Randale C. Sechrest, MD

I have been a fan of Douglas Rushkoff for some time, primarily because I have a keen interest in the impact of New Media on global culture. After finishing his new book, I contemplated increasing my Prozac dose - and his. This is essentially a condemnation of the particular strain of corporate capitalism that we are now all living. It is an intriguing analysis of the rise of centralized currencies from the Renaissance until today and the implications that stem from that history. Rushkoff sees a conspiracy that stretches across millennia - or perhaps more accurately a “force” unleashed long ago that has now gone awry as successive generations have learned to extend and optimize the expression of the DNA inherent in centralized currency. Interesting thesis and well argued, but in the end came up short on providing the solutions as promised in the subtitle.

Randale

I recently finished “The Future of Bioethics” by Howard Brody, MD, PhD. Dr. Brody took the helm at the University of Texas Medical Branch as Director for the Institute for the Medical Humanities in 2006. This book could be termed “the rest of the story” in bioethics. The book takes a very serious look at issues that have NOT necessarily been on the forefront of medical and bioethics discussion over the past decade as the discipline has grappled with high profile - and high tech - issues such as the nanotechnology and human cloning. Rather, this volume brings the focus of bioethics back to the basics and asks: “What is the role of the bioethicist in speaking for the disenfranchised, the poor and the disabled?”

I was particularly pleased to see an entire chapter devoted to the intersection of bioethics, the environment and sustainability. We may face no greater threat to our well-being during this century than environmental destruction. It is high time that we look at this as an ethical issue and worthy of attention from the medical community at large. Bravo.

This is an inquiry into social justice at its best. Get it, read it.

Randale

I ran across this video of a talk that David Brooks gave at the Alpine Institute. It literally changed my entire perception of Mr. Brooks as well as crystalized some of those nagging uncertainties that constantly inform my day to day existence. This is a very well thought out discussion and I look formward to the upcoming book that he is preparing that deals with these issues. Nothing is as it seems.

Anyone interested in the future of the food supply should visit the Slow Food Nation website and browse the videos available from the conference held in San Francisco in the Fall of 2008. The video below outlines the current crisis in the global food supply and outlines the issues clearly and succinctly.

It is readily apparent that chronic disease management requires a different paradigm than the traditional approach of “reacting” to episodic illness. Self care requires access to accurate, easily accessible and understandable “actionable information”. Rich information resources that provide real value to healthcare consumers looking to assume responsibility of managing their own health situation will become more valuable to the “system” as a whole.

Currently, the vast majority of healthcare information produced for consumption is designed to drive consumption of healthcare services.

Why?

Because that is the primary way that the costs of creating and distributing healthcare information results in a demonstrable return on investment. The healthcare system views the activity of creating and distributing information as equivalalent to advertising. This dynamic is slowly beginning to change.

Those parties that are at increased economic risk in the current health care paradigm may well choose to shift their focus to more self care, trying to avoid costly interactions with the health care “system”. This means that patients will begin to look for ways to effectively self manage much of their chronic care as they are forced to bear more of the costs. Likewise, payers at risk will look to encourage providers who offer ways to empower patients to more effective at self care.

Information that is designed to create awareness of the potential benefits of specific behaviors and disease management techniques - and then guide a patient through the steps necessary to achieve the desired behavioral change can empower and, ultimately, lead to the patient assuming increased responsibility. Facilitating this dynamic may enable improved self care and become increasingly important in improving outcomes and reducing costly interactions with the “system”.

Accessing the “system” for a one-on-one consultation to transfer this information is much too costly. But, in the current paradigm, a cascade of these sort of consultative interactions is the primary mechanism to try and create the necessary behaviors to self manage chronic disease. The patient is seldom provided easily accessible and effective “self serve” information tools necessary to create true empowerment. Why? Because the cost of creating these assets is not directly reimbursed.

Creating and distributing information does not create direct revenue for the organization (for example, a hospital) - this function is a cost center under the current paradigm. The benefits accrue indirectly from the marketing benefit - driving the fee for service offerings and increasing the utilization of these services.

Our current approach to creating and distributing information just worsens the real problem - it actually is all geared toward increasing demand for the fee for service aspects of health care delivery. We give people only enough information to entice them through the door to initiate an extremely costly cascade of interactions with the health care system. We do not create information resources that are designed to address the real problem - i.e. we do not educate and empower patients to self manage, nor do we design information assets that are designed to allow patients to prudently and effectively access and utilize the resources of the health care system. No one compensates this activity. Instead, we market our products.

But what if the paradigm shifts to optimizing population health? What if instead of a being in the business of selling a “healthcare product”, we are charged with fulfilling a “healthcare obligation” on a finite budget?

All of a sudden, we are in the business of creating a much different relationship with the patient - one where it is in our best interests to help the patient be successful at self management. Enabling patients to understand how to effectively and efficiently ACCESS care will become critical. Creating and distributing the information necessary to make actionable decisions about when and where to access the regional healthcare “system” will become as critical as providing the technical service.

Cost containment, by reducing the need for the patient to access the healthcare system for the technical service, will have a real value.

I have been involved throughout most of my medical career in trying to understand the role that information plays in the delivery of healthcare. I have been primarily interested in how to improve patient/provider communication - regardless of whether the provider is represented by a single physician or an entire healthcare organization. I started this endeavor long before the Internet had become a public space - enamored with the capabilities of the computer to deliver multimedia information. Most of the delivery methods available at the time were utilizing stand alone computer systems combined with some type of video device - such as the lazerdisc. These early attempts were cumbersome at best.

Time flies….

As the saying goes: “This changes everything” - This being the Internet.

The Internet has clearly revolutionized the paradigms for both creating and delivering information in every way imaginable. Anyone who has participated in this revolution can not help but be dumfounded by the shear magnitude of the changes that the Internet has wrought. Perhaps it is more blatant to those of us that still can remember the challenges presented by information management, information distribution and search in the “pre-Internet days”. An information “search” was actually a physical event - actually going to the library and walking through the stacks of hard bound journals… The paradigm shift that the Internet represents has occurred not in the simple, incremental way that we initially thought, but has resulted in a seismic shift in the core assumptions that we make when we conceive of the role of information.

The healthcare “system” has yet to grapple with this new reality.

One of those core assumptions that the Internet has brought into clear view is the fact that every product or service can be dissected into two components - a physical product or technical service component and a knowledge component. The knowledge component represents the information necessary to effectively utilize the product or service.

For example, a product such as a television may have an owner’s manual that provides instructions and tips for getting the most out of the product. It may have a marketing component that creates consumer awareness of the product and allows the potential customer to execute a search and analysis of the comparable benefits of this product versus the competition in order to make a buying decision. All of these bits of information represent the knowledge component and make the actual product more valuable.

A service such as knee surgery has a knowledge component as well. That component includes preoperative education and instructions, informed consent, and postoperative rehab protocols that are critical to the optimal outcome of the surgery. It includes a marketing component that allows the potential patient to seek out and select that specific surgeon and that organization as the preferred choice to perform the service (even if that component is currently more likely distributed via “word of mouth”). It includes the outcomes data of the specific surgeon and organization that provides that service.

Similarly, the lifelong task of managing a chronic disease has a large knowledge component that dramatically affects any individual’s ability to optimally manage their disease state. The knowledge an individual needs to successfully manage a chronic disease state includes knowledge about the disease itself, and knowledge about how to find and navigate the necessary and appropriate services from the healthcare system. Information about the disease may be generic, but information about how to find and navigate the appropriate service is more often region-specific — depending on where the individual pursues their care.

It is one of my core assumptions that part of the answer in improving communication between provider and patient lies in coordinating and strengthening the link between the information and service components of healthcare delivery.

In order to increase the efficiency of the process, the knowledge component of a healthcare transaction must be extracted and made available to the consumer through a “self service” or “on demand” basis. The healthcare organization must learn to more effectively articulate both “disease specific” and “system specific” information necessary for the healthcare consumer to more effectively participate in their ongoing care, and manage their relationship with the healthcare organization and provider.

We need to learn how to do this better - and create sustainable systems and processes within our organizations that are tasked with the responsibility to effectively communicate with the public.

Continuing my saga through the books and websites addressing sustainability issues (which, btw, is unfortunately an incredibly depressing and sobering activity in and of itself), I have finished absorbing a couple of other resources that are both informative and balanced.

One resource that I would highly recommend is the Worldwatch Institute. This organization publishes some really great material, including their State of the World monograph each year.

You can actually download this monograph for free from the website here.

The second resource that I found indispensable is this book by Lester R. Brown:

This book is much more wonkish with a ton of statistics that support the basic thesis that the world is going to hell in a handbasket and there is very little we can do about it. How do you spin those statistics in a way that seems palatable? Well, you can’t it turns out - and, for me at least, there was no happy ending to this book even though it lays out all sorts of recommendations (probably meant for legislators ears) that appear to address the coming human calamity. Anyway, check out the website for the organization responsible for this book as well: Earth Policy Institute.

I have been doing a great deal of research lately in sustainability. That means slogging through the plethora of books on peak oil, climate change and evaluating all the plans being put forward to right the balance.

But this one book has caught my attention more than the statistic laden tomes that tend to characterize this genre. John Michael Greer, the author, has some strange interests. Magic and the occult, for example. And did I mention that he practices Druidry?

You might think those credentials would make this book somewhat on the fringe. On the contrary, this might be the most rational “30,000 foot view” of the history of the human race and what we can expect as we go forward that I have come across. I won’t say that it is necessarily uplifting - but it certainly seems to be rationally argued and plausible. It demands that we humans seriously question our basic delusion that somehow we as a species will continue to operate outside the confines of biological limits imposed by our physical world.

Is the myth of progress really true? Will science save us? Or, are we beginning a “Long Descent” back towards a more sustainable relationship with the biological limits and carrying capacity of the planet? In Greer’s view this will take a couple of centuries to complete. If history is an accurate guide, it probably won’t be a script worthy of a disaster movie.

Well worth considering if you are interested in shedding the consensual illusion that we call the 21st Century.

The Long Descent: A User’s Guide to the End of the Industrial Age

Some of you will be familiar with Paul Hawken from the catalog that bears his name - Smith and Hawken. What you may not be familiar with is the environmental activist Paul Hawken. Yep - one and the same. I would recommend his latest book and endeavor as a worthwhile bit of information about the plight of Spaceship Earth and its travelers (you and me). Like any good 21st century book, this is simply the brochure for an entire website, maybe an entire movement, complete with its own video channel.

Blessed Unrest

Blessed Unrest: How the Largest Social Movement in History Is Restoring Grace, Justice, and Beauty to the World