4 May 2018

Dear Interested Reader


Michelle Wolf Did Not Bring Up Healthcare, But She Did Start A Conversation

Well actually, Ms.Wolf sort of brought up healthcare. The last sentence of her performance did express serious health concerns, as noted in an editorial in the Boston Globe. The last line of her monologue was “Flint still doesn’t have clean water”. There are still children and adults in Flint, Michigan who are experiencing the ravages of lead poisoning or are still at risk. The whole saga of how the water of Flint became undrinkable is not over and it is far from adequately processed to prevent something similar from occurring elsewhere. Most of us have moved on and the issue has drifted off out list of concerns, if it ever was on our list. In a way it is like a mass shooting. The water in Flint is just another inconvenient reminder of our national inability to show the same concern for the members of a disadvantaged population, or the victims of the opioid epidemic as we can muster for the concerns about taxes or the right to bear arms.

There is a passage in Hillary Clinton’s book, What Happened, which I am now reading, where she is reflecting on the vulnerability of any “entitlement” program that tries to address a need of a disadvantaged population. She notes that a program like free tuition to college is much more likely to become part of the fabric of our permanent and accepted entitlements if it is beneficial to everyone. As long as programs are just relief for the poor, or are an expense in the budget targeted for a low income group, they are vulnerable. It is good to keep this in mind as we think about how we structure access to healthcare.

What seems particularly illogical is where a program or government regulation should protect us all such as regulations around the environment we share. It is ironic that it was Richard Nixon who gave us the EPA and our first laws to protect the environment. Nixon supported the idea that we all should be “entitled” to clean air to breathe and clean water to drink, just as long as those policies did not harm the economy, but that entitlement to clean air and water does not seem to apply to Flint and the other zip codes where those who have less are corralled in ghettos by economics. Michelle Wolf closed her controversial monologue by reminding us of that uncomfortable fact. She should have known that no one likes people who make them uncomfortable.

Tuesday morning was dreary. The sun was not scheduled to come out until the afternoon. My wife and I were spending the morning reading the newspapers which were continuing to offer opinions pro and con about Michelle Wolf’s comedic performance at the annual White House Correspondents’ Dinner last Saturday night. We had tired to watch the YouTube clip of her twenty minute performance on Sunday but we were interrupted by a phone call and never finished. Based on all the flap in the media and after reading the comments in the Globe about Flint, we decided that to be informed we should try again to hear for ourselves what Michelle had really said. To our delight we discovered the entirety of the dinner was available “on demand” on MSNBC. They had covered the event like a playoff game or a political convention.

One of the nice things about retirement is that you can spend two hours midday midweek watching the rerun of a news program. The MSNBC commentators added substantial perspective to the presentation of the whole evening. They presented flashbacks to previous dinners with presidents like Clinton, George W. Bush, and Obama. They showed clips from the famous 2011 dinner that Trump attended. There were some pretty nasty barbs hurled Trump’s way that night by Seth Meyers and Obama, and some speculate that it was on that evening that he resolved to run for president as revenge. There were reviews of the performances of Stephen Colbert, Seth Meyers, and Hasan Minhaj.

In the first few minutes after Wolf’s startling presentation the MSNBC commentators were stunned. Many people, including some of them, had misheard Wolf’s comments about press secretary Sarah Huckabee Sanders. Many heard “fat” when in fact when one listens again and considers the whole sentence it is clear that Wolf said “fact” and not “fat.” She was commenting on the press secretary’s treatment of facts and the truth, and was not committing in a belittling way on her habitus. It was a comment that was meant to bite, but it was not profane and well within the range of normal for any of the contrived events where politicians and journalists get together to tell jokes about one another.

By this time almost all working comedians, including Stephen Colbert, Seth Meyers, Dave Chappelle, Jimmy Kimmel, and Trevor Noah have come to Wolf’s defense. I particularly enjoyed the comments of Tina Fey in the Washington Post. She was pushing back on negative, defensive comments from the Correspondents Association, perhaps made to ingratiate themselves with those they cover. Fey suggested that if the correspondents did not like Wolf’s presentation, next year they should “hire a children’s choir” as their program.

Fey’s comments were an answer to the “this is not what we thought she would do” generalized twitter apologies of many members of the press and of the president of the White House Correspondents’ Association, Margaret Talev, who seems to have been upset when she said:

"Last night's program was meant to offer a unifying message about our common commitment to a vigorous and free press while honoring civility, great reporting and scholarship winners, not to divide people..."

That was a noble objective that we should applaud, but Wolf went further and used the moment as much to lapoon the press as she did the entourage of the Trump administration. Trump and Company have been getting it full bore from comedians from before he was elected. It would have been hard for Wolf to trump things already said about Trump and Company by other practitioners of the comedy trade. It has been said that comedians are doing a better job commenting on the administrations performance than journalists.

Some say the press “invented” Trump, perhaps they mean in the same way Trump said Obama invented ISIS. In her book, Hillary Clinton spends a lot of time making a case against the press for her loss. She describes in great detail how Matt Lauer attacked her and fawned to Trump in a head to head program that was meant to examine what the candidates knew about foreign affairs. She presents data to support her argument about the uneven treatment in the press that favored Trump over her. Trump himself brags about all the free publicity he got from the press.

Perhaps suddenly coming to the defense of Sarah Huckabee Sanders is more comfortable than complaining about the guest speaker calling out her hosts. Wolf made many in the room squirm when she looked them straight in the eye and said:

"He couldn't sell steaks or vodka or water or college or ties or Eric. But he has helped you," she said. "He's helped you sell your papers and your books and your TV. You helped create this monster, and now you're profiting off of him."

Ouch! That line did not get many laughs. It looked like the audience took it as it should have, as an accusation. In The New Yorker blog Masha Gessen put the evening into perspective:

On Saturday, the comedian Michelle Wolf, performing at the annual White House Correspondents’ Association dinner, delivered the most consequential monologue so far of the Donald Trump era...Wolf’s monologue—sharp, unflinching, and pointedly unfunny in places—called bullshit on the role laughter has been performing in Trump’s America. Over the last year and a half, much of the culture has sought relief in humor in much the same way as citizens of extremely repressive countries. Back in the early nineties, in her book “How We Survived Communism and Even Laughed,” the Croatian writer Slavenka Drakulić described laughter as the ultimate personal triumph over the daily humiliations of life under Communist rule...

She documented how making fun of the leader and the situation is often the only defense of those who live under an authoritarian regime. There is no doubt that Michelle stunned and confused her audience. In the end she left a lot of people thinking uncomfortable thoughts. Ironic since when things are working right that should be the role of the journalist and not the comedian. It is only after facts are lost and voices are co opted that we must turn to humor to make points that others should be addressing.

Gessen’s colleague at The New Yorker, Troy Patterson, continued the analysis in another article. After pointing out that much of what Wolf said should be considered a continuation of the debate about sex and gender, he concluded that the whole affair was a throwback to another era:

At one point, while gathering steam in her denunciation, Wolf muttered an aside chiding the people who’d hired her, saying, “Shoulda done more research before you got me to do this.” It was, indeed, negligent of the White House Correspondents’ Association to provide a platform for Wolf or any other political comedian with eyes to see what is going on in this country, given the group’s mission to offer a “unifying message,” to borrow a meaningless phrase from its weaselly repudiation of Wolf’s act. This dinner does not rate as entertainment in these dire times. ...If the people who run this anachronism want it to succeed without raising any rancor, they would need to reach back further still, to the days when Bob Hope or Benny Goodman would show up, make the assembled feel swell, and dematerialize without incident…

Michelle Wolf did not leave many people laughing, but she got a lot of people thinking. We all seem to be on a strange, tedious, and dangerous journey that seems like a bad dream. Most of us never dreamed it was possible, and it will take more than humor or patience for it to end.


A Request That Got Me Thinking

I made a very late decision to go to my 55th high school reunion even though there should never have been a question of whether or not to go since I was the class president. Nevertheless it was not until I realized that the committee had moved the event from Saturday night to Friday night that I decided to go because I realized it was a “twofer.” We could fly into Charlotte and drive down to attend the event in Columbia on Friday night and then on Saturday drive North to see my Dad who lives a little west of Charlotte for the weekend before flying back to New Hampshire on Monday. It was a neat package. I felt it was a divinely guided decision when shortly after I made my plans my Dad was readmitted to his local hospital with another episode of CHF and aspiration pneumonia. Everything seemed choreographed for success. He was discharged to the rehab facility at his life care community on Monday. My sister from Birmingham drove over and spent most of the week visiting with him and relieving his wife who really needed a break, and then my wife and I arrived on Saturday to give the whole operation the “Good Housekeeping Seal of Approval.”

It was a great weekend. He looked better than he had looked to me when I had last seen him in March when my sibs and I gathered, as we do every year on our mother’s birthday. She died shortly before her 94th birthday and would have been 99 on March 3. She was almost two years older than Dad who is now 97. My sibs and I are delighted that both of our parents have had very long lives and maintained exceptional intellectual function even as their strength declined. I guess clean living and an active life are good operational strategies. Pacemakers, angioplasties, timely surgery, good meds for hypertension and hypercholesterolemia, and virtually free access to more than adequate care have also helped extend their years substantially beyond what their parents enjoyed. I like the trend and hope it continues!

Despite the fact that I spent ten or twelve hours with Dad on both Saturday and Sunday and then a few more hours on Monday before we had to go to the airport, I could sense that we were not talking about the right things. We made several runs at “meaningful discussion,” but our talk remained somewhat superficial and about the nuts and bolts of his rehab. I was delighted to see that he had virtually no edema and seemed stronger than when I had last seen him. His weight was down more than 15 pounds and I assumed that it was all water. I also assumed the improvement was due to a combination of better PT, an increase in his diuretic dose, and an increase in protein in his G tube feedings since I had seen him. I must admit that I had been apprehensive that our dream of a family reunion on Father’s Day was in jeopardy. He has four children, thirteen grandchildren children with eleven spouses, and seventeen great grandchildren, and that does not include my brother’s new wife who also has a son and two grandchildren or my father’s new wife who has a son, two granddaughters and two great grandchildren. It is a big family and most of us are coming to see him on the Father’s Day weekend. The hotel rooms are reserved, the airline tickets have been purchased and the catering has been set. I spent most of the time in a self serving presentation of all he had to motivate his attention to his rehab. He has only seen my two grandsons who live in California in pictures and on video. Let’s push that walker down the hall one more time.

Back in New Hampshire it is my routine to call several times a week. I can follow his progress on line when he is in the hospital by reading labs, imaging studies, and the doctor’s notes online through Carolinas Health’s wonderful web portal. When he is in rehab I am cut off from that day to day opportunity and must depend on second hand information.

Last weekend during one of our calls I was surprised by a comment and a request from him. He said, “I don’t know what has happened to me. I don’t understand what is wrong. Will you write me a letter that describes what my problems are?” As I explored his request I realized that he wanted “hard copy;” an email would not suffice. I promised to do it. That is when I I began to think back over all my years of practice and asked myself how often had I failed to give patients what they needed to know? What were the barriers to meaningful dialog? Over the last ten years have doctors and nurses been enabled to do a better job informing their patients than we did before I moved from seeing patient ten or twelve hours a day to leading an organization?

In retrospect I was not surprised by his request. He had led complex organizations during his professional life. I am sure that when he had a national responsibility for the Southern Baptists that he frequently requested or received memos and talking points. When he was a college president I am sure that he asked for policy papers, forecasts and analyses about major decisions. He had always paid great attention to the details of what he managed. The more complex the situation the more information he wanted. Long ago he had told me that I should always remember that most people were smart enough to understand anything that could be explained. The inference was that it was the “explainer” or the person speaking who had the major responsibility for getting their point across. I wondered how many medical professionals have the time and the support to accomplish that task with either the patient or the patient’s family.

I was glad he asked for the letter. I began immediately to try to give him and his wife what I thought they needed. As I wrote I remembered many times when at the end of an appointment when I thought my work was done and my hand was on the doorknob, my patient had said, “Oh Dr. Lindsey before you go may I ask you one more question?” That is when the appointment really began.

We all have heard variations on jokes about “practicing medicine.” I did frequently wonder whether or not I would ever get it right if I just kept “practicing.” I think that I did get continuously better at what I did through the first 15 or twenty years of practice. I became increasingly confident in my fund of knowledge, my ability to get to the important issues more efficiently so that there were fewer times when the appointment really began when I thought it was over. The last fifteen or twenty years of practice were a slow downhill slide. By then our organization was no longer able to shield its clinicians from the realities of external financial pressures. By then I was no longer trying to be a more effective doctor. I was trying to learn how to be a more efficient typist.

It was the sense that I had that my “joy in practice” was slip sliding away that made me an organizational activist. I soon realized that I was being asked to construct my medical records more to facilitate finance than the delivery of care. It was a shame because it was clear that there was much to be gained from an effective electronic medical record. We had worked with a very effective, albeit rudimentary, electronic record since 1969. The difference was inputting information that would justify a billing code versus creating a note that would be of use to guide a subsequent visit with me or a colleague. The goal was more the transfer of resources from a payer to our practice than a transfer of useful clinical information. There is no reason that the two objectives must be mutually exclusive, but in the real world they seem to be at increasing odds. Even of more importance, than the creation of understanding within the medical record that I value so much, could it be that the focus on finance is at the expense of the more important exchange of information and understanding between the clinician and the patient and family? Was my father’s lack of understanding due to a cognitive problem he had, or an inputting burden that the hospitalists that he has seen over his recent admissions had? How much of the issue of his readmission been a function of the quality of his interactions with the staff in the hospital? To paraphrase him, I know from personal experience with him that he can understand anything that someone will take the time to explain.

This week an interested reader and former colleague sent me a Wall Street Journal article about using AI to guide conversations with terminally ill patients. Currently I do not have a subscription to the WSJ so I was very happy to get the PDF from him. As I was reading the article I noticed that in the same series there was an article by Robert Wachter, Professor of Medicine, inventor of the concept of “hospitalist” and the author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (2015). I had heard him speak at the IHI Orlando meeting a few years ago and was curious to read his current thoughts. My friend sent the article to me. There is great insight and hope in the article, “How Tech Has Undermined—and May Now Save—the Doctor-Patient Relationship.” [Do not bother to click on the link unless you have a WSJ account.] Wachter writes well and the first sentence grabs any one who has ever struggled with the computer in the care of the patient:

The physician’s note has become an unlikely battleground for the soul of medicine. Once a narrative of the patient’s clinical symptoms, the note has been transformed into a bloodless and bureaucratic box-checking exercise whose goal is often to maximize reimbursement and provide a highly flawed window into “quality of care.”

Above the article is a very colorful picture drawn by a seven year old. It depicts a visit to the doctor. They say a picture is worth a thousand words but Wachter gets key points of the message in many fewer words:

This picture, drawn by a 7-year old after a visit to her pediatrician (and later published in the Journal of the American Medical Association), beautifully captures today’s predicament. The doctor, his back to the patient, is tapping away on the keyboard, while the patient, her mother and her sister are left to wonder whether the doctor is even aware that they are in the room. The picture is extraordinarily accurate but for one little detail: the smile on the doctor’s face. Studies have shown skyrocketing rates of physician burnout, and doctors place much of the blame on their computers.

[You can see the picture if you click on the JAMA link.]

Wachter estimates that the average physician spends 45% of his or her time just inputting information. Last week’s note was about innovation. Wachter holds out the idea that technology created the problem and that technology may produce the innovations that solve the problem. I hope that he is right, but I think there is a more fundamental questions that we are not facing that will be even more important to consider. What do we really want our doctors and nurses doing? What is the value added that a physician who has spent four years in medical school and anywhere from four to six years in subsequent training brings to a medical encounter? I do not think it is to efficiently generate a bill that a third party will pay.

I wish that one of my Dad’s providers had spent the time with him that was necessary to help him understand what was really wrong, what could be done, and what his choices were. By his algorithm that responsibility lies with “the explainer.” His assumption is correct. It’s not that we are not smart enough to inform our patients, it is that we have not been smart enough to structure our work flows and teams in a fashion that carve out or create the time to do our job the way our patients imagine that we can.

I am not railing against computers. I love computers. I did finally learn to type. I type thousands of words. The problem that I was trying to solve in the last decade of my professional life was the creation of a work environment that supported the practice in a way that properly supported the best aspects of practice. It was that concept that made me an advocate of looking at practice from a systems perspective. It was that concept that made me an advocate for team based care and value based financial systems. It was that concept that caused me to embrace effective innovation. It was that concept that makes me so excited about the possibilities of AI and other technical innovations. I believe in the Triple Aim. I am also a realist. The care people want and the care people want to provide cannot be delivered with our backs to the patient while we vigorously document an L4 visit.


Buds, Birds, Boats, and Bass

Spring finally came to New Hampshire this week for more than a brief preview. It was 78 when I took my walk on Wednesday while listening to the Red Sox game, and over 80 yesterday. We have some daffodils coming up in the front yard. All the trees and shrubs now have bulging buds that look like they will explode any minute. I was in Boston on Monday to watch a rain soaked Red Sox victory over the Royals and was impressed that everything there was a splash of color just like things had been in South Carolina two weeks before. Spring moves North slowly and now it has come to us. It looks like we are a little more than a week behind Boston even though it is just a hundred miles south of us.

Our cat, Lilly, has enjoyed the weather and has moved into “hunter mode.” She has returned from her many forays into the wild with two field mice. She takes no prisoners.

I love to see the yellow finches in Spring. During the winter the males and females are indistinguishable. In the summer the males sport their bright yellow feathers while the females are relegated to a military looking “olive drab.” The males have been in a mottled state for the last few weeks and now are near the end of their transition.

We have seen that at least one of the loons is back. He or she sounds quite mournful in the evening. One wonders if it is alone or we just have not seen its partner yet. I have seen a pair of mergansers. The “breeding male” looks very different than the “breeding female.” What amazes me is that the breeding male changes the color of his head to a dark green, his body to white and loses the “comb” on the back of his head. The change is so radical that the two genders appear unrelated. Our eagles are also back. Most frequently I see one soaring above Colby Point where the nest is likely to be. Last week when the ice was only partially out of lake, I saw an eagle dive into a patch of open water and then ascend with one of the fish that I would like to catch and release. The eagle then headed home with dinner.

The show is over now but “ice out” Is a slowly moving spectacle of surprising natural beauty. Some of my neighbors are artist and artisans who have aged in place here since the sixties and seventies. One such fellow was famous for the amazing work that he did creating lamp shades and sconces by turning poplar logs on a lathe. His work is beautiful and expensive. Over the last couple of years he has broadened his talents to include spectacular drone photography. Click here to see a breathtaking video of our lake that will forever change you concept of “frozen” from a static to a dynamic state.

If you watched the video you might have noticed the spectacular image of ice breaking up as the wind pushed it past a red buoy that warns boaters to go South and West of a “rock pile.” It was near that marker and submerged rock pile that I caught my first bass of the season this week which is the subject of today’s header. It was pretty heavy and rotund which makes me think it was a female full of eggs. She must have been hungry because she hit a fly that usually attracts rainbow trout. I “catch and release” so she was back to her job of eating and producing the next generation of fun for me a few seconds after this “trophy” picture was taken.

The weatherman is predicting spectacular weather for the Northeast this weekend. Wherever you are I’m hoping you find pleasure and renewal in the outdoors with your own version of something like buds, birds, boats, and bass.