Category: policy

Another day, another shooting

Another day, and another senseless act of gun violence.

I sat down tonight to start writing about my experiences working as a locums primary care physician in the heartland of America and the Indian Health Services.

There’s a lot to write about, in terms of the myriad of chronic diseases facing this population and the stressed healthcare services that’s trying to care for them.

Cancer, heart disease, diabetes, tobacco abuse, alcohol abuse, obesity etc etc.

I forgot about one particular epidemic until I received a push notification on my phone about the shooting in Lafayette, Lousiana.

Another city, different from where I’m working but still uniquely American, trying to persevere through violence perpetrated by some who believe was just a person. Other’s who will attest he’s a person who culturually and perhaps legally was allowed to obtain an unneccssary appendage of violence.

In tragedy, the natural tendency is for people to come together.
When it comes to tragedy from gun violence, we seem to grow further apart as a nation, debating the merits of a vestigial amendment. This too, another uniquely American reality.

Another shooting and another night of mourning.

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Our healthcare and "The Wire"

A few months ago, I finally started watching “The Wire.” For anyone unfamiliar with it, “The Wire” is a police drama on HBO that takes place in Baltimore, Maryland. It takes a hard look at inner city drugs and violence from the multiple points of view of an incredible tapestry of characters. It’s a wonderfully gripping show and I give kudos to the creator David Simon for painting this haunting and tragic picture of modern urban Americana.
I don’t watch a lot of TV, but right now I can’t stop thinking about this show. The show has a lot of social commentary and I’m finding its messages everywhere around me. No, I don’t work in the inner city, though I’m somewhat familiar with it. I grew up in a humble New York City neighborhood that over the years started to struggle with drugs and violence. I did my residency training in downtown Philadelphia, and as a young doctor saw many facets of inner city life from a medical perspective. Although I don’t currently work or live in the harsh inner city streets, I do exist in a place that is failing its citizens just like “The Wire.” Our healthcare system sometimes seems just as tough, destitute and hopeless as the streets of Baltimore as depicted on the show. 
Instead of street drugs, we have diseases in healthcare. But the story of “The Wire” isn’t about the drugs itself, but rather how its omnipresence shapes the lives of the entire ecosystem. The same can be said for diseases in healthcare. Diseases are the constant in healthcare and how all the players deal with its presence is diverse and fascinating. But drugs in the show and diseases in healthcare are not the antagonists in these stories. The TV show makes this painfully clear. Any attempt to physically remove drugs from the streets by arresting the end users is an exercise in futility. In medicine simply fixing one artery, treating one infection, doing one CT scan or taking a pill, solves a problem temporarily for the end user  (the patient) but does little to answer the bigger question of why someone struggles to overcome a chronic illness or in the case of “The Wire” why citizens struggle to climb the social ladder out of the ghetto. 
The show also has an incredible cast of characters. Most of them have positive attributes and an innocence that is constantly challenged by drugs and violence. I feel for  these characters. As I watch them, I cross my fingers and hope they find a way out before the “the game” catches up with them. As a primary care physician, I peer into the lives of my patients just like the characters in the TV show. I get to know them, their hopes, dreams, and their intentions while they face difficult odds against conditions like morbid obesity, diabetes, psychiatric illnesses, HIV and heart disease. I cheer for my patients while hoping that my interventions will avert some catastrophic event in their life. In “The Wire” a teenagers’ dream to become something in this world may get derailed by a random act of violence that inevitably pulls them into a life of drugs. In my world, a heart attack, stroke or any other random medical malevolence sets of a chain reaction that often makes it very difficult to meaningfully recover from.
The show also shows the perspective of the police department, the good guys. I like to think I’m one of the good guys. Instead of the guardians of the law, I view myself as a guardian of health.  In the show, the police department is depicted as a bureaucratic mess with leaders pushing misaligned incentives and convincing the hard working street cops they are doing the right thing. Street level arrests (aka “rip and runs”) of low level drug users and dealers are depicted as ineffective to curtailing drug violence and therefore a complete waste of resources. Nevertheless, arrests fill up stat sheets for the police department and numerically give the false impression that good is being done. As a primary care physician, I feel like the street cops, at the front lines of healthcare. Instead of arrests, I’m trying desperately trying to achieve numerical benchmarks which some might think are good indicators of excellent medical care. Although these numbers look good on paper, I question how effective they are in the grand scheme of changing healthcare outcomes and improving lives. True investigative work that looks deeply into patients’ lives to solve and treat root cause is not rewarded in our healthcare system nor are the investigators appreciated who take this approach in the show.
Finally, I’ve read that the creator of the “The Wire” views his show as a modern day Greek tragedy. Greek tragedies often describe a doomed people who exist at the mercy of angry, greedy, vain and selfish Olympus gods who hurl lightning bolts, pestilence and misery at their subjects. In “The Wire,” the modern gods come in many forms. Politicians, police commissioners, corporations, drug kingpins all have a responsibility to protect and help their followers, yet inevitably fail them time and time again to their own benefit. In my world, the gods are politicians, insurance companies, drug companies and perhaps the physicians themselves. In their efforts to serve, politicians fight over policy decisions while people remain without insurance. Insurance and drug companies continue to profit despite questionable business practices that often hurt average citizens. Too many physicians, despite their best intentions, mired in debt and bureaucracy blindly plunge ahead doing more and more in a fee for service world without ever stopping to see if we’re not only helping but also hurting our patients.
Occasionally I get asked about the myriad of healthcare related TV shows and which one is the most realistic. The easy thing is to point to any show that has doctors in it, be it a comedy, drama or reality show. Though “The Wire” isn’t about healthcare, its themes are very relevant to what I see every day as a primary care physician. With one more season left to watch, I’ve unfortunately come to expect a tragic hopeless ending. With several seasons left of my own story in primary care I expect many tragic story lines. But in this case, hopelessness will never be in the script.