two thoughts on the state of healthcare in the united states

(image courtesy of...)

Over the weekend, I got a chance to talk to Elli. He was attending the 2010 Missouri State Medical Association Convention, and mentioned listening to a doctor-turned-state-representative who essentially argued that healthcare is not a right. Upon further investigation of the topic, I came across this editorial (not from the same person, I assume); the author suggests healthcare is not a right because the rights that we’re guaranteed under the Constitution (life, liberty, and the pursuit) are rights to action, not rights to reward. Interesting points, but I really take issue with this paragraph:

The battle against the Clinton plan, in my opinion, depends on the doctors speaking out against the plan -- but not only on practical grounds -- rather, first of all, on moral grounds. The doctors must defend themselves and their own interests as a matter of solemn justice, upholding a moral principle, the first moral principle: self- preservation. If they can do it, all of us will still have a chance. I hope it is not already too late. Thank you.

Moral grounds? Self-preservation as the highest moral value? His argument unravels there. Self-preservation is certainly not my highest moral priority, and nor do I think we are being morally sound to deny healthcare to citizens who can’t afford it. Although we should pay for the goods and services we use, society collectively helps to educate its citizens for the betterment of the society as a whole, and doctors are no exception. Additionally, the externalities that all of us gain from having a healthy population far outweigh the costs to the individual.

Unrelated, but equally thought-provoking: regarding fee-for-service models, from the New England Journal of Medicine, in a roundtable with the well-known Atul Gawande and Dr. Elliot Fisher of Dartmouth Medical School, among others:

Fee for service does not pay for us to have long conversations with our patients. When we're feeling constrained, it's much harder for us to have that long conversation with a patient with heart failure to see if we can safely manage them at home. The default position in many communities becomes, "Gosh, I'm too busy. I better send them to the emergency room." The emergency room physician recognizes that they don't have time to manage the patient with heart failure in the emergency room, so admits them to the hospital. To the extent that those resources are available for us and we're not paid to do the things that we really would like to do or know we should do, we see huge differences in the likelihood of really unnecessary hospitalizations in different communities.

Dr. Fisher sums up the problem well – we incentivize doctors to spend less time talking to their patients and more time trying to comply with 80+ agencies’ regulatory and compliance requirements, and trying to keep their practice afloat. The practice of medicine in our society, in other words, is about so much more than patient care.

learning to say no

Something I've struggled with for a long time. I think lots of people do - they know they should, they want to say no, but they end up saying yes anyway.

From Covey:

"I don't mean to imply that you shouldn't be involved in significant service projects. Those things are important. But you have to decide what your highest priorities are and have the courage - pleasantly, smilingly, nonapologetically - to say 'no' to other things. And the way you do that is by having a bigger 'yes' burning inside. The enemy of the 'best' is often the 'good'.

Keep in mind you are always saying 'no' to something. If it isn't to the apparent, urgent things in your life, it is probably to the more fundamental, highly important things. Even when the urgent is good, the good can keep you from your best, keep you from your unique contribution, if you let it."

... it's that nonapologetically bit that gets me.

asking good questions (and getting good comments)

Just before I graduated from my undergraduate program at Georgia Tech, I sent two emails to help me through the process of figuring out where to go next.

(image courtesy of...)

The first, due to my interest in global health, was to the President of the Global Health program for the Bill and Melinda Gates Foundation, Tadataki Yamada. At the time, I was right in the thick of things with my research into technology development for global health, and had lots of ideas (and lots of questions) about how to impact healthcare in the developing world. When Dr. Yamada’s staff scheduled a 15-minute call for him to advise me on my next steps, I was thrilled. I spent weeks preparing for the call, and when I finally got my 15 minutes to talk to one of the leaders in the field, I had condensed my questions and planned my time to get some real meaningful content out of the call.

Several weeks later, I sent an email to Steve Jurvetson, a well-known venture capitalist. I had been keeping up with Steve’s flickr stream, The J Curve, and knew through several articles that Steve knew lots of things about early-stage biomedical companies. I spent 15 minutes composing a well-thought out email (or so I thought), and summarized the crux of my request as:

I am particularly interested in biomedical design for the developing world, among other things, and would love to hear your perspective and thoughts on the future of biotechnology in this area.

Looking back on that email makes me cringe. Peter Drucker once said, “The most important and difficult job is never to find the right answers; it is to find the right question.” My question didn’t give Steve any insight into what I was already thinking and what kinds of technology I was inquiring about. I was relying too much on a good answer to help me figure out where I needed to go, but I wasn’t mature enough in my question-asking to help myself get there.

It's the perfect example of understanding the space between stimulus and response. Asking a good question gives the responder the psychological space to give to a good answer, and helps both of you grow. Science is all about asking good questions, and I wasn't being a very good scientist.

Predictably, Steve sent back a very quick response along the lines of, it’s a great field, but I’m too busy right now to help. I realize now that I didn't give him enough constraints to effectively answer my question.  Strangers can’t decide for us what it is we should focus on – that has to come from us. But once we get our feet pointed in the right direction, people like Dr. Yamada can help bridge the chasms along the way.

Blogging is a little like that. I certainly don't know that I provide a lot of insight or "answers" on my fledgling blog... or that I want to. Being able to write an effective post is like asking a good question - how do you present the topic in such a way that allows people to formulate their own answers, and hopefully, their own questions?

art & science

  (image: Nikki Graziano)

I’m fascinated with things at the intersection of art and science. Jonah Lehrer has a great book called Proust Was A Neuroscientist. The High in Atlanta just sponsored a Da Vinci exhibit about the intersection between Da Vinci’s sculpture and his understanding of the physical world. The new Le Laboratoire in Paris is dedicated to exploring that space.

The image above is by Nikki Graziano, and currently serves as the background on my laptop. Lots of my coworkers come closer to take a second look, and most dismiss it as one of my nerdy hobbies (of which I apparently have plenty). And maybe it is nerdy. But it’s art. And it’s science. And it’s beautiful.

Design lies at the intersection of art and science. Maybe that's why I like it so much. Designing things – whether that’s objects, systems, shoes, or medical devices (shameless plug) – is most successful when the functional (the science) is married with the beautiful (the art). One can’t exist without the other. It makes perfect sense for engineers and scientists to pursue art as well, because engineering and science are inherently creative pursuits.

Medical devices, then, make for an interesting creative exercise. As Lehrer says about the human body, “We are such stuff as dreams are made on, but we are also just stuff.” We have to be creative in how we address the body’s science (by, say, generating electrical signals to keep the heart beating through a pacemaker), but we also have to protect and nurture its art (regulating that rhythm to fluctuate with the body during exercise).

The beautiful part of Nikki's photograph is that the function isn't a simple harmonic oscillator with whole number boundary conditions. Her equations are complex because life is complex, and her photography is beautiful because the world is so.

"Like a work of art, we exceed our materials." (Lehrer 8)

what is the gap between stimulus and response?

Buried in the back of Stephen Covey’s book, in the last chapter, he writes about an experience he had while on sabbatical of walking into a library, opening a book, and reading one sentence that changed his life. The sentence essentially reads (and here I quote Covey): “There is a gap between stimulus and response, and the key to both our growth and happiness is how we utilize that space.”

(image courtesy of...)

Essentially, we are confronted with many stimuli in our lives. Some are obvious – temperature, sound, light, actions. Others are more subtle – emotions, interactions, wayward blog postings. But each of these stimuli changes our course in some way, and the mindfulness of our actions in shaping what our response is, makes all the difference in who we become. Crafting appropriate responses to the events, people, and other stimuli in our lives is the essence of maturity.

It’s this thought that spurred my idea for a blog. There are always gaps between the stimulus and the response, and being able to capture the thoughts that fill that space is challenging. For example, there is a gap between consumption (of say, a blog post) and creation (a comment... so think about what’s happening in your gap). But consumption always leads to smarter consumption, and if I do my job well, better creation.

Great design means that you give the appropriate stimuli to elicit the desired response. Great designers, then, can anticipate the space between stimulus and response, and can assess what will happen in that space to guide a user to that outcome. When we design medical technology, we’re mindful of how patient care is affected. A good design is a device that improves the health or reduces the injury of the patient. But a great design has to be one that is also easy and intuitive for a clinician, nurse, assistant, or caregiver to use. Which isn’t an easy order to fill.

So there you have it - the gap between stimulus and response.