Archive for April, 2009

Is It Possible to Reform Health Care?

Wednesday, April 22nd, 2009

Sometimes a topic is just so big that I find myself gathering data until the pile is enormous but unable to write about it until a specific incident triggers an outpouring of all the information I’ve stored! Healthcare is a good example of this. Since I’m right in the middle of the maelstrom of controversy, I find myself almost overwhelmed by it all. Not that incidents don’t occur almost daily that should act as triggers. But where do I begin?

There are patients who’ve never seen their actual M.D.’s, or only seen them for a total of 15 minutes over the course of a year. Multitudes of people are multiple medications, with no idea of which is for what symptoms or of the side-effects or drug interactions. There are patients who need to change life-style or unhealthy habits who can’t get a 30-minute consultation with their primary care physician. Well, the M.D. just doesn’t have time! He or she has to see too many patients just to pay his administrative costs, which have risen over 25 % in recent years.

I didn’t even mention paying off school loans for the arduous process of becoming an M.D., or of rising malpractice fees. I’m sympathetic to the realities of practice. As a psychologist, my own time spent on paperwork and non-patient time has risen to the point where I have to pay someone else to fill out forms, code procedures, follow up on billings and payments, etc. etc. etc. No wonder there’s a shortage of family physicians in the U.S.

And if you have Medicare or MediCal or worse yet, no insurance, it’s often difficult to even find a doctor who will accept you as a client. A government survey done in 2007, quoted by the AARP, states that the more than 1.3 million people on Medicare have difficulty finding a doctor. And since seeing a specialist often requires the referral of a primary care physician, you’re out of luck even if you have a clear idea of what you problem is.

With economic conditions getting worse, and people losing their coverage or cutting back, the situation is just getting worse. I found this out after my serious auto accident in 2004, as described in my recent book Surviving Human Venom. Even recommended treatments can be delayed or not covered, and the insurance company can cut those treatments off or raise your premiums beyond your ability to pay for reasons that often make no sense to the poor patient. I’ve seen Workers Comp patients have treatment delayed for years, while their condition worsened, because the insurance company argued with the need.

And despite the high cost of medical care, assuming you can afford appropriate treatment on a timely basis, the U.S still has much lower positive outcomes than many other developed countries. We’ve got over 46 million Americans without health insurance, and we spend over $8000 per year per capita on all Americans, but we have lower life expectancies, a higher rate of preventable deaths, and higher child mortality rates than many Western countries.

I haven’t even mentioned quality of life issues yet! Billions are spent on advertising to convince us that some magic pill will solve all our problems. But chronic conditions and chronic pain persist, and the suffering from depression and anxiety continue to escalate. To really put patients first, psychologists and other behavioral specialists should be part of every treatment team. But more often they’re relegated to the last resort of a frustrated and busy physician, who dooms you to failure by saying, “It’s all in your head! Go see a shrink!” That hardly sets up a positive expectation of success.

I hate to keep harping on personal responsibility. But it always gets back to that, doesn’t it? LBJ brought up the idea of healthcare “regionalism,” where every doctor, clinic, and hospital was affiliated with a regional medical educational center. But instead of thinking “teamwork and collaboration,” when the idea is brought up, most doctors think “oversight and supervision” and panic. Is this just ego?

Many doctors are afraid of any program that is designed to reward efficient, high-quality services because they are afraid they don’t want measures of provider effectiveness applied to them. Insecurity and a sheer meanness of spirit make them resist being accountable for the quality of their care. Integrated care approaches help cut costs while improving services, but that would mean sharing the “golden halo” with other specialists on the team. The most difficult patients often require the most care, but even they have an improved prognosis when evidence-based treatment models and a multi-person team that includes mental health professionals, nutritionists, and other specialists are used to really treat all aspects of the patient.

Putting the patient first should be the first characteristic of healing. And if that means evaluating what you’re doing, consulting with colleagues, working with emotions and thoughts and other intangibles, then so be it! Taking better care of all patients, not just the wealthy ones, should be the goal of any reform plan. Not just splinting the bone or bandaging the wound, but actually educating, reassuring, and motivating the patient, something you can’t do in a 10-15 minutes office visit!

The major psychological organizations are busy coming up with ways to integrate psychologists into interdisciplinary teams, to ensure quality in mental health practice, and to encourage support, consultation, and collaboration among providers. Let’s see that extended to all areas of medical care.

Since I’m more familiar with sub-acute and skilled nursing homes, I’ll put my thoughts into an article or two that should help both professionals and lay persons understand how these ideas of teamwork can be put into effect. Look for them next week or so, because I’ll try to explain all the parts of being human that need care if we’re actually going to heal anybody!.

Pluralism is the Strength of Our County!

Sunday, April 12th, 2009

I keep getting myself in trouble at social dinners for the simple statement that I am mixed blood. I simply refuse to self-identify as “white”, a meaningless term with lots of baggage that does disservice to my family’s wonderfully rich background. (Obviously I am turning into a somewhat controversial guest to have at dinner, albeit inadvertently.)

For one thing the word “white” has no meaning and no real definition. As one young dinner guest pointed out recently, “I thought white was just what everybody aspired to be?”  That’s not an unfair summary of U.S. history. I still have a sign from Boston dated 1918 that says “No Irish Need Apply!” In some post-Civil War southern states hiring the :shanty” Irish was considered an nearly-acceptable alternative to owning the African-American slaves who no longer existed as slaves. Leasing convicts was about the only other option available.

And I’m used to hearing “Canuck” applied in various tones of voice to other branches of my family tree. And then there’s my great-great-grandmother, the Algonkin who married a French merchant in Quebec City, Canada. Not only did she gives up her native tongue when she married, she wore French clothes and spoke only French ‘til the day she died. How do I know? Because I was lucky enough to meet some of my great-parents when I was a child and heard stories told with some pride in her sacrifice but more embarrassment over her heritage. Only one picture (a portrait, a daguereotype?)
Existed of her because, as the family said in hushed tones, “She was a bit dark skinned, you know.”

In Canada today, which has First Nations terms not used in the U.S., I would be considered “Metis”. (Someday I’ll talk about Louis Real and the great Metis Uprising that actually got the Canadian Pacific Railroad the government funding it needed for compleion so the Royal Mounties could be speedily swept to central Canada to quell these uppity “savages.” The word Metis itself literally means mixed, but I was brought up to deck anyone who called me a “half-breed.”

And then there’s my grandfather Nikolai. I didn’t even find out his name until my father lie on his deathbed in 1995. You see, grandfather Nikolai had died in the War To End All Wars (WWI) and his memory was preserved by denying his heritage and pretending he was “Polish.” But when I worked in Poland in the 1980’s and tried to trace my family tree, my Polish friends sadly informed me that his last name was not Polish and most likely Russian. (And possibly not a “true” Russian, but a gypsy or worse yet, a Jew!) He had apparently passed for Polish when he immigrated to the U.S. because of all the languages he spoke. Lost in a semi-safe crowd at the height of the Cold War, he disappeared from family respect.

When I describe my childhood, I explain it was somewhat like the United Nations backstage, with everybody squabbling or ignoring each other in a multitude of mutually-unintelligible languages. God help the poor victim who married into the family from another background and was subject to the hostility vented on the “outsider.” My favorite maternal aunt was shunned from almost the whole family because she had the nerve to marry an “Eye-talian” whom she loved. Fortunately, he had a large family who took her in with adoration, she learned to be a great Italian cook, and they lived happily with their children for decades.

My poor mother was Irish & French-Canadian (both suspect) and was never considered to belong. Since the big goal of every immigrant to this country was to pass for Anglo-British, she bleached my fine baby hair to straw with undiluted peroxide, pinned it into painful Shirley Temple curls, and harshly slapped me or washed my mouth with soap if I dared picked up a word of the many languages spoken around me. I had to pass for “white”, as in WASP, which left a bad taste in my mouth forever after.

I was half-raised by my grandmother Mary Katherine Lynch from County Claire in Ireland, and thank God for her intervention and that of her large brood of my mother’s siblings. My ancestors sit beside me at every dinner table and I wouldn’t desecrate their lives by labeling myself “white,” a bland and vague word associated with white supremacy, the KKK, terror, and a general, overwhelming assumption of superiority and power, especially if they are male to boot!

In my teens I was “adopted” by Matchwaya Rom in New York City, and treated and taught as a daughter. I lived in Hawai’I and saw true pluralism in everyday life. I was befriended by a Japanese family who had lived through WWII, and knew how close they were to being interred in a U.S. concentration camp as an “not-white enemy.” In Nepal and India I was given a name and a caste (Matwali –that of Sherpas and foreign anthropologists) to bring me into the group, and in Haiti, my friends introduced me as their “cousine” and insisted joyfully that I must be part African.

I could go on and on, but the bottom line is that I have been naïve enough to be believe that E Pluribus Unum actually means “from the many to One”. I believe we are humans, and cannot see each other in groups of “us versus them.”

And the saddest thing to me is that we as a country cannot see Mr. Obama as our first truly “mixed” president because way too many people are so obsessed with just one strain of the many rich traditions and bloodlines that make him what he is: a man with just as rich a heritage as most of us have, more truly representative perhaps than any before him of the real population of this United States!

Does One Small Voice Really Matter?

Sunday, April 5th, 2009

I was at a disturbing dinner table conversation with a group of young people the other day. (“Young,” in this case, meaning 20’s through 30’s.) The topic came up of whether one person’s voice speaking out was of any value. And the shocking consensus of the young people at that table was a resounding “no!”

I admit to being an idealist. I admit to having a vested interest in the topic since I tend to risk my job, welfare, or life speaking out against what is wrong. The latest book I wrote is just a recent example. But to hear these young people dismiss even the voices of Gandhi or Martin Luther King or JFK as meaningless! I was overwhelmed.

One of them even said “There were others saying the same thing. Gandhi just added to his voice to theirs.” That may be true, I acknowledged. But what if he hadn’t spoken? What if Martin Luther King hadn’t spoken? Would the course of history have been the same? At sixty years old, I’ve heard these people speak or seen the direct effect of their voices. It made a tremendous difference to my heart, soul, and mind. How could they be dismissed so casually?

One of the people at the table had recently passed the Bar Exam and was looking forward to working for Legal Aid. I asked her directly if she wouldn’t be one small voice speaking out for those who couldn’t speak for themselves. “Of course not” was her reply. I wondered how many real courtrooms she had been in, when the accused was too overwhelmed or scared or uneducated to speak for themselves. What happens when your lawyer disparages the very role of being that one voice who will speak for you?

At one point I had to go outside for some fresh air. The truth was that there were tears in my eyes, and I didn’t want to spoil an otherwise social evening. But I was terribly bothered. If you don’t speak up when there is an injustice, how do you know someone else will? What if there are other minds thinking the same thing, but afraid to speak their thoughts out loud?

Should I demean the achievements of President Obama because he only said what other people had said? Or should I applaud him for taking a strong public stance and trying for the chance to do something about what he thought was wrong? I believe that “Yes we can!” echoed the sentiments of many people but I’m still going to give credit to the man who said those words out loud and often enough that something changed. I don’t know yet how much he can accomplish in respecting what’s right about this country and fixing what’s broken, but I hope everybody begins to say to themselves “Yes I can!” when faced with something that needs repair.

I don’t want to think that “one small voice” doesn’t matter because my experience has taught me that it does!

Do I wish I had a louder voice or a bigger audience? Of course I do! I don’t have the money or the celebrity status to automatically be heard. And approaches to Attorney Generals, Grand Juries, and state representatives have just resulted in form letters saying “we don’t investigate individual cases.” I don’t understand that. If you don’t start by investigating one case, then how do you ever find the pattern of wrongdoing? But I’m not going to stop whistleblowing. To be silent in the face of venom would be worse.

I think the problems I’m working to call attention to are serious ones. They require resources and power to fix that I just don’t have by myself. So I do what I can, speak up whenever I can, and try to find the resources that can (and have the guts to!) investigate and fix a broken system.

By the way, I have no grandiose illusions of being Gandhi or any of the inspiring people I mentioned. But they are my heroes and they taught me that the worst sin of all is to be silent when you see what is broken or wrong. Those who don’t speak up become accomplices in the evil, whether it happens in Nazi Germany or your local street. One small voice it may be but I’d rather be small than silent!