Friday, October 2, 2009

Random Thoughts re: Health Care Reform - 1

As one who began working in hospitals 61 years ago, the current national debate about “health care re-form” greatly interests me. Indeed, the public debate often replicates the inner debate which has engaged me for years. Those of us who have spent years involved in the care of the sick have long recognized that there were/are problems.
Certainly the lack of insurance has been, and remains, an issue.
Certainly the amount of reimbursement for services, as well as its tardiness, is an issue.
Certainly the many agents that come between patient and physician – be that agent an insurer or a government bureaucrat, is an increasing issue.
Certainly the vast disparities of qualities of care across our nation are an embarrassment.
Certainly . . . . well, you can insert your own list of problems.

One activity of my own inner debate would involve lengthy periods of time wrestling with the question:
If given unlimited power and money, what would I do to “fix” the system?
The time spent in that wrestling, over decades, has increased my understanding of (and sympathy for) those leaders who have, seemingly, been unable to develop their own fix! “Power” [such legislation, licensing, etc.] and “financing” will not solve our many problems involved in the care of the sick. Indeed, one is even able to make a strong argument that they are among the causes of the problems.

However, the over six decades of involvement with the care of the sick plus the hundreds of hours spent in internal debate on ways to improve such care have given me ideas which often seem not to receive sufficient consideration. Those ideas will be the focus of this presentation [and, subsequent ones].

A. What’s in a name?

Whenever I was involved in purchasing a house in which to live my realtors almost always gave the same advice – “Location, location, location!” Everything else desired to make the home a more desirable residence could be added or re-modeled. But – you could do nothing about ‘location’.

A similar mantra ought to be attached to attempts at “health care reform” – Diagnosis, diagnosis, diagnosis! Unless we properly diagnose the problem, no “cures” will work.

The first concern for diagnosis in this process we have labeled “health care reform” is that very name!

Up until the 1960s our major institutions for the care of the sick were known as hospitals. They were places of refuge to which the sick and infirm could retreat. They were places of hospitality, in which the sick could feel secure as s/he sought healing and restoration. They were places that had either been started by religious groups or by community governments in recognition of the moral imperative to care “for even the least among us”.

Gradually throughout the 1960s and into the 1970s these institutions began shifting away from being “hospitals” to be Medical Centers. Certainly there were reasons for such a shift. Services other than caring for the sick were initiated! Many of these represented different “costing centers”. And, quite frankly, “Medical Center” sounded more prestigious than “Hospital”.

Then, in the late 1970s and 1980s another shift in name occurred. “Medical Centers” became “Health Centers”. Proponents of a “wholistic” approach to the care of the sick [or is it “holistic”] often felt constrained by words such as “hospital” or “medical center”. But Health Center – now there is a theme around which we can all rally!

Ahh, but wait a moment stated many of those who cared for the sick! We take care of the “sick” – and there are years of experience that help define shat “sick” means. What, though, do you mean by “health”? The nurses and doctors and therapists and technicians are trained in caring for the sick – trained, licensed; accredited and experienced.

But there is almost no universal agreement on the definition for “health”! None. Nada.
One issue has to do with our understanding of what disease means.
- Is disease the result of forces external to the self? Bugs, Germs, Physical traumas.
- Is disease the response of the self to those external forces?
Another issue would involve problems of social or behavioral concerns:
- Are wrinkles in one’s skin a “health” issue?
- Are smaller breast sizes or erectile dysfunction “health” issues?
- Are arguments between spouses a “health” issue?
- Is depression a “health” issue or a natural response to loss?
Also, we have the issue of death!
- Is death the antithesis to health and to be fought at all cost?
- Is death the ultimate in the process of homeostasis – the “final” solution?
- Is the “naturalness” of death to be determined by age? I.Q.? Social status? Wealth?
- Is the “naturalness” of death to be determined by theologies? Is anything less than all-out treatment an abomination before God? Or, as an act of love for others should death be welcomed – even sought?

There are studies which suggest the need for adequate diagnosis also exists in treatment approaches. The reliance on technologies has greatly hampered the process of diagnosis because it almost solely only looks at externals. Decades ago the act of diagnosis involved anamnesis – “out of the memory”. Patients were asked to tell/narrate the story of their sickness – and, almost always, that story revealed important criteria for treatment:
- Placement of a cardiac stent was complemented with help with stress, diet, etc.
- High blood pressure also involved styles of living.
- Obesity was not just a consequence of food additives.
- Etc.

And, because my involvement in the care of the sick was as a response to my vocation, what of the religious factors in the care of the sick?
Factors that can be positive assets for health as well as factors that can mitigate against health?
Are there any “meanings” for sickness? [How often do religious folk exclaim that such and such is God’s will?]
Is the role of the religious institution limited to times when medicine cannot treat and/or death occurs?
How do the religious institutions foster “healthier” [or, less dangerous] activities?

This is enough for the first installment. Hopefully the 2nd will come shortly.