Reasonable and Necessary

"...how many deaths will it take 'til we know that too many people have died."
Blowin' in the Wind, Bob Dylan

Three years ago, my daughter had a liver transplant after an intense battle with hepatoblastoma, a rare form of liver cancer. Thankfully, she is doing very well today as a happy and headstrong six year-old. Many others, however, have not been so lucky. It was with great interest and sadness that I read this week about the teen age girl who died after her insurance company denied her a liver transplant. Not that it will ease their pain, but the family is suing the company and attempting to bring charges of manslaughter or murder for the delay caused by bureaucratic red-tape and the desire to save a few bucks. Okay a lot of bucks. Liver transplants don't come cheap, but that pales in comparison to the cost this family now has to bear.

I must say that, in Canada, we are extrordinarily lucky. Expense was not raised as an issue once during Maryn's journey. We received excellent care within the health care system and incredible generosity from those who supported us. We have watched others in the same situation have to fight for everything, a burden that should not be borne by those already pushed to their limits by the illness of their child.

Beyond the emotional responses of anger and sadness, the process at work in this story interests me - as it should all of us. From the article:
"Doctors at UCLA determined she needed a transplant and sent a letter to Cigna Corp.’s Cigna HealthCare on Dec. 11. The Philadelphia-based health insurance company denied payment for the transplant, saying the procedure was experimental and outside the scope of coverage...The insurer reversed the decision Thursday as about 150 teenagers and nurses rallied outside of its office. But Nataline died hours later."
I guess some credit is due for reversing their intitial decision, but the company first cited lack of medical evidence that the transplant would work in Nataline's case as their justification.

I want to highlight two very important issues here:
(1) It is the payer who holds the power in determining health care received - overruling the determination of the medical professionals involved in the care. Insurance companies, of course, have their own medical consultants, but they have little to no direct contact with the patient and their mandate is questionable in light of the profit motive.
(2) Medical evidence for many procedures is woefully inadequate. There's a saying that absence of evidence is not evidence of absence. Now I am all for medical research, but it is difficult to keep up with the emerging possibilities. In my own daughter's case, the stats certainly did not look promising. But when it comes to judging the value of a human life, perhaps it is worth experimenting.

Although it is nowhere close to the same scale, I see similar dynamics in my practice every day. More and more, it is the courts who will decide what is "reasonable and necessary" for a given individual. As health care dollars become more scarce, even as insurers coffers grow, understanding and fighting for your right to care becomes increasingly important. If not, you could become one too many.

A Big FAT Lie

Ten Lemmings Leaping is one too many. Read this before the 10th day of Christmas - guaranteed to make your New Year better.

In this interview, Gary Taubes, science writer and author of Good Calories, Bad Calories, declares his interest in "this problem of establishing reliable knowledge about the universe and how easy it is to get the wrong answer." The subject of this particular investigation is the cause of obesity and the commitment of many to the dogma of sloth and gluttony. Speaking in terms of deadly sins makes it sound harsh, but that is exactly what is being said when "they" say obesity is caused by sedentary behavior and over-eating. Somehow sedentary behaviour doesn't carry quite the same punch as sloth. Taubes turns this whole holier-than-thou thing on its head - simply by looking at the evidence and realizing it does not support the sloth/gluttony hypothesis. He claims that, rather than being as simple as energy in must be less than energy out, changes in energy will result in behavioral and metabolic changes sensitive to the overall change in energy. In other words, if energy intake is decreased, energy output will also decrease. The same holds true for increases. According to this hypothesis, over-eating and sedentary behaviour do not cause obesity, but rather result from it.

Taubes says "one thing dogmas do very well is perpetuate themselves, not through any explicit conspiracies, but because so many people are so invested in one point of view that they will always, when given the chance, act in a way that supports that view." This, of course, is not science. One might question whence such investment comes and why it creates such resistance to change, but few would argue that such dogma touches almost every human endeavour. There comes a time, in every person's life, when dogma must be challenged if one wishes for more than following the herd. And when the herd is a pack of lemmings leaping toward their demise, pausing for thought and considering a different path is not such a bad idea.

Taubes challenges the current nutritional orthodoxy based on mountains of historical evidence, clear scientific principles, and emerging research. He makes it clear that the way to combat obesity is not a low-fat diet or attempting to shame the slothful into more exercise, but rather understanding the hormonal consequences of the foods we eat. Put simply, carbohydrates, particularly white sugar and white flour, cause insulin to promote fat storage and inhibit the metabolism of fat for fuel. This is indeed a complex interplay of nature and nurture, but complex problems often require simple solutions. Ironically, those accused of gluttony are actually under-nourished, but their hormonal milieu is not favorable for losing fat. Bottom line: if you want to be leaner and healthier, stop racing for the cliff and eat fewer carbs.

Hear more from Taubes here or watch his webcast for a fascinating look at unconventional wisdom. It is a smarter conversation we need to have...desperately. Don't be a lemming.

Health 2.1

There are one too many edges.

I apologize if my thoughts seem scattered and random, but that is how my mind operates sometimes, especially when surfing the net. So bear with me. Perhaps my thinking and philosophies will crystallize as I write. Then again, fluidity is likely preferable in many ways. I've always maintained that my greatest strength as a clinician (perhaps my only strength?) is my willingness to adapt and change in light of better information. Too often, I think, people's attitudes and actions solidify into unbreakable habits. Change is, I suppose, frightening, but it is also very exhilirating. For instance, I constantly try to have my clients open themselves to the possibility of exploring new ways of moving. This requires letting go and that can be difficult. Like Come to the Edge:

"Come to the edge.
We might fall.

Come to the edge.
It's too high!

Come to the edge.
And they came,

and we pushed,
And they flew."


Christopher Logue


In a post a couple of months ago, Esther Dyson discusses a panel of health care experts. "They explained the problems with the system eloquently: mis-aligned incentives, stalled information flows, undereducated consumers, overworked doctors, prohibitive liability insurance and excessive CYA testing, and on and on. It was clear nothing could be done."
She goes on to comment that, "If this session had been held in my industry, I thought, there would have been five ex-doctors with perpetual-motion-like schemes to predict the onset of cancer, realign incentives, re-train consumers and avoid the extra testing through better information management. And there would have been ten VCs waiting to fund them. Where was the energy, naivete - and funding - that could foster change?"
This is fascinating writing for me. Where are the solutions? It is so interesting to see different worlds colliding. The idea of venture capitalists in health care may seem foreign or perhaps repugnant to Canadians, but the desire for change is no less evident here. We'd mostly agree that "at the center of everything there's a calcified heart pumping blood/information/money in the wrong direction through a tangled mass of arteries that misdirects resources to tumors and useless vestigial organs." Clearly some radical surgery is required. I, for one, think it will require far more than the quest on which my local health authority has embarked. Though I guess seeing people as people is a good start.

How does a doctor's role change when a patient is directing him what to research on Google? Maybe it will not change that much at all. Dyson asks, "much of the conversation centered around getting information to users, but what about getting them to act on it?" That has always been the issue, hasn't it? Again, it is not so much in the knowing as in the doing.

Dyson concludes: "In the end, the cheapest way to foster health is to maintain it, reducing the need for health care in the first place." I couldn't agree more and we better start soon.

Smarter Conversations

Because once can never be too many, I'll post one of my favorite bloglists here again.

From Hugh MacLeod's www.gapingvoid.com, here are some of my ground rules:

How to have smarter conversations.

Somewhere along the the line I decided that embracing "Smarter Conversations" was preferable to prematurely consigning my career to the dustbin of history. I just wrote down some random thoughts:

1. Understand why what you're offering to do for other people is interesting, important, meaningful etc then start telling people about it.
Think about this one. Hard. If you don't know, then how will other people know? Exactly. They won't.

2. Live like you know the difference between remarkable and unremarkable, like it matters to you.
The more "remarkable" matters to you, the more likely that it will appear in the product you're selling. The more likely other people will notice it.

3. Seek out the exceptional minds.
This is my basic mantra. It's a good one to have. Not everybody gets it. Their loss.

4. Start a blog.
Blogs are funny things. Say something smart, people pay attention. Say something dumb, you're ignored. We big media folk just can't seem to get our heads around that concept, for some reason. Regular blogging can help train you to better discern between smart and dumb. Makes it easier to extend this to the rest of one's business.

5. Ruthlessly avoid working for companies that "don't get it".
Yeah, you may have to turn down a few gigs, and that can really hurt when the rent is due. Still, anything that's easy to get isn't worth having.

6. Ruthlessly avoid working for companies that think they know better than you.
Luckily, if you get the whole "smarter conversations" thing, their "Yes, Buts" will just seem rather empty. Making them easier to "toss out like old furniture".

7. Be nice.
Smarter conversations are fuelled by goodwill. Lose it and die.

8. Be honest.
Again, smarter conversations are fuelled by goodwill etc.

9. Karma is key.
But you already know that. Or you're stupid. No middle ground on this one, sorry.

10. Listen.
Tongues are dumber than brains, brains are dumber than ears etc.


Posted by hugh macleod at August 27, 2004 10:34 AM TrackBack

One Too Many

It's a restless hungry feeling
That don't mean no one no good,
When ev'rything I'm a-sayin'
You can say it just as good.
You're right from your side,
I'm right from mine.
We're both just one too many mornings
An' a thousand miles behind.

One Too Many Mornings, Bob Dylan

I’ve heard it one too many times.

I’m not sure if I’m a thousand miles behind or a thousand miles ahead, but things look different from where I stand. As much as I’m theoretically drawn to consensus, I cannot be imprisoned by the demands for standardization. I can’t think inside that box. And besides, it seems to me that things need to change. Health care is a bit of a mess in case you haven’t noticed. Consuming over 40% of our provincial budget at last count. People are completely confused by conflicting information, marketing overload, and professional squabbling. Who knows how to look after themselves anymore? Then again, I could be wrong. I won’t deny that possibility and remain open to change. I’ll leave it up to you if you think I need convincing.

One too many times – actually far more, but I’ll stick with my theme - I have heard someone say how they tried physiotherapy and it did nothing for them. Next I’m regaled with tales of hotpacks, ultrasound, or silly repetitive exercises that no one ever does anyway. I’m convinced we can do better. To quote Mr. Dylan again, the times they are a changin’.

I’ve noticed over the last few years that I don’t often see garden variety ankle sprains or strained muscles in my office. In fact, apart from sports medicine, I think these conditions are rare in most physiotherapy clinics. Instead, I see people with persistent pain, arthritis, osteoporosis, obesity, heart problems, frailty, and so on. Chronic conditions that defy many of the tools that have served my profession, if not our patients, so well. These are conditions that require lifestyle solutions. They require that people are motivated toward self-care and prevention, that they recognize the slippery slope we call aging and do the work to do it well. As a physiotherapist, I knew my understanding of these conditions meant I could help people achieve these aims. But how?

Enter the world of exercise. And I thought things were contentious in rehabilitation?! That pales in comparison to the flame wars, grudge matches, and outright lunacy in the fitness industry. Poisoned by subjectivity and built firmly on the shifting sand of opinion, the world of fitness is based on chasing an elusive target. It is all about keeping people engaged and entertained – hopefully enough that they don’t notice their lack of results. The fun trumps the frustration. Now everyone likes to have a good time, but it’s not enough. The statistics are frightening. Chronic disease is on the rise. An aging population means that health care demand is poised to skyrocket. But the system is already broken. It is broken because it does not and cannot keep us well.

It has been shown time and time again that diet and exercise combined are the keys to better health. These are the two modifiable aspects that affect health. That means they can change; they are within your control. The hard part is not in the knowing although, in an age of information overload, confusion is understandable. The harder part is doing what you know. Taking action…today.

It begins with smarter conversations. Thank you for joining me to explore topics like pain, exercise, neuroscience, movement and whatever else you bring to my attention. My aim is to teach, to learn, and to do things differently. I hope this blog shows you why and helps you along your own path .

If you want a different RESULT, you must take some different ACTION!