Saturday, January 19, 2013

A well care rant

What we have now in Canada, and the US too for that matter, is not a health care system. It's a sick care system. It mostly knows how to cope with emergencies and various large bodily injuries. However it's biggest failure is that it doesn't have any incentive to keep people out of the system, quite the opposite in fact. It doesn't have the least idea how to cope with people it can't fix up and push out the door.

Let me tell you where I'm coming from personally, before I tell you what I want from an actual health care system. We are very fortunate in many ways. One of the main ones was to win the genetic lottery in terms of health. Throughout much of human history, someone my age would be considered very old.  By modern Canadian standards I am middle aged and much healthier than other men my age. Statistics tell me I can reasonably expect to live another 25 years. If I take care of myself and have a bit of medical luck, I might well make it to 100. And then if you believe even a bit of what Ray Kurzweil has to say, by then I might be on the threshold of living forever.

I'm old enough to not have starry eyed delusions about our society, but not so old to be set in my ways. I'm wealthy enough (now) to not mind paying more taxes provided I can see the benefit of doing so, and funding a proper health care system is to my obvious advantage. I will almost certainly need it over the coming decades.

What do I want to see? The current system dwindle to a tiny fraction of it's current size. I do NOT mean dwindling the Canadian system so an American system can be implemented. I see no reason to allow vulture insurance companies to get rich from denying people medical care.

I want to see a birth to death health system that is focused on keeping people healthy. Lets explore what that might look like. In Calgary it is extremely difficult to get a family doctor. One co-worker flew back to BC to visit her doctor because she couldn't find one here. I'm supposed to get a physical annually, and I was astonished to discovered two years ago, that if I booked the day of the physical, the next appointment was 1.5 years out. I booked it. I rearranged my life to keep the appointment. Good thing I only work one block away.

But most of us don't really need an annual physical by a medical doctor. That medical experience is overkill for most patients most of the time, and the time frame is much too infrequent to get any idea of what normal is. The doctor is the gatekeeper to seeing specialists, but the real word for what they are is the bottleneck.

What we should have in every strip mall big enough to have a convenience store is a small medical office staffed by someone with credentials similar to that of a Registered Nurse, but with additional training in the resources available to the system, and the overall normal healthy human life cycle. Their primary role is to regularly see a group of patients, typically people that live within walking distance. By regularly I mean every few months, with the exact schedule determined by the patients specific needs. Some people might be every 6 months, some monthly, and it will almost certainly change as the person ages.

During a visit a number of things happen:

  • the patient gets weighed on the fancy scale that gives the detailed fat level. These might not be exact, but they are pretty close, and they are consistent. They are also very fast and very cheap compared to a hydraulic test.
  • Blood pressure, and a blood sample taken. Maybe two, with one going to automated testing, and the other put in storage for later detailed testing if necessary. (See automated testing further on down.)
  • Listen to the heart and lungs, look in the various bodily orifices, test reflexes, mobility. 
  • Maybe a urine sample for automated testing.
  • Discuss on going health issues, noting trends. For example most of us gradually gain weight. A few pounds up or down is no big deal, but a longer term trend can be caught early, and the person advised about issues, and appropriate help found if necessary.
  • All data is tracked, and the most important thing is to compare to previous results. The idea is to get a grip on what is normal for that person, and to see when things change. This becomes an invaluable took if the person is involved with some catastrophic medical event, such as an auto collision or the onset of some disease. Then tracking when something changed from the low end of normal, to the high end of normal might be very important.
  • When something comes up that is abnormal, or warrants further investigation, the practitioner is their guide to the system, helping them to see the appropriate people, get the appropriate tests, and coordinate any medication issues.
  • They would be a central place for all the patient's medical data from checks done in that office, but also from routine eye examinations, dental procedures, OB/GY, hearing tests, occupational rehabilitation and other such things all done by the appropriate specialists.
  • As the person ages, the routine checks might change, become more detailed, or additional ones could be added. They key is that it is personalized because we have the data. It might well be that with genetic sequencing becoming cheaper by the week, this office might sequence every new patient and use it as an indicator of what to watch for.
  • All this should be paid for out of our taxes. The practitioner reports that they see a particular list of patients from year to year, and that drives a medical tax rate. People that do not see such a practitioner pay a higher rate, perhaps much higher, on the theory that sooner or later they will need the services of the more expensive system.
The first objection to this is that such practitioners don't exist, and it will be expensive. Firstly, nothing is expensive compared to our current system. Preventing from people getting sick or injured has to be cheaper than fixing them up afterward. While the system is strained for medical staff now, the system itself is part of the problem. I've known people with valuable medical training that simply can't cope with the stresses any more, and they find another job. What a waste! (Don't get me started on how we train doctors now!)

I am convinced that we can start recruiting back some of these ex medical staff, and current staff willing to learn a new way of doing things, with a promise of reasonable pay, and a holistic life based practice. I'd love to see such a system get started in a small city where we can start tracking the changes and compare to other centers. The more things like diabetes we can catch before it really gets going, the system will start to pay for itself, and we can gradually devote more and more resources to it, transitioning from our current system to the new one.

Part of the issue is to drag the medical system, kicking and screaming every inch of the way, out of the primitive tracking practices. Paper? Puh-leaze. Every person should have all their medical data encrypted in such a way that the various staff in various offices can see what they need, such as the eye doctor seeing the eye information she created, and the overall health notes, but not the details of treating that nasty little STD you picked up. Perhaps the patient carries a card that is the only practical way to un-encrypt the data. Or a key is buried in your smart phone, or tied to your genetic code. 

Right now the doctors are the centre of the whole system and they like it that way just fine. The blunt fact is that they are a big part of the problem. Remember what I said about bottleneck? There is a scientist who once said, scientific progress happens one death at a time. It's almost like that in the medical industry. A little over 100 years ago it took them years to accept that washing their hands between patients saved lives, and it's still a problem now. Why do we put up with it? 

I don't know the details of the medical lab practice, but I'm pretty sure there is a group of very bored people doing the same tests over and over, hundreds of times a day, and reporting the results. I'd like to believe that significant variations from the norm are flagged, checked, and reported to the doctor for followup. Yeah, lets ask the Newfoundland cancer patients what they think of that.

Where I'm going with this that we should be putting research money into automating these tests. Canadian Blood Services used to put the drop of blood into a blue solution to see if it floated. Now they put it on a tiny chip, and slide it into a machine. It beeps almost instantly with results. Next time I give blood I should ask what all it reports. We should be able to feed in a drop of blood, or urine and get the results from a whole host of tests in real time. They have a little machine that automates blood pressure readings, and my doctor cannot explain why he doesn't have one. The time it takes for him to do the test, as opposed to noting a reading and thinking about what it really means, is time that could be better spent doing something else.

Lately there's been some media attention about old people not driving cars very well any more, and discussion about how to prevent this from happening. Typically the family doctor is the one that recommends to the authorities that driver's license should be revoked, or have limitations. This is based on the old model where the doctor actually knew the patients and saw them in day to day lives. Seeing someone for a few minutes once a year is no basis for such an important decision, and as if they have the time. But a practitioner like I discussed will have a long term relationship with that person, or a new person in that position will have access to the data. They would have a much better grip on the person's medical issues in relation to driving, and how it's changing over time. If such a practitioner has been helping that person find the appropriate medical resources for much of their life, it will be one more thing to have them say "You know, your peripheral vision isn't what it once was," or "Your depth perception is shot" or  "you aren't reacting to sudden changes the way you once did" and suggesting ways to get it checked out, or modifying activities for safety. It might be as simple as not driving at night or rush hour. Or maybe a short drive is ok, but anything longer than an hour is too tiring. They can help the person do the right thing. Maybe we should build simulators to objectively test such things, and run everybody through one every year.

Then there will be the people saying they're too busy, and don't have the time. I suspect this would take maybe an hour or so, every few months. Since I started working out, I've come to have a whole new attitude about what's important, and what I have time for. Someone will watch 12 hours of reality TV a week, and not have time to work out. Bah! During the run up to IMC, I was typically putting in 12 to 15 hours a week in cardio activity. Plus things like yoga, stretching, rollering, and other maintenance activities. Now I'm aiming for an hour a day. One of the internet memes that I really liked had the doctor saying to the patient "It's your choice, you can cut back a bit on junk food, and spend an hour a day working on your health, or you can be dead 24 hours a day".

The problem is that it isn't that simple a binary choice. There are a lot of very, very expensive options in between those choices. Lots of guys my age have a heart attack. Our current system is very good at dealing with them. If I ever want to go to the head of the line at emergency, I just have to say I feel shooting pains down my arms, and that elephant is squishing my chest. Boom, I'll be in there so fast. And Bang, will they be mad when they find out something else not so serious is the issue. Some of them change their lives, and others don't, leading to further expensive medical issues. Maybe, just maybe, if they haven't changed their lives, we should take the position that if they aren't interested in their health, why should we pay for the consequences of that disinterest?

A hospital is the last place in the world an old person should be. A while ago I listened to a doctor talking about his practice of making house calls. He had a group of people he saw regularly in their homes. He could discern an amazing amount seeing someone in their home environment on a week to week, or even day to day basis. He despaired when they had to go into the hospital for some reason, like a fall. The hospital buggered up their routines, disrupted the delicate balance of their medications, and they generally never recovered back to where they were. 

A hospital is the last place in the world a pregnant woman should be. Being pregnant is not a disease; it's a natural part of life. Hospitals are a great place to catch horrible diseases. Starting a person's medical care by starting with their pregnant mother seems like a no brainer to me. Why are we still having people born with Fetal Alcohol Spectrum Disorder? Maybe the practitioners specialize in male or female life cycle issues, since we generally do have different issues. It's hard to compare the numbers, but Canada's infant mortality rates are not as good as other peer countries. We can do better.

Our medical system generally treats impending death as an all hands on deck emergency. Even if that person has signed a do not resuscitate order, sometimes next of kin go and mess with that. Maybe it's better if we let some people die. Every medical procedure has a dollar value, and an opportunity cost. To maybe save that person will cost x, and also means we can't treat those other x many people. Right now the medical system doesn't want to say triage, but that's what they are doing. It's a pity we aren't mature enough to have a discussion about it like grown ups. I will come right out and say that not every life is worth an infinite amount of money. 

I would very much like to see a graph of the medical costs per person. Somewhere in Alberta is the one person that cost the system the most money. At this second I don't need to know who, but I do want to know how much. Somewhere are some other people that cost half as much, and lots more that cost a quarter as much, and then a great many that all cost about the same, and a few fortunate people that don't cost the system much at all. This year. Malcom Gladwell wrote about this extensively in his article about Million Dollar Murray. It's worth reading if you haven't. It's very likely there are some inexpensive things that can be done for that one expensive person that would save a ton of medical and social costs.

There are many people waiting for organ transplants. We are not quite yet at the point where we can grow an organ on demand. We are so close. It looks medically possible to take a skin scraping, run those cells through a procedure to turn them into stem cells, and then build a liver, for example on a substrate. Such a liver would have no donor rejection issues. In the mean time, why are are we not harvesting all the medically suitable organs or other material from dying people? Rather than having to sign a paper saying take what you can, this should be routine practice. Religious scruples be damned. Every kidney from a dying person that can be matched to someone needing it, saves the system a huge chunk of money from routine dialysis and other medical interventions, to say nothing of giving life back to someone who is essentially on death row.

That's what my proposals are about, giving more life to more people. Helping them understand the medical choices available now, avoiding the pitfalls leading to expensive medical interventions later in life, getting medical professionals dealing with the living instead of the dying.

One of the key statements in Gladwell's article is from a guy named Philip Mangano. He says, "It is very much ingrained in me that you do not manage a social wrong. You should be ending it." And that's what we should be doing with the current health care system. It isn't serving us. We need to graduate to a real health care system, and end the problems with the current one.


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