Stuff, maybe nonsense

So I have been finding myself more easily angered lately; certainly grief resulting from the death of my friend J a week before Thanksgiving is a huge factor but perhaps there is more to it. I attended a couple of presentations lately where it seemed that large topics were oversimplified and where the speakers' own point of view was presented as fact. This is the sort of thing that can (and did) make me totally nuts. One is reminded that, when the only tool one has is a hammer, then everything tends to look a hell of a lot like a nail. It is so easy not to notice that one has only a hammer.

There is much to annoy in current health care discourse and sometimes it seems the job of chaplain brings me to notice those things acutely. At present there is an enormous focus on how patients need to change their lives so as to improve health, with an underlying sense of judgment applied to folks who are perceived as using "more than their share" of health care resources. Consider smokers. You cannot read an H and P (history and physical) about a patient who has smoked or is smoking without that fact being noted, no matter what the reason for the patient's visit to a health facility. Some health professionals are openly scornful of smokers feeling that they have brought some health issues upon themselves and should have known and done better. Which in an abstract sense is true--the dangers of smoking have certainly been widely published and an informed consumer certainly can find the information that suggests quitting would be a Good Thing. I don't know, though, if we understand what it is we ask folks to do when we keep harping on the topic. If I live in a family where everyone smokes, and I work with smokers, and my friends smoke, and indeed some of my social contacts come from "smoke breaks" at work, say, then is it really an individual thing that I can simply stop? Will I not have to do something about my environment if I am taking the dangers of smoke seriously? That's a lot harder than slapping a nicotine patch on and fighting cravings, which is hard enough on its own.

I begin to wonder why we don't get as righteous when we deal with people who have a lifetime of participating in sports, from jogging on up, and now are needing joint replacements, physical therapy, etc., related to wear and tear from athletic activity. Are such people not also taking "more than their share?" But hospitals, far from scorning the Boomers with blown knees, are building fancy new orthopedics units and buying fancy new robots for surgeries and competing like mad to get the business. Maybe joint replacements, being procedures, are reimbursed at a more reasonable rate compared to obstructive pulmonary disease, which can involve repeated hospital stays and is ultimately not curable. I don't know--but health care is not neutral in its views of its consumers. I have heard folks blame returns to hospital (that is, patient is discharged but only maintains in the home or nursing home for a day or so and comes right back) on patients' failure to adhere to discharge instructions. I suppose this accounts for some, but the ones I've seen happen with medically complex patients who are discharged because their insurer demands that they move to a lower level of care in a certain number of days. The guidelines for length of stay depend on the main problem for which the patient is being treated. Which is probably highly appropriate and cost-effective for patients whose condition is relatively straightforward, but for patients with underlying health issues may be kind of nuts. Thus we see patients discharged from the hospital on Day X after some procedure, when something may be brewing but it's too early to know, and a day or so after they get to a rehab facility or home, there's a full-blown infection somewhere and back to the hospital they go. That certainly cannot be blamed on patient failure. So better patient education is not going to be the big fix for this problem. The fact is, hospitals discharge patients earlier and sicker than once was the case, and not all patients have the support in the home to recover well, and care facilities are getting sicker patients without in many cases the staffing to care for these patients. No simple fix here, so when I hear a speaker talk about how repeat admissions must be fixed by patients being more responsible I am annoyed to put it mildly.

It seems to me that the huge push to reduce employee expenses in aid of controlling costs is nuts. First off, the more people get put out of work, the wider the gap becomes between rich and poor. Also, when people are not working, they are not able to consume the products and services being offered so "efficiently." Cutting numbers of workers has been disastrous in a number of areas--I'd say health care is one. Robots, scanners, protocols can only do so much. At some point none of these can substitute for a set of skilled human eyes that can assess a patient and understand when to use, and when not to use, the tools at hand. I'd also say that food production is an activity that should be more labor-intensive. Perhaps there would be less food-borne illness if more eyes and hands were on the job, and more care taken for quality. Perhaps food production could happen in more sustainable ways if the entities doing it were less concerned with "efficiency--" I don't know.

Last night I remember fragments of a dream--I was in a place where there was a fair bit of land and there were gates where I could let my dogs into fenced areas. Somehow a mother bear and two cubs got into the area where the dogs were and I was terrified. I wanted to get the dogs in and away from the bears, but one bear cub got into the house for awhile. Eventually the bears were on a neighboring golf course, and I called the authorities. The authorities could hear the bears but couldn't find them. Eventually they told me I was simply going to have to work on dealing with the bears, finding ways to keep the dogs safe knowing the bears were around. Not the news I wanted by a long shot. Puzzling.

Weird times, these are, in the inner as well as outer life. That's all for now--need sleep.