Narrative Concepts

The idea of narrative is becoming recognized as basic to understanding humans and culture.   Philosopher Alisdair MacIntyre writes, "[W]e all live out narratives in our lives" and "we understand our own lives in terms of the narratives that we live out."   (MacIntyre, 1981) . The default mode of the brain according to Washington University neuroscientist Raichle is to make up stories.   It is what we do easiest.   It is what burns the least amount of glucose.   It is, according to neuroscientists and artificial intelligence experts Shank and Abelson, the template for human memory.   We humans actually think more in terms of verbs than in nouns.   When we see something, we want a story about it.   We want to know what it does or what it can be used for.

What is narrative?   The shortest narrative consists of two action clauses and an orienting clause.   I like to tell a short story that one of our clients told.   She said, "One time I killed my boyfriend, but then he came back to live and tried to kill me.   That was when we were living in Georgia and I was dealing coke."   This short story tells so much.   It conveys the essence of a character, of a human being positioning herself to be seen in a certain light.   It contains values and emotions.   It conveys a richness of understanding far beyond its mere words.   It is a work of social art, complexly rich and detailed.

University of Auckland Professor Brian Boyd argues that our big brains arose to do story.   Brain evolved to do story because story worked.   Story worked because it is the most efficient way to store massive social information as illustrated above.    Each of us can, apparently, know about 500 other people.   The amount of information we need to negotiate relationships with these others is massive.   We retain it in the form of stories.  

Thus, narrative medicine means an understanding of health and disease for humans, that is grounded in the stories humans live out in their lives and the stories that we understand about our lives which give our lives meaning and purpose.   Whatever we do only makes sense in the context of being grounded in a story or two.   When you recognize that I have a belief, that belief only makes sense if I tell about the experiences that led me to form that belief.   This belief rests upon experiences that led to certain conclusions that are stored in a narrative template.

Probably you wonder why this excites me so much!   I would answer, "because it bridges my indigenous parts with my non-indigenous parts.   In growing up, I learned that everything that mattered was a story.   If my grandparents had something important to tell me, they would tell me a story.   I was expected to interpret the story, to make sense of the story and to grasp what they wanted me to know.   I learned that "all there is, is story".   In Lakota, our personhood is the synthesis or integration of a swarm of stories that surround us called the nagy.   These stories consist of all the stories that form us or that we have told or are enacting as we move about in the world.   This nagy also consists of all the tellers of those stories.   We are forever embedded in each other's nagy's.  
To bring that into the practice of medicine, it means that illness is embedded in the stories we are performing and that are performing us.   There is a biological story about how we are organisms who are born, live, wear out, and die.   Our lives are finite.   Within that finitude, however, are multiple social stories which interact with the "how long do I have to live story".   Another story tells us that some events within our lives appear to be random, meaning that I can't make sense of them.   I can't place them within a story.   However, if I find the stories that people are telling and that are told about them, often their illnesses are illuminated in some way.   The illnesses make more sense.  
David B. Morris of the University of Virginia, writes that narrative is above all a form of knowledge (Morris, 2005) .   In this view, narrative knowledge complements and differs from traditional "logicoscientific" knowledge (Charon, 2001) .   For Charon, narrative knowledge is less of a product than a tool.   It is "what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means."   Its identifiable properties -- beginnings, middles, endings, characters, conflicts, and turning points -- for Morris are more descriptive than definitive.
Narrative comes from the Latin word, narrare, which means "to tell" and refers to various forms of telling.   Philosopher Richard Kearney writes that, "[N]o matter how distinct in style, voice, or plot, every story shares the common function of someone telling something to someone about something" (Kearney, 2002) .   For Morris, these tellings include the gamut from fragments of discourse to ancient formulaic epic poems like the Iliad or The Odyssey to cryptic post-modern novels.   Other scholars go further than Charon to argue that all knowledge, even the conventional declarative knowledge of modern medicine is narrative because all knowledge is embedded in theory which is a story about how the world is supposed to work.   These stories have characters in the form of biological entities or molecules, they have plot in the sense of operations that take place upon these entities (enzymatic reactions, flows of ions, passage of molecules across membranes).   They have implicit values such as preserving the life of the organism.   Even mathematical proofs can be seen as narratives.   Some neuroscientists see human identity and the operation of human consciousness as narrative (Fireman, McVay, & Flanigan, 2003) .

Narrative is not strictly verbal.   It is visual, bodily, kinetic, musical, and mixtures of all these.   Choreographed dances are stories, such as American Spring as are musicals like Oklahoma.   For Morris, stories also hold the negative, what cannot be told, the gaps, silences, and what cannot be said.   Stories always contain a matrix of choices -- what is valued, what is marginalized, and what is excluded.   Within medicine, narrative reminds us that illness is always caught up in stories involving families, jobs, cultures, and meanings and is not limited to the simply biological rendering, which we call "the natural history of the disease".   Indeed, I suggest that illness is without natural history because it is always affected by human affairs -- by people's search for meaning and happiness, by the relationships in which they find themselves, and by the broader stories of culture.   Biology is not an island unaffected by the sea in which it swins.

Bibliography

Charon, R. (2001). Narrative Medicine: a model for empathy, reflection, profession, trust. JAMA, 286, 1897-1902.

Fireman, G. D., McVay, T. D., & Flanigan, O. J. (2003). Narrative and Consciousness: Literature, Psychology, and the Brain. Oxford: Oxford University Press.

Kearney, R. (2002). On Stories. New York City: Routledge.

MacIntyre, A. (1981). After Virtue: A Study in Moral Theory. South Bend, Indiana, U.S.A.: University of Notre Dame Press.

Morris, D. B. (2005). Success Stories: Narrative, Pain, and the Limits of Storylessness. In D. B. Carr, J. B. Loeser, & D. B. Morris, Narrative, Pain, and Suffering (Vol. 34, pp. 269-285). Seattle, Wash8ington, USA: Intertnational Association for the Study of Pain Press.

Single Payer Health

People's stories about health and disease determine their health behaviors.  I begin with an example of a patient whom I told 25 years ago that he had to take better care of himself and who just dropped dead of a heart attack in his 50's.  I wonder about how we help people change the story that they are living.  How do we help them change health destructive behaviors in a respectful way that honors the story they have brought?

Who should pay for health care?   If health care is a right and not a privilege and we should all contribute to each other's wellbeing, then how do we do that?   Taxation is the main means for governments to raise money, though I suspect that the current profits being generated in our capitalistic health care could go far to reducing the actual cost of health care if we no longer had shareholders and owners to please and CEO's of hospitals and health systems were public servants instead of capitalists.   The last time I checked the CEO of Health Care America was making an annual salary of 150 million dollars plus stock options and other perks.   We wouldn't tolerate salaries like that in the private sector.

I received enough comments related to single payer health systems on my last blog to make me want to write another essay on this topic (rather than respond to each comment one-by-one).

U.S. health care is the most expensive in the world by a factor of four and results in ratings that average about 27^th in the developed world, all factors considered.

I think we should subsidize each other's health care because none of us are willing to sit and watch someone die in the waiting room because they haven't bought health insurance.   The Republicans argue that it is their right to eschew health insurance, but I'm sure few people would renounce health insurance if they could afford it.   Their argument is specious because few of them would stand by and let people die in the waiting room, either.   I'm quite sure some would, however, as they would see it as the will of God.   Like the Catholic Church in the Middle Ages, they would not want to interfere between God and man by helping a person to recover from God's punishment in the form of illness.   Once most of us agree that people can't just be allowed to die, then we have to pay for their care and some people's care is more expensive than others.   How are we to answer the question of people's own behavioral contributions to their ill health?   Should smokers pay a higher tax than non-smokers or is that factored into the tax on cigarettes?   Should people who regularly exercise pay a lower tax than sedentary people?   Should vegetarians be taxed at a lower rate than fast food aficionados?   The list is endless.   Figuring out the nuances of human behavior and how they affect health occupies the lives of endless epidemiology departments in public health schools around the world.   

The surprising downside (though maybe it's not) from some of single-payer health is that your health and your health related behaviors become my business.   I have an interest (because I pay for your illness) in controlling your behavior because "bad" behavior costs me money.   Therefore, matters that we have considered private are now public.   We must debate the cost of providing contraceptive care to which some Republicans object.   From a cost perspective, birth control is much less costly than children.   Only poor people could not afford birth control and the costs of not using it are then borne by all of us in the form of paying for the cost of their raising their children or our raising their children.   One Republican answer would be that many childless families (mostly white) are available to adopt children and should do so.

In the International Journal of Health Care Finance and Economics from 2009 (Volume 9, pages 1--24), in a paper on "Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's", A. H. G. M. Spithoven writes about how the U.S. spends most of all developed countries on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been known for decades. The turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada.   The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 revealed that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol's cost disease and pharmaceutical prices. It was not inefficiency in providing health.

What is Baumol's cost disease?   Assuming that wages in low productivity sectors must keep up with wages in high productivity sectors, prices for labor intensive goods or services will rise relatively to prices of goods and services produced by the high productivity sectors (McPake et al. 2003).

Productivity in health care is difficult to improve because health care relies for a large part on a direct face to face relation between the health care worker and the patient.   For example, washing a patient needs time that cannot be reduced beyond a certain point. Health care, where a large part of cost comes from staff looking after patients, is a low productivity sector. Baumol's costs disease may be overstated because the "output" used in measuring productivity in health care fails to capture major improvements in quality or results. So, while the cost of medical spending shot up from 1960 to 2000, largely as a result of the development and wide-spread use of new medical techniques, the cost per quality-adjusted life year decreased.   Health indicators for both males and females, such as life expectancy at birth and infant mortality rates, reveal that the quality of health care did not improve in the U.S. in comparison to Canada in the 1960--2000 period (United Nations 2005 data).

Administration costs prove to be a significant variable to explain the difference in health care expenditure between the U.S. and Canada. America's health care is characterized by a fragmented payer system, while Canada has a single-payer system. The first has less economies of scale in administration than the latter because competition among providers of health care, on the one hand, and competition among insurers of health care on the other, result, among other things, in extra expenses in billing and administrative operations of health care providers who have to deal with 100s of payers and different rules and prices.

Overhead costs in Canada's single payer system are much lower than in the U.S. with 72 US$ health care administration expenditure per capita in Canada in 2002 and 367 US$ per capita in the U.S. For 1999: "In the United States, health care administration cost $294.3 billion, or $1,059 per capita [. . .] In Canada, health care administration cost $9.4 billion, or $307 per capita [. . .] After exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada". Using the same broad definition, this big difference is also reported by Himmelstein et al. (2003): "The U.S. wastes more on health care bureaucracy than it would cost to provide health care to all of the uninsured. Administrative expenses will consume at least $399.4 billion out of total health care expenditure of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003, $6,940 for each of the 41.2million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage."

Another surprising public debate becomes for what should we pay?   In Canada, the National health system does not pay for dental care.   Apparently, teeth are superfluous.   In Holland, from where I am today returning, the government is about to decide that psychiatrists will no longer be paid for psychotherapy, only for prescribing medications for depression because medication is more cost-effective than psychotherapy and people can get cheaper psychotherapy from others.    I learned this at a Dutch hypnosis conference attended by a number of psychiatrists and family physicians.   Actually, the evidence in the literature does not support this contention.   A number of studies have shown that psychotherapy is more effective than medication or medication plus psychotherapy at 16 weeks.   For depression, a 2010 meta-analysis using the Freedom of Information Act to obtain all the clinical trials ever done on antidepressants (all must be reported to the FDA but not necessarily published) found no difference between medication and placebo.   A 2010 study compared behavioral activation (prescribing behaviors that cause the person to become more active) to cognitive-behavior therapy and to medication over 16 weeks.   Most antidepressant studies last 6 weeks, not long enough for psychotherapy to show its full effect.   

However, how much control should the payer have over how we physicians choose to treat people?   Typically, there are many equally good ways to treat a problem, though bureaucrats are not apt to notice this.   They wish the best way.   They wish a quick and easy answer.   And a bias exists!   Therapies that involve human interaction are always less trusted than technology.   We live in a world in which the bias is toward technology solving problems.   Payers for health care have an interest in what is provided just as do recipients of health care.   Where do the two intersect?   Her again, I would prefer Bernie Sanders (Senator, Vermont) solution of giving control of health care to local governmental units.   I think I would have a better chance of arguing my methods and why they should be compensated to a local board than to a faceless, nameless government agency.

Thus, in thinking about a single payer system, we must consider the politics of power.   Who decides what will be covered.   Who decides what we physicians are allowed to do and what we are not allowed to do.

Even as we consider who pays for health care, we must consider the kind of health care that we wish to have and how to insure that we get it. Today's health care relies extensively on technology which often fails to achieve its desired goals.   Some of us at the margin of health care want more human-oriented care.   We believe that health improves in the context of relationship and that physicians need to take the time to develop relationships with patients.   We need to have the time to develop the relationships to help people change the way they live and to change the way they see the world.   We need ways to provide care that allows us to spend time with patients and provide care that we and the patients believe will help.   The downside of single payer systems that are far removed from the doctor-patient relationship is that the control lies far from the relationship.   Bureaucrats don't necessarily even make evidence-based decisions, and evidence changes constantly.   Doctors and patients need some autonomy over what they decide to do to improve health.

Himmelstein, D. U., et al. (2003). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the district of Columbia, with state-specific estimates of potential savings. Cambridge MA: The Division of Social and Community Medicine, Department of Medicine, The Cambridge Hospital and Harvard Medical School; Washington, DC: The Public Citizen Health Research Group.

Post Election Thoughts on ObamaCare

I haven't yet taken the opportunity this year to render my thoughts on U.S. health care and how it should be funded and implemented.    President Obama's plan for health care has come before the U.S. Supreme Court and its fate has already been decided.   We are waiting for the clerks of the Justices to write their opinions.   The Republicans maintain, in a strange twist of logic, that people demand the right not to buy health insurance.   With some exceptions of extremists, who would actually choose not to have health insurance if they could afford it?   The Republicans will next argue that people have the right to be poor and that we shouldn't take that right away from them!

My mother was leaning toward the Republican argument until I asked her what she would have me do if someone entered the emergency room in the midst of a potentially lethal heart attack without health insurance.   Should I save his life even if he doesn't have insurance? I asked.   Of course, she answered.   

"There's the rub," I responded.   "Once you believe that we as a society have the duty to save people's lives when they are having health crises for which they cannot pay, then we need a way to pay for it.   That's what we have now.   The nation's hospitals provide a somewhat dysfunctional local health insurance by virtue of laws preventing them from turning people away at the emergency room door.   Hospitals in New Hampshire have sued their state government because they are going broke from this policy arising from laws forcing them to provide care without any means of remuneration.   It's also important to remember that when those who have not had health insurance come to the emergency department, their bills are usually larger than those who have had care, because more has gone wrong.  

I found the interstate commerce debate confusing.   It seemed simple to me that we must care for whoever comes to our door regardless of where they live.   For example, our hospital in Brattleboro is the closest hospital for people who live in Hinsdale, New Hampshire.   If they have an emergency, the ambulance is going to bring them to Vermont regardless of any other concerns.   Our hospital is three minutes from downtown Hinsdale, while the closest New Hampshire hospital is 35 minutes away in Keene.   I'm not sure how well New Hampshire insurance pays our hospital, but I know that we do not accept New Hampshire Medicaid for psychiatric services since it pays $23 per hour visit (less for shorter visits).   That compares to Vermont Medicaid which pays $87 for a one hour visit.   State lines don't appear to exist when it comes to medical emergencies and hospitalizations; only for routine visits.   The New Hampshire to Vermont transfer works in reverse when we have really sick people in our hospital.   The closest major medical center is at Dartmouth University, which is in Lebanon, New Hampshire.   They send a helicopter to pick up our really sick people and bring them to the academic medical center for the advanced technology they have there.   Apparently state lines don't matter there either, for we don't send people the 260 km to Burlington, Vermont, to the University of Vermont medical center just because it's in-state.

The proposal which makes the most sense to me is that of Senator Bernie Sanders of Vermont, who believes that local regions should control their own health care budget.   I think this could work in Vermont because we could decide where the money is best used in accordance with our local values and practices.   We might choose to cover supplements and fish oil and not the most expensive drugs in the pharmacopeia.   We might add massage therapy for people with chronic pain and perhaps stop paying for anesthesia blocks since these do not appear to be better than placebo.   We might change every six months as data and preferences change, but we could do that.

I do think everyone needs health care coverage.   We need to know that we are covered in the event of illness or accident.   Someone must pay for this coverage.   It must come from health care insurance premiums paid by people or from tax funds also paid by people.   Either way, people must pay for health care, either through taxes or through premiums.   I would prefer taxes over premiums, but that is my personal feeling.   I would prefer a decentralized system in which each locality has a health authority which is populated by a community board of directors who determines how our portion of the health care tax is going to be spent in our community.   We could struggle together to make the hard decisions about allocation.   We could engage in the dialogic process as we do that.   It wouldn't be perfect, but no perfect decision making system exists.   Plus if we had the money locally, we would be forced to think locally about our neighbors and friends and not abstract concepts.

In my experience, what no one wants to address is the escalating costs of health care and why they are not going to stop rising.   Health care is only getting more expensive and will continue to become progressively, even exponentially, more expensive as time progresses.   New technology costs money and everyone wants more technology (seemingly).   New drugs cost more than old drugs, and everyone seemingly wants new drugs (though few new drugs work much better than old drugs).   When we invent a new test, we rarely stop performing the old test that the new test was meant to supplant.   Usually we do both tests.

The medicalization of life has generated tremendous costs for health care.   Ordinary misery has been elevated to a pathological condition.   Every ache or pain demands a label and a diagnosis.   In my role as family doctor, people bring to me a myriad of symptoms in search of diagnosis.   Most of these symptoms will defy diagnosis unless I can convince them that their symptoms are part of life.   Life involves aches and pains.   Life involves some element of suffering.   We get tense.   We get uncomfortable.   We forget how to relax.   We get anxious and experience the somatic symptoms of anxiety.   Our lifestyle leads us to pro-inflammatory conditions.   This irritates our joints, causes our immune system to produce pro-inflammatory cytokines which makes us feel flu-like, makes us feel depressed and more anxious, and promotes the development of other chronic medical conditions.   This pro-inflammatory syndrome is just being recognized and has no real pharmaceutical treatment.   Its solution is to sleep more, to exercise more, to eat an anti-inflammatory diet, to have more fun with other people, to stretch more, and the like.   So much of family medicine is about moving people in common sense directions to reduce inflammation which will improve their symptoms.   Laboratory studies don't really help me to do that, but are what patients often want.

Chronic pain represents another example from my area of practice.   Countless thousands of dollars are spent on X-rays, MRI's, and CT scans of the areas of pain.   They are really revealing.   Studies have shown that the findings of these studies rarely correlate with levels of pain.   They "hypnotize" an entire population of patients to believe that they are hopelessly immured in chronic pain with no hope of recovery, when that is not necessarily the case.   Often, the same simple measures will work wonders with chronic pain and cost very little.   Similarly, coaching people to lose weight and to exercise costs relatively little compared to the costs of being obese and not exercising, yet current health insurance does not cover these costs.   If we had local control over our health care dollars, we could make decisions about these types of matters on the local level and spend our money as we believe would benefit us best.   That's my recommendation for health care -- use tax dollars, cover everyone, give the money to the smallest local entity possible (village, township, shire, etc.), let the local entity decide how to spend it, and struggle with our unrealistic expectations of contemporary health care.