politics and practice based on mindfulness

Tuesday, February 17, 2009

St Francis's hovel

I'm on a mini-retreat at Casa Chamisa a B&B in Los Ranchos de Albuquerque.  Every day I spend a few hours with my teacher and enjoy hours of personal practice every morning ... what a treat!  I was looking outside at dawn in a fairly rosy mood, and discovered something quite delightful on the verandah wall:  a lovely Mexican tile mural of St Francis feeding the birds. 

There seems to be a St Francis inspiration at this B&B.  Casa Chamisa has 5 chickens, two horses, 3 roosters, four cats and an "attack parrot" (that's the sign on her cage but Tildy is a sweetheart with a G-rated vocabulary). The furniture in my room floats on a cloud of cat hair.  Arnold Sargeant's hospitality and cooking are outstanding, but if you don't like critters, don't come here! 
On the plane to NM I read that fine, fine article in Harper's magazine (Luke Mitchell "Sick in the Head: Why America won't get the health care system it needs" February 2009).  

Mitchell shows why the health insurance lobby enthusiastically backs Obama's healthcare plan (universal coverage w/no single payer).  The new system will ride on the coattails of insurance company vendors who provide the multibillions' worth of computerized prescription and clinical records every year.   As they expand their industrial healthcare business model they'll achieve near-total mechanization of primary care treatment, a "streamlining" process that will eliminate most family physician-patient visits.

In the article, insurance industry leaders say they'll create economies in the new system by reducing the (already attenuated) amount of contact time between patient and physician.  

How will they begin?  Through a highly-regulated system of patient-doctor communication.  The article describes the prototype of an email system enabling patients to contact doctors ... the system integrates with an ATM-style, fully automated, pill-distribution system.  This plan may reduce medication error (that will be its selling point).  And it will be much easier for clinicians to over-prescribe unnecessary meds to patients without examining non-pharmaceutical treatments such as "talk" therapy, PT, yoga acupuncture (non-automated care).  

Only a very small part of the Obama stimulus law will try to measure the efficacy of meds vs. treatments that require lots more hands-on, personal, clinical care.  And insurers are trying to block this provision because even a small amount of research supporting non-pharmaceutical treatments could halt the gradual mechanization of care. 

Oh, and we can forget about doctor's visits as a standard part of insurance coverage: most symptoms that are anything less than acute or emergent will be emailed  by patients (that is, by those patients lucky enough to be part of the broadband system).  Maybe the really really lucky patients will be able to be "seen" on the doc's videoconference device.    

These changes are only a heartbeat away from implementation.  Patients complain all the time that the private-insurance model undermines their relationship with docs.  Things look to be getting worse.

We need to remember St Francis's home -- a "hovel" (in the words of one of his biographers).  There are apochryphal stories about how clerical examiners from Rome arrived in Assisi and were dismayed by St Francis's enthusiastic return to the vows of simplicity and poverty.  Shocked by the friars' tenement, and irregular housekeeping, the examiners nearly had the place condemned, ecclesiastically speaking.  The friars kept no customary "hours" because they were mendicants, begging for alms.  They trusted that prayer, and their relationships to their flocks (human and animal) would pull them through.  Francis's vow of poverty was a healing corrective to the entrenched materialism of the medieval church.

My point: there is a certain amount of  improvisation in healing relationships.  A student lets a small fact slip, an hour after my orderly, written intake, and as a result, I see the case in an entirely different, and clearer light.  Or I run into a doctor in the hallway, and remember to follow up about a student; important information is exchanged and the doctor finds good reason to call and check on the patient/student.

The unexpected connection, a serendipitous observation, the everyday accidents and slips that are part of an authentic communication experience will be LOST in the new automated system. 

Francis's example as a compassionate healer reminds us to be generous with ourselves not our material assets, to find surprising solutions together, and to aspire to be fully present in our connections to each other.  

If, as now seems inevitable, Americans allow medicine to be comprehensively automated, then alternative practitioners like me who preserve this authentic messiness in communication, need to be included despite issues of credentialling and expense.