LONELINESS

Many years ago I treated a patient who was suffering from a near fatal case of loneliness.

 

No, I am not exaggerating for this person would later confess that she had come to me in a last-ditch attempt to resolve her problems while promising herself that if I couldn’t help she would hang herself. She was a 20-something attractive and very modestly dressed woman who did indeed look very despondent with the psychomotor retardation and furrowed brow characteristics of clinical depression. When I asked her why she was there to see me, she hung her head, stared at the floor, and tearfully responded that she had been shunned.

 

She went on to tell of how her infraction of the church’s rules (one that most of us would consider a minor infraction) had resulted in her being officially designated as one with whom the entire church should have no contact whatsoever. You may be thinking: “Big deal go find another church.” But her story was more complicated. She had grown up attending this church. It was the center of not only her spiritual, but also her social and family life. Since the church doctrine insisted that only members of their church were true Christians, the members were warned about the dangers of consorting with people outside the church, apparently convinced that sin was contagious. Thus, when alienated from the congregation, which to make matters worse, included her entire family, she found herself totally alone.

 

Such stories are not new as evidenced by Nathaniel Hawthorne’s tear-jerker, THE SCARLET LETTER, but give witness to the importance of relationships and the pain of loneliness. Many religions have used banishment of varying degrees of severity to punish wayward members. The Catholic Church’s policy of excommunication appears to be less stringent and is viewed by the church as a means to save souls whereby one can return to the fold and regain salvation by repenting. Such tools are powerful and their use can have long lasting effects. For example, I recently discovered that my Great, Great, Great Grandfather was shunned and ejected from the Quaker church. It occurred to me that if he had toed the line, I might be a Quaker.

 

AND YOU THOUGHT SMOKING WAS BAD

Solitary confinement has long been used as a means to enhance the discomfort of imprisonment, and is agreed by many to be a form of torture. In a previous blog, WHAT’S LOVE GOT TO DO WITH IT? I contended that our need for relationships is encoded in our DNA, having evolved long ago as a major contributor to the survival of our species. If one were to accept that premise, it would be logical to assume that loneliness could be a major problem for us. Indeed, according to Vivek Murthy, M.D., the former Surgeon General of the U.S., loneliness has become “a growing public health crisis.” He has said that loneliness is a more effective agent in reducing longevity than obesity, and that its toxic effects are worse than smoking 15 cigarettes per day. Recent research into the prevalence and effects of loneliness tends to confirm Murthy’s assessment. Last year Cigna released a report on a study of 20,000 people age 18 and over as measured by the UCLA loneliness scale.

 

Nearly half reported loneliness as a problem, but even more concerning was that 27% felt no one understood them, and 43% admitted they felt their relationships were not meaningful. One in five felt they rarely or never felt close to others or that there was anyone they could talk to. It was also noted that Generation Z (those born after 1996) were the loneliest of all the generations measured.

There have been a number of studies which confirm the effects of loneliness on physical and mental health. It is not surprising that it could result in affective disorders such as depression, and may help explain the increase incidence of suicide as mentioned in my previous blog, but there is also evidence that loneliness can cause or aggravate innumerable maladies including: hypertension, coronary artery disease, dementia, inflammatory diseases such as arthritis, impairment of immune systems, and even some malignancies to name a few.
A study in the Archives of Internal Medicine sponsored by the National Institute of Health followed 1604 people over the age of 60 (average age 70) for 6 years and measured their physical decline and mortality rate. Their stark conclusion was: “Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.” Need I say more about our need to engage with our fellow man?

 

WE ARE NOT THE ONLY LONELY

It turns out that we are not the only nation where loneliness has become a problem, both from a public health and productivity perspective. Great Britain’s parliament has recently appointed a commissioner to investigate remedies for what has been called a silent epidemic after a study showed that 20% of Brits reported they were lonely most or all of the time. It appears there are similar studies in progress in other European countries. It would be helpful to know if loneliness is a worldwide problem or peculiar to our culture.

NOTHING ELSE TO DO

If one accepts the premise that loneliness is a significant problem, the question arises as to how did we get this way and what can we do about it. Prior to the industrial revolution, multi-generational families provided a sense of belonging. Relatives galore, including parents, siblings, cousins, grandparents, aunts, and uncles usually lived in close proximity. With the switch from an agrarian to an industrial society, there had been a migration to cities where houses were built close together, which resulted in the development of neighborhoods usually composed of people with common interests. There was the inevitable clustering of children who interacted with only minimal adult supervision, and stay-at-home moms who could relate to each other in a very personal way. Neighbors were evaluated based on certain standards including friendliness and mutual respect. The lack of air conditioning and television made front porches very popular especially on hot evenings, and provided an opportunity for informal socializing. The only taboo subjects were sex, religion, and politics.

 

BETTER THINGS TO DO?

Soon after World War II ended, front porches began to disappear from neighborhoods, and there was a wild rush to the suburbs where large green lawns were treasured and families had fewer opportunities to be “neighborly.” On hot summer nights, it became more comfortable to be inside the house (with air conditioning) than outside. There were also new-found entertainment devices available – first radio, then TV, movies in the VCR and then DVD Player, video games, and then the internet which gave us social media and streaming. One could go for months or longer without ever having face-to- face contact with one’s neighbors. There was no longer danger of an errant foul tip sending a baseball through someone’s window. Privacy became important, and it was no longer considered a snub to build a fence between houses.  There were no kids playing hopscotch on the sidewalks, as a matter of fact, there often were no sidewalks in these new neighborhoods.

Competing Schedules and Activities

As more mothers joined the workforce and children were exposed to more structured extra-curricular activities, long-held family traditions changed. There was concern about the “latch key children” so named because they would come home to an empty house. The evening meal, often the only time in which the entire family came together, was often disrupted due to conflicting schedules. This led to the so-called crock pot families where the family meal was available to all who passed by…making it easy to just grab a bite and be on your way without any hassle (or conversation).

Forced Socialization in the Pew

Another effective defense against loneliness was the weekly church service. Traditionally, religious institutions encouraged socializing (and in some cases, demanded it). However, attendance at religious institutions has declined in recent years (one study says church membership in the U.S. has declined from 70% in 1999 to 50% in 2018).

 

WHY SO MUCH LONELINESS?

It is ironic that in this digital age when we have vastly improved modes of communication, that we would identify loneliness as a problem. Facebook’s founder, Mark Zuckerberg, insists that he saw his invention as a tool by which relationships could be fostered throughout the world and help dispel feelings of loneliness and dissention, but it appears that it has done more to promote divisiveness and distrust.

 

With the invention of the telephone we gave up non-verbal cues in our conversations, and the trade-off for its convenience seemed like a good deal. Now kids have largely given up talking on their cell phones in favor of texting. Voices from the internet, news media and politicians all conspire to promote divisiveness and paranoia to the point that it is almost impossible to have a rational conversation about many of the issues of the day.

 
Today people are marrying later and living longer. As reflected in the census figures of 2012, 32 million or 27% of Americans lived alone which was up from 17% in 1970. As you might expect, widowhood is likely responsible for many single occupant households, and in another study it was found that 47% of women over the age of 75 lived alone. With aging, comes the inevitable debilities and limitations. The National Institute on Aging reports that nearly half of all people over the age of 75 have hearing loss, which can be a major impediment to any meaningful social interaction resulting in withdrawal from friends and family.

 

It has been said that Americans are losing faith in our institutions, and our political leanings are often shaped by who we hate rather than who we like. Political discourse has hit a new low. Muck raking is no longer good enough, and has been replaced by personal insults a la grade school rants. Respect for contrary opinions has now gone out of fashion. Divide and conquer is the new strategy, and a tactic that seems to have even been adopted by the news media (Matt Taibbi has written an entire book about it, called “Hate Inc.”). We lack heroes. We frequently hear the term “disenfranchised” these days, a synonym for “left out” and to be an outsider is lonely for any herd critter.

ALL IS NOT LOST (stay with me…a little break from “downer” time)

There is some evidence that there may be some efforts underway to deal with the loneliness issue. I was pleased to see a recent article in Psychiatric News suggesting that psychiatrists are focusing more on loneliness as an underlying psychiatric problem (don’t know why it took so long to figure that out). A former president of the American Psychiatric Association has suggested that assessment for loneliness be part of any evaluation or perhaps become a diagnostic category in the DSM 5 (the shrink bible). There is also a growing awareness of a worldwide suicide epidemic which most would agree loneliness all too often plays a part.  Lonely lifestyles also frequently seem to be common with mass murderers.
lonely quote

LONELINESS VS. BEING ALONE

Proximity to other people is not necessarily a solution for loneliness, for it is not unusual to feel lonely in the midst of a crowd. Obviously, some type of emotional engagement is necessary to dispel lonely feelings. Ordinary discourse involves much more than words. Unfortunately, in our digital world many of the nuances of communication are lost. Not only are the tone, rhythm, volume, and timbre involved, but there are multiple non-verbal cues which can modify or even completely change a communication. As a matter of fact, some very significant interactions may occur without any words spoken. In that vein a text hardly measures up to a face to face encounter as a means to communicate feelings.

 

Emotional tone is less relevant, for even an argument can dispel lonely feelings.
Although, until recently, there have been few attempts to measure the extent of loneliness, there is definitely a consensus among sociologists and mental health professionals that there has been a definite increase. Employers have taken note of recent research which has shown that employees are more productive when they are encouraged to interact with each other. As a consequence, in many cases the traditional office cubical arrangement has been scrapped in favor of a more open environment, teamwork is encouraged, and brief chats at the water fountain are less likely to result in a dirty look from the boss. Since most workers spend nearly half of their waking hours in the workplace such changes could be very beneficial for large segments of society.

 

GO TEAM

The needs for engagement with other humans has long been addressed by the formation of millions of organizations that bring groups of people together with myriad goals, but which also provide an opportunity to relate to others. The sense of belonging to a group is a powerful antidote to loneliness. Young people who feel neglected or alienated are more likely to join street gangs (easier to radicalize for terrorism and/or recruit for “religious” cults*). Athletic events and concerts attract millions, most of whom “show their colors” and cheer as one. One of my all-time favorite TV shows was Cheers which identified the locus of the show as the place “where everybody knows your name.” Organizations of all kinds including sports teams, military, and political groups or for that matter any group of people with a common goal make use of the need to belong which at the end of the day is an antidote to loneliness.

THEY NEED EACH OTHER

AARP sponsors a very interesting and apparently successful program called “Experience Corps” in which volunteer over 50 are enrolled in a program where they are trained to help children develop literacy skills. They spend 6 to 15 hours per week working with K-3 students with spectacular results including as much as 60% improvement in reading skills, fewer behavior problems, improved attendance, and increased graduation rates  The AARP foundation at last report had 2,000 volunteers throughout the country serving over 30,000 students. However; it appears the volunteers may be benefiting more than the kids from the program. A University of Michigan study reported a statistical decrease in depressive symptoms and functional limitations among the volunteers after two years involvement in the Experience Corps. There may also be a secondary benefit in that some kids may learn to venerate rather than denigrate us old folks. (Score 1 for the Old Farts!)

 

BE CAREFUL WHAT YOU WISH FOR

None of this should be interpreted as an attempt to diminish the value of solitude. Certainly, this need to relate can be overdone, and in some cases become pathological. In many cases of marital therapy, for example, too much togetherness can be identified as the problem. In testimony before Congress, Prof. Julianne Holt-Lunstad defined loneliness as ” the perceived discrepancy between one’s desired level of social connection and their actual level of social connection.”  She explained that some people who are socially isolated don’t necessarily feel lonely, and some people who are lonely are surrounded by people who make them feel more alienated.

 

One’s work may require so much contact with others that it can become oppressive, and some personalities may cause anal pain of the worst kind!  Nevertheless; before you make plans to spend the rest of your life on a deserted island or join an order of non-verbal monks, be careful what you wish for. Time-alone can be refreshing, relaxing and creative, but as with most things in life, it can be overdone. Alone can be good, but lonely can be very bad. In this time in which we are all mutually dependent, it has become even more necessary to have relationships than we did in those days when we needed help to bring down a woolly mammoth. It is difficult nowadays to survive in this world as a loner. We face enormous problems including an increased global population, competition for resources, and degradation of our environment. It is once again time for us to hang together or hang separately.

WHAT MAKES THEM TICK?

The ability of the human race to relate to each other has allowed us to survive and to thrive.  We need to exercise that talent now more than ever.  As I finished writing this, once again two hate-filled young people described as loners committed horrible atrocities within hours of each other. It goes without saying that we need to take logical steps to limit access to those instruments designed to kill people, but the prevalence of these kinds of behaviors also require us to learn more about the milieu in which they occur.  For example: are there genetic influences involved, does our society in some way generate such hatred, are certain personalities more easily recruited to violent organizations, is shyness a precursor, and finally does the hatred cause the loneliness or vice versa?  We need to understand more about how these people end up the way they are if we are to have any success at solving the problem.

The Way It Was | Part 2

Note from the editor: Click here to read Part 1 of “The Way It Was”

Conversations Overheard

There was a fringe benefit for me from the depression in that I received my first indoctrination into the ways of the world which included comprehensive discussions of politics, economics, world affairs, and morality but with a special focus on means of survival in difficult times.  My education occurred while lying on our living room floor listening to Dad and friends (not to be confused with Fox and Friends) debate all kinds of issues while they focused on possible work sites.  The men were regular visitors to our house where they met and planned strategy to find work.  It is likely that they were attracted to our house as a meeting place by Dad’s famed home brew.  Although he was not a bootlegger per se, he was known to have occasionally traded a bottle or two for some needed commodity.    I was an accomplice in the enterprise as I took great delight in placing a cap on each bottle and watching Dad press it in place. 

There must have been a robust feeling of camaraderie amongst those guys who were all in the same sinking boat.  There was laughter in spite of their dire circumstances, and there were frequently told colorful stories which without benefit of Dad’s home brew would not likely have reached my tender ears.  The coarse language was not lost on me, and was quickly incorporated into my vocabulary, the use of which would often get me in trouble.   One particularly memorable event occurred when Dad took the guys down to our cellar to show them his success of the day.  He had received a feisty old rooster in return for a day’s work, and the rooster was confined to the cellar, a small space with a dirt floor cool enough to render the beer palatable.  Someone stumbled over the pan of water left for the rooster and Dad filled it with beer.  Surprisingly, the old guy imbibed with gusto and was soon stumbling, flapping his wings, and attempting to crow in a falsetto voice.  If he was hung over in the morning it was short-lived as a few hours later he would be on a platter sharing space with some drop dumplings.

Work

In spite of the bravado most of the conversations had to do with work or rather the lack of it.  The meetings were unscheduled and men would drop in at various times during the evening with comments like “I thought I would drop in to shoot the shit.”  There were always rumors of things to come both good and bad… this place was laying off, another was going to be hiring, another business was in trouble and about to go under, etc.   In 1933 the unemployment rate is said to have been 25%, but that number does not tell the whole story.  Many who were said to be employed were actually able to work only part time.  For example, Barb recalls her Father listed as an employee at a local steel mill, but usually actually working only one day a week and sometimes sent home early even for those days.  He avoided eviction by painting houses owned by his landlord. 

One conversation in particular stands out in which one of the men who was employed at a local glass container factory said he had just come from his workplace and had been turned away.  He reported that at every shift change there were huge crowds of employees at the entrance hoping to be chosen to work that day, but few would be chosen.  He loudly and profanely complained that the foremen “suck asses” and relatives were always the first chosen to work.  Some jobs or professions previously considered ordinary were highly prized.  Postal workers, school teachers, and local government jobs were highly prized for their stability.  The lack of available cash led to a great deal of bartering, especially with farmers who had no one to whom to sell their crops.  Conversely, professionals such as doctors and lawyers along with day laborers were often paid with food (e.g. the story of the inebriated rooster).   

Civics (Yesterday’s Term for Politics)

No education is complete without lessons in civics and the down-but-not-outers were not shy about expressing their opinions in such matters which was probably enhanced by the tongue loosening effects of Dad’s beer.  There was considerable disagreement amongst the group with almost everything.  In our home Dad was registered as a Republican and Mom was a lifelong Democrat.  I have the opinion that in those days one usually belonged to the party with which they had grown up much as with they do with religion.  Dad in spite of his upbringing had experienced an epiphany: he blamed Hoover for the depression and lauded FDR’s efforts to restore the economy. 

Those on the negative side of the debate were equally vociferous in their ridicule of FDR’s “make work programs” and “socialist stuff.” There were all kinds of jokes referring to the WPA and their workers having a penchant to be seen leaning on their shovels.  With the establishment of social security in the mid- thirties the idea of government taking money out of his check (if he had one) and giving it to someone just because he got to be 65 years old did not sit well with the naysayers.  A typical analysis might go something like this: “What ever happened to the idea of saving for old age” or “If they can’t take care of themselves, they should go to the poor house” (large forbidding appearing buildings euphemistically referred to as county homes).  Families were expected to care for their elderly or infirm parents consequently; they shared in the disgrace, and were denigrated for forcing their parents to “suck on the public tit.”

The most often discussed and vilified make work program was the WPA (Works Progress Administration).  The average wage was $52 per month yet one of my uncles worked in the program until it was disbanded in the early 1940s.  During that time, he managed to raise two children with the help of his wife who was able to find work cleaning the house of an affluent neighbor.  Although largely removed from most employment opportunities, wives did find ways to contribute.  For example, Barb’s Mother did laundry in her home in spite of a childhood injury that left her crippled.  The WPA worked on infrastructure projects while the CCC (Civilian Conservation Corps) focused on environmental projects.  It was an organization for young men who were housed in barracks throughout the nation and paid even less.  They were best known for planting millions of trees, often in areas where logging had left a desolate landscape.  Roosevelt in announcing its formation said; “forests are the lungs of our nation.”  They also fought forest fires, worked in national parks and landmarks building roads, trails and camping facilities.  Many such projects remain in use to this day.

Philosophy 101

While listening in on those conversations from my vantage point on the living room floor I was also privy to discussions of moral issues some of which have bedeviled philosophers for eons.  For example, one evening one of the guys reported that he knew of a place where it was possible to steal casing head gas.  Although gasoline was 18 cents a gallon, he did not have 18 cents, his car was out of gas, and he couldn’t look for work. (For the unenlightened of my readership: casing head gas is formed by compression of natural gas by functioning oil wells.  It is a very low quality fuel and can cause significant damage to automobile engines.)  Since he was without the means to get there, he was attempting to recruit an accomplice.  This provoked a heated debate.  Not only was his proposal illegal there was that “thou shalt not steal” thing in the Bible for which some thought there were no exceptions.  This brought up oft delivered hypotheticals one of which was very relevant to their situation which was “would you steal food if your children were starving?”   

Keep Walking or Go to Jail

Vagrancy laws made homelessness even a greater problem than it is today for one could go to jail for “having no physical means of support.” When I looked up the origin of such laws, I was surprised to find they were written after the Civil War as as a means to get freed slaves off the street and into the chain gangs which could be rented out, a process some called a new form of slavery.  These laws were found to be useful during The Depression as a means to rid the parks and other public facilities of the homeless.  I had always wondered where all those men I used to see walking along the highways were going.  Later it became obvious that they must stay on the move or go to jail.

These were the same guys who would sometimes appear at my Grandmother’s back door offering to do work for food.  Of course, there was no expectation that work would be done.   Grandma would bring a plate out for them and after a brief repast they were on their way. Since farmers were those who were most likely to have food to spare and cops were scarce these backroads were fertile territory.   I heard stories of farmers who discovered “bums” asleep in their haymows especially during inclement weather.  Depending on the compassion of the farmer they might be awakened by the business end of a pitchfork or sent to the house for something to eat then on their way.

Many of these hoboes or bums as they were called in those days would become so enured to that lifestyle that they would spend the rest of their lives on the move never staying more that a few days in one place.  They became expert at hopping freight trains, knowing their schedules and where they slowed enough to get on them.  They often migrated with the birds following the seasons.  They eventually developed places where they could hide for a few days at a time usually close to a rail depot but far enough away to avoid the railroad police.  It is said they verbally catalogued places that were soft touches for hand-outs.  Thus, a nomadic subculture came into being demonstrating the remarkable change which can be brought about in an industrial society by an economic crisis.

An Early Exit Prevented

At some undetermined time during those preschool years I experienced life threatening incidents one of which would label my Father as an unlikely hero.  In what was probably an effort to provide food and recreation simultaneously, he had decided to take me, my brother and mother fishing probably with the hope of making a meal of our catch.  The site, called Pleasant Valley was a favorite of mine and was next to a small conclave of houses reached via a covered bridge over the Licking river.  Its only reason for existence was a Post Office situated next to a major rail line.  It was a mail distribution facility for a large part of the county, and its fascination for me was to be able to watch the train rush past at what seemed to me to be at least 100 mph, while a metal arm reached out from the mail car, dropping a bag of mail, while snatching a similar bag, and pulling it back into the car without even slowing.

Most likely, on that day I was preoccupied with the hope that the mail train would come by.  The river was high, and I recall staring at the water as it rushed by, then everything was suddenly brown.  Probably that memory remains so vivid due to fact that I would have a recurring dream of that incident for years although; such dreams were not frightening but consisted of the sensation of floating in that brown water.  I am told that Dad saw me fall into the swollen river and immediately jumped in although he could not swim.  I was told that my life was saved by a single button for I was wearing a light jacket with one button fastened and Dad reached out with one hand and was able to grasp the jacket with one hand.  He threw me upon the bank and as he was floating by, managed to grab a root growing out of the river bank and save himself.  Thanks be to God that the button held for had it not you would have been denied the joy of reading these blogs!

Editor’s Note: Stay tuned for Part 3 of The Way It Was! 

WHO CRITIQUES THE CRITICS?

The critics of the world are puzzling to me. I am puzzled not only by what they say, but how they become experts in the particular activities they critique. I have always seen myself as the possessor of normal intelligence and on good days think I may even belong on the plus side of that bell-shaped curve. But when I read some of the reviews of music, books, movies, art and even scientific articles, I realize how really stupid I must be. I often have no idea what they are talking about, and wonder if I am on the wrong page.
It reminds me of something one of my patients said when describing his former psychiatrist’s intelligence. His assessment was: “He was so smart that I could hardly understand a word he said.” I admit that I have used the big word tactic in the past hoping to impress people of my superior intellect, and with that in mind have accumulated several multi-syllabic ones which I keep in reserve for special occasions, but I could never compete with these guys in the weird word department.
Most of my exposure to critics comes from the several publications to which I subscribe (and sometimes even read). Much of human behavior can be explained in my opinion by our origins as herd animals, and to be a good member of the herd one must follow the leader or in this case the expert. As a relatively compliant human I tend to take seriously the critics’ recommendations, but often find their assessment so far from mine that I have difficulty touting it to others. All is not lost in those situations for it gives me the opportunity to let my audience know that I am well read and something of a connoisseur myself. If that is well received I may even launch an attack on the critic.
Their in-depth analyses especially of artistic stuff runs so deep that I often find myself drowning. It has been said that beauty is in the eyes of the beholder, and I suppose that also applies to ugliness. For example, the music that is pleasing to my grandchildren is experienced by me as simply loud and irritating noise. This would not likely result in an objective review by me of the latest hip hop or rap song. In like fashion, my parents were turned off by the swing music of the ’40s and ’50s with which I grew up.

Art: Ugly or Genius?

Nowhere is the critic more likely to wax poetic than when reviewing visual art. For me a painting for example is either pleasing or not, but these guys find hidden meanings which continue to be invisible to me even after they point them out. I am very fond of the impressionists who were the “Polly-Annas”  of the art world in that they chose to enhance the beauty of things they portrayed. I do realize that ugly has a legitimate placed in the art world. If the purpose of art is to elicit emotions, then art can be a powerful tool which forces us to face the world’s ugliness. Unfortunately, it appears to me that much art that is ugly was not intended to be so, nevertheless it may be taken by some critics to be a mark of genius. It has occurred to me that were Picasso to have shown up in an art therapy session in my hospital and do his cubism thing, I would have set about forming a plan of treatment for his psychosis.
Could this be yet another example of the “Tail Wagging the Dog?”

The better-known critics have a great deal of power. A favorable review from a big-time critic can put a starving artist into a much higher tax bracket, or conversely send him looking for a low paying day job. Many critics become celebrities in their own right. I can only imagine how many wannabes would gladly suck up to an art critic from the New York Times. Likewise, a visit from one of these gurus must be a major coup for a gallery owner. With all this influence available could it be that this is another example of the tail wagging the dog? Are the ever-changing fads in art due to boredom with the status quo or simply another instance of follow the leader?
Poetry: Schizophrenic Word Salad or Genius?

Perhaps the most glaring example of my literary deficiency lies in the inability to understand much of contemporary poetry. Admittedly, when it comes to poetry, I am a simple-minded person of the roses are red, violets are blue category. However, I recently inadvertently read a rave review of a book of poetry and subsequently happened on one of the poems in that collection. It reminded me of the “word salad” sometimes heard from those who suffer from a severe form of schizophrenia. The alleged profound thoughts these words were to elicit never reached my brain. It probably sounds heretical to many, but I can’t help wondering if I am really missing something or if these guys are just blowing smoke.
Art: The Language of Feelings

As you might expect, an old-fashioned guy like me is a big fan of Robert Frost. I must have been in junior high school when I first read his classic “Stopping by Woods on a Snowy Evening.” After all these years I am amazed at how it still takes me to that place and time, and leaves me in that snowy place for a minute or so. Were I a critic, I might describe the last three lines of the poem (“I have promises to keep, and miles to go before I sleep, and miles to go before I sleep “) as a metaphor for life, but I choose to simply luxuriate in the feelings the poem elicits. When I attempt to define those feelings, I am at a loss for words, but perhaps that is what art is all about i.e. the language of feelings.

 

Music

Music is another category of which I am blissfully ignorant. Having flunked out of a couple of attempts to learn to play a musical instrument, I am vaguely aware of the complexities involved, and have the greatest respect for musicians of all stripes not only for their talent but dedication and work ethic. Nevertheless; since I am unencumbered by enough knowledge to analyze music I am left free to either enjoy or abhor it

Movies

When it comes to movie critics, my favorite hands down was the Siskel and Ebert TV show which lasted nearly 25 years. These two guys who must have spent most of their waking hours watching movies presented their opinions of current movies. The interesting part was that they frequently and sometimes violently disagreed in their critiques. Their debates demonstrated that pronouncements by experts are by definition subjective.
Where the Critics Really Shine: Scientific Literature

None of this is meant to diminish the value of critics for we are in need of those who can sort through the massive amounts of information dumped on us, and make recommendations. Nowhere are critics not only important but essential than in scientific literature.  Studies are often very complex and beyond our ability to understand.  Fortunately, there are always other scientists familiar with the subject at hand who are passionate about the pursuit of truth, eager to examine the data, and study the design and conclusions.

The Undiscovered Geniuses are Waiting…

No matter the subject scrutinized, it behooves us to remember that that in most cases such critiques are only opinions, and one should not close their mind to other possibilities. Undoubtedly, there are many undiscovered geniuses among us. What a tragedy if there were a Michelangelo or Shakespeare out there somewhere lost in the crowd.

P. S.To the best of my knowledge there are no blog critics active as yet, but if you happen to be one please be merciful.

LEST WE FORGET

In a previous blog I mentioned our local newspaper, and recounted “the good old days” when our small town had three competing daily papers. I subsequently made a number of disparaging remarks about our one remaining paper which was purchased some time ago by Gannett. Nevertheless, my day usually begins with a cup of coffee and a perusal of the Times Recorder. It doesn’t take long. The front page usually has some local human-interest story which I don’t find very interesting so I usually proceed to page 2 and the obituaries which is the real reason I continue to subscribe to the thing.

WHY THIS SUBJECT?
Barb insists that it is absolutely morbid that I choose obituaries as the subject of this blog, but I feel it is both important and timely. Long before he had reached my present age, my Father wrote his and my Mother’s obituaries. He was always one who liked to be in control and I am sure he did not have much faith in anyone getting it right. Regardless of his motivation, it turned out to be a blessing for we survivors.

As you may have surmised motivation for my daily obituary searches has much to do with the fact that at my age I now see more familiar names on page 2 than I have in the past. Indeed, my contemporaries are dying at an alarming rate. I have no plans to write my obituary as we have an experienced obituary writer in the family. Before leaving for less green but more lucrative pastures in the big city, Maggie was in charge of obituaries for the TR (don’t you hate acronyms?). She tells me it is standard practice to assign that job to cub reporters, which says much about journalistic priorities.

BORING!!!
Sadly, most obituaries are boring recitations which are little more than death notices which say little more than when and where he or she was born and died along with a brief chronicle of their life with a focus on their occupation. This is followed by a list of family members living and dead, and information about funeral arrangements. It does appear to me that those traditions are gradually being swept away as I see many instances in which there is only a graveside service restricted to family members, but that’s another story. For many families cost may be a factor in the length of obituaries as they usually charge per line of type. In larger cities it is much more expensive. For example, the New York Times charges $263 for the first 4 lines and $52 for each subsequent line. Each line contains only 28 characters and is printed in very small (7 point type).
WORTH REMEMBERING
In spite of the brevity of the average obituary in our paper there are some which give hints as to the nature of the subject’s life. Just this morning I read the obit of a 96 year old woman and found the loving portrait inspiring. She was said to have had a “long well-lived life.” She was described as a “feisty woman who lived life to the fullest and enjoyed the thrill of playing slot machines.” She also enjoyed her grandchildren, great grandchildren and great great grandchildren. She had worked in a factory all her adult life and attended church which was “just up the road from where she was born.” Most important was the statement “She was a loving woman who will be missed by family and friends throughout Morgan and Perry counties.” In my opinion, to be missed allows one’s life to continue in others’ thoughts; consequently no one wants to be forgotten.

FORGETTABLE
Throughout history it has been important to immortalize our heroes with statues and other icons so they will continue to inspire us, and not be forgotten. It is also not unusual for the living to build their own monuments. Likewise, it is common for people to prescribe in detail the hymns to be sung, the burial method and even the entire process of the funeral with the possible exception of the eulogy. This is done in spite of the realization that they will not be a witness to the festivities. In the old days one could easily identify the most affluent buried in the graveyard by the size of their gravestone. Now modern cemeteries are devoid of monuments expressly to be more egalitarian, but coincidently eliminating impediments to mowing the grass.

In spite of our best efforts, we will in all probability soon be forgotten. The odds of our being remembered for longer than a couple of generations is probably much less than winning the power-ball jackpot. Millions have gone before you and failing extinction of the species millions will follow. You will need to be very, very famous to stick out in such a crowd. Even a famous blogger is not likely to make the cut. Although your name will be recorded in various places you will have been long forgotten until someone encounters your name as they work on their genealogy, and they will wonder what it would have been like to-know you.

FAVORITE OBITS
It is true that obituaries have a certain utilitarian value in that they not only announce the death but list those to whom you might want to send a sympathy card, provide the time and place of the funeral, etc., but I find little information which would help me to know the person. There have been some examples in which anecdotal information has provided me with an idea as to a person’s identity, and a feeling that I would like to have known them. One such case was a single statement in an otherwise generic obit of an elderly woman as follows: “Edna’s family gathered at her home for Sunday dinner at 1 o’clock every week for over 60 years and welcomed all guests with open arms. Edna will be remembered for her peach-pecan and pumpkin pies, noodles, and birthday cakes, her patience, kindness, and unwavering and unconditional love for others, and most of all, her heart of gold.” In the annals of motherhood, it is difficult to imagine anyone topping that record of nurturing. I felt as if I would like to have known Edna. Maybe I could even have wrangled an invitation to Sunday dinner.
My all-time favorite obituary was one which kept me laughing. It was written by a daughter who began with a quest for anyone interested in dinner plates. It turned out that her mother had been a collector of all kinds of different items, including dinner plates, and the daughter was overwhelmed. She went on to describe all her mother’s quirks in a most loving and tender but funny way. It was my all time favorite and I consider it a masterpiece. I tried to save it, but since we have a rule in this house to never lose anything unless it is important it has disappeared.
WHY THE IMPORTANCE
For those of us who will not have a bronze likeness in the courthouse square, our obituary will be the most lasting chronicle of our lives. It will probably be written or directed by someone who loved us and thus emphasize our better natures providing a template for living a full life. Obituaries remind us of our mortality which is not always a bad thing as such awareness can be a powerful motivator.
Obituaries have been with us since Roman times but as print media is replaced by the internet, obituaries are likely to follow suite. One such example is “The Blog of Death” written by Jade Walker who was formerly a chronicler of the deaths of the rich and famous in the New York Times. She was also hailed for producing a publication of the obits for all the victims of the nine eleven attacks. She describes her blog as: “…featuring the famous, infamous and interesting unknowns.” Undoubtedly, major newspapers will continue to publish obituaries deemed newsworthy. One often cited example is the Los Angeles Times preparation of Elizabeth Taylor’s obituary two years before her death presumably in order to be ready for the great event. Ironically, the person who wrote it died before it was published.
With the demise of local newspapers throughout the country, I assume that their archives containing millions of obituaries will be lost. There are organizations which profess to have access to nearly a century of published obituaries; however I am not sure how that is done, e.g., do they simply access newspaper archives? For most of us our obituary is all that remains of us to be remembered for longer than a few years.

SAVED BY THE CLOUD
As Jade Walker points out, the internet provides opportunity to include pictures, personal anecdotes, and experiences which could allow us to relate to lives that are gone. In an era when there is data available to unravel the human genome, keep track of who and where we are, who we talk to, and what we buy, it does not seem unreasonable to catalog obituaries. Perhaps the information could be managed by the Library of Congress, and the millions of wondrous stories which are now literally buried could be available for all to see. It could even contain the recipe for Edna’s peach-pecan pie

THE SMARTEST GUY “He’s so smart, I didn’t understand a word he said.”

Editor’s Note: Due to my ability to type really fast, one of my first jobs was to use the Dictaphone at my dad’s office to type information dictated by the psychiatrists. I would use my foot to press the peddle that played the tape and type along as they spoke. I typed letters to consulting physicians and articles they wrote for publications. I remember being surprised at my dad’s vast vocabulary. He certainly didn’t use those fancy words in the office or at home. When I discussed this perplexing issue with my dad, I learned two lessons that have stuck with me my entire life. 1) Don’t use a dollar word when a dime one will do. 2) Know your audience and communicate in the language they speak. One of our running family quotes is part of this blog post: “Doc, he was so smart I didn’t understand a word he said.”

THE SMARTEST GUY 
My Grandson gave me an interesting book for Christmas. This is not a book review so the title is not important. Suffice it to say, it has to do with some theological issues which he and I had discussed in the past, and in particular a “doubting Thomas” streak owned by me. There was much food for thought, some of which was not very digestible.
The author was obviously well read as there were 53 pages of references cited. It was well written; although I found some of the reasoning a bit convoluted. It was a tedious read for me, but I must confess that I also have trouble deciphering the Bible. All of the quotes the author offered throughout the book often added to my confusion. I am sure those guys are all very famous; however I had never heard of most of them. The author would make his point then throw in a “in the words of……….” which was not nearly as coherent as his original statement. Perhaps he was only paying homage to the experts in his field, but I was impressed that he must be a speed reader to have read all that stuff. I was also surprised to learn that Christianity could be so complicated. 
As I read the book, I was reminded of an experience from many years ago. I was seeing a patient for the first time. His was a chronic, although not disabling condition, which had been exacerbated by the unexpected death of his psychiatrist. He talked warmly of his feelings for the deceased, and shared that he missed his counsel. He also spoke of his respect for the man’s intelligence with: “Dr………. was the smartest man I ever knew. He was so smart that when he said something I couldn’t understand a word he said.”
Now all these years later, I can identify with this patient’s assessment of the good doctor’s intelligence for some of the guys quoted in the aforementioned book were much too smart for me to understand. You may be thinking that the alternate explanation might be that I am too stupid to understand, a conclusion that I am loath to accept. After all, I did manage to limp through 24 years of school even though my scholastic career was admittedly undistinguished. My mother proudly said that I knew my ABCs, and could count to 100 by the time I entered the first grade. I have a vivid memory of my father showing my third grade report card to everyone in Varner’s store who would look. Even though this was the first and last time he would be able to exhibit a report card with all A’s, I feel it should count for something. 
There is the possibility of another less flattering explanation, which could help explain the comprehension problem. I have a friend whom I have always admired for his scholarship. His writings demonstrate a vast knowledge of classical literature, history, philosophy and classical music. He is also a veritable expert in psychoanalytic theory. His writings make use of metaphor and relevant quotes. Imagine my surprise when in my confessions of envy for his use of all this knowledge in his writings, his wife responded, “I think it is just showing off.” Perhaps she was having a bad day or he had forgotten to take out the trash, for she has shown her love for him in many ways during the many years they have been together.
The comment by my friend’s spouse does raise the question as to whether our writings are often more about ourselves than the subject about which we are writing. Could it be that sometimes the message intended may be corrupted by our ego needs? How much of the motivation of this author’s writings were motivated by a need to “show off”? For that matter does that same dynamic have anything to do with my writing of this paper. I have often said in jest that I would like to be rich and famous. Since the former has escaped me, perhaps I am still holding out for the latter. But then I have also had fantasies of winning the $1.5 billion power ball thing; even though I have never bought a ticket. 

When I was a kid we sometimes perpetrated cruel party jokes designed to humiliate and embarrass. One such stunt involved telling a joke with a nonsense punch line. The group who was in on the joke would laugh loudly, and the butt of the joke would join in the laughter even though there was nothing remotely funny. We called such tactics “shaggy dog stories.” I must admit there are times when I feel I have nodded in agreement with someone when I had no idea what they were talking about, much as the patient who idolized his dead psychiatrist must have done. 
There are times when reading something that is clearly beyond my abilities to grasp, I wonder if I am the victim of a shaggy dog story, and that the author is having a good laugh at my expense. The most recent example is my attempt to wade through a book on quantum mechanics. I was humbled by my inability to make any sense of that stuff. Upon learning that the book was written for ordinary people like myself left my ego was left in shreds. This was not Greek to me. It was more like a mixture of Mandarin Chinese, Arabic and Apache indian. What I could decipher was so implausible that I found myself thinking “can this person be serious?” and again wondering if this was not a variation on the shaggy dog theme. 
It has been said the best defense against Alzheimer’s and similar dementias is to make liberal use one’s brain. All intellectual pursuits are encouraged, but I have noted that this can clearly be overdone. I submit that a brain can also become fatigued; consequently, I will now put down my book on particle physics, fire up my kindle, and escape to a mindless mystery novel. 

HEALTHCARE GOES DIGITAL

HEALTHCARE GOES DIGITAL
In my last blog, I promised to delight you with my observations about the Electronic Medical Record (EMR). In accordance with the current custom of using anachronisms rather than words in the medical literature, I will henceforth use the term EMR in my discussion of the topic. Since early on in its development the computer has contributed much to medicine. Without it the various scanners routinely used to make instant diagnoses could not have been developed. It has become an essential tool in medical research. Without computers what many believe was the most important medical discovery of the century, namely the unraveling of the complexities of the human genome could not have happened. One can hardly imagine any area of medicine that has not been influenced by the so called digital age.

Considering all this, it is little wonder that the computer would eventually be touted as the answer to all the problems said to exist in the delivery of healthcare in the United States. The promise was that it would: 1) save money, 2) reduce errors, and 3) improve outcomes. The stick that The Department of Health and Human Services used to encourage adoption of EMRs was to penalize those non-compliant by reducing their reimbursement rates.
1) SAVE MONEY (?)
It is a bit difficult to imagine there could be significant savings when one considers the cost of the initiation and ongoing support for these systems. One study estimates the initial cost of a five physician group to set up a system to be $233,000, not taking into account an average of 600 hours needed for training in its use. Following the initial investment it is estimated maintenance costs would average $17,000 per year. Since the costs for a solo practitioner would obviously be higher, it is not surprising that many such individualists are either retiring, joining a group, or taking a salaried position.

1) SAVE MONEY (continued) / Too many zeros…
But physicians’ costs are chickenfeed compared to the costs of hospital computer systems. Perhaps the most outlandish was the $4 billion spent by Kaiser Permanente. They report however that this will result in a cost of only $444.00 per each of their insured. This came after an admitted $300,000 dollars was spent on a previous plan which was abandoned. The interviewee, CIO Philip Fasano, insists that the $4 billion expended for the current plan is well spent as he believes it will save 15 to 17 percent of costs by eliminating duplicate testing. It will be interesting to see if such savings will result in a reduction of premiums. In addition to the price paid by hospitals and physicians to set up and maintain EMRs, there is the $30 billion spent by the feds on these projects. In my research on this subject I did come upon more numbers, but by then I was so busy counting zeros that I became too dizzy to record them.

2) REDUCE MEDICAL ERRORS ?
As for the reduction in medical errors, the most obvious benefit accrues from the virtual elimination of handwritten orders, reports, prescriptions etc. From personal experience I can attest these are often illegible, and consequently subject to interpretation. Some may insist that poor handwriting is a prerequisite for graduation from medical school. If that is true, then I have been imminently qualified as penmanship was not my strong suite in first grade and it has gone downhill from there. In spite of the problems associated with writing, verbal orders and reports carry an even greater risk of miscommunication. It has been demonstrated time and again that the more steps through which information passes, the greater the likelihood of error.

2) REDUCE MEDICAL ERRORS / The disconnect between theory and application
When information is communicated digitally, it follows there should be fewer errors. If such information can be delivered automatically the risk should be even less. For example, hospital laboratories are largely automated these days, and it follows that if a machine delivers its report seamlessly i.e. without touching human hands it should be less likely to be misread, misplaced, or ascribed to the wrong patient. Unfortunately, Erin McCann of Healthcare IT reports that in a nationwide study 74% of nurses reported feeling burdened by the need to do data entry, which took time away from patient care. The impression left is that much data must be entered manually; consequently most systems are anything but seamless, and therefore still subject to error.

It is easy to imagine the scenario in which a patient’s electronic medical record could be lifesaving. For example, when an unconscious patient is brought to an emergency room his medical record may be critical in making a diagnosis in situations where time may be literally a matter of life and death. As a matter of fact there are many situations when the instantaneous availability of a patient’s record may save time, unnecessary tests, and even lives. It should no longer be necessary to spend time in hospital record rooms or doctor’s offices copying records, x-rays, scans and such. Not only written reports, but actual copies of films, EKGs and such could be called up in order to see if changes have occurred. Come to think of it, there would be no need for record rooms or the floor to ceiling racks stuffed with file folders we see in our doctor’s offices. Yes, in a perfect digital world Joe Patient would carry his entire medical record with him wherever he went and it would be accessible whenever needed, but anyone who owns a computer knows that we are some distance from perfection when it comes to this computer stuff (more about that later).

3) BETTER OUTCOMES ?
The third premise that EMR would create “better outcomes” is still up for grabs. It is noteworthy that, according to a report in FiercehealthIT, 17% of physicians surveyed thought EMRs actually worsened patient care. One might be led to think this group would consist mostly of old digitally challenged physicians like myself, but the disturbing fact is that the number of negative comments has increased since 2012.

According to a Patrick Caldwell piece in Mother Jones5, 75.5% of hospitals were using EMR programs by 2014, but I am not aware of any indications that quality of medical care has improved. Indeed, I don’t know if it would be possible to do such an assessment of an issue that complex. He goes on to issue a scathing report on the business practices of competing providers of EMR software. He contends that the various programs do not share information with each other in order to protect company secrets. This would prevent the seamless passage of information unless all his healthcare providers subscribe to the same system thus defeating a major purpose of the program. Thus Joe’s record would only be available to a consulting doctor or hospital ER if they subscribed to the same version as did Joe’s regular physician. Peter Pronovost MD, director for patient safety and quality at Johns Hopkins, was likewise critical with his statement that: “Medicine invests heavily in medical technology, yet the promised improvement in patient safety and productivity has not been realized.”
EMRs and Me
My own brief experience with an EMR tends to validate the premise that interoperability is a problem. When a facility where I was working adopted a program, I was able to sufficiently overcome my age related aversiveness to change and make a half-hearted attempt at compliance. I tried to hone my deficient typing skills (we had no typing classes in medical school), and dutifully began typing check marks in the boxes provided, which often resulted in a great deal of useless information. There were some advantages, such as the ability to send prescriptions on line rather than writing them on paper or calling the pharmacy. In addition to the convenience for both myself and my patients, it solved my penmanship problem, reduced errors, and prevented forged or altered prescriptions.

Maybe this EMR thing will work after all
With that in mind, I was heartened by the news that our local hospital was going digital. We were dependent upon the hospital’s psychiatric department as a place to send our patients who needed intensive treatment, and for the psychiatric department’s extensive outpatient diagnostic capabilities. I had visions of entering my patients’ identifying numbers in the computer and instantly being privy to every bit of medical information about him. No longer would nurses spend time on the phone calling about lab work, or waiting for the record room to respond to requests for discharge summaries, or reports from consults. The fax machine would no longer go through a ream of paper every couple of days. I would no longer be accused of nurse abuse because of questions like: “Where in the hell did you put that lab work?” As some of my younger, more verbal patients would say: “Dream on baby!” For as computer geeks would say their system was incompatible with ours (in plain speak, their system would not talk to ours) and we were forced to continue to rely on that older, but more reliable invention called the telephone.

Is our healthcare system broken?
The statistics available seem to confirm the premise that the U.S. healthcare system is broken. In an interview by PBS, Mark Pearson the head of the health policy division of the Organization for Economic Co-operation and Development (OECD) provided some discouraging statistics. Politicians have long trumpeted the fact that we spend over 17% of the gross national product (GNP) on healthcare, which is second only to defense spending.
Healthcare by the numbers
Pearson reported that we spent $8,233 dollars per person in 2010, which was two and a half times more than the average per person cost in 33 other developed countries. The average cost for a hospital stay in the U.S. is $18,000 which is three times that of the other countries, in spite of the fact that hospital stays were shorter in the U.S. The Commonwealth fund  reports that 25% of that cost is for administration. Drug prices in other countries are sometimes less than half the price we pay, in spite of the fact that the majority of new medications are developed in the U.S., often with financial support from the National Institute of Health. Of course the drug companies also get some help from their friends in congress who have without apology passed a law forbidding Medicare from negotiating prices. Oh yes, just another example of the perverse golden rule of the corridors of power, namely: “those with the gold make the rules.”

What are we getting for all this money?
After digesting all this information, you may be asking, what am I getting for all this money? The answer: not much. There is no doubt that we lead the world in medical research, and people come from all over the world to study in our institutions. We have been the absolute leader in the development of medical technology.  Then, why is my life expectancy over one year less than it is in 33 other countries? We might blame it on lifestyle, obesity and such, or could it be that our shortened hospital stays could have a deleterious effect?

Words matter, but true listening requires vision
Patients have complained to me that they are often told their doctor cannot see them in between appointments and they are told to go to the emergency room sometimes with even minor complaints. But the most frequently heard grievance was “my doctor doesn’t listen to me.” Not surprisingly, this was more commonly heard as the digital age invaded the consultation room and some physicians pecked away at their computers while the patient talked. Of course, there is much more to effective communication than the use of words, and no matter how attentive the listener, without visual cues much of the message is lost.
In my humble opinion, it is incredibly naïve to think that computerization could have a major effect in closing the gap between us and the OECD nations. After all we are undoubtedly ahead of them in implementing EMRs and management systems; consequently, any advantage gained would be countered as they would inevitably follow suit with similar technology. You may be asking what is the answer, if EMRs are not. I have long held the position that there is a shortage of medical doctors in this country, and OECD study tends to bear this out. They report the U.S. has 2.4 physicians per 1,000 people while the average for the countries scrutinized was 3.1 per 1,000. Thus we have fewer physicians, fewer hospitals, and shorter hospital stays at 2 ½ times the cost.

What we do have are more CT and MRI scanners along with lots of other expensive gadgets, and they are utilized much more frequently than in other countries. One disturbing bit of research by the Dartmouth Institute for Health Policy concludes there are very large differences in the rates of utilization of such diagnostic machines in different areas of the country.
Even more upsetting is their conclusions that the number of elective surgeries, cardiac interventions, and even open heart surgeries are all performed at vastly different rates in different areas of the country. Should we conclude from this that some areas of the country are over treated or that others are undertreated? Information obtained from the OECD study would suggest the former is likely true. Hospitals are required to have a utilization committee composed of physicians who look for outliers among their peers; however, in my experience they are not very effective in rooting out excesses.  Indeed, if they were one would not expect to see such disparities in diagnostic procedures and treatments.

Enter Managed Care
In recent years insurance companies’ managed care programs have gotten into the act. They exercise control by simply not paying for services they feel are excessive. I believe it is safe to say that they are universally hated by physicians. I share that feeling with more intensity than most of my colleagues because I blame them for the too early discharge of one of my patients which led to his death. It is interesting that the courts have ruled in such cases that the managed care company suffers no liability with the rationale that they are not denying treatment, only refusing to pay for it.

No doubt, many of the problems I have enumerated with The EMRs will be fixed eventually, and the concept can be of marvelous benefit, but it is also clear to me that computers will not fix everything that is wrong with our medical system.

So, what is the answer?
At this point, if you are still awake, you may be thinking: “OK wise guy, if you are so smart, what would you do about it?” And I would reply, “Thanks for asking for of course I have all the answers.” After all, I have been a participant and observer as medicine evolved into the current mess, besides I now have learned how to use Google.

The Age of Assembly Line Medicine
It may seem counterintuitive, but I am convinced that a significant part of the problem is due to a shortage of physicians. No, it is not merely a matter of competition although that is not necessarily a bad thing, rather it has to do with the pressure to be productive. Dealing with lives merits deliberation, and impulsive decision making is apt to lead to errors. The production processes of assembly line manufacturing Henry Ford developed may be advantageous for manufacturing cars, but completely inappropriate for treating human beings, especially those who are sick, in pain and in distress.

The lost art of LISTENING
One of my professors from medical school once said: “if you listen carefully to your patients they will make the diagnosis for you 80% of the time.” As I mentioned previously many of my patients complained that their doctor was not attentive, and always seemed in a hurry. Since there is a shortage of physicians, there will be a need to see more patients; consequently less time is made available to talk, and the doctor seems remote and uncaring. The patient may leave with unanswered questions and harboring a great deal of anger. When called upon to consult with hospitalized patients as a psychiatrist, I often found the problem to be the result of a doctor patient relationship gone bad. To the physician, the patient seemed unruly and uncooperative when they just didn’t feel they were being heard.

Litigation
Another downside of failed communication between a physician and patient is litigation. As a matter of fact, insurers report this scenario is a major cause of malpractice suits, and that the best protection from malpractice suits is a good doctor patient relationship. Of course the cost of these suits, which are less prevalent in other countries is also said to be a major cost factor. Some states have initiated procedures to help reduce the number of suits and to limit the amounts which could be paid; meanwhile refusing to search for reasons for why there are so many suits filed.

The Conundrum
A few years ago, after retiring from private practice, I began working part time at a public facility that had a very long waiting list of people needing to be seen. I was asked if I would be able see a patient every 10 minutes. I replied haughtily that I was not a prescription technician, yet afterward wondered how many of the people on that waiting list might be suicidal. These are the kinds of dilemmas facing doctors, especially those in primary care settings (i.e., if you spend adequate time with each patient, how many won’t be seen at all). In my small town, there are very few primary care physicians who are currently accepting new patients leaving many people to seek care at our ER which of course is much more expensive. The solution, which is currently underway, is to license those with lessor training to diagnose and treat. I am sure there is also the thought that these nurse practitioners, physician’s assistants and such will demand lower fees, although that may not have work out as expected. I also question the wisdom of solving the doctor shortage in this manner, especially during a time when the increasing complexities in medicine demand more knowledge than ever before.
Fee-based vs. appointment-based physicians
There is also, in my opinion, a maldistribution of physicians, with the shortage most acute among primary care doctors. Family doctors have always been the grunts in the healthcare domain, with the specialists commanding the most respect especially the surgical specialties. Those who do procedures are reimbursed based on a fee schedule while primary care docs are essentially paid based on time spent with the patient. This can lead to serious inequities in incomes. The days of the solo general practitioner are past, for most find they cannot generate enough income to pay their overhead. It requires a considerable staff to do billing, get authorizations from insurance companies, fill out forms, deal with managed care, medicare, medicaid, pharmacies etc. He is forced to accept insurance company fee schedules if he wants to be “on their panel”. Add his malpractice insurance to the mix and soon he will be looking for a salaried job or a group to join. Young doctors may be saddled with hundreds of thousands of dollars of student loan debt which can be a powerful motivator in choosing a career choice as he may look toward the more lucrative specialties.
Living History
In 1965, I had been doing general practice for a very few years and when medicare came in to being that year I was convinced that this was the beginning of the end, and Joe McCarthy was right when he said we were well on our way to being taken over by the communists. The precedent of connecting healthcare to employment had already become entrenched by corporations who used that fringe benefit to attract workers during the labor shortages of world war II, but in the 60s Blue Cross and Blue Shield were the only significant players and all that was necessary was to send a bill and receive payment. Of course it made no sense for health insurance to be tied to employment, but the labor unions were not about to give up that goody, and it remains in ObamaCare, which is one of the reasons why although better than nothing it is not by much.

Eating crow
Now, 50 years later, I have eaten so much crow that I regurgitate black feathers as I have become an unabashed promoter of a single payer system, that is medicare for everyone. Such an idea is certainly not new as it was first proposed by Teddy Roosevelt in 1912. I have dealt with a system that has become increasingly complex each year, and have done battle with giant corporations whose major function appears to be to find ways to deny treatment to those whom I feel are in need. I have this perhaps naïve view that with the insurance companies out of business and their lobbyists gone maybe our do nothing congress might do something beneficial for their constituents.

One frequently hears that socialized medicine would bankrupt the country due to the inevitable inefficiencies that would result. The reality is that medicare may be the only efficiently run federal program in existence with an administrative overhead of less than 3%. The affordable care act only allows health insurance companies 20% in administrative costs, whoopee. Of course this does not take into account the millions of dollars spent by hospitals and doctors which would be greatly simplified if they only had one entity with whom to deal. Even without taking this into account, we would reduce total health care costs by at least 15% if not more.

More savings could also accrue were congress to repeal that ridiculous law prohibiting medicare from negotiating drug prices. In addition to the effect on total costs, I find it repugnant that populations all over the world pay less than I do for my medications. This seems unlikely to change since Pharma seems to be especially adroit with their lobbying efforts. I would be very interested to hear from Congress their rationale for this law. It must be a dandy.
There is also the economic effect on businesses to be considered. Many industries report that providing health care for their employees is a rapidly rising expense that makes it difficult for them to compete internationally. One would think they would be busy lobbying for a single payer system. The digital movement in healthcare has spawned new departments in most institutions. In the mental health center where I had recently worked one person managed to keep all the computer stuff running, until the introduction of an EMR. It soon became necessary to hire 2 more people, and an IT department was born.

Longevity has its advantages, and in my case it has allowed me to witness and in a small way be part of the profession of medicine during a period of momentous discoveries. The 60 years of my involvement saw the virtual elimination of many illnesses which had been responsible for millions of deaths and untold suffering. When I began practicing medicine, if someone told me that it would one day be possible to transplant a human heart I would have laughed in their face. To confirm the suspicion of a brain tumor would require two or three days of tests some of which were dangerous, now an in depth picture of the brain is available in a matter of minutes. Even in my own field of psychiatry the study of the mechanisms underlying brain functions has revolutionized the field, and the complexities described often leave me wondering what the hell they are talking about. This paper is in no way meant to denigrate these accomplishments; rather it is an attempt to expose some of the factors which have resulted in an inefficient and costly system of providing them to the masses.

At the outset, I listed three goals that were hoped to be accomplished by the digitization of our medical records. The first was to decrease cost. From what I was able to glean from my research and personal experience I have concluded that the attainment of such a goal is unlikely. As for the other two, I am convinced that an all-encompassing computerized system has the potential to improve treatment outcomes and reduce errors. Unfortunately, the systems in play are too fragmented for that potential to be realized. It would appear that fixes are readily available. It remains to be seen if they will be applied.

Reminisces
As with most old guys I like to end my conversations with reminiscences of the good old days even though the current ones may be better. In spite of a lifetime in which I have witnessed the most exciting time ever in medicine, a time of more discoveries and progress made in the alleviation of suffering than had occurred in thousands of years, I sometimes feel nostalgic for the way things used to be even though without the miracles of modern medicine I would probably not be here today. I recall a time when the doctor patient relationship seemed much more personal than it does today, when doctors saw themselves as healers rather than fixers or technicians. I remember a time when one could even talk to one’s doctor on the phone. Now if I have a question for my doctor I must answer to the receptionist regarding my reason for calling, and if she considers it worthy of note, she will post a message to the doctor’s nurse or direct the call to the nurse’s voice mail, and if the nurse considers the question worth consideration she may consult with the doctor, but if not will devise her own answer. If she is not too busy, I may be fortunate enough to receive a call back with either the doctor’s or her answer to my question. In any event the doctor will be insulated from the stupid patient with his stupid questions. You might think that since I am a physician I would be more readily granted access, but you would be wrong for the fellowship of physicians is no longer a strong tradition.
How it used to work
I remember a time when most people had a personal physician, and usually their relationship was indeed personal. If admitted to the hospital your personal physician would see you daily even if he had referred you to a specialist, now you are apt to be followed by a hospitalist whom you are meeting for the first time. Were you to have surgery, your doctor would assist if possible. A visit to the emergency room would prompt a call to your doctor. If you were unable to come to his office, he would come to you. In short your doctor was in charge and responsible for your treatment. He would likely know your strengths, your weaknesses and usually knew most of the members of your family. In short the doctor patient relationship was very personal.

There have always been those dedicated to healing their fellow man even in prehistoric times and in the most primitive of cultures. Much of the science has been off track; however, there has been much learned about the art of medicine. It would be a great loss if that knowledge were abandoned in favor of purely digital solutions.
1. Health Affairs: Study puts a price on EMR implementation in small practices
2. Info World: tech’s bottom line May 2, 2013.
3. Healthcare IT News: Nurses blame interoperability woes for medical errors. March 15, 2015
4. FierceHealthIT: The cost benefit calculation of electronic health records systems.
5. Mother Jones: Epic Fail, November/December 2015.
6. PBS Newshour: Health Costs, How the U.S. compares with other countries October22,2012.
7. The Dartmouth Atlas of Healthcare: Reflections on Geographic Variations in Healthcare, May 12, 2010.

THE POPE AND I

No, I did not have an audience with the Pope. I confess that this title is a bit misleading, but you must admit it got your attention.

The Pope’s visit got everyone’s attention especially viewers of CNN, for their coverage was non-stop from arrival to departure. This must have made their bean counters happy, since I imagine their bottom line could be adversely affected were they to pay independent journalists to cover the horrors taking place in the middle-east and Africa, or the desperation of immigrants around the world.

You may be wondering why I didn’t change the channel to Fox and watch them trash democrats or MSNBC, as they did the same for republicans, or even to Sesame Street in case I wanted to learn something worthwhile. The problem is that Barb likes CNN.

Although I don’t wear a long white dress and beanie, I found his speeches interesting and even inspirational. At one point I nearly pulled a John Boehner and could feel a tear about to erupt. In most cases, his thoughts and opinions paralleled mine therefore; he must be pretty smart. In particular, his speech at the U. N. caught my attention when he talked about the need for people to bond and trust each other. I concluded that the Pope had much in common with this old Presbyterian. It occurred to me that our need to bond with each other seems to be universal and can have both good and bad consequences.

My understanding of Pope Francis's statement, which would result in people caring for each other, and in so doing to learn trust. There is little doubt that if such feelings for our fellow man were present in everyone, this world would be a much more pleasant place in which to live. Of course, this in not a novel idea. Many have espoused it for the past couple of thousand years, if not longer, but with minimal effect. In fact, religions both past and present, expect their members to meet and worship together. They usually encourage fellowship, and the experience of belonging to a caring group of people is fertile ground for the development of trusting relationships. The Pope must have felt there was a lot of bonding going on as millions flocked to hear his words and receive his blessings.

The Pope and I agree that bonding and trust are important. A very common complaint by my patients was of loneliness, and feeling a lack of connection to others. As a matter of fact, most of the perpetrators of the recent spate of mass murders are said to have been alienated from society. Notes they left reflect the anger they felt at being left out and alone. Group therapy has been a useful tool in dealing with such problems as it provides an opportunity to relate in an atmosphere where one can share in a safe environment, and learn to trust and be trusted. This need to bond appears to be so ingrained in our very nature that we sometimes look for other ways to satisfy the need. Those whose lifestyle or physical infirmities limit their relationships may find solace in a pet. There have even been instances reported in which prisoners who are isolated attempt to befriend the rats who visit their cells.

It is not clear when this need, so powerful that if unrequited may lead to suicidal or even homicidal behavior, became so ingrained in our psyche. There is evidence that earliest man  learned the advantages of close relationships. Indeed, it is likely that without such bonding, our prehistoric ancestors might not have survived, and could have become extinct as did other branches of the hominid progeny. Indeed, in a world where predators threatened their existence and competed with them for food, it would not have taken them long to realize there is safety in numbers. Likewise, as they developed carnivorous tastes they would have found that teaming with others would contribute to successful hunting. Such lessons learned were not unique to humans for many other mammals found that bonding with others of their species enhanced their chances of survival. With such a history spanning thousands of years, it should not surprise us that this need to bond would eventually become imprinted on our DNA.

There are some, myself among them, who are concerned about the ways in which our children are limited in developing relationships to which they can bond. Home schooling has become more popular and is likely to become more so as the digital world expands. I have long been concerned as I have seen the consolidation of small neighborhood schools to become institutions that are so large it is very easy for a child to be left out of the mainstream. Since K through 12 school is where children learn social skills, and develop much of their self-image, such feelings of alienation can have serious consequences. Parents face a great deal of stress sometimes working two jobs, and stay-at-home moms are less plentiful. It appears that kids spend much more time texting than talking. The rest of their free time is often spent playing video games. And, yes I know that a previous generation had the same concerns with the invention of the telephone, as my Grandson eloquently pointed out to me a few months ago. I agreed that the phone was a step down from looking one in the eye, but did preserve voice inflections and thereby we were not quite so insulated from the feelings of callers.

Most people would agree that neighborhoods are not as neighborly as they once were. The current generation prefers distance from their neighbors as witnessed by the current housing developments where larger lots are preferred and “houses are not jammed up against each other." Studies of large city apartment buildings indicate that many residents do not even recognize their neighbors. On the other hand, I did recently read that some companies are now eliminating the cubicles in which they isolated their employees, as they have decided that their workers were much more productive in an open office space. It was felt that the changes also resulted in feelings of camaraderie with coworkers, company loyalty was strengthened, and absenteeism was reduced. Such examples illustrate when barriers are removed, there is a natural tendency to bond.
Of course the ultimate bonds are those with our immediate families, but for most this does not seem to be enough. When populations grow so large that physical contact is impossible, they still find ways to bond. Witness any athletic contest and you will see groups sometimes numbering in the thousands banding together to cheer on their team and boo the bad guys. Though there are some loners among us, most seem to have a need to closely align themselves to a group or organization. There are lodges, fraternities, sororities, clubs, religious and political groups, reunions, and volunteer organizations to name a few. There seems to be an almost universal need to belong, to be attached in some way to others.

History tells us that nothing unites a group of people, whether it is a neighborhood, tribe, or country, like a common enemy. It makes little difference if the threat is real or imagined. Throughout history leaders of nations have been able to mobilize and bond their subjects by convincing them they have an enemy. Coaches have long known that their team’s success depends to a great extent on the relationships between their players, and their ability to function as a unit. Those who work in dangerous positions such as fire fighters, policemen, heavy machinery operators and such must depend on others to “watch my back;" consequently, trust is essential, and camaraderie is a prerequisite. Many religions bond together in their struggle against demonic forces of one kind or another.

Nowhere except within families is bonding more intense than in the military. Recruits soon unite by learning to hate their drill sergeant. The entire unit may be punished for the transgressions of one; thereby teaching him a sense of responsibility to his buddies. One may enter the service for a variety of reasons, but once in combat they report their allegiance is to those who fight beside them. The bonds formed are so intense that some experience grief after leaving their unit in spite of the dangers and horrors they may have faced. This sense of loss in addition to the survivor guilt often felt are undoubtedly factors which account for the epidemic of suicides by returning soldiers from our latest war. Some have volunteered for return tours of duty apparently hoping to recapture that which was lost.

It is true that relationships are not only pleasing, but probably necessary in order for us to maintain sanity. Indeed, one study from many years ago where volunteers were subjected to total isolation, all developed psychotic symptoms in as little as two weeks. It is also true that throughout the ages there have been the cunning and unscrupulous who have perverted this need of ours to service their lust for power. The mechanism as I mentioned previously is simply to convince a group of people that they have a common enemy and that they must unite to protect themselves or punish the miscreant for his alleged misdeeds. One need only to turn on the nightly news, and hear about the violence and chaos that persists throughout the world to see how successful these strategies have been as populations bond together to destroy their own version of the bad guys.

Although in the U.S. we moderns no longer have saber tooth tigers to fear, there are many who have no difficulty finding people to hate and whom we should fear. We have the white supremacists who are convinced we are in danger of being persecuted by blacks, the gun lobby who wants us to fear everyone, and other groups too numerous to mention. And let us not leave out our politicians as the republicans convince us we should fear the democrats and the democrats tell us the republicans are the ones who will do us in if given the vote. In other words, we are encouraged to choose sides, bond, and fight with each other. In order to fight we need a leader to save us, and there are always those who are gracious enough to be that person if only we will vote for him.

If I ever did have an audience with the Pope, I would enjoy discussing this bonding and trust stuff with him. I would probably agree that more bonding and trust is needed, but that in many instances those same qualities can also be used for nefarious purposes. In that vein, I can see myself saying, “Frank, be careful what you wish for” or in his case it would be more appropriate to modify the admonition by substituting the word "pray" for the word "wish."