Thursday, April 22, 2010

Earth day healthcare

This post is a continuation of the series looking at the cross-roads of peak oil and healthcare.

Happy anniversary of Lenin's birth, everyone! Yes, the Communist Revolution's leader was born on this day in 1870!

But much more seriously and importantly, happy Earth Day! No matter how cynical you may be about what this day has turned into, you can personally take this time to reflect on your interaction with our Mother. The Buddha felt that we are not distinct from anything, including the earth and the rest of the Universe. So, if you are an intermediate-to-advanced Buddhist, this is a good day to practice oneness. For the rest of us, perhaps we can engage our thoughts to be mindful and notice throughout our day how our actions impact the environment.

And this, as everything does eventually, brings me to healthcare. As I mentioned in my recent post, healthcare system is a tremendously heavy consumer of our natural resources and, as a result, a huge producer of the greenhouse gases. "But it is all in the name of health", you say! Is it really? Dig deep down and ask yourself why you ordered that EKG on the perfectly healthy asymptomatic guy who is starting an exercise regimen, or why you got an MRI for that chronic low back pain? "But look at the strides we have made diagnosing and curing disease", you say! Is this progress not a fair trade-off for the little energy expenditure and a slightly enlarged carbon footprint?

OK, so I have a couple of problems with this argument. First of all, some people would say that the vast majority of the strides we have made in health and longevity are due to such public health interventions as water and sewage treatment, municipal solid waste removal, and the advent of antibiotics. Most of the progress we are making today comes in minute increments at the cost of not only exorbitant dollar amounts, but also of the environmental resources. Not only does this "innovation" require an input of energy and materials, but the waste that its development and manufacturing produces can be staggering, counting not only the green house gas emissions, but also the garbage it yields on the back end. Similarly, the utilization of so much technological "advancement" requires materials, energy, as well as the means of waste disposal. And just because once the trash is hauled away we do not see it does not mean that there is no environmental toll from it.

At this time of healthcare reform, we as a nation are beginning to ask some questions previously regarded as heresy: Are the effects of this intervention worth the healthcare dollars spent on it? I believe that we must go way upstream from the technology being in use on the market, and must start factoring in the environmental toll of its evolution from the genesis of the idea itself. Only this way can we understand the true worth of what we are proposing to use in the name of healthcare.

I know that for most of us to feel one with the world around us is not feasible or desired at this moment. So if chanting Om does not unite us the Universe even for a moment, let us use our well developed minds. The resources of this earth are finite. And even it you do not believe in climate change (though it is difficult for me to imagine how one can believe in God and yet not see the verity of the science behind global warming), perhaps you can start to cultivate a little doubt in your conviction that we can continue as we are with impunity. Perhaps by using our resources mindfully, by asking ourselves several times whether opening that extra needle or ordering that extra head CT is really necessary prior to plunging into action, we can not only forestall the impending oil and climate crises, but also develop a closer relationship with the planet that is ours and our children's home.        


Tuesday, April 20, 2010

Imagining post-peak oil healthcare

This post is the first in a series that will examine some ideas on the potential impact of peak oil on healthcare, as well as some solutions for meeting this change in a prepared way. 

As you all know, I do believe in the peak oil theory. Think about it: in a closed system nothing is infinite. Since oil is a product of millions of years of decay, unless we use it at the same rate that is it produced, we will run out. I do not have a crystal ball any more than anyone else I know, so I will not hang my hat on when, but will commit to whether: yes, it will happen. And while a lot of people have conjectured about what the world will look like post-peak oil, there is a surprising paucity of hypotheses or suggestions about healthcare. So, I will try to use my imagination to start to fill this gap.

First, a few facts.
Fact 1: The world, including the healthcare system, runs on cheap oil. The world's daily use is 80 million barrels, 20 million barrels of which is used in the US, and 70% of those 20 million goes to the transportation sector.
Fact 2: The healthcare sector is a super-user of energy. The US Department of Energy estimates that
...hospitals use 836 trillion BTUs of energy annually and have more than 2.5 times the energy intensity and carbon dioxide emissions of commercial office buildings, producing more than 30 pounds of CO2 emissions per square foot.
As we know, hospitals are incredibly technology-heavy institutions. In addition, literally tons of medicines and plastic disposables made from petroleum are the cornerstone of our healthcare model.
Fact 3: There is no imminent technological solution for the impending oil shortage.

Now, why should you take my predictions of such doom and gloom seriously? Well, for one I am not prophesying doom and gloom. Rather, since forewarned is forearmed, I am reiterating a warning still with time enough for us to start preparing for a different way of life. You don't believe me that it is coming? Do you believe the US military? Their recent report clearly points to a drop in production and impending shortages of oil. They ought to know, being the biggest global consumer of this resource!

But back to medicine. What will it look like post-peak oil? I am happy to say that you still do not have to trust me, but perhaps Howard Frumkin's of the CDC thoughts on this topic (subscription required) in JAMA can make you scratch your heads a bit:
Petroleum scarcity will affect the health system in at least 4 ways: through effects on medical supplies and equipment, transportation, energy generation, and food production.
It is worth reading the entire editorial to get the flavor for what is likely to come. At the same time, one can easily engage one's not too wild imagination to start visualizing the situation. Taking it item by item, medical supplies and equipment are not only manufactured from or with petroleum, but they need oil to get to our hospitals and to run. Transportation needs very little explanation, given our reliance on emergency transportation by such modalities as ambulances and helicopters, as well as the need for regional and national referral centers based on expertise and availability of services. Frumkin does a nice job talking about energy generation, and the concern here is an increased reliance on coal with its propensity for green house gas emissions, and so on, and so on. Finally, our industrial food production, having moved away from local integrated traditional farming to monocultures supported by automation which runs on oil, relies on additional oil for pesticides and fertilizers and transportation from the farm to the table.

So, what will medicine be like under these circumstances? The reality is that, if we as communities fail to prepare for this change gradually, we will be hit with it abruptly, and, you have to admit that sudden and unplanned changes are tougher to deal with than anticipated ones. I myself do not have all the answers, but I would like to challenge everyone, clinicians, administrators, patients and public alike, to begin this conversation. It would behoove us all to keep this idea in the backs of our minds as we move through our days, so that we can mindfully note what changes have to be made and what infrastructures need to be built to optimize our collective future.

Your participation in this discussion and comments with specific solutions will be greatly appreciated.


Monday, April 19, 2010

What's in a name or the furor over the proposed PA name change

Much like many other news items, I came upon the one about the proposed name change for Physician Assistants quite by accident: it came to me as an e-mail notification of a new topic being discussed on one of the physician only discussion boards that I am a part of. Apparently, after 40+ years of the profession's existence, there is a grassroots effort afoot to upgrade the name, and presumably the clout, to Physician Associate.

Well, as you can imagine, while the move is met with praise by the PA profession, the MD profession is seething. Some of the comments that I have seen from my colleagues betray such tremendous pain and suffering as a profession that it threatens my equanimity: I feel organically how lost we are as a profession to be expressing such bile without much thought over what appears to be a relatively innocuous event. But surprised I am not, and here is why. The medical profession's victory over all other potential modalities is hard-won and filled with a history of major turf battles and occasional demagoguery. The historically either-or approach of modern-day practice of medicine is responsible for the current landscape of our healthcare. In short, physicians have been only too successful at becoming the final word in health, at the exclusion of all others. With the allied providers, such as nurse practitioners and PAs, gaining in importance, particularly at this time of great uncertainty about the future of our healthcare "system",  understandably the MDs are reflexively bracing themselves for any and all turf battles. So, the perception of a power grab that this proposed name change has engendered in my hallowed profession is a classic fight-or-flight response, an activation of the survival instinct.

There are several aspects of this response that I find disturbing. At the most basic level, the response betrays such tremendous emotional pain among so many good people that it is all I can do to keep myself from sinking into a depression. And while I feel compassion for them, I am also forced to remind them that, as Eleanor Roosevelt once said, "No one can make you feel inferior without your consent". Applying the thought to the current situation, how the society may view PAs, whether they are called assistants or associates, should have absolutely no bearing on how physicians are perceived. Simply put, this perceived elevation in the status of the PAs relative to that of the MDs should not in any way make the MD profession diminish in its or the public's view.

The next layer of why this is a dysfunctional response lies in a poor choice of battles that this represents. I once had a boss, whom, despite working for myself currently, I frequently allude to as "the best boss I have ever had". When I would get hot under the collar, she would pointedly ask me to clarify for myself whether this was an issue to fall on my dagger for, thus teaching me that falling on my dagger too many times would make me politically into Swiss cheese, or, worse yet, dead. Under the circumstances, do MDs and their organizations really feel that this is an important dagger to fall on? In the current atmosphere of public distrust rightly or wrongly bestowed upon the profession, such indiscriminate issue picking will rightfully appear self-serving.

Finally, for a profession with, on average, a very high intelligence quotient, I am amazed that we are focusing on the minutia instead of looking at the big picture. Healthcare is a behemoth, an inefficient and inequitable trough at which there has been a feeding frenzy for too long. We need to be reining it in to the best of our abilities. And yes, altruism, not unmitigated self-interest should be driving us to do this. Gentleness toward and respect for each other, our communities and our planet should be the values that determine our actions as a profession. I am convinced that these are the values that brought us into medicine.

These are difficult times, made more so by the external forces all ganging up to deprive us of our humanity. Let's get back to the reasons why we went into medicine; let's sit quietly and find that lost thread of contentment and pride. Or else, if there is no joy left for you in your practice, resolve to find something else that you can be happy about. And no, it is not easier said than done. It is much more difficult to go through life carrying the baggage of self-imposed misery than to set it down in favor of finding happiness in this brief sojourn that is our life.                

Tuesday, April 6, 2010

Evidence: What the bleep do we really know?

So I know that my blogging has fallen off a bit, and I am sure you are all sorely disappointed (or not). Let me try to explain why.

There are several things going on to nudge me toward the next rung in the evolution of my thinking about healthcare and evidence. The event most responsible for this re-examination of my assumptions is the previously-mentioned illness of a loved one, along with my need to be closely involved with his care decisions. I think that I have generally adequately voiced my frustration with how decisions are made in our healthcare system, and where the switches for these choices should be as opposed to where they are. I am even more convinced now that by the time the physician and the family are considering expensive options with marginal effectiveness, the cat is already out of the bag: how can either the distraught family or the committed healthcare provider not consider those, despite shaky evidence of the value?

But this is not all. I have actually been cogitating the entire way we do evidence and evidence-based medicine. When we invoke evidence, we generally talk about some scientific study's findings, or a group of studies either showing similar or differing results. Let's keep stepping back and looking at the components. The scientific community, based on some statistical and other methodological considerations has come to a consensus around what constitutes valid study designs. This consensus is based on a profound understanding of the tools available to us to answer the questions at hand. The key concept here is that of "available tools". As new tools become available, we introduce them into our research armamentarium to go deeper and further. What we need to appreciate, however, is that "deeper" and "further" are directional words: they imply the same direction as before, only beyond the current stopping point. This is a natural way for us to think, since even our tools are built on the foundation of what has been used previously.

So, what emerges is a picture of being emotionally committed to a certain way of viewing the question, the processes of answering it and the actual answers. And what if by narrowing ourselves to this one particular way of examining the world, to this one particular way to collect and interpret the evidence, we have effectively ignored all other possibilities?

Let me try to clarify what I mean a little further. We spend our days walking through waves. Some of these waves we can detect through our own senses: sound, light, for example. Others we need special external "receptors" to detect, such as radio and micro-waves. Is it possible that there are some other, heretofore unknown waves (or other phenomena) that are around us that we are unable to attune to because of our biology? Is it kooky to think that this is possible, or is it simply blind to walk away from such possibility?

The answer may be that it is both. Nevertheless, it is highly likely that there are many biological phenomena that are not amenable to being examined through our narrow prism of current methodology. We as scientists and clinicians need to be open to this possibility. The Buddha said that both preachers and scholars are blind because they constantly commit themselves to partially-seen truths. Given the shambles in which we find not only our nation's healthcare system, but also the health of its citizens, this would be a great time for this epiphany to penetrate our collective psyche and strive toward a broader view of possibilities. Let's give up the arrogance of ignorance in favor of the humbleness of enlightenment.

And these are my latest thoughts. I am not saying that they are the only way or that they are even remotely correct. But here they are nevertheless. Do with them what you will.