I Have Some Silly Questions

Last year I used some of Alfred North Whitehead’s pithy quotations to talk about healthcare, starting with the provocative “It is the business of the future to be dangerous.”  I want to revisit another of his quotations that I’d like to spend more time on: “The silly question is the first intimation of some totally new development.”

Credit: Getty Images

I can’t promise that I even have intimations of what the totally new developments are going to be, but if any industry lends itself to asking “silly” questions about it, it is healthcare.  Hopefully I can at least spark some thought and discussion. 

In no particular order:

Why do we prefer to spend money on care when people are no longer healthy than we do on keeping them healthy?

The U.S. healthcare system well known for being exorbitantly expensive while delivering rather mediocre results.  Everyone laments it but we keep throwing more money into the system that is producing these results.

We’d be smarter to invest in upstream spending.  Like making sure people get enough to eat, with foods that are good for us.  We’d rather spend money on diabetes or obesity drugs rather than addressing the root causes of each disease.  Or like making sure the water we drink, the air we breathe, the things we eat, aren’t polluted (how many toxins or microplastics have you ingested today?).  Not to mention reducing poverty, improving education, or fixing social media.

We know the kinds of things we should do, we say we want to do them, but we lack the political will to achieve them and the infrastructure to ensure them.  So we end up paying for our neglect through our ever-more expensive healthcare system.  That’s silly.

Credit: Gracia Lam/The Commonwealth Fund

Why is everything in healthcare so expensive?

People used to talk about how the military had $600 hammers and $640 toilet seats, but healthcare just says “hold my beer” to all those examples.  It’s been well established that U.S. healthcare’s spending problem is not oversupply or overutilization – although there is both – but “It’s the prices, stupid.”  Whether it is tests, procedures, hospital stays, prescription drugs, or anything else, in U.S. healthcare things just cost more. 

Yet no one in healthcare thinks their prices are too high, and no one admits they’re making too much money.  We’d hoped making patients pay more of their bills, or making prices more transparent, would make them more price conscious, but that hasn’t happened.  We’ve even recently found that those big health insurers who supposedly are tough negotiators often don’t get better prices than people paying directly. 

Prices are high because no one cares enough to force them to be lower. That’s silly.

How come our physicians are becoming more specialized even though we’re realizing how interdependent everything in our body is?

Primary care doctors make up at most only a third of U.S. physicians, a percentage that is both declining and well below the comparable percentage in other developed countries.  Moreover, the physicians who are specialists are increasingly becoming sub-specialists.  That’s great if you have only one very specific health issue, but if that issue is only one of many, or if that issue is due to or has created other health issues – as is likely – then it is not so good.  It means lots of referrals, many doctors, and sometimes conflicting recommendations, Primary care doctors were supposed to coordinate everything, but, as I said, there aren’t that many of them, and they don’t have the time anyway.

If we want more holistic care, we’re training physicians wrong, we’re incenting them wrong financially, and we’re not getting anyone with the big picture of our health.  That’s silly.

Credit: Yale Medicine

How come there is no one in the health care system whose job it is to keep us healthy, and who is rewarded accordingly?

Everyone in healthcare talks about wanting patients to be healthy, and many of them pay at least lip service to reminding you about doing things that might help, but let’s be clear: they get paid when you get sick (or, at least, use services).  It’s not a health system in any sense; it is a health care at best, and, more accurately, a medical care system.

If you have one, a primary care doctor might claim to fill that space, but, admit it, they don’t really know what your health habits are and have little ability to influence them.  Arguably, there are a great many health behaviors that are outside physicians’ training and expertise anyway.  The health care system thinks about people only when they become patients, and primarily relies on reactive, medical interventions to address health issues. 

Hypothetically, one can imagine a health care system in which you pay for the periods during which you are healthy, and don’t pay when you aren’t.  Instead, we use a system in which the more you use it, the more you pay.  That’s silly.

Since we’ve discovered that our microbiome outnumbers “us” – in terms of cells, DNA, etc. – and has direct impacts on “our” health, why does our health care still focus on “us” and not on “we”?

It was a huge step forward for medicine, and our health, when we discovered bacteria, viruses, etc., but we quickly decided they were the enemy and declared war on them.  Yes, advances like penicillin have saved countless lives, but, as with many advances, we didn’t fully understand the consequences. 

To the extent we think about our microbiome, it’s usually in conjunction with our gut, and mostly only in relation to our gut health, but research is showing that the gut microbiome impacts other areas of the body (such as our brain), and that our microbiome has impacts on almost all aspects of our health.  Our vaunted theories of disease badly need a 21^st century, microbiome-inclusive update. Like it or not, if it isn’t not healthy, we’re not healthy.

We indiscriminately kill off “good” microbes along with the “bad” ones, rather than trying to optimize the balance.  That’s silly.

Credit: NIH

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Our health care system has a “The Emperor Has No Clothes” problem. Many of us realize that it is badly flawed, perhaps even irredeemable, but it is the system we have, and we figure that it would take too much to fundamentally change it.  Well, that’s silly.

So I’ll keep trying to ask silly questions about healthcare and hope that others can get intimations of something totally new.