People with multiple chronic medical conditions accumulate hospital visits like RVs collect bumper stickers. Tokens of “been there, done that”, both the stickers and the reams of discharge instructions function to conjure memories of past exploits in hospital corridors and national park access roads. Neither the stickers nor the medication lists materially improve the bearer’s current situation. Which is to say, the frail complex patient receives disjointed care that can be beautiful for a week, but that does not last beyond Labor Day.
Mr. S was a 69 year old veteran who had been hospitalized 24 times for pneumonia. “I get sick real quick doc,” he said, almost with pride. Each time the health system performed admirably, with paramedics triaging and bringing him to the ED, where he got antibiotics for sepsis, and was efficiently admitted, treated and discharged home. He gave the hospitals high marks for satisfaction. And yet, the whole cycle just kept endlessly repeating, with another fever and another hospital stay. I started visiting him at home, and learned about his chronic pain from an old car accident, with narcotic use and frequent bouts of falling asleep on the couch. I learned about the daily RockStar he uses to try to stay awake after his oxycodone, and then the stomach bloating and gas which he treats with strong acid blocking medication, twice daily.
This is a man over-treated by medicine, not under. His acid blocker allows stomach bacteria to multiply, so when he goes semi-conscious with pain medication, he aspirates from stomach to lungs and then is soon febrile, not breathing well, and calling the ambulance. Over months we changed his diet, got him off the acid blocker and off the narcotics. He is awake most of the time now and has not been back to the ED. After my last visit he asked me to hurry up because he was going out to cut a Christmas tree with his grandkids.
I now do home-based care, bringing medical knowledge to patients’ real lives rather than trying to force cookie cutter solutions on them by following the model of the Cheesecake Factory, as has been proposed elsewhere. My medical group contracts to only take care of the most frail patients with multiple chronic conditions, the ones costing the American health system a tremendous amount of money with little to show for it. We have found that by becoming intimately involved in their lives, at home, surrounded by family and their unique living situation, we can reduce the utilization of expensive health resources while, at the same time, improving their quality of life.
Why does the factory model of care often end up worsening lives rather than improving them? Because standardized care employs abstractions. Most of medical care starts from the standpoint of the disease, like pneumonia or cancer. But diseases are actually conceptualizations, a step beyond the material existences of people. A person develops a fever and cough; we conceive of this as “pneumonia”. But patients live this as “spirits”, or an annoyance, or a punishment, or a million other things. Philosophy attempted to ground itself in materialism two hundred years ago with Karl Marx:
“We do not set out from what men say, imagine, conceive, nor from men as narrated, thought of, imagined, conceived, in order to arrive at men in the flesh. We set out from real, active men, and on the basis of their real life-process we demonstrate the development of ideological reflexes… phantoms formed in the human brain.” — Karl Marx, The German Ideology 1847
As I re-read Marx I am fascinated by how spectacularly wrong he was, despite his fundamental insight that someone’s historical and material conditions of life determine their existence. At the same time as he insisted on the specificity of historical circumstance, he mistakenly lumped incredibly varied peoples into “classes” such as bourgeoisie and proletariat. The actual material conditions of lives turned out to be different in Russia, and Vietnam, and with Hispanics and Norwegians, and you and me and in fact, everyone. In the same way, what the medical system calls “pneumonia” will never signify the same thing in different cultures and for different people. When we treat every pneumonia with the “standard of care”, antibiotics, we are making the Cheesecake Factory mistake: lumping abstractions together rather than dealing with someone’s historical and material situation.
Here is what one provider charted after a recent home visit: “Patient continues to minimize amount of beer he drinks, stated that the 3 empty beer cans at bedside are all he’s had in days. However, 2 garbage bags-full of empty beer cans seen in kitchen. Neighbor buys him beer.”
The insight into someone’s historical and material life illuminates far more than any abstract diagnosis of a disease in this case. The hospital frequent flyer has had her abstractions treated thoroughly, completely, and repeatedly. But she has not had the “material conditions of her life” confronted nor addressed. Until we do, medicine will continue to be a cheesecake factory which offers up sweet treats rather than solid life-sustaining fare.