I am presently between my 10th and 11th draft of my new novel Retribution, time to come up for air and to get away from it. Breaks are good. I leave a draft thinking to myself, “Hey chap, you nailed it! A Pulitzer Prize nominee for sure.” Then I come back two weeks later, open the manuscript and read. “Holy crap! What was I trying to say? That’s clumsy. How did I miss that typo? Garbage!”
I’ve attended many classes in my search for being a better writer. I am encouraged to know that even the talented writers go through this editing ritual. One such famous author said, and I can’t remember which one now, “I edit and edit until I come to the point of saying to myself, ‘It’s still messed up but I don’t know how to fix it,’ then I publish it.” My ambition is to write one excellent book before I die, so I’m taking my time with this one.
I looked at the articles that I have in draft form here at this blog and I counted 35. I thought about brining one of those to maturity and post it during this break, but, I’m going to bring snippets from several under the general theme of the three forces or tensions that permeate much of the universe, including human endeavors. This is long, so I titled each section and you can choose if is something that you want to read.
Four weeks ago, I was sitting on the sixth floor of the Seattle Cancer Care Alliance. Many of you, unfortunately, have had to go there (but it is great care if you need it). It is a lovely semi-circular building of aqua-tinted glass, on a hill overlooking the most scenic part of the north end of Seattle, Lake Union, and the Space Needle.
While I sat anxiously waiting on my appointment, anticipating the news that I was getting sicker and going suffer mercilessly and die . . . or I’m stable and will live awhile (the verdict is still out). You know, little things. Many of you can relate to that situation because you’ve been there. While trying to quieten my anxious heart (besides prayers riding on every breath) I watched the crew on the ground below building a fresh addition to the building.
On that day, I noticed the familiar pattern of triangles in the cranes, machines … and the entire universe around me. This started me on a fascinating journey, into patterns, like Alice stepping behind the looking glass. Just look for triangles in the photo below.
The Triangle in the Material World
The humble triangle is the fundamental form for engineering because it is the strongest simple form (see). It tempted me to say the reason is that we live in a three-dimensional universe, however, the triangle can fit neatly within a two-dimensional plane and still be strong. Put another one, perpendicular, then you have a pyramid. Maybe the engineers among you can explain it better.
We consider the Roman arch a engineering marvel upon which they built western civilization. However, it is nothing but a row of triangles with their hypotenuses in line.
A decade ago, a local bridge over I-5 fell into the river after a truck struck and broke just one of those triangles.
While one could argue these complex mathematical constructs in nature results from a very long period and random chance, or that humans have evolved to the point of imposing order on things they see, which have no intrinsic order, for me, they speak loudly of an universe with design. As I’ve said many times, mathematics is the native tongue of God. If you are a mystic, either atheistic-mystic, or theistic-mystic you cannot ignore the fact that this fabric of the universe is written in a mysterious code. The consistency of this math allows us to land a 2,000 lb SUV on a precise location in the Jezero Crater, or to discover new particles in physics using equations without experimentation. This grand order comforts me, even when facing serious news.
Besides the presences of triangles throughout physical nature, you can also examine most human endeavors through the prism of the triad of forces. Triangles are everywhere within the subjective and the objective. I may be oversimplifying these issues, but maybe that’s a good thing.
The Human Psyche/Soul (the words are from the same Greek root as do spiritual and emotional)
We humans have three basic parts, often in tension. The biological, emotional (aka spiritual), and reason. While the biologic is the superstructure of them all, reason is perceives and make sense of the external world, and emotions are there to enjoy or fear what reason learns.
Unfortunately, we run into most of our troubles when we allow emotions make sense of the world (emotional reasoning). Men beat their wives when they allow emotions to tell them that the wife is threatening to them (because they see the wife as better than themselves). The teenaged girl jumps off a high bridge when her boyfriend leaves her, via emotional reasoning, thinking that she is worthless and will never be happy again.
I know for mean, as much as I struggle against the flesh (the cancer in the material) I struggle in this emotional realm. It is a battle to maintain a sense of self-worth when I’ve lost my physical stamina and professional career. It is my emotional reasoning that is enticing.
The biological force can throw a wrench into the whole being when it does not function well. Many forms of mental illness have such a biological base, such as schizophrenia or chronic depression. So, there is a tension within along those three lines.
Christian apologists argue that the fact the Christian God has three balancing parts, Father, Son, and Holy Ghost, sets it apart from other religions and makes it more congruent with what we see in the material world. Rather than arguing for or against that position here, I will pivot and go to another topic entirely, using the Triune God argument only as a segue.
About twenty years ago, I attended a lecture by a professor of philosophy and comparative religions at Harvard. This man, while raised as a Hindu in Delhi, converted to Christianity. The title of his lecture was something like “The Superiority of the Christian Triune God.”
A Word About Harvard (here comes the awkward segue)
What drew me to this professor’s lecture wasn’t the topic as much as the man’s association with the university. Harvard is another one of those sacred places in my mind, having been on the campus only twice. The reason is, the motto for the college is “veritas,” meaning truth, or the pursuit of. I love truth, meaning that which is consistent with reality. I rubbed John Harvard’s brass foot as an act of a pilgrimage on my first visit.
John Harvard was a Puritan pastor and relic of the enlightenment. While he was dying in 1636 from TB, he gave a verbal will, donating his orchard, money, and crate of 400 books for the formation of the college. Those 400 books (you can see the original 1636 book catalogue of the donation here) were books of theology, science and literature. The books represented John’s own pursuit of truth and thus the motto of the school.
I know this is hard to imagine in this age of when evangelical Christianity has an anti-reason bias and is against objective truth, however, Harvard’s pursuit of truth, love of knowledge and science, was not despite his Christianity … but the result of.
This Harvard professor, twenty years ago, said something interesting, but totally missed the point. He used the example of the American army’s successful invasion of Iraq as proof of the superiority of the Christian triune God, the nature of the trinity reflected in nature. In summary, the American bombs, missiles, and bullets were so accurate because they could triangulate their targets, while the Iraqis fired randomly. The latter serving a monotheistic god.
The use of the mathematical triangle makes bombings precise (most of the time) through the GPS system. There was also a network of triangulated microphones which could pinpoint the source of enemy gunfire and thus return fire accurately. However, the use of such examples missed the point of humanity, or to borrow a Biblical metaphor, strained at a gnat while swallowing a camel.
During that lecture, I was sitting beside four Muslim men from an Arab heritage. I could tell from what they said to me, that they thought the speaker was saying the Christian God was superior to the Muslim Allah, because the Christian God is more efficient at murdering innocent civilians. “Why does such reckless brutality make one God superior to the next?” I tried to explain, that’s not what he’s saying but my words mute, damage done. As he connected to his audience, while he tried to use a rational argument (using the reason part of our psyche), this speaker unintentionally left a greater impact in the emotional realm by using such a poor example.
Of course, in America, we have three seats of power in government, the presidency, judicial, and legislative branches. Our founding fathers knew, philosophically, that a triune balance of power was the most efficient. Within the realm of political power on a personal level, there are also three major areas of tension, 1) Personal (Art of persuasion of the masses), 2) Money, and 3) Facts. The most power, unfortunately, often falls in that order, sometimes money first, facts almost always last.
To win elections, you must persuade people to vote for you. It takes money to persuade the most. Lies work better than truth, because you can cater reality to fit the voter’s wants or biases. This is especially true during our age of electronic media and short attention spans, where baseless soundbites work. This is how our society has produced the likes of Donald Trump, who is brilliant in using advertising and persuasive speech, and he had the money to reach the masses. So he could be a great success, although he treats truth and reality as extraneous. I’m afraid it may get worse, unless we figure out a way to put truth as the front of this triad.
Writing (applies to all fine arts).
Three forces occur in writing, art (creativity), science (technique), and business. Plenty of writers who are profoundly creative, who don’t follow all the rules of grammar (technique), and are lousy at business. Other writers who do fantastic at business (James Patterson) but, in my opinion, don’t have a lot of creativity.
I’ve entered creative writing late in life. I have tried to learn the business of writing the best I can. As I have entered the real inner circle of creative writing, I am finding the technology of writing (to have it published by a major publisher) oppressive . . . if not depressive. For one, the grammar has to be pristine. I’ve tried to be creative by (coloring outside the Chicago Manual of Style’s lines or rules of grammar) only to have editors smash me like a bug. But it is now beyond grammar. Now, there are formulas for numbers of adjectives, adverbs, nouns, pronouns etc. to have a “good manuscript.” I have three computer programs that look for these variations. But, if I want to get the attention of a major publisher, I have to play by these rules. The rules are so precise now, that people are saying that in the future, computers with A.I. will write all our novels and they will all be perfect. Lord, I hope not.
But it has not always been that way. Shakespeare created 1700 nonexistent words in his writing. I’ve tried to create one new word in a manuscript of 150,000 words and have an editor write me a nasty note, “You can’t do that. It’s not an actual word.” For example, if I wrote, “The bright yellow sun was dominating the azure sky with such an intensity that he had to drop his chores and get behind the wheel of his T-Brid and go convertibling on Highway 101.” The editor would send it back and demand that I delete the word, “convertibling,” although the reader would know what I mean. I find that sad. But If I had to choose, I would rather be creative than successful. I wish I could be successful just enough to pay for my expenses so I can continue. I love the work.
I wanted to write an informative article on the good and ills of the practice of medicine, both evidence-based and alternative medicine. I base this on my thirty-nine years of medical practice, and now my two years of being a high consumer of healthcare. Yet, so far, I have not found a concise way to discuss my observations. But I could summarize and simplify it through this filter of the triad of forces.
The three forces in health care are the science (facts), the art (the humanity), and the business (or money).
Science Vs Humanity
Evidence-based (what some call “western”) medicine is bold on science and weak on art/humanity. Alternative medicine emphasizes the art/humanity but is weak on science. Both are the victims of the business aspect.
I had a patient who had suffered a stroke when a chiropractor manipulated his neck. This is a very rare side effect from such manipulations. The patient was in my office in tears as he was loosing his livelihood because of the disability (I can now relate to the depression of loosing your career). I asked him if he was going to sue the chiropractor. His eyes became as round as saucers and he said, “No. Never! I love the guy, he’s one of my best friends. We go fishing together. But I am thinking about suing the hospital.”
“The hospital? Why them?” I asked.
“It took them a day to schedule my brain MRI.”
The man had a deep personal relationship with his chiropractor . . . none with his hospital or his evidence-based provider. This is where art can trump science.
If my quarrel with evidence-based medicine is the loss of a personal relationship between provider and patients (It would not surprise me if one of my providers hope for my demise, just so I would not be on their schedules with my complex disease), I argue with “alternative medicine” because of their lack of science.
Alternative medicine often claims a scientific basis, but with testimonials rather than true science. They built true science around the double-blind study that eliminates personal bias (emotional reasoning) which contaminates testimonials. Most of the time they just make things up, “This works for that.”
I ask, “How do you know that?” The answer is almost never from a study but from a person, a guru in alternative medicine who said so.
I am most disappointed that alternative medicine practitioners often spread conspiracy theories to discredit evidence-based medicine such as “the corruption of big pharma.” I wish that alternative medicine was truly complimentary. I think evidence-based medicine has a lot to learn from them.
When I was a member of the American Headache Society, I was a member of the CAM (complimentary and alternative medicine) sub-group. I really wanted to find “natural” treatments for migraine, but those that were proven to work. But we did not make things up.
The Business of Healthcare
I would be naïve to say that business is a bad thing in healthcare. Would healthcare providers work for free? I think not. There has to be a monetary exchange to make it function. But it’s the misapplication of business that’s the problem. This problem with the business model is not greed. Yes, you will find a few people within all aspects of medicine that are overpaid (e.g. insurance executives that earn annual salaries in the tens of millions of dollars, a very few medical providers in both evidence-based and alternative medicine). But its not the driving force.
In a nutshell, the business of healthcare is now dictated, for the most part, by insurance companies. The original purpose of insurance companies is to level the cost of healthcare across society, as those costs skyrocketed. Costs were driven up, not by greed so much, but by the complexity of medicine (meaning our growing understanding of the complexity of disease and the treatments thereof). Things we knew about disease and treatment 50 years ago were the low-hanging fruit. Now, diagnosis is far more complex, as is the treatment. Before insurance, if a treatment was expensive, you had to choose to die or go bankrupt. With no insurance, you hope and pray that you never get sick.
Society has two ways of spreading out the costs, through taxes and government paying for the care, or through private companies and premiums. America opted for private companies.
You can debate the cause of the super inflation of healthcare cost, but the driving force is the advancements in technology. I am a perfect example of this. My healthcare cost in 2019 was over one million dollars. With my $15,000 per capsule of my present chemotherapy, this year it will be in the hundreds of thousands. It is because these treatments are complex and costly to develop. If it was not for the insurance companies averaging out these costs over thousands of subscribers, I could not afford it and would have no choice but to die.
I used to demonize health care insurance companies. After all, they caused the downfall of my own medical practice. My goal was to bring the humanity back into headache care. However, 70% of our fees were left unpaid by the insurance companies, plus the cost of doing business with them was overwhelming. However, watching them pay these enormous bills for my personal care has dampened my hostility toward them.
Here’s the negative influence that insurance companies have had on the delivery of healthcare. As a VP of a major health insurance company told me (when I was confronting him on this issue), “I lay in bed at night thinking about our stockholders. For every penny we don’t pay on claims, it is a penny we return to our investors.”
Insurance companies have a monopoly on health care. Health care providers don’t have clout to fight back against them, unless they are huge, for example, the University of Washington in Seattle’s insurance market, or Mayo Clinic in the Minnesota insurance market. For that reason, almost all private practices have disappeared. In the future, unless something changes, medical practices will continue merging into even larger systems. It is inevitable in this present climate. Larger systems dehumanize patients because of the dilution within the volume and for the sake of efficiency (the Henry Ford effect).
It is more than the insurance companies paying less to a provider for a patient’s appointment. It is a chess game, where the insurance companies are constantly changing the rules to their favor. The more complex the rules are for a medical provider, the more difficult it is for them to comply, and therefore more money the insurance company can keep.
Enter The EMR
A new metaphysical phenomenon occurred within healthcare in the 1970s. Malpractice lawsuits were becoming more and more lucrative. The lawyers were able to win cases based on documentation alone.
For example, if you were a nurse and up put the rails up on the bed of Ms. X as you left the room, but did not write that you put the rails up, then Ms. X falls and breaks her hip, they could sue you for not putting up the rails. The mantra was, “If not documented, it didn’t happen.”
The insurance companies have now adopted the same metaphysical reality. They pay for what you have documented doing . . . not for what you’ve done. There are x number of points that must the provider must document, for the insurance company to reimburse them for the visit. To document these things, the provider has to focus more on the record than the patient. It isn’t because of callused providers but for hospital groups to stay in business, the pressure to conform to insurance mandates often damages the patient-provider relationship (the art).
When I was a small boy, I remember going to my pediatrician, Dr. Brown’s office. You could walk in, Saturday mornings were only walk-ins. The doctor saw 40-50 patients in a day. He charged 25 dollars a visit and did well. He also had a relationship with my family and me, knowing me by my first name and what happened our previous visit. However, his note was one or two sentences written by pen, taking less than a minute. The medical knowledge was much more limited, treatments simpler. Now we know five times as much so diagnoses and treatments are far more complex.
There is much more to say about this, but I think that evidence medicine training has erased empathy (the art or humanity) by the science and the business. My dream is that we can restore it despite those pressures.
I will mention one more thing in closing about the way science has pressured out the humanity in medicine. It is from how they teach evidence-based medicine. They taught us in our PA school, which mimicked the medical school, that we cannot fraternize with the patients. Unlike the example above with the man and his chiropractor, they taught us it damages our objectivity if we see patients as friends (or see our family as patients). The fear is it skews our judgement.
In the later years of my practice, I made the point of asking about one personal (non headache) issue with my patients during our visit (e.g. How’s your son whose studying math). I would put that in the note to remind myself to ask more about it on the next visit. I wanted to see my patients as my personal friends. Maybe this is the reason I was never successful in medicine … from a business standpoint.
I came here to delineate the problem and it would take much more space to come up with remedies.