Thursday, January 29, 2009

Superlative is Sometimes Less

There are three seemingly random thoughts here, but hang on. Bear with me. I think they come together at the end.


I have had numerous people ask me what it was like to be at last week's inauguration of Barack Obama, and had a very hard time knowing how to answer. It was definitely the most historic inauguration of my lifetime, and perhaps the most important I'm ever likely to see. Except I didn't really see any of it.

I didn't expect to, seeing as I had volunteered to be in the medical corps/response team for the event. Now to be fair to DC Department of Health, secret service, the city and the federal government, they had never dealt with anything this big that needed so much security. But, to put it nicely, organization was actually minimal and there was a lot of frustration and mess that officials are just now beginning to admit to. Many spectators never got in, even though there was still space on the mall and the parade route. Once you got in, you were essentially trapped and couldn't get out until the public transportation re-opened in the late afternoon, and at that point the rush meant a very long wait in crushing crowds. The fact that there were no arrests and no super-major health emergencies or injuries was more due to good will and luck than great planning.

That's the side of the inauguration I saw. Once my group finally found a post where we could be helpful (DOH had assigned us to the wrong one and not given us proper security clearance for it anyway), we saw the people who were cold, hungry, and frustrated. We ran out of hand and foot warmers around 1pm and had to share every emergency blanket. We spent much of the afternoon just holding people's cold feet with our lukewarm hands.

But that "back-to-basics" health care was refreshing in its own way. We were not a medical team. We had nothing "medical" to offer. Rubbing feet and offering water is about health, and like Obama himself, about hope. That is the best answer for my experience of the day. I saw hope. And I saw hope coexisting with exhaustion, fear, and frustration. Many of the folks who stopped in for their 15 minutes under a blanket or their turn with a 1/2 cooled foot warmer were feeling all of those things. As President Obama takes over at what is most likely the most difficult time in our nation's history since World War II, his challenge is helping hope coexist with the reality of disorganization, inexperience, and patience.


In church today we read an interesting commentary about moral progress. The author's argument was that it doesn't exist, and that it is a huge myth of modern society that we are getting better morally. I'm not sure if this writer was stating a belief in original sin, but I do see a point here. We undoubtedly have developed societal structures that can shape and control morality. Not that they always work well, but in a free society, at least the potential exists to keep debating and modifying these structures that they help us function with each other despite our moral failings. Do they make us better people or just limit our ability to do bad things? Every life is worth something, but are we inherently good or bad? God-like or sinful dust? I'm not sure, but the idea that we're headed to perfection on earth is probably overblown. Living things, including the universe itself, I suppose, are complex and messy. "Morality" will never be clear. Accepting that doesn't mean we are bad or that there's no hope for a society that is more just and that works more effectively. Would we be better at making that society if we accepted that we're just not so good at being good on our own?


In the midst of what is going to sound like a fairly pessimistic week, I had a bright spot listening to the head of DC PCA criticize Community Health Centers, the very entities her organization exists to support (in a way). Sharon Baskerville's beef with the CHC model (and she makes it well known, so I'm not "outing" her here), is its arrogance and self-righteousness. "We're doing good things for poor people," we say, but what we mean is: "We're doing better than nothing for people no one else cares about." We who reject a "cush" job in the 'burbs with a well-educated, well-insured patient population are sure we're saints. (And to be sure, many people who work in CHC's have indeed made great personal sacrifices to work with and advocate for their patients.) The danger in this arrogance, however, is the "better-than-nothing" mindset. It makes us work hard and feel justified, even if our patients wait for hours to see us only to be turned away or told they need to go to the emergency room. Even if our clinic looks dingy and has folding chairs and no toys or magazines during those waits. Even if we skimp on using phone translation because it's so darn slow and seeing more patients must mean we're doing "better".

We get so caught up in doing better care for the indigent, we excuse the fact that we're don't question why medical indigence even exists. We doctors don't want to admit that a few trained community health workers could do at least half of the services we're doing more efficiently. No one wants to ask the patients what they really want because we already know the answer. They want what we want, and we wouldn't want to travel by bus and by foot for 30 minutes just to sit in a dingy waiting room all day only to be told that our baby's horrible, scary cough doesn't need any treatment and then be scolded for not using the thermometer correctly.

We would want a trusted person or persons we could call on when we were afraid of a symptom or unsure whether to go to the doctor. Someone who would gather community members together to help everyone figure out how to make the whole environment healthier. When we did need a doctor, we would want to go to a warm, welcoming place where the staff greeted us as a friend and enjoyed serving us and we were happy to pay for their care in one way or another. We want a relationship with at least one person in this office that we can trust to be our advocate. We want these people to communicate well with any higher-level or specialty care we might need.

And if some of us deserve this, all of us deserve it. Some would argue that nobody deserves it, but no matter. Shouldn't we all work for it? We would have to give up a system of "better than..." The trouble with trying to make things good for everyone is that a lot of better than disappears. Martyrdom and crusades have to be let go of, given up. We crusaders don't think we are holding up change, but as long as we work for CHC's existing in their present form, we are part of the inertia.


I think so. Michael Fine talks about using a primary care base and self-designated patient centered medical homes as the way to take medicine "over the rainbow" and into a new era. Indeed, the vision of what we all idealize in health care in many ways resembles the concept of "patient-centered medical home" that many hail as the savior of primary care and the health care system.

But the truth is we're not going over the rainbow, because there isn't one. New problems will arise, there will be 2 steps forward and 1 step back, even in the best of reforms. Like morality, health is complex, and the idea that we can "progress" it to an ideal may be a myth. But we can keep working on the systems, the control mechanisms, and the goals that try to achieve justice, balance, and efficiency.

The risk of "better" is that it is sometimes so obvious that something is better than something else, we forget to ask if it's actually good in the first place. We use the complacency of better to allow ourselves the luxury of avoiding the critical. We become the inertia we originally fought against.

All my life presidential elections have invariably elicited the phrase, "the lesser of 2 evils" to explain many people's voting. During the campaign that Obama eventually won, I never heard it once. Maybe there is hope now. Hope that we can look for and invest in what is actually good instead of settling for what is simply "better."

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