Sunday, January 07, 2007
I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point of this post. As much as I love it when able to do surgery in a way that I consider some sort of artistry, and as much as I realize that being able to do so is the result of the efforts of nearly countless people, there are times when I've had a moment of disconnection (or is it clarity perhaps?) and have wondered if it's all insanity.
For an operation of anything more than the most minimal magnitude, the team consists of at least five people -- and often more: anesthetist, surgeon, assistant, scrub nurse or tech, and circulator (meaning the person who runs around getting stuff, more or less) but it's always in fact way more than that: anesthesia tech, people in the sterile core, in the pre-op holding area, admitting, in the recovery room. Central supply techs, assistants to set up and turn the rooms over between cases. Schedulers, people at the front desk keeping the day in synch. And these are just some of the folks surrounding the operation itself. One-on-one or one-on-two nursing in the intensive care unit, around the clock. Nurses, aides, assistants on the surgical floor; physical therapists, social workers, unit managers and clerks. Pharmacists, lab techs. The number of people involved in supporting an operation on any individual is staggering. Clearly, for the patient and his/her family, it seems worth it. But is it crazy to wonder if it makes sense, economically? Or even, given limited resources, ethically? Thinking of so many people involved in the care of a single individual makes me wonder, sometimes, if societies would be better off if that effort and treasure were directed in ways that would benefit more people. Is surgery an example of our fundamental instincts to help one another; or a sign of misguided priorities? Do we allow such lop-sided economics because, at bottom, we want that effort when it's our turn, damn the cost? I'm no philosopher, nor an economist. I don't suppose societies ought to behave only on the basis of cost-effectiveness: some values are reflected in ways that don't fit bottom-line thinking. Still, there are times when I look at all the effort involved in supporting what I do, and it gives me pause. Funny thing is, I've never regarded any patient -- famous or infamous, wealthy or destitute, brilliant or slow -- as unworthy of that effort. It's only when I think of myself lying on an OR table, and of all the people called upon to do whatever they'd be doing to accomplish whatever operation I'd be getting, that I think of it as somehow unseemly. But that's just me, I guess.
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Well now, as luck would have it, while I'm putting the finishing touches on this post, there appears an article in the local paper about an eight-year-old boy receiving an intestinal transplant. So maybe it's destiny that this becomes about something larger (as I implied in a recent post, we're not in charge of our thoughts anyway.) The pictures show it: he's a really cute kid, and he's looking forward to being able to eat. It's heartwarming; it really is. And yet. The operations that gave me pause above are in the most minor of leagues compared to this sort of thing. Dozens of OR personnel, people involved in the harvesting, the maintenance of the organ; lab folks. The immediate post-operative care is highly labor-intensive; the drugs, the after-care. And oh, the dollars.
I recall watching Ronald Reagan many years ago, as he made a very public show of donating to the fund for a liver transplant for some cute little kid, during a time in his presidency when he'd been loudly decrying the costs of health care. There's a huge disconnect: who isn't moved by this beautiful child, who would admit to begrudging him whatever it takes? And who, if in a darkened room away from prying eyes and ears, if not given the particulars of any individual, if crunching numbers trying to balance budgets, would argue for paying a million bucks or more for a procedure whose long-term survival is discussed in terms of three-year alloquots? But if it were their child...?
It seems inevitable that at some point the US will join the rest of the western world and provide some form of universal healthcare. I wonder when, in the process of discussing it, the R-word will finally be raised and addressed head on? Unless there's agreement that healthcare is the sort of priority that gets all the money it takes to provide all the care possible to everyone in need no matter the details, sooner or later "RATIONING" (call it whatever you prefer) has to be part of the mix. Somewhere along the line, we will have to say THIS is how much or our federal budget we're willing to spend on healthcare; THESE are the things we're willing to pay for; and HERE is how we'll pay it. It's way too important to leave to the insurance companies, and it's way too difficult to think politicians would tackle it seriously, let alone with an eye to finding actual solutions. (They're all too busy electing themselves and playing power games -- and have been for several years.) If anyone asks me, I'll tell them we need to convene a dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers. Maybe lock 'em in a room with hardtack and water, don't let them out until they come up with a plan and a price; maybe a couple of them. And then let everyone think about it for awhile, and put it to a vote. It's long overdue. Meanwhile, out of concern for your money, I promise not to have an intestinal transplant.