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oedipusDoing 60, 90, 120…ignoring or liberally interpreting the yellow “RIGHT LANE ENDS, MERGE NOW” sign, the driver of a white pick up truck scattering gravel in the break down lane passed us and cut us off, the raised bumper inches from ours, the dual exhaust rumbling.  I was captaining our station wagon.  My beautiful wife sat next to me, her hand proffering reassurance to my shoulder.
     “Just ignore him,” she said, reading my mind (the lower, primitive regions of the limbic system, amygdala and hippocampus) or the adrenalin gauge (not on the dashboard) with its indicator at the redline.

Instead, I ignored her, tailgating and then swerving in front of the truck at the next available opportunity—a straightaway after a service station where the road widened from one lane to three, allowing for left and right turns into strip malls, as well as the occasional drag race.  The lackadaisical evening traffic and numerous stoplights, however, made this particular use tenuous.

Fortunately for us, the driver, after gunning past one more time, swooped off the road into a liquor store parking lot without taking further heed of my challenge.  He probably had a jiggling beer cooler on the front seat in need of replenishment, to go with a (fully legal) handgun in the glove compartment.  I escaped the confrontation with only an earful from my wife for risking my life, and hers: minor damage.

In fact, I’ve mostly gotten pretty good at defusing such situations, mostly by defusing myself in time.   But sometimes caught in the wrong mood at the right moment…I…The funny thing is, were I to come across the obnoxious operator of said truck at a revolving door or in a movie line, each one of us might well have said, “after you.”  Somehow, climbing into a car’s personal space with its anonymity and raw power deactivates the courtesy that keeps us from each other’s throats.

Manners, as a word, suggests a kind of officious veneer associated with prep or finishing schools, a gratuitous expertise in the social graces.  The well-mannered individual always uses the correct fork for his salad, and gets his thank-you cards written punctually.  But I postulate here that at least on the roads and highways of America good manners can save your life.  We’re a short tempered and irritable society (at least while motoring) and a violent one.  Perhaps there’s a connection?  According to the National Highway Traffic Safety Administration, aggressive driving accounts for one third of “accidents” (my quotation marks) and two thirds of automobile fatalities.  That’s frightening.  On the Pennsylvania Turnpike, a thoroughfare I frequent, two women were killed a few years ago after the driver of another car, angered and retaliating over an unintentional “slight,” caused theirs to lose control and crash.  If he’d displayed just a hint of the gallantry he might have on foot, he’d be a free man today and two women would still be alive.

According to Freud, we are motivated by sex (Eros), and death (Thanatos).  I would agree with the first at least, though I think there are often less elaborate, in fact stupidly simple explanations for our behavior.  For example, much has been written about the so called Oedipal conflict, which Freud hypothesized, where a boy subconsciously wishes for his father’s death  because he harbors repressed desire for his mother.  Sex and death, death and sex.  But if we go back to Sophocles, the ancient Greek dramatist, and his Oedipus Rex, we find a much more banal kind of human foible at work.

Remember the story?  An oracle forecasts that Laius will have a son who will grow up to kill his father.  So Laius disposes of this son, Oedipus, binding his feet and leaving him on a mountain to subvert the fate decreed by the gods.  The infant Oedipus survives and years later, as a grown man, finds himself face to face with his father.  Except neither recognizes the other.  Oedipus believes his father is the shepherd who raised him as a boy.  Laius thinks his child is dead.  So they are in essence strangers when they argue at an intersection over who has the right of way.

When Oedipus kills his father it has nothing to do with the superego, or the id, stifled libido.  It’s a simple case of road rage, and fatuous as it sounds, bad manners.  Had either one of them waved the other past with genteel deference, there would have been no bloodshed, no humiliating abdication, no suicide by Jocasta, no self-mutilation by Oedipus in his shame and grief and guilt.  This variety of Oedipus complex isn’t complex at all.  Unfortunately, like fate, neither is it trivial or easily avoided.  And it takes its toll off the road as well, has done so for centuries in petty struggles over honor, pride, saving face.  The gods and the playwrights could always count on us to be impulsive, ill mannered, and self-destructive.  They still can.

MassGeneralHospitalWhat’s wrong with the current system? Gross inefficiency, redundancy of services (generally lowering overall quality because the added programs lack adequate proficiency and don’t significantly improve access), irrational deployment of resources (i.e. too many specialists and too few primary care physicians, simultaneous physician gluts and shortages in different geographies, an excessive density of programs providing complex high cost care in some locations, a dearth of such programs in others), inadequate provision of primary care, psychiatric care, & translational care facilitating recovery once the patient is released from the hospital), increasingly arcane and inscrutable bureaucracy associated with fees and payments, antiquated processes (incomplete and disorganized medical documentation via pen and paper, versus (fully) electronic record keeping utilized by other countries), inadequate validation of processes, a lack of quality assurance, excessive negligence, inadequately investigated bad outcomes, inadequate trending and statistical analysis of outcomes, inadequate safeguards or remedies for negligence, runaway litigation, physician incompetence and impairment, inadequate regulation and/or control of insurance company practices, lack of adequate preventative or therapeutic care for the poor, the elderly, or children, a distorted focus on procedures versus outcomes, a failure to consider the whole person when treating patients, an inadequate focus on the psychological dimensions of illness, on the social and employment aspects of illness, inadequate mechanisms for addressing pain control, especially in terminal illness, inconsistent and arbitrary approaches to end-of-life-care (if you think your grandmother isn’t already refused adequate or compassionate treatment as an elderly patient, you’re sadly mistaken), inadequate recourse for patients denied choice or coverage, inadequate recourse for physicians or hospitals denied payment for indicated services or procedures. I could go on with the list, or expand any of these items in detail, but that would only add to the tedium of this already languid litany. I suspect most of the charges I’ve leveled will not sound unfounded or unfamiliar to you.

What is to be done? Obama’s initiative and what congress has done with it as a reform package is far from perfect and doesn’t begin to go far enough in terms of tinkering with the mechanics of very fouled up health care system. Nevertheless, it’s a lifeline thrown to a drowning person and if we are to have any chance of preserving our wellness—personal, societal, financial—we must grab it avidly and quickly. There is no chance the proposed changes will aggravate our predicament, and every chance they will improve it in manifold and significant ways. The plan will add to our choices as health care consumers, lower costs, and begin the process of trimming waste. The plan will also protect the uninsured (and the insured) from being without adequate coverage to manage catastrophic illness. In doing so, the proposed reforms will protect the rest of us from the high expenses to society associated with refusing to provide care when it is still timely and effective.

Beyond the plan we need a peer review system comparable to that used by NIH (National Institute of Health) which is run by the government yet is highly efficient, effective, and in fact as research systems go, is the envy of the world. Disinterested physicians, and other health care experts, (versus government bureaucrats) need to determine the appropriate use and deployment of finite resources. Simply pretending we can do everything when we know we can’t and can’t afford to (the ostrich approach) has to stop. We need to keep our insurance companies, but regulate and restrict them (like utilities) given their stewardship of a vital public resource. No longer can they be allowed to enrich themselves at our expense while pretending to “control costs” by denying us choice in what care we receive and from whom we receive it. No longer should we let them refuse to take care of us once we are sick. Of what use is health insurance that only insures the healthy? We the public need to make informed decisions about what happens to us when we are sick, such choice a welcome change from the current model in which we are kept in the dark as to the motives, workings, and impact of those taking care of us.

lymphangI won’t lie and say the moment was transformative.  I’d always had compassion for my patients, even the less sympathetic ones.  On my psychiatry rotation, I received a tongue lashing from my resident for being disorganized–spending extra time with the retired subway driver who’d attempted suicide after secretly battling depression, and now wanted to talk to someone.  I objected mentally if not aloud when my attending stood over the alcoholic lying in the ER in an encephalopathic daze, and poked and prodded her with grim harshness.  He was “teaching” me the signs of endstage liver disease, and he was also showing me his position of power and contempt.  But my own paternalistic sympathy had given way to fraternal empathy.  I had something in common with my patients, even the “charity cases” who showed up on clinic days, an inkling at least about their helplessness and shame.

In our country, more than ever, illness is stigma, and the more dread the disease, the more profound the ostracism.  A patient becomes his condition, and someone with a serious one like cancer is often beyond help and so beyond  redemption.  You are uninsurable and of abridged longevity.  You are undesirable, a liability.  In a culture of youth and innovation, infirmity disfigures you socially and psychologically.  You must keep your leprosy hidden.   You don’t have to be poor or “lower” middle class to suffer this fate, though for them ruin is swifter and more certain.  The guy who works in the hardware department at Walmart married to the part-time secretary in a small office—neither of them gets insurance as a “benny,” and neither of them can afford it out of pocket.  One of them gets sick and it’s catastrophic for both of them and for their children.  They borrow thousands from family and friends.  They lose their car, their house, if they have one.  They get chased by creditors or declare bankruptcy, and the cost of health care for the rest of us gets ratcheted up one more notch.

Even if you have insurance, you shouldn’t be complacent.  Even from a “me first” perspective there is much that’s alarming about the current state of health care in America.   Much of what is broken affects everyone.  There is an illusion of choice in our current system, but it’s only an illusion.  Most people get their insurance at work, and most employers have only one or two “plans” from which to choose when offering insurance to their employees, and most employees have just one choice, the plan they’re offered, whose costs have risen dramatically and will keep doing so.   There is no choice between what we have and a “government” alternative.   Insurance companies currently use Medicare as a guide (excuse) for what they cover (do not cover).   And what we have now will shortly be gone, replaced by grossly inadequate care for an increasingly uninsured fraction of our population (with the rest of us shouldering the social and direct costs), and the remaining fraction spending more and more of their money on insurance that covers less and less.  If you think the economy has nose-dived recently, just wait until the pervasive effects of bloat and neglect in our health care system really kick in.

Even at the personal level, most patients make arbitrary decisions with enormous consequences about the care they receive.  They assume that care they will be superior or at least adequate, because they’re in America after all, and we have the best, no?  But in fact our system of physicians and hospitals and the insurance companies which control what these providers do, is highly uneven in quality.  The primary motivations of the participants are less and less patient care and more and more pecuniary concerns or are heavily distorted by pecuniary concerns.   Reimbursements and coding have crowded out the “art” in medicine.  As a doctor, you don’t have time to see patients as individuals, to listen to them long enough to make wise decisions about what to do for them.  You don’t even want to be judicious about what you “do” since insurance only pays you for what you do and not for what you say, or how long you listen.  Patients have become their conditions, their broken parts, the procedures that repair them.  How many knees does the orthopod have on his schedule in the morning, how many colonoscopies can the gasteroenterologist squeeze into his busy calendar on Friday?  The hospital down the street, the one that’s convenient and where your primary (who’s local and has privileges there) wants to send you?  Your hospital is competing for patients with the university hospital downtown, so now you have cardiac bypass close to home, and renal transplant, though the physicians performing those procedures in these redundant programs perform fewer of them and are less expert than the physicians downtown, and you are less likely to have a good outcome, no matter how “good” your insurance.

I’ve practiced medicine for most of my adult life, and I’ve also lain on the other end of the stethoscope.   I’ve benefited directly and personally both as a doctor and as a patient from a health care system that at its best leads the world in know-how, technology, and personnel.  And I’ve witnessed first hand medical practice so repugnant I believe it rivals for squalor that of the worst back waters on the planet.  All this within a few square miles in the same city.

Let’s consider my own disease as an example of the difference who, how, and where make on outcome.  There was a study published a number of years ago in which the outcomes for stage one and two Hodgkin’s disease were compared at Stanford, a major tertiary care center, with those at a large community hospital in the same area.  The Stanford patients had around a 95% cure rate, which is what one expects for the early stages of this curable cancer.  The community hospital patients had a 75% cure rate, substantially lower.  Why?  In spite of treating the same kind of patients with the same methods, the community hospital failed in many small ways.  Cancer is a disease whose treatment requires the collaborative skill of numerous people.  A good cancer center has good radiologists to read the CT scans and x-rays, good pathologists to examine tissue specimens, good radiation therapists to properly define the treatment portals, and excellence among the other non-physician staff who play active roles in cancer care, the nurses and technicians who are so essential.

There is redundancy in the cancer center “market.”  There are cancer centers of lesser quality selling themselves to the public, and other similar complex care programs doing the same: cardiac bypass, organ transplant, trauma—it’s a long list.   The health care system’s problems are mostly not about the haves and the have-nots, though having so many uninsured people does insidiously aggravate the other issues.  Ultimately, these individuals turn up in emergency rooms in the later stages of their illnesses and must receive care, often ineffective and a good deal more expensive than that of timely intervention.  And it is a travesty that among the European nations and Japan we are near bottom of the list in measures such as life expectancy and infant mortality.   The best care is available here, but you have to look carefully to find it.  And you need to be a physician or a quick study as a lay person to know what you’re looking for.

Three doctors saved me from cancer.  But that was years ago.  I no longer trust the health care system they personified and to which I owe my life, and have devoted that life as a practitioner.  I’m dubious of the diagnostic strategies used and procedures ordered in the care of friends and family, and for myself.  As a user I’ve become a minimalist, and then only after a thorough researching of the medical circumstances and the available literature.  There is too much shoddy care, too little choice for me as a “consumer” to do otherwise…to be continued

cxrDaniel Haller, Julius Mackie, William Powlis—these three men saved my life.  I was 25 and in my final year of medical school.  I’d had a nagging cough for several months and my friends urged me off and on to get a chest X-ray, check it out, though they half laughed when they told me.  No one, I least of all, imagined anything would turn up.  I was interested in radiology at the time.  It seemed like a good specialty.  New technology and a growing field—MRI was really taking off—great hours, a residency that wouldn’t kill me with years and years of on-call, plus I really liked it and was pretty good at reading films.  So when I put my own chest film up on the light box the last thing I expected was a large mass—as we call things that shouldn’t be in a person’s body.  The word has such connotations of size and weight, Newtonian physics, a cold, precise world where everything ends predictably.

Fortunately, Dan Haller, my oncologist, told me I had Hodgkin’s Disease, a “good” cancer to have, because it was always treatable and usually curable.  He put me through the drill of tests and scans, including a special form of torture no longer practiced called a lymphangiogram, where dye is inserted with needles in the webs of your toes.   Julius Mackie cut me open, took out my spleen, and assorted lymph nodes— a “staging laparotomy” to determine the spread of the disease and guide treatment.   Then he sewed me back up.  I was not an easy patient.  When the surgery residents gathered around me in my room on the med-surg floor, I told them I thought I might have an obstruction.  I was still woozy from the morphine, but I knew everything, which means I knew too much, and was sure I’d suffer all the complications.  Most medical students were part-time hypochondriacs.  You couldn’t read about so many terrible diseases and take care of people afflicted with them and not become infected with a little fear, a little irrational fatalism.  In my case, an overactive imagination had actually produced results.  But somehow, despite my elaborate concerns, I recovered from the surgery unremarkably and began my radiation treatments.

When I inscribed my first book, Plums & Ashes, for Bill Powlis, my radiation oncologist, years after he cured my cancer, I wrote that aside from my parents, he was the person most responsible for my being in the world.  About this, there is no exaggeration.  Although rare, Hodgkin’s disease had been inexorable, a death sentence for children and young adults until its modern treatment with radiotherapy (and/or combination chemotherapy).  Bill Powlis was and is a master of that field.  He is a remarkable physician, fully informed and proficient, gentle, good natured, unflappable, an excellent listener, and a great teacher, which is so important because all patients, not just medical students, have much to learn if they are to collaborate effectively in their own recovery.  There’s a lot to know when it comes to cancer treatment, and the stakes are high.  Fortunately for me, I was treated by one of the best and at one of the best institutions in the country, the Hospital of the University of Pennsylvania.

Even then, I found it a difficult road.  I wore a hat religiously in an effort to hide the back of my scalp where my hair fell out.  More than once I had to explain to someone (in a whisper) why my head remained impolitely covered indoors.  The actual treatment took only a few seconds.  But the whir of the machine casting its high-energy beam promised that a few hours later, with clockwork punctuality, I would become sick to my stomach.  And the treatments followed a workaday schedule, Monday through Friday, for months.  Nonetheless, I tried to go on with my life.  I changed my residency plans—decided to go into pathology instead, less on-call, and I could do research, pursue poetry as a dual ambition.  I sat in on Daniel Hoffman’s graduate writing seminar on the other side of campus, telling him in confidence that I would have to leave early each session, so I could get back to my apartment before the nausea kicked in.  Only once did I mistime my exit, though I don’t think I’ve ever felt so wretched in my life, before or since, even during my initial diagnosis, when cancer transformed me from indestructible hot-shot proto-doctor into one of my on-call “admissions” lying on a gurney.  I’d loitered, to toss in my two cents about an interesting poem, and didn’t quite make it home.  It was February, and I bent over between the ATM and the convenience store in my gray parka while passersby tried to ignore me, just another drunk or homeless person in the snow…to be continued

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