January 16, 2014

Where’s the better medicine that would make all of us all healthier, without miracle surgery?

The Rise of Modern Medicine

braunwaldIn the annals of Boston medicine two historic chapters in the last 50 years were the near conquest of sudden death by heart attack and (not unrelated) the rise of corporate, cathedral hospitals around the practice of heroic scientific medicine with a big arsenal of new drugs, surgical measures, bypasses, catheters and stents.

All this is the stuff of our guest Dr. Tom Lee’s biography of a giant cardiologist and an expanding industry in Boston. His book is Eugene Braunwald and the Rise of Modern Medicine, a complex and fascinating tale. Don Berwick – a doctor who’s running for governor — is covering the downsides all around this story: overtreatment for some, undertreatment for many, intrusions of finance and breakdowns in the humanity of doctoring, and of course gigantic expense.

We’re talking this hour about Boston’s bluest of blue-chip industries, medicine, in a prosperous maybe triumphant time that may also be the moment for rethinking and reform. Dr. Braunwald and Nobel Prize winner Bernard Lown make cameo appearances — drawn from longer podcast visits with each of them. Perhaps the core question is: where’s the better medicine that would make all of us all healthier, even without miracle surgery?

Guest List
Dr. Tom Lee

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  • Ley Westcott

    I think, unfortunately, in large measure the latter. We are all caught within “a system” – an economic one – which largely determines models based on economics. It is my observation that economics does not dictate good science or health care, though prudent, competitive economic policy is essential to a thriving society. Generally speaking, our diet is bad and so is our health as a nation. Among the worst in the world among developed nations — for the wealthiest nation the world has ever known. How does that happen? Our medical technology is the most advanced in the world so emergency-intervention medicine is the best, cutting-edge technology (and its economics) driving that. But, unfortunately, at the cost of high-quality preventive, optimal health care. The two appear unable to coexist in our present health care/economic model. Competition – the struggle for resources/funding dollars – determines what gets acknowledged/funded and Big Pharma/surgical and other medical technologies are what largely fund medical schools, so that is what doctors learn. And these technologies are life-saving and invaluable. But if to the exclusion of good health knowledge/practice then we are creating a sick nation in order to artificially keep its diseased individuals alive. Many vital, life-saving technologies are available, have demonstrable benefit, yet are virtually unknown. Two, Frequency Specific Microcurrent and PEMFs (Pulsed Electromagnetic Fields), have been used successfully for years yet are largely unknown to doctors and patients in the U.S. Columbia University Orthopedics, NYC, under Andrew Bassett, MD, have since 1983 used Microcurrent to heal non-union bone fractures, which, failing to join, would otherwise require amputation of the affected limb. If the bone cannot join, the essential integrated life physiology of the body-limb cannot be maintained and the limb dies. These two technologies are predicated on electromagnetism — a natural force of Nature that drives biochemistry/physiology, allows life as we know it. Doctors learn this in medical school and then forget it. Most, that is. These technologies benefit wide-ranging physiological issues, including optimizing brain and other organ function. Yet technologies based on what we have learned since James Clerk Maxwell unified electricity and magnetism have been disparaged, disregarded. These technologies are FDA-approved for relief of intractable pain yet are routinely DENIED by health insurance companies. Yet these same companies will cover a 60-yr. old TENS (Trans-Electrical-Neural-Stimulation) technology that is completely ineffective for severe, intractable pain. Why? Economics, I suspect, the insurance companies likely owning or having interest in these older technology companies. While older TENS technology provides pain-relief for moderate pain to many, it does not facilitate the body’s regenerative healing capacity. It is thought Microcurrent and PEMFs do. With such powerful technology already benefiting those who have discovered it, we need research to establish how it accomplishes this and to make it known and available to all. At present, the FDA approves these technologies only for Pain relief and they are not, to my knowledge, being researched to the degree they need to be, though NIH is aware of them and NASA conducted an extensive in-vitro research study into PEMFs that indicated their regenerative efficacy for neurons.
    So, no surprise, in a competitive evolution, there is competition in ideas, technologies — and yes, health care technologies. Doctors, guardians of our health, need to take back control of health care. And as patients, so do we, though it be a formidable challenge. As ever, good journalism, such as Open Source, remains an essential component of a free and informed citizenry.

  • Drego

    No discussion of modern medicine can ignore the growing influence of nutrition in health and disease. With the help of the web, low carb high fat diets have spread, and with pretty significant results. So much so that clinicians are now now using them to treat patients for diseases like heart disease and diabetes. LCHF diets are not at all new, older research has documented the decline in health among aboriginal peoples when they switch to a Western Diet, see Otto Schaeffer, and Weston Price’s work on this. Price went around the world and photographed kids in same family, the difference in diet between the older kids and younger kids was that younger kids in the photos need braces and have significant dental problems. The difference is the diet. No orthodontist wants to hear that if you don’t feed your kid Fruit Loops they’ll never need his services.

    There are extensive blogs run by doctors and clinical trials under way now to support broad dietary changes, but there is one thing wesay can for sure: the high carb, low fat, high sugar diet is killing us. Go back to the beginning of this advice in the mid-1970s and then look at the CDC graph for the rise in obesity and diabetes; they correlate very well. The problem is no one makes a dime off of telling folks what not to eat. Even with medicare about to be bust by 2050 (see Lustig) we still have not stressed prevention as much as we should.

    The literature is robust, extensive, and crosses a few disciplines. Any good show/series-in my opinion- would feature these people:

    Steven Phinney M.D-Low Carb Diets
    Gary Taubes-Low Carb researcher and nutrition historian
    Loren Cordain P.h.D, Paleo Diet researcher
    Mary Vernon M.D bariatrician and low carb Dr.
    Rober Lustig M.D. endocrinologist, and clinician, sugar researcher
    Kimber Stanhope M.D. sugar researcher
    Lynda Frasetto M.D. has used paleo diet in clinical settings with good results.
    T. Colin Campbell Ph.D, author of The China Study, a bible of the vegan/vegetarian movement, even though many assert this study has been debunked.

    William Davis M.D., cardiologist, author of Wheat Belly

    Richard Bernstein M.D., has been treating diabetics with low carb diet for 40 years.

    • Drego–I agree with your perspective. Most of the patients I see every day have chronic diseases caused by eating the Standard American Diet. There is no pill out there that rivals the benefits of eating a healthy diet and exercising on a regular basis, yet the medical profession tends to largely ignore this approach in favor of loading people up on drugs.

  • Steev

    I’ve been in the healthcare business for 25 years as a sales representative. The buildings keep getting bigger, the administrations more dense, the regulation more arcane…There is so much money thrown at healthcare; how could this NOT happen? In a land that considers itself an uber nation we find ourselves >30% “clinically obese”. To solve this obesity we do SURGERY.
    It goes beyond the system itself; it goes to how we live. An insane medical system is a reflection of our society.

    Now, ultimately our medical system is socialized. This has grave social precedent. This has been done before…

  • Kathleen

    My elderly father has been seeing doctors at the same healthcare conglomerate for years. Now at 93, he’s really housebound — unable to get out. And he’s in need of so little: someone to check his feet, someone to update medicines. But since he can’t get to see them, he’s no longer their patient. I am astounded. How much would it cost this ‘system’ to have a nurse practitioner or a young doctor go out to visit people like my father?

  • Patsy

    Don Berwick will bring a lot — his lot — of thoughtfulness to this conversation. Can’t wait! More later.

  • marilyn bentov

    The most significant statement on this program came from Dr. Bernard Lown, who learned, years ago, that a doctor’s words can kill, and they can also heal. We now know that the most important aspect of patient care is the doctor-patient relationship, one in which the manner and words of the doctor have huge potency in the healing process.

    But the 15-20 minute time slot for patients, which sends most doctors scurrying from patient to patient, with no time to talk or review the patient record before the appointment, turns doctors into technicians. My PCP, a marvelous MD, whom I saw for 13 years, just left the HMO where i got my health care, taking a cut in salary, because, as she said, the system was too big for her to practice medicine as she hoped when she trained for the profession. Where did she go? From Wellesley to Roxbury, to work with a group of doctors where, “I can help an underserved population.” I mourn having lost her, and i envy her new patients. Where else will i find an MD who took the time to call me on weekends or at night to give me the result of a significant test or to ask how a particular treatment worked out? As an aging person managing everything on my own, losing such an MD is huge.

    A few years ago, I had a pneumonia that hospitalized me, and was given antibiotics that saved me, but also gave me atrial fibrillation. I was barely home when the HMO anti-coagulation unit wrote and called me, several times, and tried to impress on me that i must come in IMMEDIATELY to begin treatment with the anti-coagulant, coumadin. It is actually the law to so advise a patient with a-fib; but it’s not the law to pressure a person who decided to wait and see. For several reasons, and having read up on health care developments, treatments, etc. most of my adult life, I decided to wait and see.

    I consulted the HMO cardiologist about an alternative medication, which has been on the market for only 3 years, and was already having a significant number of serious side effects. The MD, knowing my concern re coumadin, advised the alternative and told me to come back IN A YEAR! After some searching, I found a cardiologist at Tufts Medical Center who, when he met me, sat down with his back to the computer and said: “I want to hear your story. The computer can wait.” (I was almost shocked!) We talked for nearly an hour at the end of which he said: “I give my patients my findings, my opinion, and all the information they should have . They must decide what to do; it’s their health.”

    When i have a question, or questions, i email this cardiologist, who answers within hours. Recently i had a stress test for possible angina. Two hours later, when i was home, I opened my email, and the first was a congratulatory note from the cardiologist
    that began “Thank God!”

    This is the practice of the art of medicine.

    There’s so much I could write about, but i just wanted to write about the significance of what Christopher Lydon stressed on the program: the heart, and, indeed, the art of medical practice, which has been lost to greed and technological over-reach–a kind of obesity of the medical field.

    One last point re pharmaceutical companies and their role in the cost fo health care, and the priorities set for research into effective medications.
    I’m losing my vision to severe glaucoma, which yields trillions for the pharmaceutical companies that charge wild prices for topical drops designed to bring down pressures that weaken the optic nerve. Very little research is being done on glaucoma, which is caused by multiple factors; reduction of pressure on the optic nerve treats the symptom, not the cause. In my case, the treatment has slowed down the progression, but is now essentially futile. The pressure is definitely reduced by the medication, but the visual field test, not to mention my own eyes, shows continual loss of vision. (I’ve also had 3 surgeries that reduced pressure for a while, but the loss of vision continued,)

    So I see the opthamologist every 3 months, who checks my pressure and the health of my eyes, and would love to do something to stop the vision loss, but that’s the end of the road. It’s certainly an example of repeating and repeating the same thing and getting the same results, which are not the ones you want. So who’s crazy here?

    As for the pharmaceutical companies, whose cost per oz. of glaucoma medications is less than a dollar, as good, ;aw abiding corporations, why would they fund significant research when an ounce of a non-generic medication can cost the patient over $200? I need glaucoma drops without a preservative, to which i’m allergic. The brand i need costs, with Medicare part D insurance coverage, $73 for a 9 day supply. That’s almost $300 per month!

    And so it goes. The problems of American health care are an illustration of the diseased heart of the American economy, one that supports industries that grow fat with wealth, but not a glance back, a compassionate glance, at the harm and even destruction it continues to cause, wherever you look.

  • A. David Wunsch

    I listened to the show and grew impatient with the constant reminders that doctors should take time to listen to their patients. Everyone knows this. I used to see a primary care doctor affiliated with Mt. Auburn Hospital in Cambridge. Whenever I tried to speak to him beyond the 12 minutes that he had allotted me, he would cut me short and say “I have 10 people in the waiting room who I have to see after you.” Indeed, his waiting room was crowded. A doctor who books fewer patients will make less money . There is an inherent conflict of interest. Moreover, primary care doctors are not especially well paid, compared to specialists, so there is no inducement for them to “take time and listen.”

    The show seemed to lack substance and a sense of political reality. Sure, a single payer plan makes sense but in the United States it’s seen as (help!) dreaded socialism– something they might have in a country like France or England where, strange to say, life expectancy is longer than in the US.

  • Robert Zucchi

    What a lucid exposition of of the past and future of medical science and its economics. Thank you, Christopher and participants.

    Our family doctor when I was a child in the 1940s was a superb diagnostician. Fortunately, our various maladies mostly lay within the ambit of his training and the contemporary state of the medical arts. Dr. W. exuded proficiency, which even more than a solicitous bedside manner inspired us to trust in him.

    Climbing the stairs to his office with today sensibilities, though, would provoke to doubt. The stairs were worn and they creaked. The waiting room, though clean, was furnished in what we might call paleo thrift store. The only personal touch was the doctor’s initials inlaid in the worn linoleum. The consulting office was no more opulent.

    I think it was Madonna who was having a baby years ago, and declined to deliver in Britain because the hospitals looked derelict to her American eyes. I imagine a lot of Americans today would have the same reaction, so accustomed are we to the sprawling Bunchadocs LLC medical campus. But the cost to build and maintain these monstrosities is surely part of financial burden besetting all the stakeholders in our health system today. As is the zeal to qualify these medical-industrial complexes to provide the most lucrative procedures, sometimes with minimal attention paid to the community’s demographics and the actual health needs implicit in them.

    Another problem today is that fee-for-service medicine is necessarily subject to the unforgiving ravages of capitalist inflation. In order to preserve income levels, physicians adopted the ten-minute OV, which is often more punishing for them than it is for the patients. The delegation of duties to nurse practitioners and other subordinate medicos does not seem to have slowed costs (I speak as one who had as a client an NP who earned north of $100k…at a VA hospital…for duties she claimed were not too strenuous. Probably she was being modest).

    Other advanced nations have worked out that a national health scheme, like national defense, needs to be social and not private if it is to be comprehensive and fiscally accountable. A tall order for the USA, a country that regularly prostrates itself in demonstration that it has the sense of common purpose of a termite colony.

  • Thank you for your program and the topic. I caught about the last 15 minutes of the program. I appreciated the show and Ley Westcott and David’ Wunsch’s comments caught my attention. I couldn’t agree with them more.

    I’d like to offer a great quote by Albert Einstein, “You cannot solve a problem with the same consciousness that created it. You must stand on a higher ground.” I would add to this quote, “You cannot solve a problem with the same consciousness and heart that created it. You must expand your heart.

    I don’t know if healthcare disparities was also brought up in the discussion. The Institution of Medicine created a landmark report in 2002 called Unequal Treatment.
    The Kellogg Foundation released a report that in the fall of 2013 the Kellogg Foundation released a report outlining the economic impact of racism in our country and underscored the impact it’s having in healthcare, “disparities in health alone are costing the U.S. $82 billion per year in excess medical costs and lost productivity, the message is clear: our future depends on racial equity.”

    We need to focus on the question of how we can create a nation where all people can be healthy. We need to create business models that rewards and empowers people to be healthy.

    If our healthcare system continues to be driven by profit and not by a mission, a vision focused on the health and well being of all people we will continue to create a system that put profits first and patients are just a means to making a profit.

    Thank you again for the discussion. I hope that it inspires change in the healthcare system.

  • mary

    Our show highlighted the lede story in the New York Times yesterday – about the bloat in the medical industrial complex coming in part from the soaring incomes of specialists and the epidemic of biopsies, treatments and procedures they’re prescribing. And it’s not just the fees for those services they’re cashing in on; many are investors in the labs, the surgical and ambulatory centers and physical therapy offices that provide the services!

  • Potter

    I was remembering back to the 1950’s, in NYC, my uncle had “terminal” cancer. He was in his 40’s just home from the war a few years and now had young children.There was nothing that the New York doctors could do for him anymore. And so we saw my aunt in her desperation take him off to Boston in a wheelchair to see the big doctors. That was my awakening about medicine in Boston.

    But from this show, the history told, it seems it was war, the torn bodies on the field and coming home, that helped make modern medicine what it is today, right up to the Boston Marathon. The great advances by those audacious doctors came as they were standing on the shoulders of the others before them. The horrors I can’t imagine that they saw and went through trying to mend broken bodies.

    We have been very fortunate with the medical care that we have received here in Boston. My young Dr. does not any longer push me out in 15 minutes waiting to get to the next patient; she listens and chats with me for however long I need. We are a team regarding my healthcare. She does not send me to a specialist right away. This kind of care should be available to everyone regardless of ability to pay.

    As was said, there is too much profit making in healthcare if there needs to be any at all. A month ago the NYTimes had another article about the overuse of ADD drugs in children. The article said that it is estimated that about 5% of children may perhaps actually need medication but about 15% are on it!!

    The Selling of Attention Deficit Disorder

    I am glad you mentioned Atul Gawande. And thanks also for the quote you pulled out of your hat from Henry James: “Do go to Venice!”- advice to allow oneself space to heal, and to raise the spirit.

    The guests were all wonderful. Thank you.

  • The Parrot

    Thank you Chris, Dr. Lee, Dr. Berwick, and Dr. Lown for an excellent discussion. A much wiser conversation than most I’ve heard on this matter. Yet, it still falls somewhat short in the sense that the force of economics, and implicitly, actuarial and statistical techniques, are still calling the tune (– see below). It is probably no accident that we have two human focused systems, medicine and actuarial practice, meet and turn into a monstrosity we call, managed health care. A marriage of sorts, I suppose, since both fields use statistics, probability, measurement, analysis and interpretation, and data collection as a normal course of activity. Yes, it must be a logical marriage that brings medical institutions and actuarial institutions together into a enterprise where health and biology become a secondary concern.

    That is to stay, the stench of “no margin, no mission” is a miasma which permeates as a core feature of the delivery of health care. We seem to be having trouble finding our way out of it. If you really want to understand the tone-deaf nature of medical care, go visit a an army of discharge nurses and administrators, and bring them into the discussion. Listen closely. “No margin, no mission” is the overriding criterion, not patient need. Actuarial order is the rule of the day. And like all human creations, it becomes the proverbial hammer that sees only nails.

    I’m merely a lay-person, but I feel the necessity to offer my $0.02 on this matter; after all, it’s a concern for all of us. For what follows, Chris and Mary, accept my apology for its length. My old bottles hold new wine. What can I say? I needs to type and post. Since this thread appears to be fairly quiescent, it shouldn’t bother anyone. Best regards to ROS… let’s proceed with the typing.

    First a show suggestion: I would like to hear a discussion about health care policy (i.e. the PPACA) and how the public accorded itself, and continues to accord itself in this matter. Who would participate in such a discussion? I have no idea. But please, not the usual blow-hards we have heard from and continue to hear from (present company excluded). They offer nothing but their incompetence and venal desires. ‘They’ helped create the bog the rest of us struggle with. Since Massachusetts is ground zero for such matters, perhaps a local discussion which focuses NOT! on implementation, but how the discourse evolved, and what stakeholders were included in the conversation. You could move from there to a more general national discussion regarding how the PPACA was dealt with in the public forums.

    My general thesis regarding the current problem: we frame a matter of biology using the tools of economics. An obvious mismatch. Absent miracles and panaceas, one should expect continual cracks in the coverage system. Allow me to provide a very simple actual situation, showing one of many flaws in the health care service sector: dental & vision should be included in all health care plans. There’s a biological imperative here. Dental and vision are inclusive, and not exclusive to overall health. My family went through the federal exchange. Dental & vision (for adults) do not qualify as a basic service, nor for subsidy in separate plans (at least in my state). The premiums and deductibles are expensive, and these plans (D&V) cover very little beyond modest services (basically junk policies). Any plan less than a ‘gold’ plan seem to partition these services into the category of ‘bolt-on’ or extraneous services (also, prevention, pharmacological, mental health, various therapy needs, in-network, outside-network, etc. are partitioned up as well, but these areas are integrated to some extent into these plans with varying price points and options).

    Too bad our biology doesn’t work the same way insurer business models work. That is, too bad for our biology. Works out well for insurer business models. It would appear to the untrained eye, ear, and mind that our health care delivery system is directly and conditionally coupled to and hobbled by lobbying dollars and corporate concern (i.e. corporate speech).

    Now to the crux: we have been missing an authentic dialog: this country, my country of origin, continues to frame an issue of biological necessity (i.e. maintaining individual and collective equilibrium; a public and epidemiological health concern) not around biology, but around a model of economics (i.e. ROI, revenue generation, cost and risk management, quarterly myopia, etc.). Politically, one side wants to shower dollars upon the problem, the other impose austerity law-of-the-jungle methods. Unfortunately, I, and members of my family, are biological beings not incarnated by nor composed of economic units. The mismatch has been, and will continue to be, catastrophic towards decline and partial or total collapse for both our collective and individual biology, as well as, our economic practices.

    Who controls the dialog thus far? The opinion, pundit, political, and policy wonk class, all owned to varying degrees by corporate interests. This class continues to frame health issues around economic units as omni-dictate. I suspect there is little to any coercion in this framing. I once heard an NPR reporter express the following: their listening audience wasn’t sophisticated or educated enough to understand the complexity and nuance involved in health care policy. Thus, complexity and nuance had to be drained from the reporting (i.e. dumbed down to the spectacle of town hall shouting level, or a parade of droning policy wonks and pundits arguing over cost containment and risk management). It seemed a discussion of biology and health was an extravagance they couldn’t afford. I’m not suggesting NPR is the problem, they simply gave voice to what was obviously occurring across a wide, diffuse media landscape. Just as the terms of war are dictated by the pentagon and the political class (e.g. collateral damage, war on terror, etc.), the terms for policy discussion are internalized and parroted without resistance. The terms are economic, not biological or medical. The issue: who gets the bill. Though, no serious discussion about how much the bill should be nor how such costs should be arrived upon. Telling.

    The mediator class which holds sway over a diffuse media landscape has simply internalized a framework through a lifetime of social conditioning, which essentially requires blind obedience to corporate interests and apathy or indifference to other concerns. Corporate concerns are paramount, all other concern is an externality. And corporate interest can be viewed as nearly seamless to political interests. Thus, those who own the discussion in the public and private forums of record, end up performing as mouth-pieces and spear-carriers for a corporate-state super structure. A structure which is concerned with power and profit, and not serving the needs of those for whom they empowered to govern and serve. A furtherance of rule-by-fiat, not govern-as-partner

    This will certainly continue as long as we allow ourselves to be treated as ‘consumers’ (a herd with few rights and privileges and no responsibility beyond feeding an inexhaustible appetite) and not as citizens (the invisible branch of self-governance where rights, privileges, and responsibilities must be accorded and earned). Consumers are an exploitable resource to tap into or drain from upon demand. Citizens are partners for governance and service, and require a give-and-take interaction based upon mutual interest and concern. Consumers are neo-feudal serfs and sharecroppers who are ruled by the lords of the manor. Citizens are governed by consent, and hold final authority regarding checks-and-balance. Consumers cannot be expected to hold a thought in their head for very long, let alone participate in a rational conversation. Citizens are required to throw their energy into a protracted effort, by negotiating and articulating their view-point with the same tireless redundancy that brand-makers use, but without the hollowing-out effect that brand making requires.

    It’s fairly clear the conversation (a multi-voiced monologue among vested entities) has been hijacked to serve corporate political interest. The why is clear. It’s the how that’s interesting: the citizenry, behaving as a consumer demographic, has allowed it to happen without demanding a different conversation. I suppose we too have internalized the social conditioning. That said, it is interesting that those who control the conversation (or monologue) have nothing to do with the delivery of care. It’s fairly easy to identify the mismatch: when you, or someone nearby or close to you, requires medical services, (say for influenza, cardiac or stroke events, cancer treatments, etc.) who do you call upon for assistance? Do you call your HMO? HMO executive teams? HMO Board of Directors? HMO Shareholders? An actuary? An economist? Labor leaders? HR staff? Media pundit? Congressperson? Supreme Court Justice? President? Policy wonk? Brookings Institute? CATO Institute? Grover Norquist? George Soros? The Koch brothers? David Geffen? The Kaiser Family Foundation?

    For me, the answer is I don’t call upon these folks. And though most of these entities are unqualified to deal with health issues, they exercise a ridiculous measure of control over the conversation. When I have a health related issue, I call upon medical practitioners and staff. I call upon the healer class (or my own internal resources). I expect them to communicate to me where things stand and what the options are. They attend to health care and assist in maintaining equilibrium, usually to the best of their abilities and understanding.

    It seems to me therefore, we have a disconnect. A disconnect between players in the discourse, and players in the practice. This suggests that the discourse is twisted and distorted by power interests. The discourse is framed around economic and political policy, and not those areas of epistemology with a biological orientation (or those domains which emerge out of human biology). Economic and political hegemony have taken over (game over folks? probably), and their interests are served by quashing and reducing the citizenry to a directionless consumer mob. These hegemonies have no interest in ceding their position.

    Some elementary questions arise: why are issues such as health and the delivery of care managed in the public and private forums by those with no other interest other than power and profit? Why do we allow hegemonic encroachments into arenas where those entities have no expertise or interest or concern other than asserting their power prerogative? Enabled by a media conduit. Why are the specialist classes largely silent? And trained to be so. Scientific, technical, medical, and engineering training must be bereft in policy training, for they are usually silent when speaking up about public policy; apparently a matter of non-concern from their perspective. Or perhaps, they are excluded from participation. The professional class, in this case, the medical practitioner and research class, is seen as treating public participation with indifference, as an afterthought, or as a matter best left to those trained in ethical posturing, persuasion, coercion, and manipulation. Or perhaps, the specialists are too busy attending to the day-in-day-out practice of medicine, and cannot allocate the resources of time and energy to the conversation. Great demands have been placed upon them.

    I would suggest that part of any professional training, where interaction and engagement are required with the general public, that this training make communication, and its scheduling and management, be required as an additional core competency. This would obviously dictate a team effort view on such matters. Thus, coordination needs to be baked into student training. Not all professions need this. But in areas where public interaction is wide and deep, technical and scientific competence demands communication and goodwill. Communication must be treated with the same necessity as any other professional practice. Otherwise, such professions will place their fate to suffer in the hands of others. Of course, the market doesn’t require nor reward such competence. In fact, it would tend to punish it. Market concerns are by nature opaque and non-transparent. Information is seen as a proprietary concern. A fungible asset meant to be weaponized for position against competition. Another mismatch arises.

    Thus, medical practitioners have attached themselves to health management organizations and hospital administration monstrosities. Now, they suffer the stigma and association of participating in a system where in some instances patients have historically been left to fend for themselves. It’s still a recent history when policy dollars can be exhausted (caps) or pre-existing conditions used to deny economic assistance for the care patient need. Patients, that is policy holders and payers in good standing, have been given death sentences or debilitating outcomes due to these industry practices; aided and abetted by medical practitioners. Furthermore, therapies and regimes can be dictated by cost and profit criteria by insurers or manipulated by product makers

    It would be bone-headed wrong to lay the current health care morass and problems at the feet of doctors and other health care practitioners, or corporate opportunists searching for profit. The system of managed care didn’t get all boogered up on its own. It had our permission. The consumer class. We allowed a monster to be created that was supposed to serve us. The loss or debilitation of life, the financial ruin suffered by those struggling for survival due to corporate and medical malfeasance rests upon all our shoulders. One would think, given that all our interests are involved, that we would give a damn about such matters, and participate as citizens and not as a spectator consumer class.

    In Malcolm Gladwell’s book “Outliers: The Story of Success” the book leads off with a section titled “The Roseto Mystery.” It centers on the health history of a community of people who have immigrated from Italy to the United States. The overall health of this community can be summed up in two sentences: “These people were dying of old age. That’s it.” I suggest its reading to both medical practitioners and laypeople alike.

    I cannot verify the veracity of Mr. Gladwell’s examination and claims. Regardless, it does suggest something I find very important. It suggests that health and its care go well beyond the physical and material wealth or scarcity we experience. Thus health is a community concern, not an economic profit center. IMO, the tragedy of the health care discussion is not merely it’s focus on the “no margin, no mission” zeitgeist. Or the unstated, yet underlying monster of actuarial and statistical practices. But, that we as a community have lost our way in caring for each other in ways that far surpass what medical practitioners and researchers are able to provide.

    We’ve lost equilibrium. It’s clear in the discussion itself. A spectacle managed by vested interest have assisted us in avoiding a substantial collective huddle up to decide the what, the why, the who, the where in regards to our care, and how to proceed in its practice. This is not a small discussion that goes away after five minutes of contemplation and conversation. This has so far been a missed opportunity. In short, we’ve lost an opportunity for self determination, both collectively and individually. The very cornerstone of democracy has been usurped by the specter of its death knell once again.