Archives for posts with tag: change

Given that many attempts to improve the US health care system have failed, what should be done next, and how can real change be achieved?

Read my piece on Medium.

We have lost so much in the past year. Some losses are obvious and concrete (voting without foreign interference; the freedom to pursue rigorous journalism; access to reproductive health; leaders who eschew corruption). Others, no less important, are more abstract, beliefs and hopes whose promise our country has never achieved: that any human deserves respect no matter what group she belongs to; that pluralism makes us stronger. But there’s much that is less tangible whose loss we haven’t realized. What if there are so many missing pieces to our imagined America that we are left with a vague sense of unrightness rather than a clear mark of absence?1_D1m2utm_oCFAhDmTLXLupA

New on Medium, my thoughts about the concept of yeush (despair) in Jewish law, and how it can help us figure out what to do with the losses of the Trump era.

Cross-posted to the blog at Talking To Your Doctor.

I am always interested in asking, “What questions should you have asked before….” And with the ellipsis I am talking about any health care situation. What questions should you have asked before you picked a doctor? chose a treatment? heard about your diagnosis? filled your prescription? discussed end-of-life care with your family member?

So what should you have known? What could you have done differently in the process of making decisions, advising, treating yourself or others, or just coping?

And, to take it a step farther, now that you have thought about what you should have asked differently, will that change what you do in the future? How are you going to make that change happen?

 

Cross-posted to the book blog.

A comment by a friend got me thinking. She mentioned that the constantly changing guidelines occasionally make her skeptical of medical advice.

It is true that guidelines change. By the same token, though, all knowledge changes. There are different ways to model the function of knowledge change. Are we asymptotically approaching truth? Does each generation of scientists invest in a new explanatory model, which is then discarded some time down the line in favor of another – a new paradigm, not necessarily closer to the truth? Or are scientists continually confronting new problems, with different narratives, so we’re not so much finding new answers as dealing with new questions?

All these possibilities apply to medicine. Guidelines for, say, the optimal control of blood pressure don’t change simply because we have a better idea of what the perfect blood pressure is. We have a different array of blood pressure treatments than we did just a few years ago; we have a different understanding of the relationship between systolic and diastolic blood pressure; we think a lot more about patient preferences than we did 10 or 20 years ago.

Where does this leave us? I hope not with widespread disillusionment that medicine, after all, does not inexorably march towards truth and health. Like any other empirical caravan, we trundle along for a while, get lost, find a new byway, and discover that we weren’t lost at all, and now we are in an even better place than we thought possible. Or we discover that the folks with us are not merely passengers along for the ride, but they know how to drive as well as we can.

When you hear about changing health care, you might be worried about a loss of stability. I would say that understanding the world requires constant change, in a world of flux.

 

I am a skeptic by nature. More often than not, however, skepticism has to be suspended to take good care of patients. Many is the time that a person has sworn up and down that they are ready to take the next step in behavioral change. For example, I am not a haranguer, but no matter how subtle I try to be, it’s rare for a patient not to pick up the very clear message that they should quit smoking. People have heard often enough that they should do so.

They come to my office with a natural instinct, to make me happy – and thus they tell me they are going to quit. Or if they aren’t really ready, they feel bad about saying it right out, so they don’t come to that statement right away but save it for later. If they tell me they are going to quit, though, I am duty bound by something older than the Hippocratic oath to say Yes you can! and support them. In other words, I must put aside my skepticism for a moment and believe in the possibility of change.

Then, of course, I realize time and again that I make mistakes in my practice. Despite the ever-present excuse of inertia, I need to believe that I can get better, as well as the system I am a part of. 

Believing in the possibility of my change can reinforce my optimism that my patients can change their own lives for the better, with my help.

 

Another problem with implementing healthcare standardization on a large scale is that there’s no possible way of judging empirically whether it will all work. (Standardization is the question here. Other issues are easier. For example, I think it’s uncontroversial at this point that expanding healthcare access will save lives.) Neither is there an experimental design which could test the question. We basically have to take it on faith that checklists will scale up to entire healthcare systems.

Is there a way to foresee problems when large systematic change like this is undertaken – in any field, not just medicine? I am asking you, dear readers, because it’s frankly something I haven’t looked into much. Did anyone say, wait a minute, we shouldn’t construct a huge network of interstate highways? Or: let’s think a minute before we build and test an atomic bomb?

There are instances where people did stand athwart history and yell  Stop. Iraq comes to mind. But political change, war and peace, seems different, more reactive, than systematic change which we try to initiate on an a priori basis.

Of course, I don’t think healthcare standardization is per se dangerous. I just think, per  my previous post, that much of what’s worthwhile in healthcare is not currently quantified. Not unquantifiable as I said before, but currently understudied. Do we know enough about what will be left behind if we move forward under our current, imperfect assumptions about quality?

Two movements approach change in Judaism in different ways. Orthodoxy constructs a myth according to which change does not occur, at least consciously, in the halachic process. It is imposed from without, sure, by social forces and non-Jewish perfidy, but never by poskim themselves for the purpose of change itself. 

Conservative Judaism claims that they have the steering wheel of halachic change in their hands and turn it only when moral considerations become urgent and primary. The Bandaid must be ripped off at some point when the gap between moral reality and halachic text becomes too great to bear. This is painful, as can be seen from this teshuvah, where – even in egalitarian synagogues – the number of women wearing tallis and tefillin are few and far between. A halachic change was made for moral reasons, and it was painful but necessary.

Orthodoxy deals pain, too, but in a different way – to classes of people excluded from the halachic process. People change faster than Orthodox halachah. Gays and lesbians and women are two obvious groups that are considered only very slowly.

Pain is part of life, and I don’t think either of these groups has a monopoly on it, or – conversely – a magic formula to avoid it. You pays your synagogue dues and you takes your choice.