U.S. Healthcare: Micro to Macro

From the Higgs boson to light-bending galaxies, a physics lesson on scale, and how our vantage point can make all the difference.

From the Higgs boson to light-bending galaxies, a physics lesson on scale, and how our vantage point can make all the difference.  
   
The standard joke is told so many ways. Question: Where should a doctor stand to change the world? Answer: Anywhere, because the world will revolve around him. We get so caught up in healthcare and health policy that we forget that most of the world goes on around us, not giving a damn what we do or think. Within reasonable limits, the rules of the world don’t change. First, we are all going to die, and most of us are soon forgotten. Second, giving meaning to our lives is a matter of quality not quantity. Some very short lives have made stunning changes in world history. Lastly, as life goes on in this primordial intellectual sea, with its surfeit of pundits and procrastinations, our ability to separate shit from Shinola becomes harder and harder. All change is not progress, and we must not confuse new with improved.

This past week is one in which we must sit back and reflect on the vastness of both “big history” (since the Big Bang), and fundamental science. 2012 may go down as the annus mirabilis of the 21st century, much as 1905 was for the 20th century. That was the year in which Einstein published three papers which changed the post-Copernican world as we had come to know it. On July 4th of this year, the director general of CERN announced the identification of the Higgs boson. Before you go, “Ho hum, what’s for dinner?” I will remind you that this is not just another subatomic particle. It is the subatomic particle. It is the one that Peter Higgs and his colleagues calculated in 1964, and is now proven to be correct. It has been nicknamed “The God Particle” because it gives mass to matter. It’s what makes fermions, leptons and quarks make sense. It completes the standard model of physical existence. If we crawled through the worm hole back to the 1950s in Princeton, New Jersey, there would be a smile on Albert’s face. He spent the last 30 years of his life trying to unite all four primary forces into one equation. And the Higgs boson brings us one step closer. Does it prove everything at the quantum level? No. But it goes a long way to help us understand life at 10 to the 40th power.

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At the other end of the spectrum, in that week of July, things were turned on their head in another way. Professor Jörg Dietrich – from the home school (The University of Michigan) – published in Nature a series of experiments that circuitously confirm the existence of dark matter. By looking at the bending of light between galaxies Abell 222 and 223, they were able to calculate the gravitational pull required to cause the observed photo bending effects. Since we’ve now confirmed that 85 percent of the matter in the universe we can’t see and that 70 percent of the energy is dark energy, our smallness becomes all the clearer. Dr. Dietrich states that: “The gravitational mass needed for such light bending is about 60 trillion times the mass of our sun.” Contemplate for me 60 trillion. That’s more rhinestones than there are in Vegas. By now, if you are still reading, you are saying, “Greg, what in the world does this have to do with emergency medicine or healthcare?” My answer is “scale.” Sometimes we need to look for solutions to problems at many levels, big and small, the micro and the macro.

Our thinking on healthcare problems must not be a simple pastiche of what we learned in medical school. Questions must be asked – and answered – at appropriate levels. No macro, 20,000-foot national policy can answer the question of whether a young adult with a minor head injury needs a CT scan. There are no macro answers, only micro problems. Then again, simply going along and ordering such a study (which has 180 times the radiation of a chest X-ray) dooms us to further cancers and greater poverty. Don’t ever think that individual decisions of physicians at the boson level can’t affect residual gravitational pull.

As we discussed last month, there is no relationship between the amount spent and the amount achieved in healthcare. Separating the dross from the diamonds on health spending is a dilemma which seems to baffle the federal government at the macro level. Let each state decide what it feels is healthcare. That’s what the Canadians do when they aren’t saying, “Eh.” Canada has broad healthcare mandates, but it is taxed, paid for and run at the provincial (state) level. From a policy perspective this has one great advantage. It forces the discussion to take place where the action happens. States, unlike the federal government, must balance their budgets. No kicking the can down the road and bankrupting our grandchildren. What we have done to our future generations is immoral, disgusting and frankly, unconscionable. We have, as Shakespeare said, “hoisted by our own petard.” Without imposing strict cliometrics to our situation, the societal basis of our perverted thinking remains a virtual Hallelujah

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Chorus of idiocy.
At the state level, we have a scale we understand. We can intelligently decide whether to “rent or buy.” We can respect certain traditions. If the people of Miami, Florida want to spend three times per person in the Medicare program than the people in Minneapolis, Minnesota do, so be it. But let them pay the cost. Let them tax themselves. Let them ask the correct questions about what they’re getting for their money. Let’s then debate the issue and talk about solutions. We can then better decide what is right. At the state level, we would ask questions about the marginal utility of most of the medications that we now prescribe and the limitations of our “life-saving ICUs.” We would give high credence to intelligent home care and appropriate – not exceptional – care to patients in persistent vegetative states.

Orpheus visited hell thinking he could change the past. He couldn’t, and neither can we. Not even God can change the past. But we can learn from the past; indeed we must if we want to avoid repeating our mistakes. We have fallen into a vicious loop of lunacy in which we do the same things over and over and expect different results. The time has come for physicians to guide the particulars of this social conversation and bring some sanity to a machine which has spun out of control. The ancients understood. Aristotle’s Ethics and Aquinas’ Summa Theologica complement the efforts to delineate the limits of nature. The natural law is placed upon us, and we must begin to coordinate our resource utilization with those things which living creatures cannot avoid. Both of these ancient texts seek to educate man about how best to live within these limits through the practice of virtue in order to achieve a condition of human flourishing.

Alexis de Toqueville was the first political philosopher to accept how a contractual liberalism would be applied beyond politics (in the narrow sense of the term). He saw that in a liberal democracy, the principles of consent would be applied not just to the political order but to the better part of human life. He saw clearly the potential splintering effects of democratic individualism which have now overtaken us. Everyone has rights. No one has responsibility. And no one wants to pay. Everyone thinks grandma ought to have everything, yet nothing should come out of their pockets. But Tocqueville was, in his own words, a “strange liberal.” He knew the American success story depended on an American soul, and he held that the belief in a higher calling – and in each other – could elevate the station of the human
race and the discussion of human needs and desires.

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Let me close by returning to the first paragraph, where we looked at the universe over 80 magnitudes of 10. The question: Can we as a people find a magnitude of scale at which to solve our health care problems, so that such magnitude does not smother and drown what was the magnificence of America?

Ignis aurum probat, miseri fortes viros.

Greg Henry, MD – Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.