Reflections on Treating the Poor

It is altogether curious your first contact with poverty. You have thought
so much about poverty — it is the thing you have feared all your life, the
thing you knew would happen sooner or later; and it is all so utterly and
prosaically different. You thought it would be quite simple; it is
extraordinarily complicated. You thought it would be terrible; it is merely
squalid and boring. It is the peculiar lowness of poverty that you
discover first; the shifts that it puts you to, the complicated meanness,
the crust-wiping.

– George Orwell, Down and Out in Paris and London


George Orwell’s 1933 memoir, Down and Out in Paris and London,
relates the clear-eyed experience of being homeless and penniless. The
novel’s protagonist lives in Paris giving English lessons and eventually
experiences a stroke of bad fortune and loses his job; money slowly but
surely disappears. He is overcome with “a feeling of relief, almost of
pleasure, at knowing yourself at last genuinely down and out.”

Imagine, Orwell asks of us, what this bad fortune means. You cannot send
letters because stamps are too expensive. At the baker, an ordered pound of
bread weighs in slightly more and thus costs slightly more — and you cannot
pay for it. You avoid “a prosperous friend” on the street so he
won’t see that you’re “hard up.” And you’re hungry. Wherever you walk there
are inescapable reminders of this: bakeries, restaurants, coffee shops.
“Hunger,” Orwell writes, “reduces one to an utterly spineless, brainless
condition, more like the after-effects of influenza than anything else.” Months pass by in between baths. Clothing is pawned. In the midst
of this scramble to live, however, one forgets that there is, indeed, a lot
of time with nothing to do at all: “you discover the boredom which is
inseparable from poverty; the times when you have nothing to do and, being
underfed, can interest yourself in nothing.”

Orwell based such descriptions largely on personal experiences. In 1927 he
spent time in the company of tramps and beggars in London, dressed in
worn-out clothing and sleeping in poor lodging-houses for two or three
days. He subsequently moved to Paris and subjected
himself to similar experiences. In doing so, he eventually brought
attention to the plight of the poor, providing an honest, unvarnished look
at what it was like to be down and out.

~

Rereading the book reminds me of Bellevue Hospital, New York City’s
flagship public hospital. Bellevue, or its progenitor, was originally an
infirmary in Manhattan in the 1660s and became the most well-known of the
public hospitals in the country (I have

written about it
 for Public Discourse). Here physicians treat the uninsured, the
undocumented, and the homeless. It is a rare day when a physician at
Bellevue does not interact with New York’s poorest residents.

Jim Henderson (Creative Commons)

Sometimes they come in search of medical care and sometimes they come in
search of a meal. They stumble in from homeless shelters or from street
corners, inebriated, withdrawing from drugs or alcohol, psychotic,
suicidal, deathly ill or sober. Occasionally they unknowingly enter the
emergency room with lice or bedbugs and nurses delouse them with multiple
layers of permethrin, an insecticide. The physician must approach these infested patients with
a hairnet, gown, and gloves — the lice crawl on the patient’s head, chest,
arms and bed sheets. The smell sometimes overwhelms the doctor or nurse,
too. It may have been months since the patient has bathed, and the odor
percolates throughout the room and the hallway.

As I wrote in my Public Discourse piece, the patient presentations
are frightening and remarkable:

Ride the elevator down, and you will stare in horror as an agitated drug
addict with an infection tries to punch a physician while bolting out of
his hospital room with security guards and nurses in pursuit. Next door, a
homeless patient lies in bed with heart failure. Next to him is a patient
who’s visiting New York from Africa with a raging AIDS infection. Peer into
another room down the hall, and you can watch patients withdrawing from
alcohol or heroin, thrashing about and screaming.

Physicians have the unique privilege at Bellevue to see poverty up close,
which so rarely occurs in upper and middle class professions. But as close
as we are, we don’t really understand the poor the way Orwell did. We don’t
live amongst them or feel the curse of extended hunger or the uncertainty
of when the next meal will come. We don’t experience that odd sensation of
boredom, where there is nothing to do because one has nothing to do it
with. And we cannot fully empathize with their fragile health.

~

This is why Orwell’s book is so enlightening. At least we get a description
of what some of Bellevue’s patients may go through; at least we get a
glimpse. It creates a little less space between the comfortable and the
impoverished.

But Orwell wasn’t wholly right about the poor. He wrote in Down and Out:

The mass of the rich and the poor are differentiated by their incomes and
nothing else, and the average millionaire is only the average dishwasher
dressed in a new suit. Change places, and handy dandy, which is the
justice, which is the thief? Everyone who has mixed on equal terms with the
poor knows this quite well. But the trouble is that intelligent, cultivated
people, the very people who might be expected to have liberal opinions,
never do mix with the poor.

True, there is a closeness between “intelligent, cultivated people” and the
“poor” simply by virtue of being human. However, there are deep differences
that would not disappear if the two simply switched jobs and clothing. For
instance, in 2016,
four percent of U.S. adults experienced a “serious mental illness.” This did not cover patients without
fixed addresses — the homeless. And     
approximately one fifth of the homeless in the United States
 suffer from a severe mental illness. Even if the definitions of “severe”
and “serious” don’t match up precisely, the difference between mental
illness among the homeless and other US adults is huge. And these
differences matter both to policy analysts and to physicians.

Two epidemiologists, Elizabeth Bradley and Lauren Taylor, have written a
thoughtful book dealing with the issue of rising health care costs entitled The American Health Care Paradox. In it they argue that our
skyrocketing health care expenditures (we spend

more than double the share of GDP
 of other developed countries on health care) and poor outcomes (we are in the high 20s or low 30s in rankings among OECD developed countries for maternal mortality, life expectancy, low birth weight, and
infant mortality) are not due to
overspending, but rather to underspending by the United States on social services — affordable housing,
education, access to healthy food, and so forth.

Bradley and Taylor
explain how this happens:

Several studies have demonstrated the health toll of living on the
streets; more than two-thirds of America’s homeless population suffer from
mental illness or substance dependency, while nearly half have at least one
additional chronic condition such as diabetes or hypertension. The high
costs of health care provided to people who are homeless have been well
documented. For instance, in one five-year period, 119 people who were
chronically homeless and tracked by the Boston Health Care for the Homeless
Program incurred a total of 18,834 emergency room visits estimated to cost
$12.7 million.

This makes sense. Many of our homeless patients deal with chronic diseases
like diabetes, mental illness, or congestive heart failure. We stabilize
them in the hospital and send them back to a shelter or the street. Often
they return the next week with exacerbation of their heart failure or
sky-high blood sugars or psychosis, even when medication is provided by the
hospital without charging the patient.

Thus a chasm separates our world and that of the poor, yet they are
entangled. How can you get someone to start eating vegetables and fruits
and whole grains in order to mitigate the effects of diabetes if they don’t
have money to buy these foods? How can you control a child’s asthma if a
family does not have money to clean their apartment and rid it of the
vermin, bugs, and dirt that pervade the nooks and crannies? How can you ensure a psychotic patient takes his medication when he can barely feed himself? The homeless
face a very different and more intimidating set of difficulties than the
wealthy. And these translate into challenges for physicians, who do
not have the time or skill to be both doctors and social workers.

We, as physicians, care for the patients until they are ready to leave the
hospital. Then they face their poverty on the street. Our view is but a
brief and skewed snapshot. In our myopic hospital world, the hospital
stretcher is detached from daily life. And this is necessarily so, to
a certain degree. Physicians can only do so much to fix societal ills — they cannot create a job, a safe home environment, or a loving family for
the patient.

Nevertheless, both wealthy patients and poor patients succumb to cancer,
strokes, and heart attacks. Both undergo the

humiliating process of death and dying
. In this sense, death and disease are often great equalizers. Neither the
poor nor the rich can escape them. They rapidly close the chasm between the
two classes. And at least in that vein, Orwell was right.

Should Computers Replace Physicians?

In 2012, at the Health Innovation Summit in San Francisco, Vinod Khosla, Sun Microsystems co-founder and venture capitalist, declared: “Health care is like witchcraft and just based on
tradition.” Biased and fallible physicians, he continued, don’t use enough science or data — and thus machines will someday rightly replace 80 percent of doctors. Earlier that same year, Khosla had penned an article for TechCrunch in which he had made a similar point.
With the capacity to store and analyze every single biological detail, computers would soon outperform human doctors. He writes, “there are three thousand or more metabolic pathways, I was once told, in the human body and they
impact each other in very complex ways. These tasks are perfect for a computer to model as ‘systems biology’ researchers are trying to do.” In Khosla’s
vision of the future, by around 2022 he expects he will “be able to ask Siri’s great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get
today from the average physician.” In May 2014,

Khosla reiterated his assertion that computers will replace most doctors
. “Humans are not good when 500 variables affect a disease. We can handle three to five to seven, maybe,” he said. “We are guided too much by opinions, not by
statistical science.”

The dream of replacing doctors with advanced artificial intelligence is unsurprising, as talk of robots replacing human workers in various fields — from eldercare to taxi driving — has become common. But is Vinod Khosla right about medicine? Will we soon
walk into clinics and be seen by robot diagnosticians who will cull our health information, evaluate our symptoms, and prescribe a treatment? Whether or not the technology will exist is difficult to predict, but we are certainly on our way there. The IBM
supercomputer Watson is already being used in some hospitals to help diagnose cancer and recommend treatment, which it does by sifting through millions of patient records and producing treatment options based on previous outcomes. Analysts at Memorial Sloan Kettering Cancer Center are training Watson “to extract and interpret
physician notes, lab results, and clinical research.” All this is awe-inspiring. Let us generously assume, then, for a moment, that the technology for Khosla’s future will be
available and that all knowledge about and treatment options for medical problems will be readily analyzable by a computer within the next decade or so. If this is the future, why
shouldn’t physicians be replaced?

There are several errors in Khosla’s way of thinking about this issue. First of all, modern health care is not “like witchcraft.” Academic
physicians, for example, use evidence-based medicine whenever it is available.
And when it isn’t, then they try to reason through a problem using what biologists know about disease presentation, physiology, and pharmacology.

Moreover, Khosla mischaracterizes the doctor-patient interaction. For Khosla, a visit to the doctor involves “friendly banter” and questions about symptoms. The
doctor then assesses these symptoms, “hunts around … for clues as to their source, provides the diagnosis, writes a prescription, and sends you off.” In Khosla’s estimation the entire
visit “should take no more than 15 minutes and usually takes probably less than that.” But the kind of visit Khosla writes about is an urgent care visit wherein quick and minor issues are addressed: strep throat or a small laceration requiring a
stitch or two. Yes, these visits can take fifteen minutes, but so much of medicine does not involve these brief interactions. Consider the diabetic
patient who has poorly controlled blood sugars, putting her at risk for stroke, heart attack, peripheral nerve destruction, and kidney failure, but who hasn’t
been taking her medications. Or consider a patient addicted to cigarettes or on the verge of alcoholism. Consider the patient with Parkinson’s disease who wonders how this new diagnosis
will affect his life. And what about the worried parents who want antibiotics for their child even though their child has a viral infection and not a
bacterial infection? I can go on and on with scenarios like these, which occur hourly, if not daily, in nearly every medical specialty. In fact,
fifteen-minute visits are the exception to the kind of medicine most physicians need to practice. One cannot convince an alcoholic to give up alcohol, get
a diabetic patient to take her medications, or teach a Spanish-speaking patient to take his pills correctly in fifteen minutes. In addition, all this is impossible without “friendly banter.”

As Dr. Danielle Ofri, an associate professor of medicine at the New York University School of Medicine,

wrote in a New York Times blog post, compliance with blood pressure medications or diabetic medications is extremely difficult, involving multiple factors:

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the
patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make
it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots — on top of remembering to take the morning pills
and then the evening pills each and every day.

Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the
doctor’s recommendations.

Because of the difficulties involved in getting a patient to comply with a complex treatment plan, Dr. John Steiner argues in an article in the Annals of Internal Medicine that in
order to be effective we must address individual, social, and environmental factors:

Counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. …[F]ront-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in
ways that exemplify the underlying principles of health care reform.

Therefore, the interaction between physician and patient cannot be dispensed with in fifteen minutes. No, the relationship involves, at minimum, a
negotiation between what the doctor thinks is right and what the patient is capable of and wants. To use the example of the diabetic patient, perhaps the
first step is to get the patient to give up soda for water, which will help lower blood sugars, or to start walking instead of driving, or taking the
stairs instead of the elevator. We make small suggestions and patients make small compromises in order to change for the better — a negotiation that helps
patients improve in a way that is admittedly slow, but necessarily slow. This requires the kind of give-and-take that we naturally have in relationships with other people, but not with computers.

This kind of interaction also necessitates trust — trust regarding illicit drugs, alcohol, tobacco, and sexual activity, all of which can contribute to or
cause certain medical problems. And a computer may ask the questions but cannot earn a patient’s confidence. After all, these kinds of secrets can only be
exchanged between two human beings. David Eagleman, a neuroscientist at the Baylor College of Medicine, writes in his book Incognito that when we reveal a secret, we almost always feel that “the receiver of the secrets
has to be human.” He wonders why, for example, “telling a wall, a lizard or a goat your secrets is much less satisfying.” As patients, we long for that human reception
and understanding that a physician can provide and use to our advantage in coming up with a diagnosis.

Khosla neglects other elements of medical care, too. Implicit in his comments is the idea that the
patient is a consumer and the doctor a salesman. In this setting, the patient buys health in the same way that he or she buys corn on the cob. One doesn’t need friendly banter or a packet of paperwork to get the best corn, only a short visit to the
grocery store.

And yet, issues of health are far more serious than buying produce. Let’s take the example of a mother who brings her child in for ADHD medication, a
scenario I’ve seen multiple times. “My child has ADHD,” she says. “He needs Ritalin to help his symptoms.” In a consumer-provider scenario, the doctor gives the
mother Ritalin. This is what she wants; she is paying for the visit; the customer is king. But someone must explain to the mother what ADHD
is and whether her child actually has this disorder. There must be a conversation about the diagnosis, the medication, and its side effects, because the consequences of these are lifelong. Machines would have to be more than just clerks. In many instances, they would have to convince the parent that, perhaps, her child does not have
ADHD; that she should hold off on medications and schedule a follow-up to see how the child is doing. Because the exchange of goods in
medicine is so unique, consequential, and rife with emotion, it is not just a consumer-cashier relationship. Thus computers, no matter how
efficient, are ill-fitted to this task.

Khosla also misunderstands certain treatments, which are directly based on human interactions. Take psychiatry for example. We know that

cognitive behavioral therapy and medication combined are the best treatment for a disease like depression
. And cognitive behavioral therapy has at its core the relationship between the
psychiatrist or therapist and the patient, who together work through a depressed patient’s illness during therapy sessions. In cognitive behavioral therapy, private
aspects of life are discussed and comfort is offered — human expressions and emotions are critical for this mode of treatment.


To be sure, Khosla is right about quite a lot. Yes, technology ought to make certain aspects of the patient visit more efficient. Our vital signs may one day easily be taken with the help of our mobile phones, as he suggests, which
would save time checking in to a clinic and could help give physicians constant and accurate measurements of blood pressure in hypertensive patients or EKG
recordings in patients with heart disease. Technology of this sort could also indicate when an emergency is happening or how a patient ought to alter medication
doses.
Furthermore, Khosla correctly identifies some of the limitations of human physicians: “We cannot expect our doctor to be able to remember everything from medical
school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth.”
True, the amount of information accumulated by modern medical research is beyond the capability of any human being to know, and doctors do make mistakes because they forget or are not up on the latest research. In a 2002 study in the Journal of Neurology, Neurosurgery and Psychiatry, investigators found that 15 percent of patients with a diagnosis of Parkinson’s disease do not
necessarily fulfill criteria for the disease and 20 percent of patients with Parkinson’s disease who have already seen medical providers have not been diagnosed.
These are large percentages that have profound implications for people’s lives. And this is exactly why physicians must use technologies like Watson to do a
better job, not necessarily abdicate the job altogether. Most of us already carry smartphones or tablets on rounds, to look up disease processes or confirm
our choice of antibiotic.
Lastly, Khosla wisely points out that physician bias can negatively affect a patient’s treatment. As he writes, “a physician’s bias makes all these
personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what ‘preferences’ are being
incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing
countries, in my estimation.” Undoubtedly, this dilemma is real. I have spent many of my posts on this blog writing about the issue of remaining unbiased or level-headed in the face of difficult patient interactions.
study published in Obesity in 2013 found that physicians “demonstrated less emotional rapport with overweight and obese patients … than for normal weight patients,” which may
“weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.”
And

as Tara Parker-Pope remarks in the New York Times
, “studies show that patients are far more likely to follow a doctor’s advice and to have a better health outcome when they believe their doctor empathizes
with their plight.” If bias exists in lieu of empathy, it makes sense that patients have worse outcomes. What makes doctors most valuable,
their humanity, can have negative consequences.
But people can learn from studies, alter their behavior, and remain human. Computers or robots can learn from studies and alter their behavior, but they will
always be robots. They will never earn the trust of the chronically ill drug addict. They will never be able to negotiate with the most difficult patients
who demand specific treatments but may not be entirely sure why. An ideal system would not be one built solely on fallible human doctors but one
in which new tools significantly augment human physicians’ skill and knowledge. A measured combination of these will put all the information at a doctor’s
fingertips while keeping the art of medicine alive.

Becoming Cynical, Part 3

The problem of physician burnout, which in a previous post I defined as a
“loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment,” increasingly plagues the American medical profession. In an article in the Archives of Internal Medicine in 2012, researchers
found that U.S. physicians suffer more burnout than other American workers. This year, a Medscape Physician Lifestyle Report found that 46 percent of all
physicians who responded had burnout, “a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40 percent of respondents.”

The consequences are deleterious: burnout negatively affects
patient care and is associated with higher rates of suicidal ideation. In two earlier posts (here and here) I offered a couple of reasons why physicians become
cynical. In this post, I expand on my previous entry
suggesting this phenomenon is partially due to the “patient population one deals with.”

Let me start with a story.

One night, the general medical team admitted a patient with severe hyperglycemia, or high blood sugar, who had a
history of IV drug abuse, alcoholism, diabetes, and hepatitis C, a viral disease that can destroy the
liver. The patient drank so much hard liquor that he got dehydrated, neglected to take his insulin and
went into a hyperosmolar hyperglycemic state. Patients with diabetes develop this
condition when they have an infection, preceding illness, or dehydration. In diabetics, physiological stresses like these reduce insulin, a hormone which
normally regulates blood sugar levels, causing unmitigated hyperglycemia. The blood becomes hyperosmolar due to the excess sugar and draws more fluid into the intravascular space
leading to dehydration of cells within the body and increased excretion of water in the urine — which in turn worsens the pre-existing dehydration. As urine is
excreted there is also a loss of electrolytes like sodium and potassium. Severe hypotension (low blood pressure) ensues and
patients can die. Treatment involves IV fluids, insulin to correct the hyperglycemia and continuous monitoring.

After recovering overnight, our patient declared that he would start a new life and give up drinking — he was ready to make a change. As his symptoms
improved and his labs normalized the medical team worked toward this goal. We arranged for follow-up appointments with a primary care physician, an
infectious disease physician, and a psychiatrist. The pharmacist managed to get him insulin through a hospital-assistance program. And the social worker
arranged for him to go directly to an intensive alcoholic recovery program gratis. In order to get there, he was offered transportation from the hospital. The
hospital ate the cost for treating him because he was uninsured. It is both wonderful and incredible that all these resources, given freely, go towards
helping a patient get back on his feet.

However, on the day of his discharge, the patient left the hospital but did not take the ride or his insulin. He drank two bottles of vodka and came back
that evening in a drunken stupor and a hyperosmolar hyperglycemic state. He cursed at his nurses and the female resident who admitted him. Because he also
threatened them, the hospital staff put him in restraints in his bed so he wouldn’t violently swing at those giving him medications. The medical team
repeated the previous day’s actions — but two days later, the patient did the exact same thing. And for the third time, the medical team readmitted him.

Shutterstock

This sequence of events elicits all kinds of thoughts and visceral reactions pulling us in two different directions. Surely, this patient has an illness
(alcoholism) and so we need to be understanding even if we hold him responsible for his actions. And yet, the hospital gave him multiple golden
opportunities to attempt to turn his life around and he declined to do so. At what point does the hospital turn him away and refuse to pay for his medical
care? Would it be ethical to do so? The money can be better spent on destitute patients who will take their medications but can’t pay for them. Given the
limited resources of any system, shouldn’t we at least entertain the idea?

Unfortunately, doctors face this conundrum on a weekly basis. Some diabetics refuse to take insulin; other patients refuse to give up an unhealthy diet;
some don’t take their blood pressure medications. Statistics back this up: in one particular review article in the Journal of the American Pharmacists Association in 2000, 43 percent of
the general population and 55 percent of the elderly population were found to be nonadherent to their medications. Approximately 125,000 deaths per year have been
attributed to nonadherence to treatment for cardiovascular disease. Finally, the direct and indirect costs of nonadherence to medications are estimated to
be $100 billion per year in the United States.

Physicians want patients to get better, and this is more than just a matter of prescribing medicine. They spend time talking to patients about their illnesses and treatments. They call consults from specialists who then take time to figure out a plan for a particular aspect of the patient’s ailment.
Social workers arrange for affordable medical services, transportation, and institutional and governmental help. Physical therapists and occupational
therapists see patients who need to regain strength. All this requires logistical tasks that aren’t always intellectually stimulating or exciting and may
not even be compensated for at all.

Of course it is true that the doctor can fail the patient, but it is also true that the patient can fail the doctor. In the Medscape survey I referenced above, physicians cited “too many difficult patients” as one of the reasons for their burnout. This reaction is completely understandable. After seeing patients make poor choices again and again, a general malaise can set in. At some point, physicians ask themselves, “why should we care?” Doctors may start to go through the motions of writing notes, coming up with a plan, and making
arrangements for these patients but with an emptiness of spirit. We may become embittered, both toward the patient and toward some of the annoying tasks involved in the work. A sense of futility and even detachment can follow.

Let’s not forget that the practice of medicine is a very human enterprise. Indeed, as healthcare professionals, we ought to
recognize the problem of nonadherence even after putting aside the issue of limited resources. However, it is useless to just complain about uselessness — to throw our hands in the air and ask “Why even bother?” In every field there is work that does not bear fruit; entrepreneurs, for example, fail 80 percent of the time when starting a new
business. Why expect a profession that relies on the Sisyphean task of changing a human being’s behavior and habits will be exempt from this fact?
Patient failure, just like physician failure, is an integral part of our fallible medical system.