This professional convenience, however, turns patients and their inevitable co-morbidities of modern life into mere packages of DRGs in search of CPTs. The complex billing systems we dignify with the phrase modern electronic medical records are more than innocent co-conspirators in this crime. The success of the modern health care enterprise will depend on its ability to simultaneously fulfill the desires and needs of each patient in the contexts of their physical, emotional, and social problems. This will require teams and systems that are at once lean and adaptive.

7.    Long before science impacted the work of physicians, medicine was described as an art and I believe there still is much art to our work insofar as you might look at art as anything that is choice. Science and evidence cannot and will never define all of our choices in medicine. Two fundamental questions define modern health care. The first is: what does the patient (and family) really need and want? The second is: what does society want from its health care enterprise? The answers to the two questions are quite different. It is the first question that drives our essential transactions in health care, patient-by-patient and family-by-family. Of course these transactions must exist in the framework of society and the sense of what is right and reasonable to do for each individual patient. On the other hand as we create public policies and deploy health care systems, the second question comes heavily into play and begs the question: how much should a nation spend on the well-being of its people? So is 20% of GDP, for example, too much or is it not enough? It’s interesting to compare health care to food expenses. In some nations, families spend 60% of their household income on food, while in the USA food accounts for less than 10%. Granted that individual household expenses and national GDP are very different “apples and oranges” and the constraints of a nation differ from those of a household, it is clear that the more one expense dominates a budget the less remains for other necessary and desirable expenses. As a matter of public policy, however, ideally how much should a nation spend on its health care? How much on the education of its next generation? How much on its self-defense, on its research & development, on its infrastructure depreciation, or on its service of past debt? However you answer these questions, it is a fact that in the USA we are moving towards 20% of GDP for health care, and other advanced nations are not terribly far behind and moving towards us. That being said – a good third of the expense is generally recognized as waste – money spent that helps neither patients nor society.

[Table from The Economist]

[Huffington Post July 10, 2014]

8.    An interesting point of view, written 2 years ago in the New England Journal of Medicine by MJ Barry and S Edgman-Levitan, called Shared Decision Making discussed a Picker Institute report that identified eight characteristics of care as the most important indicators of quality and safety from the perspective of patients. These characteristics are: respect for patient values, preferences & expressed needs, coordinated & integrated care, clear information & education of high value for the patient & family, physical comfort with alleviation of fear & anxiety, appropriate involvement of family & friends, continuity, and access to care. This list mirrors a more simple set of things that I believe patients want, since these are the simple things I want from my personal physicians: kindness, expertise, and convenience. Perhaps the attributes you might list would differ in number or terminology, but I think most people want roughly the same things. [MJ Barry and S Edgman-Levitan, Shared Decision Making. NEJM 366:780, 2012]

9.    

I’ve shown this picture before in our Department of Urology “What’s New” column, but am compelled to share it again. The picture appeared on the cover of JAMA, a fact that dates this work since for the past year or so the new editor of the journal, Howard Bauchner, while he retained the art feature, moved it from its long-standing place on the cover of each issue. [JAMA 3017:2497, 2012. Toll E. The cost of technology. Copyright 2011 Thomas Murphy] Change is inexorable, however, and I have to say that he has done a superb job with the journal, both in format and in topic selection. The illustration shown (with previous permission of the author, Elizabeth Toll) shows a crayon drawing of a scene in a doctor’s office. The 7-year old artist drew her sister sitting on the examining table looking at the viewer in a most Vermeer-like fashion. Mother, with a younger child on her lap, is seated at the far right. The artist sits in between, at work on her picture, but also gazing intently at the viewer. The astonishing feature of the artwork however is the physician sitting at the far left, totally absorbed at the keyboard in the technology that is mandated in healthcare. The software has become a surrogate for the patient. The artist told it as it was and, no doubt the physician felt some shame on viewing the artwork. The enormous sums of money we have been forced to expend on clunky and dated software, compliance for poorly fashioned regulation, and the turmoil of the restructuring of a massive industry are a significant part of the waste. What will the next generation of health care look like when we leave behind the RVU, meaningful use, EPIC, and ICD-10? Such a world cannot be too far away. We hope academia, industry, and public policy can put together systems that are accessible, fair, lean, adaptive, and good for patients.

[Jeff Halter, Howard Bauchner, Preeti Malani, & Eve Kerr at a reception at   Preeti’s home 2013]

10.   The well patient exam has been challenged as “unnecessary.” So too has the routine pelvic exam, the PSA testing, and even routine urinalysis. This brings me to the question, what is the point of healthcare? As physicians we like to solve and fix problems of patients, but is that all that patients really want? Yes, often a patient comes with a very specific problem, but very often not all the problems are evident and sometimes they are deeply entangled with the other issues we like to call co-morbidities. This brings me back to Dr. Davenport’s thought. People and their cars have to stop at service stations from time to time. Sometimes they need gas or have a flat tire. At times the car isn’t working well and help is needed of one sort or another, but the problem isn’t immediately evident and the attendant must diagnose before repair. It is also useful, at other times, to have an expert look at the car, see how it runs, listen to the engine, and check under the hood. Preventive maintenance and inspections may discover occult issues for which early intervention can prevent serious harm. I can’t believe this isn’t true for human bodies and minds. People need to stop by the service stations of life from time to time just as well, for after all we are susceptible to far more ills than our motor vehicles. A doctor, or other health care provider, can look, listen, counsel, advise, and teach. The pastoral side of a doctor’s art should still be a major part of the toolkit. Not every problem discovered needs remedy, but every person should be seen, listened to, and examined periodically by some kind and expert attendant at the service stations of life where art and medicine converge. This is how we care for the human condition.

[1936 Union Gas Station. Main & Weatherlow. Lassen County History. Wikipedia – Historic gas stations]

Best wishes, and thanks for spending time on “Matula Thoughts.”

David A. Bloom, Department of Urology, University of Michigan