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. 

recovering our balance

OK, today's silly, hypothetical question (from too many hours spent teaching yoga perhaps?):

Given our inclination NOT to ... move in slow, deliberate ways ...to walk rather than drive ... to wean ourselves from drugs that interfere with our motor capacity ... or to do a daily personal yoga practice... I have to wonder whether we're collectively losing our chops as successful bipeds.  Instead of legs, we'll have long slender fins to push the car pedals.

Modern life is making us lose our balance.  According to author Scott McCredie, America is facing a near-epidemic in debilitating falls. I took a look at McCredie's newish book (new to me), Balance: recovering the lost sense. It's a collection of essays on the evolution evolution of balance, and contemporary masters of this sixth sense (see the Amazon page). 

Poor balance is common among students who come to the studio, so I treat it seriously.  Just one fall can lead to death within months for the very old.  But more often than not the falls begin in late youth and middle age.  The effects are cumulative, and they can make life very unpleasant through head injuries, torn ligaments, plates to hold together broken bones ... every serious injury increases the odds for future impairment (meaning less walking, balancing activity: the cycle that leads to the next fall is strengthened).

When students tell me they're having dizzy spells, or have fallen, I'm moved by their vulnerable, self-incriminating sadness. The guilt is strikingly common. And sometimes it results in the blame of others, "unsafe" surfaces, weather conditions etc.

Maybe a fall is one of the few times we can actually see a consequence from our inattantion, pretty much as the lapse occurs.  

Balanced movement is much harder when we're in a state of obsession, preoccupation, or anxiety, such as overreacting to an overreactive media.  

Yoga helps balance of course.  But it takes a kind of inner equilibrium to do an appropriate daily practice, which is what's required for any real progress.  When your balance is out of whack, that commitment comes hard, especially if you lack a close relationship with a teacher. So, balance deficits resist a "quick fix".   The sense remains an elusive combination of so many skills and faculties  (vision, attention, proprioception, and the vestibular functions of the inner ear, and can be affected by so many other factors, illness, hormonal changes etc).  So we need to practice, practice, practice.

Losing our balance may mean losing a lot more than firm feet on the ground.  From the mind-body perspective, it's associated with changes in thinking and judgment.  Biped alignment is one of the signal, evolutionary leaps that distinguish human consciousness. Placing the spine upright at a right angle to the ground, has had extraordinary consequences.  In this position, humans can more easily meditate and enjoy the "relaxed alertness" that leads to profound concentration, insight, and bliss.   

art therapy for cancer (post-surgery)

Today from Reuters, an illuminating article on a small, Swedish study that demonstrated significant clinical improvements in breast cancer patients from art therapy (link here). What caught my eye: the protocol offers time and space for expression and reflection.  Sounds like meditation to me.   Through an introspective and personal process guided by the teacher, patients gradually abandoned false ideas about the gender stereotype of a perfect, healthy female body.  And that gave them more hope.  Consequently their physical healing improved according to standard, quality-of-life measures.  Having worked with cancer-diagnosed students for some time now, I'd infer that  the art therapy was similar to meditation: a form of reflection and stable attention that can provide authentic insight and positive life changes.  

Personal anecdote: I recently attended a one-day art workshop with Lee Alter, one of Charlottesville's favorite watercolor painters.  Lee's work is light in touch, minimalist and abstract, and yet she reveres our sensuous world.  She favors subjects such as figures, flowers, her beloved musician friends, and nature.  

I learned so much from her teaching, especially from her demonstrations of using breath as a guide for each brushstroke.  This technique, and her gentle method of encouragement, seemed to generate a slow, intense hum of concentration through the sunny afternoon in a local studio ... several personal discoveries and breakthroughs followed.  One participant, a post-surgery cancer patient, is a devoted student and relies on these classes to further her healing.  

I felt I was actually seeing things differently (literally) the next day.  Hard to describe how: a bit more right brained, impressionistic, less conditioned vision.  It's so good, so lucky that an artist-teacher we know can help us discover parts of ourselves that are new and regenerate.

there's gonna be a revolution ... oh yeah

A pilot program in Arizona, based on the "medical home" model,  will give primary care physicians more authority and money than usual to monitor their patients over time and check on the outcomes of outpatient, specialist services.  That is, doctors will be paid to act more like doctors and less like gatekeepers to an expensive maze of services. Instead they'll be paid to ensure that patients have the appropriate care, at the right time and in the right order.

IBM of Arizona is the employer backing this effort.  Impressive corporate sponsor.  According to Dr. Paul Grundy,  IBM's director of health care, "We're not doing this because we expect to see savings ... I think it's the right thing to do."

At the studio I hear about quality of care from my students, who are usually patients, doctors, or nurses.  Based on their complaints, ANY model that increases the time spent attending and listening to patients has to be given a fair trial.  As patients we're swamped with overwhelming information online and we're underexposed to experience and guidance.  Trust in doctors inevitably disappears when they can't spend time to help patients put information in perspective.

Florida doctors declined to participate in a previous pilot of the "medical home" from the same insurer, United Health Group, because they were being asked to do too much for too little reimbursement.  It's a reasonable point, and it displays the power of the current paradigm which mandates almost no money for low-tech, compassionate care.   Some experts on health care policy say the pilot, although promising, will likely place too much stress on small doctors' offices as they adapt to increased paperwork and time demands.  

Outmoded institutional narratives may prevent this model from working widely on a sustainable scale:  

1. Our healthcare system is not even a system, it's a hodgepodge pasted together by competing private insurers, erratic record management, and the varying financial means of the employers offering insurance.  Pharma ads and the internet compound the chaos, so patients see themselves as consumers not patients.   And I am afraid that individual outcomes will always reflect the unpredictable "system" enveloping doctor and patient alike.
2. Medical records should all be computerized to make case management affordable.  We'll need to conquer our paranoia about insurers invading privacy and find ways to secure the system. Doctors require quick access to notes from EVERYONE involved in their patients' care.  Alternative practitioners like me should be allowed to enter data on individuals because I spend more time with them than most doctors can.  That way, docs will learn more about complementary/alternative medicine.  Presumably they'll be able to make referrals to CAM with more confidence. As for MY reimbursement issues, that's material for a later blog!
3. Overuse of high technology will continue to inflate costs.  And high-tech doesn't always equate better diagnosis and care.  Hands-on doctoring and communication with patients (which takes time) may still go relatively unrewarded by insurance because it just doesn't seem as snazzy as MRIs, nor is it easy to assess in a controlled, randomized study.

Having said that, if all the findings about placebos are true (and the literature on placebo efficacy keeps growing), a health care model offering slightly more hands-on care, with a few extra physician phone calls, could make a significant difference to patients.  Trust and connection are essential ingredients in healing, and we need more of both.

(the reporting on the Arizona program is taken from Reed Abelson's story in NYT 2/7/09, B3 "For IBM Insurer Reopens Test of Rewarding Doctors for Healthy Patients")

Tara Pope Parker & the health revolution

When the health revolution comes, let's remember to thank intrepid editor Tara Parker Pope of the Well blog and her fellow online editors at the Times.  

Parker Pope's selects studies that matter to us.  And she deftly places in perspective those studies that should matter to us, because they concern the insane complexities of modern healthcare.   A recent refreshing look at the economic costs to patients for their office wait time proves her point.  We're all paying for a system that has unrealistic expectations of how much can be done in a 15 minute clinical visit.  The result? chronic logjams in physician offices.

Other NYT Health articles online reveal the ways patients are abandoned by the system once surgery and other reimbursable services end.  The article "Health scares reduce smoking not waistlines, study finds," reaches broadly into issues of insurance reimbursement and its typically grotesque outcomes.  

In our system, there's this nutty bias toward more surgery over cheaper, behavioral therapy (like yoga therapy or psychotherapy).  

Exercise-based weight loss programs seem expensive, at least upfront.  The programs require clinical supervision,  stress reduction techniques, counseling, nutrition education, blood tests for thyroid etc, and ongoing coaching/counseling.  In contrast, smoking cessation groups are ridiculously common and usually free.  

According to the article, the study's cardiac patients, who desperately need to lose weight and to quit smoking, only gave up ciggies, and maintained the same weight that helped lead to their heart attacks.  Or the most overweight cardiac patients opted for costly bariatric surgery -- that's stomach-stapling to you and me. A bariatric procedure is ineffective when performed without vital but unreimbursed coaching and counseling afterwards.  But what do we reimburse?  Surgery without counseling ... and tragically, the ER costs from the (now, more likely) second heart "event".  Crazy!

Hospitals like Martha Jeff are so committed to patient care that they try to retain at least some of their patient education programs in the current climate.  But they deserve to be reimbursed by Medicare/Medicaid, no question.

Cancer survivor students participate in the Yoga for Life program, offered free at the studio thanks to the Martha Jeff Cancer Care Center.   Students tell me one of the reasons why the class means so much is that it provides individual guidance and caring from someone trained to understand their needs beyond the treatment stage. 

Parker Pope is not only a great editor, but from her choices we see she has a public health agenda. Her blog regularly includes research on the scarcity of good, old-fashioned, hands-on, low-tech healthcare.  Check out a recent piece on  insurance mandates that FORCE physicians to be "unethical" in their care.  Then ... let's all think about how we change this.  Viva la revolucion!