A Plague on All Your Houses

 

 

I still remember a seminar I went to years ago in university. It was part of a nebulous course on ‘Health’ that some of us took as a soft route on the way to a bachelor’s degree. It was reputed to consist of essays and a true or false final examination. Also, because the class was small, it was amenable to division into even smaller numbers for several interactive sessions.

There were five of us and a teacher’s aide at the one I remember so well. We were all fresh from high school and, at least in those faraway days, used to being lectured at, rather than actually contributing to the subject matter. The topic that day was Disease, and I remember being mildly interested, but expecting only a list of the usual culprits, complete with causes and treatments -memory fodder for later regurgitation, I suppose.

“What is disease?” the TA started, as soon as we were seated around a rather small wooden table.

One of us -I don’t remember his name now- rolled his eyes and smiled. “Sickness,” he answered, rather smugly.

She smiled in return, as if he’d fallen into her trap rather too easily. “Okay, but haven’t you just used a synonym -defined it in terms of itself?”

He stared at her for a moment, obviously confused. “Well… then, how about saying disease is an abnormality of an organ or a system caused by germs -probably particular germs depending on the disease.”

Her face relaxed and her smile broadened. “Now we’re getting somewhere.” She leaned forward on the table. “Let’s get more specific for a moment. Let’s take tuberculosis… Anybody know the cause for TB?” She glanced around the room, determined to involve us all, apparently.

I looked up at the wrong moment, and she brushed my face with her question and pinned me to my seat with another smile. “Do you know the cause of TB…?” she said, locking eyes with me.

There was no escape. “Uhmm…” I felt embarrassed at being singled out, but the question seemed fairly straightforward. “It’s the tubercle bacterium, isn’t it?”

She sat back in her chair, and shrugged nonchalantly. “Is it?” She said, softly and with just a hint of gentle sarcasm. But her eyes were still sitting on me, and I could tell they meant no harm.

“Tubercle bacillus?” I corrected myself, remembering that people sometimes called it that.

“So…” she glanced around the table again, lifting the weight off my shoulders. “Would you all agree that TB is caused by a bacterium -a bacillus?” she added, looking at me once more. Everybody nodded.

“But don’t some healthy people have a positive skin test for it -the Mantoux test?” she continued.

We all nodded, most of us unwilling to show that we hadn’t known what the test was called.

“So, why is that?” She paused to see if any of us had an explanation, but when nobody said anything, she continued. “If the bacterium Mycobacterium tuberculosis is present…” she slowed down even more for effect. “… if some of us have it… and it causes TB… then why don’t those people have TB?” She straightened in her chair and leaned on the table with her elbows as she searched our faces for the answer.

But she was greeted by blank, albeit confused expressions around the table.

“If disease is caused by the acquisition of a bacterium, then what stops some people from acquiring the disease?”

This was new territory for us, and yet, her eyes stopped at me again. “Our defense mechanisms -the immune system…?” I suppose it wasn’t exactly a scholarly response -even in those days we’d all heard of vaccinations and antibody production.

She started nodding. “Okay, but what makes the immune system strong enough to resist?”

“VSG?” someone said, and immediately blushed because he had obviously taken a leap in the dark with the initials.

She smiled reassuringly. “BCG -Bacille Calmette-Guerin, to give it its full name?” He nodded, presumably relieved. But even in those days, there was some doubt as to its effectiveness, so she merely shrugged again. “But the person may never go for the skin test and so never know she has the bacterium…”

She stared at me again, for some reason. “Well, suppose they’re in good condition -healthy, I mean?” To tell the truth, I didn’t really know what I meant.

“But doesn’t ‘healthy’ mean free of disease? Isn’t that another tautology…?” She walked around the table with her eyes again, but this time more slowly. “So, might there be other causes of disease -apart from the infecting agent, I mean?”

I remember some of us looking at each other, as if we were beginning to understand where she was going with this.

“Where -or maybe under what conditions- do we see a lot of diseases like TB?”

I suppose I remember the seminar so well, because she kept looking at me when nobody else answered. “You mean if somebody’s poor, or living in unfortunate circumstances? Poverty…?” I managed to mumble, hoping that was what she was after.

I still remember her smile.

It was a seminal moment for me, and maybe one of the reasons why I eventually went into Medicine. But it all resurfaced when I happened upon an article in the CMAJ (Canadian Medical Association Journal) from January 22/18 with the rather long and certainly uninviting title, Effect of provincial spending on social services and health care on health outcomes in Canada: an observational longitudinal study: http://www.cmaj.ca/content/190/3/E66

Its thesis, was that spending on health care is escalating so significantly it will soon be unaffordable. The question then, was what to do about it. The study ‘used retrospective data from Canadian provincial expenditure reports, for the period 1981 to 2011, to model the effects of social and health spending (as a ratio, social/health) on potentially avoidable mortality, infant mortality and life expectancy.’ And after using various methods to analyze the figures that I didn’t even try to understand, like ‘linear regressions, accounting for provincial fixed effects and time, and controlling for confounding variables at the provincial level.’ decided that ‘Population-level health outcomes could benefit from a reallocation of government dollars from health to social spending […].’ Or, as they worded it more succinctly in their concluding paragraph: ‘The results of our study suggest that spending on social services can improve health. Social policy changes at the margins, where it is possible to affect population health outcomes by reallocating spending in a way that has no effect on the overall government budget.’

It made me wonder, though, why, if I learned the same thing many years ago, did it still need investigation? Were we so wrong back then? So naïve…?

 

 

 

 

 

 

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What is the Merit of Originality?

‘I am not young enough to know everything,’ as Oscar Wilde once said, and maybe the rest of us aren’t either. It is often an unquestioned assumption that New trumps Old, that innovation usually leads to improvement, and that by standing on the shoulders of giants, the view is necessarily better. Clearer.

But there is wisdom in both the long as well as the panoramic views. Neither changing  your shoes nor altering your hat, really improves the safety of a voyage -nor does it address the original goal of a safe arrival of everybody on board. Appearing modern, seeming prepared, only helps if it helps –a leak is still a leak, especially if there are only lifeboats for a few…

Let me explain. I happened upon an article in the journal Nature that chronicled the introduction of a new, and highly accurate method of diagnosing TB through genetic analysis.  https://www.nature.com/news/improved-diagnostics-fail-to-halt-the-rise-of-tuberculosis-1.23000?WT ‘The World Health Organization (WHO), promptly endorsed the test, called GeneXpert, and promoted its roll-out around the globe to replace a microscope-based test that missed half of all cases.’ It sounded like a perfect technological fix for a disease that has so far avoided effective control. ‘Some 10.4 million people were infected with TB last year, according to a WHO report published on 30 October [2016?]. More than half of the cases occurred in China, India, Indonesia, Pakistan and the Philippines. The infection, which causes coughing, weight loss and chest pain, often goes undiagnosed for months or years, spurring transmission.’

Unfortunately, ‘[…] the high hopes have since crashed as rates of tuberculosis rates have not fallen dramatically, and nations are now looking to address the problems that cause so many TB cases to be missed and the difficulties in treating those who are diagnosed. […] The tale is a familiar one in global health care: a solution that seems extraordinarily promising in the lab or clinical trials falters when deployed in the struggling health-care systems of developing and middle-income countries. “What GeneXpert has taught us in TB is that inserting one new tool into a system that isn’t working overall is not going to by itself be a game changer. We need more investment in health systems,” says Erica Lessem, deputy executive director at the Treatment Action Group, an activist organization in New York City.’

But I mean, just think about it for a minute. ‘The machines cost $17,000 each and require constant electricity and air-conditioning — infrastructure that is not widely available in the TB clinics of countries with a high incidence of the disease, requiring the machines to be placed in central facilities.’ Sure, various groups agreed to subsidize the tests in 2012, but: ‘each cost $16.86 (the price fell to $9.98), compared with a few dollars for a microscope TB test.’ So which test would you choose if you were a government strapped for cash to provide for healthcare for a broad spectrum of other equally pressing needs?

‘Even countries that fully embraced GeneXpert are not seeing the returns they had hoped for. After a countrywide roll-out begun in 2011, the test is available for all suspected TB cases in South Africa. But a randomized clinical trial conducted in 2015 during the roll-out found that people diagnosed using GeneXpert were just as likely to die from TB as those diagnosed at labs still using the microscope test.’ That seems counterintuitive to say the least.

So what might be happening? ‘Churchyard [a physician specializing in TB at the Aurum Institute in Johannesburg, South Africa] suspects that doctors have been giving people with TB-like symptoms drugs, even if their microscope test was negative or missing, and that this helps to explain why his team found no benefit from implementing the GeneXpert test. Others have speculated that, by being involved in a clinical trial, patients in both arms of the trial received better care than they would otherwise have done, obfuscating any differences between the groups.’

‘Even with accurate tests, cases are still being missed. Results from the GeneXpert tests take just as long to deliver as microscope tests, and many people never return to the clinic to get their results and drugs; those who begin antibiotics often do not complete the regimen.’ Clearly, technology alone, without an adequate infrastructure to support it –without a properly funded and administered health care system- is not sufficient.

And it’s simply not enough to have even a well-funded health system that benefits just those who can afford it, leaving the rest of the population to fend for itself, and only seeking help when they can no longer cope –often when it is too late. Health care is a right, not a privilege –no matter what those in power would have us believe.

I’m certainly not arguing that improving technology is not part of the solution, but sometimes I wonder if it is merely putting new clothes on a beggar. Handing out flowers in a slum.

Let’s face it, real Health Care is more than a sign on a door, more than a few people in white coats. It is a kind of national empathy. A recognition that even the poorest among us, have something valuable to contribute; that even those who have strayed from society’s chosen path, are who any of us might be, but in different clothes.

The myth of Baucis and Philemon tugs at my memory: They were an old married couple living in a small village in Anatolia (part of Asian Turkey nowadays) who, unlike everyone else in the town, welcomed two peasants at their door who were seeking refuge for the night. The couple, of course, were unaware that they were actually welcoming two gods, Zeus and Hermes, disguised as humans. A common enough trope, perhaps, but an instructive one, I think -one that transcends virtually all cultures, and borders: the idea of helping others without any expectation of reward. It is not an exchange -a transaction- so much as an action. Agape, in fact.

Health care is like that. Or should be… It’s not about the glittering display in the shop window –there to impress the passersby- it’s about the people in the shop.

 

 

 

 

 

 

 

 

 

 

 

 

 

An Even More Modest Proposal

How many of you remember being presented with Jonathan Swift’s ‘A Modest Proposal’ in English 101? It was a not so subtle satire of 18th century British treatment of the Irish, in which he hyperbolically –and anonymously- suggested that the Irish might be able to ease their economic distress by selling their children for food to English gentry. It was clearly so outrageous and inflammatory that it was intended to make the readers see how wrong the then-prevailing treatment of fellow human beings could be. To alter, in other words, the perspective, and facilitate the shift to a different world view. To allow people to see what they had hitherto ignored and perhaps make them want to improve it.

My own modest proposal is less preposterous and certainly not satirical, but it does fly in the face of what we in the richer nations have come to expect and accept: only the use of professionals in our health system; and discount: the adjunctive use of non-professionals to help with some aspects of that care. It was engendered by a segment in an October 2016 PBS program and has intrigued me ever since: http://www.pbs.org/newshour/bb/can-ordinary-citizens-help-fill-gaps-u-s-health-care/ The idea that health care is becoming increasingly expensive and that even with universal coverage, there are still a lot of gaps that are unlikely to improve even with the addition of more doctors and nurses. Training and equipping them is expensive, and still does not usually solve the problem of their accessibility to those most in need –the poor and disadvantaged in our societies.

Professionals are viewed as part of a power structure that is often alien to a population all too frequently ignored, isolated and denigrated by the mainstream. Issues of cultural safety frequently play a role in this –lack of understanding and respect for cultural or economic disparities may make them unwilling to engage with professionals until the problem is untenable or even irremediable. Prejudices don’t need to be stated; they are too often felt. So the idea that there may be bridges into this demographic –keys, however counterintuitive, that could unlock barred doors- is worth exploring.

The idea of using trained volunteers to talk to those in society that are often ignored until in extremis is certainly not new. Think of the ‘barefoot doctors’ working in rural villages in China, for example. Or, ‘In sub-Saharan Africa, community health workers have long formed the backbone of health systems, filling in gaps where doctors and nurses are in short supply.’ The key concept for the acceptance of these para-medical workers, of course, was the relative lack of other facilities and professionals to fill them.

So why should we, in our relative affluence, consider the use of non-professionals? Especially here in Canada where, in 2003 at least, there were 2.14 doctors and 9.95 nurses per 1000 population? Perhaps in Malawi, where there is 1 doctor per 50,000 people (2004) the need is more readily apparent, but Canada…?  Well, it seems to me that the gap is not so much one of professional numbers as engagement. As one of the patients interviewed in the PBS program said of the volunteer that talks to her about her severe diabetes condition: ‘With your doctor, you don’t really want to say what you eat, so I’m able to tell her like, really, if I’m not going well, or, you know, if I sneaked and cheated. I tell her the right things, and she helps me.’

In other words, the volunteer is not attempting to take the place of the doctor or nurse and give medical advice, but is acting almost as a translator of patient concerns that are not verbalized in front of the doctor or nurse. We sometimes forget the power discrepancies on display between doctor and marginalized patient.

The addition of trained community volunteers should not be seen as a threat to the professions, but rather as a helpful, and essential, adjunct to expand the reach of healthcare beyond its present boundaries. Nor should it be seen as creeping multi-tiered medicine with the poor being relegated to substandard care –swept under a carpet where they can be safely ignored until they become seriously ill and show up in Emergency Departments across the land -an expensive way to provide health care, not to mention wellness-promotion. It is simply not cost-effective, no matter the system.

The volunteers can be used to penetrate the layers and develop relationships with people who otherwise might not seek help until they had no other choice. Help them to know when to seek professional advice. Check to see if they are following whatever recommendations were given; make sure they take their medicines as directed. Emergency care is expensive and its facilities limited; timely, early intervention is both preferable and, ultimately, more humane. I know that our Social Service is already doing a sterling job in this regard -especially in our larger cities- but they are stretched pretty thinly nowadays; I would think they might appreciate a little help. Doctors and nurses in the various walk-in community clinics or in smaller towns could suggest clients who might benefit from some additional help, and the word would spread from there… As I have suggested, there are layers within layers to penetrate in a neighbourhood.

And if we agree that the volunteers would be better prepared and more useful if they received an appropriate basic training course to equip them for what they are likely to encounter, why not fund this? For that matter, why not pay them? Or am I being naive?

It’s a modest proposal, though… Isn’t it?

 

 

 

 

 

 

 

 

 

The Justice of Justice

Okay, I’m Canadian; I do not understand the objection to universal health care south of the border. And I certainly don’t know how a society that purports to believe in equal opportunity for all could be so resistant to accepting the inalienable right of every person to access affordable medical treatment, the right to a personal choice as to whether or not to become -or stay- pregnant; and, so long as it does no harm to anyone else, the right to make a decision about what to do with their own bodies. Isn’t that part of the Life, Liberty and pursuit of Happiness in the U.S. Declaration of Independence?

Each person has the right to choose a path for herself. That does not mean that others have to make the same choice –or even agree with it. But they should respect the right to do so. Live and let live; not judge and punish. Life –society- is far too complex; there are too many interactions, too many competing values (each one held and defended by someone) – too much going on for there to be just one direction, just one answer that is forever correct no matter the circumstances.

We all have ideas that we embrace and cherish. Often, one of the hardest things to do is read contrary opinions; we –most of at any rate- are subject to a confirmation bias. That is we tend to read or watch only those things that confirm our opinions. We do not frequently seek to explore those that contradict. We do not usually parse them to discover if there is a way they might be compatible with our own. If the contrary opinion expressed is about a strongly held belief we certainly do not examine it as closely as we might an article commenting on a foreign war atrocity. And religion seems to inhabit an entirely different Magisterium where compromise is considered a form of moral compromise and is anathema. Unacceptable. Wrong.

For what it’s worth, I think the answer to opposing values does not lie in denying them to the point of anger but rather in examining them to discover why they are held, and what benefits might obtain by considering them. Incorporating them, Compromising with them. In fact, it seems to me that even being willing to assess them is a step in the right direction.

What started me thinking about this was a BBC report of a recent 5-4 decision by the U.S. Supreme Court which “found that some corporations can hold religious objections that exempt them from a legal requirement that companies with 50 or more employees offer a health insurance plan that pays for contraception at no charge to the worker or pay a fine.”

 http://www.bbc.com/news/28093756

One has to assume that the Supreme Court is impartial and that its judgements are delivered only after a dispassionate consideration of all the relevant details of the case in point. The fact that all three female justices disagreed with five of their male colleagues does give one pause for thought, however. Is it a coincidence unrelated to the judgement on what can certainly be seen as a comment on the value of a woman’s rights, a woman’s choice -or something else?

But one has to be careful in evaluating the judgment. It’s not really an issue of increasing the difficulty for a woman to obtain contraception, nor even that it should be paid for by a company. Fortunately there are some foresightful provisions that the White House thought to include that may mitigate the ruling –the BBC once again: As the court noted, the Obama administration has already devised a mechanism under which workers of non-profit organisations that object to the contraception mandate could keep coverage without the organisation having to pay for it.

So then, what’s the big deal about the Supreme Court ruling? Well, The decision marks the first time the Supreme Court has found a profit-seeking business can hold religious views under federal law, analysts say. In other words, it suggests that religious beliefs trump individual rights -women’s rights in this case. And no doubt it is the thin edge of a wedge for further disruptive –not to mention religious- challenges.

In a dissent she read aloud from the bench, Justice Ruth Bader Ginsburg called the decision “potentially sweeping” because it minimizes the government’s interest in uniform compliance with laws affecting the workplace. “And it discounts the disadvantages religion-based opt-outs impose on others, in particular, employees who do not share their employer’s religious beliefs.”

And don’t think this is an attitude peculiar to America; Canada is not exempt:

http://www.calgaryherald.com/health/Calgary+doctor+refuses+prescribe+birth+control+over+moral+beliefs/9978442/story.html

We are all subject to our own biases; it’s just when they interfere with the rights of others that I worry.

The internet has exposed us all to a plethora of competing viewpoints. Of course, if we don’t agree we can just read the first sentence, make a judgment, and then move on to another. Or if we’re so inclined, we could even take the time to comment on it. But those ideas with which we disagree require some examination to refute online or the rebuttal seems fatuous. Ill considered. Unrealistic. And it will have little effect. Some of us don’t care, of course: anonymity is a seductive drug. That’s what cyber-bullying is all about: not changing opinions, merely inflaming them. Freedom to speak -or write- is not really freedom unless it makes sense. Connects in some meaningful way. Justifies… I suspect that most of us would not make the same vapid and vituperative comments if our names were appended and we knew that others were judging us. Or if we could be held accountable in the courts, for that matter.

This time Shakespeare (Coriolanus speaking to a group of mutinous citizens): What’s the matter you dissentious rogues, that, rubbing the poor itch of your opinion, make yourselves scabs? I’m not sure that I’ve entirely escaped a confirmation bias here, of course –I’ll have to examine my position- but I think he’s on to something…

 

 

 

 

 

Health Care Provisos

I think one’s occupation tends to encourage a tightly focussed view of only one lane on the road, and a trust that it and it alone will lead to the intended destination. In my hitherto tunnelled vision, it had always been the Medical Model that dominated -to the exclusion of any rival Magisterium. But as time matures, I have come to realize that what makes you well has less to do with Medicine than life style, apportioned genes, good luck… The doctor plays only a minor and maybe incidental role in the spectrum that is a healthy life. Health care, then, is not only ‘doctor’ care, or ‘nurse’ care, or even hospital care -it is Society care.

Is our currently extended life expectancy the result of doctors and technology? Partly, no doubt, and yet of all the six billion or so people now extant, how many have been saved by organ transplants throughout the world? How many by dialysis? How many spend time in an ICU? It is an insignificantly small fraction of humanity and yet in many -most- countries we are living longer. I would submit that this is a result of better sanitation, better hygiene and better nutrition -as well as better doctors…

It’s interesting to me that one could correctly attribute several causes to, say, tuberculosis. There is the one we doctors seem to prioritize: the tubercle bacillus. And yet although it may qualify as a necessary cause -a sine qua non for the disease we label TB- is it a sufficient cause? If I have a positive skin test for TB but do not have the disease, and yet the poor homeless woman begging on the corner with the same positive test does, why is that? One could be forgiven for wondering if TB is caused by malnutrition, overcrowding, or poor hygiene -poverty, in other words.

For health ministers, QALYs (Quality Adjusted Life Years) have been in and out of vogue for a while now.  I do not pretend to understand all the intricacies of their assignment, but the concept does seem a bit too heavy on John Stuart Mill’s Utilitarianism for me. Let’s say, for example, you give a person in a wheel chair only 0.5 QALYs because of her limited mobility -compared to a ‘normal’ individual (who gets 1). Doing a renal transplant on her would still not result in the same number of QALYs for that treatment that you would get if you transplanted a kidney into an otherwise ‘normal’ woman because no matter the new kidney, she would still be in the wheelchair… So if you were trying to utilize those scarce resources to maximize QALYs, who would you pick? And would that be fair?

On the other hand, there is the theoretical ‘black hole’ phenomenon that political bioethical philosopher Jonathan Wolff describes: if you were to spend all the health care dollars on the worst off or the most needy, it would not much benefit the rest of that society who also have needs -and it would consume the entire budget as well… The compromise, of course, is to prioritize the most needy and yet acknowledge others in the resource allocation… And consider additional needs that at first glance, might seem peripheral to wellness.

What am I getting at? Well, it has been suggested that an alternative to throwing all the limited resources even a rich society has available for health care at the ill (traditional health care provision, medicines, new and expensive technologies) would be to spend some of it on improving housing and opportunities for the poor -the proverbial ounce of prevention… The ultimate cost of preventing illness would be less than having to treat it. So: affordable housing; education; the provision of contraception for women in situations where they might wish or require it; new vaccines instead of (or at least in addition to) new medicines to treat the diseases they might have prevented; affordable daycares to allow single mothers to work, decent minimal wages; provision of breakfasts and lunches at inner city schools for disadvantaged children… The list is even longer of course, and yet it is cheaper than the alternative in the long run.

We have to get away from the idea that Health Care is just treating illness, visiting clinics, or getting tests. It is an attitude of caring and providing sustenance for those in difficult circumstances; it is anticipatory intervention long before the overt manifestations of sickness or disease. It is the recognition that illness can arise as much in the situation, the milieu, as in the body. John Steinbeck summarized it well, I think: A sad soul can kill you quicker than a germ.

Health care is one thing,  access to health care is another. There are many barriers to its acquisition: in some countries it is money, in others,availability of services. But for most non life-threatening health care needs, an underlying problem in all I would suspect, is fear. Not so much fear for safety as a feeling of unease: is what I have serious, will the doctor think I’m wasting his time, will he actually listen to me? So much of who we are -who we think we are- is bound up in our relationships and encounters with others. The medical visit is no different.

Illness, however serious, is still an article of clothing we wear. No matter how much of us it covers, no matter how it weighs us down, it is still we who wear it, we who peek out through the folds. It is important therefore that we meet with acceptance and respect when we finally bare ourselves enough to seek advice.

Cultural safety is one aspect of it. We are less likely to seek help if we feel that our views -cultural or otherwise- will meet with derision or condescension. I’ve always felt that my own specialty -certainly  the obstetrics side of it- is very much like the United Nations. It’s hard to miss the obvious; there’s a common theme that runs through my day; no matter the culture, the background, the social stratum, we all want the same things: our families to be happy, healthy and safe. We want that for ourselves as well. I would think it would be difficult to be prejudiced and a good obstetrician at the same time. I often learn more from my patients than they ever learn from me.

But along with the grateful acceptance of our superficial differences, I think there are other things that make the medical encounter more comfortable, less stressful. The waiting room for example. A picture on the wall, a plant in the corner, or even a carpet on the floor may seem trivial and unnecessary -I suppose they are- but they go a long way to helping the person seeking help feel less like they are about to visit a stethoscope and more that there may be a human in the other room. I realize that the physical constraints of an office impose many limits on the ability to make it look more appealing, but if you lived in that space -and most doctors do for the majority of the week- would you leave it bare and tasteless? Does it really have to look like a holding area, a resting place in a mall? A waiting room says a lot about who the patient is about to see. It can alter expectations.

If ambience is important in a waiting room, it is even more critical in the office. That is where secrets are told, trust is engendered, rapport is established. For new patients especially, what they see is what they judge. They haven’t met you yet, and they are both nervous and fearful. Putting them at their ease is part of establishing a meaningful contact, part of teasing a story out of them, part of actually helping them. It is not the Emergency Department where symptoms speak louder than words, and the diagnosis is often enabled by a wordless glance or an expressionless examination of a person lying on a bed. I’m certainly not suggesting than compassion and rapport are not important under those circumstances because they always are, but merely that the severity of symptoms and the urgency of need is often different in an office.  The approach is usually slower, more gradual -more dependent on mutual understanding and trust. The doctor is more able to explore the issues that surround the need for the visit, as much as the concern itself. He is, in short, more able to talk to the patient, understand her, listen to her -according her the respect and dignity she expects and needs from a health care encounter. It is never easy to confide in a stranger, let alone trust him with personal and often embarrassing problems. But a non-threatening environment may help to ease the transition in an otherwise awkward and frightening meeting.

I realize that considering the venue where health care is administered may seem trivial, but for some it may prove to be the difference between feeling comfortable with seeking help, and deciding to wait until it is truly an emergency. That comfort level takes time. It has to be earned and friends need to be consulted about their experiences. Many important things depend on the word of mouth: reputation, trustworthiness, honesty… and maybe health care utilization.

Health care is…