Looking out at the big, empty Pacific — just beyond the outer break, Kauai, Hawaii
Note: While I can’t promise this post will be what some might consider “jargon free” — I’m going to do my best to illustrate some important concepts in my work in the context of medicine. If you’re ingratiated in the rest of this, hopefully you’ll still find it useful. And I’m going to start with my own recent health story.
This past year, I had the misfortune of actually having a health problem that could acutely kill me, at some accelerated time from what I thought would be my actual departure. We all don’t live forever, of course, and as Clint Eastwood said in the movie Unforgiven, “we’ve all got it coming.”
The problem was an irregular heartbeat, caused as much by a combination of ani inherited genetic frailty, along with the stress of dealing with the last days of the cordoned pandemic. Racing hearts are easily detected (or felt), especially during exercise, so I was referred, and then scheduled an appointment with a cardiologist, who happened to be located in Coeur D’Alene. Coeur D’Alene, Idaho, is about a 90 minute drive from my house, so it’s a day out of my life to drive up there.
The doctor did the usual miniature stress test on me, read the trace, said “yep, you have a small arrhythmia” and prescribed a dose of magnesium to be taken daily. Done and done.
Except it wasn’t done. Sometime, in the middle of the summer, I received a phone call from a local hospital that will go unnamed. “We are supposed to schedule you for a formal stress test,” the nurse said. I said “Are you sure? My cardiologist didn’t mention anything about future testing during my visit. And it’s been three months.”
The nurse snapped into the phone, “I don’t take orders from patients! Only doctors!” and then basically hung up on me as I pleaded to her to check with the cardiologist’s office.
Three months passed, and I finally get another call from the hospital to schedule the test. This time it was a different nurse, the order had been checked — apparently the cardiologist thought it would be a good idea, but had not thought to contact me. So I said “sure,” and ended up on the schedule for the end of October.
While I am not quite an exercise nut, I’m pretty serious about my exercise habit. I ride my bike (a real one, not an electric one) anywhere from 1300 miles to 2000 miles a year. If you are interested in my weight loss story, I’ve written extensively on the memetics of our dysfunctional approach to holistic health and nutrition, basically starting here. I lost approximately 65 lbs. about six years ago through fixing my diet and pursuing a LCHF approach. I had always exercised, and had basically resigned myself to being a ‘fit fat guy’ until friend Ryan prodded me to “just try something different.” That something different forced an entire re-evaluation on how we approach diet and health, which, not surprisingly, is powerfully distorted by the uniformly low level of psycho-social evolution of the medical community.
So, like any good exercise nut, I went trundling into my heart stress test armed with my phone and its Garmin Connect app, which records the various traces of my heart in different activities, including my bike riding. The nurse was nice enough, and I said “I’m in really pretty good shape for a 60 year old guy. Let me show you my bike traces.” When I ride, I normally get my heart up to 150 bpm. And considering the nominal max heart rate for my age is only 160 bpm (220 – age) that’s not too bad. In the cardiologist’s office last April, everyone but me looked like death warmed over.
“That’s all fine and good,” she said. “But we have to get you to be winded in order for the test to be effective.” “No problem,” I said.
So I got on the treadmill. These things run something like 10 minutes, and the short description is they turn up the knob on the speed until you can’t take it any more. At the time, I had no perspective on any of this, other than the weird detached comfort I have around doctors (my father was a physician) mixed in with a healthy dose of skepticism. Most doctors have never fixed any problem I’ve ever had, and with the whole system of Primary Care Physicians (PCP) you’re lucky to even spend any time with a doctor that might have some familiarity with the long term arc of your health trajectory.
So, I got on, and she turned up the treadmill rheostat. We got to 130 bpm, and then 140 bpm, and the nurse exclaimed “You’re not breaking down!” I responded “well, I ride my bike blah blah blah…” And she kept turning up the speed.
In hindsight I should have thought about the world that cardiac nurse lives in. She sees mostly fat, unhealthy people that don’t exercise. If they can get even to 135 bpm without being out of breath, they are the exception — not the rule.
We got to 155 bpm, and I was still going strong. “You’re not breaking down!” she said, and I said more blah blah. We got to 160 bpm, and I could see she was getting excited. “You’ve got to break down!” And like a good Boy Scout, I ran harder. My heart rate went to 165 bpm, and then I was finally getting winded. I SHOULD have stopped, but I didn’t. “You’ve got to break down!” she said again. “Only 20 more seconds!”
And then my heart went sideways. It was pretty clear on the traces. The mild arrhythmia turned into a major arrhythmia, and my heart did NOT feel good. I got off the treadmill, as she whimpered “you only had 20 more seconds…” I said “I really do not feel good,” and then packed my bags and got out of there. Where before I had never felt any heart pain, now I had a strange, dull angina. It is unprovable, of course, but I likely had a heart attack during my stress test.
The whole reason I had the test was because I had to, for my insurance, pre-qualify to the more advanced thallium-tracer “nuke stress test.” Now, since I some real documentation of a fucked up heart, likely really fucked up by the test itself, insurance would now approve this next level.
I’m not completely sure about all the timing of this, but in the same range, I also had a Trans-Ischemic Attack — a mini-stroke. Whether it happened post-stress test, or just right before (I think it was afterwards) it wasn’t a big deal. I didn’t shit myself, or pass out. I was getting ready to walk into my classroom, where I am famous for knowing all the students’ names. And I couldn’t remember any of them. I had also had a dizzy spell and some temporary (very!) crossed eyes.
There were now some increased diagnostic activities in the mix. I got the modern version of a Holter Monitor – a microelectronic device to record 2 weeks of my heartbeats, as well as an MRI. But the next real milestone happened some six weeks later. I was scheduled for the “nuke stress test”, which tells you your ejection fraction — the amount of blood moved out of your lower heart, and a generalized measure of efficacy. So I went back to the hospital, and donned my mask like a good boy, and sat down. My name was finally called, and I went back to the CT scanner for the initial scan. The radiation tech was a very nice man, and I said “look, we have to have some ground rules here. I’m not convinced that the last round I had didn’t cause me to have a heart attack. It’s a problem because I’m in really good shape for a 60 year old man, and we can’t run my heart up to 170 bpm because that’s where I experience failure.” He was very nice, and reassured me that was not the case. Then he shot me up with drugs and did the scan. Easy.
The next stop was at the stress test with the cardiac nurse. I started “OK, I have some ground rules.” She immediately snapped back at me – “You don’t make the rules in this office. I make the rules.” I was taken aback, but firm with her. “I am the patient here. I have rights. You don’t get to kill me because you have issues,” I told her. She then immediately launched into “you’re not wearing a mask!” and then started running around the treatment room, attempting to find a mask to put on my face. I had left my original in the other room with the CT machine. More tense words ensued, and my blood pressure shot through the roof. She then put the blood pressure cuff on me, and declared she couldn’t do the test. Then she left the room. I had already almost walked out, and was thinking of the futility of all of this. When my blood pressure goes up, it doesn’t come back down after sitting in a chair in a conflict situation.
She came back, declared the test incapable of being performed, and I gathered my clothes and got out of there. I was very careful to not use any threatening body language, or language in general. When you live with limited medical options, you cannot get banned from a hospital. One day, you might need services, and they’ll refuse treatment.
So I left. I called my PCP’s office, and told them I wouldn’t be returning to that facility. There was one other local option, and they sent me there.
A very different scenario unfolded at that facility. There was only one radiation tech., in charge of both steps — the CT scan and the stress test. She was very kind, and our conversation led to an informal advice-giving session on how to deal with adolescent child problems. I told her about the heart rate limits, and the blood pressure issues with the last test. She said “we never get even close to that high for this test. And regarding your blood pressure, if we can’t get your blood pressure in an acceptable range, there are drug-based alternatives.” So we went through the steps, and she checked the scans.
Then came the bad news. “I can’t let you leave. The scan shows you have a problem. We may have to move to immediate admission. I have to check with the local cardiologist, because I’m not sure you can even drive.” We are now nine months after the initial diagnosis by the cardiologist in Coeur D’Alene.
In 15 minutes, the cardiologist called her back and released me. Because of the bond we had built over conversation, the radiation tech. immediately sent my files to everyone in the sphere of my care. That day, the cardiologist’s office in Coeur D’Alene called me and recommended that I have a heart catheterization/angiogram completed. I attempted to communicate the sequence of events to that nurse/scheduler (at no time did I talk to a doctor) and she accused me of being a high conflict patient. “Well, you first had a problem at Hospital X, and now you’re telling me you’re having problems at Hospital Y.” I said “no — I had a problem at Hospital X, but I went to Hospital Y and everything went fine. It’s the reason we’re having this conversation.” She hurriedly hung up on me, and called back later with a potential date three days later. To be fair, her tone was very apologetic, though she did not address the former comments. Since I had been asking questions, she asked if I wanted to schedule a visit with the cardiologist first, and then return for the treatment. “No,” I said. “That’s just going to push us back another week at a minimum.” I elected to talk with the cardiologist — all he basically did was angiograms — right before the procedure.
Scheduled for an angiogram, my wife and I drove to Coeur D’Alene, and spent the night. We were first on the list for treatment that Friday morning. It involved getting up at 5:00 AM, but my wife was adamant. “If there’s something wrong with you, then you can just go and get treated.” So we did. But after we checked in at the hospital, we discovered the real reason that going in at 5:30 AM was the correct call. “If you get bumped because it’s the end of the day, and the cardiologist doesn’t get done, you’ve got to come back tomorrow. And hope there’s room.” The receptionist never said it. But it sure looked like it could go on for days, if luck wasn’t with you.
At 5:30 AM, we showed up at the hospital. Everything was nominal. The cardiologist came in. An affable man in his 30s, he explained the procedure to me. I said “fine”. Then he said “OK — where are you feeling pain in your heart?” I said I had felt no pain, at least not until my original stress test. And that pain was a dull ache. “When are you having shortness of breath?” he next inquired. I said “I’m not having any shortness of breath. I exercise…” and then I’m sure I went on about my Garmin traces. Blah, blah, blah.
He then said “OK — this is what I think is going to happen. We’re going to thread the catheter up your wrist and look around in all your arteries. If we see a constriction, then I’ll just go ahead and put in a stent. But we may find nothing. And if I had to bet, I’ll bet we find nothing.”
The procedure went off without a hitch. The performing cardiologist came into the room, drew a quick picture — 3 out of 4 arteries were perfectly lean, but one had a clog, but had already formed collateral veins around the clog. “You’re fine,” he said. “Take a baby aspirin once a day, and double your cholesterol medicine.” I was still woozy, but relieved.
Two weeks later, I am finally scheduled in my PCP’s office. “I don’t think this looks very good,” he said. I said “why?” I had a misunderstanding of the state of the one clogged artery. I said, “well, what can we do?” He said “take a baby aspirin a day, and double your cholesterol medicine.”
As of this date, I finally have a real appointment with yet another cardiologist to understand the poor results on my Nuke Stress Test. I am still not dead.
While it may not be obvious, my case is an emblematic example of a good hunk of what is wrong with American medicine today. And the core problem? A lack of empathetic development of both the social system, and the individual providers along my journey created a circumstance where if I had been more sick, I would very likely be dead. If I had not encountered effective advocates at stages of my journey, I would be in even worse shape than I am now. I am absolutely not an expert in anything related to care for coronary heart disease, so it is difficult for me to evaluate exactly whether a specific act of care was adequate or not. Since there has been no positive treatment modalities in my journey, other than taking magnesium (which did help) it is also difficult for me to understand efficacy. I only know that I’m a pretty smart guy, and a systems thinker, and importantly, not fear-bound.
But I also know what it means to be an expert — and I certainly am not in cardiac medicine. I am, however, an expert in processes, and analysis of individual actors I encountered along the way. So that’s where I’m going to start.
First off — when I talk about empathy, I am not talking about giving someone a hug. A global picture of empathy is a nested stack, with lower levels being incorporated into higher levels as scaffolding. If you want a medical system that works, it is incumbent that almost ALL the people in the system have a combination of developed empathy as well as emotional self-separation (the ability to discriminate their own emotional responses from the patients they deal with) from their patients. While certain parts of medical practice do not require as much as others — it IS helpful to have a practiced specialist in one of the more manual/craft-oriented branches of medicine, like heart surgery — every patient that presents to the medical system is a host of physical and psychological symptoms and history.
A quick review of empathy — let’s look at the Empathy Pyramid.
Understanding empathy is really understanding how humans (and in general, sentient beings) connect. It is not just “feeling bad” for someone. Empathy in individuals can be characterized by the type of connection one has. In order to have the higher levels, you have to have evolved, at some minimum, from the bottom. So you can have someone at a higher empathetic level of development connect with someone more down to the bottom — in fact, it’s imperative in a field like medicine.
The other poorly understood consequence of empathy (or a lack of it) is the ability/inability to process complexity. A cornerstone concept of this blog is “as we relate, so we think.” Complex, nuanced relationships condition our brains to create more containers for other types of complex, nuanced knowledge. The simplest indicator of this is the ability of a person to entertain more than one solution to a problem. As opposed to dichotomous, black-and-white thinking, higher levels of thinking contain multiple avenues, and many different shades of gray.
If one needs more coupling to the relational space, think of the ability and brain practice of a person to connect to multiple people and sort out multiple opinions in the context of coming up with a diagnosis. In order for this to even be possible, a person has to have the abilities to: a.) talk to multiple people; b.) actually understand what was said by those people in a coherent fashion, and c.) integrate/synthesize that train of thought into a combined diagnosis. One can see also that this requires a sublimation of ego — there’s no point in seeking alternate opinions if you cannot change your mind.
Finally, social structures in institutions, according to their topologies, and their aggregate empathy levels, profoundly reward or discourage all the different levels of empathy. And practice makes perfect. Doctors exist primarily in hierarchies (often rigid) and tend to lower empathy development than nurses, who congregate in work groups around nursing stations, with directions to provide appropriate care for patients, reading the signals that often come directly from the patients themselves. Doctors give orders — and orders are one-way and inherently top-down. Nurses deal with a variety of patient requests, while being reminded through the social structure of their position in the hierarchy.
And while certainly not all doctors are hierarchical, narcissistic assholes, some certainly are. Perfect for rising to the top of dominance hierarchies that are so prevalent in medicine. Nurses, with their more communitarian sensibilities are often caught in a neurotic anxiety trap. A sign of this imbalance — it used to be that nurses were considered heavily sexualized and attractive. Now, they are by and large obese, consuming brownies at their nurses’ stations. The people who are supposed to be delivering health, through a combination of self similar social dynamics that I call the Principle of Reinforcement, are often the most unhealthy.
It gets worse. As medicine has advanced (and I believe it has) the need for specialists has also grown. But specialists are inherently ensconced in silos — their titles matter, and their diagnostic spread is limited. The people that are selected to study also must conform to this ‘complicated knowledge’ paradigm — and to the readers of this blog, the emphasis is very likely to award success to complicated procedure followers (Legalistic/Absolutistic v-Memes) than someone with a broader, more integrated perspective who can parse information from a patient.
Nor is the system likely to create scenarios to fix its bad habits. In fact, one thing I immediately noticed in the context of my own care was the ‘McKinsey-ization’ of health care. You went to a specialist for a particular ailment, and that specialist did that one thing, over and over. If you needed that thing done, well, it was going to be thoroughly practiced. But if you didn’t need that thing, or you had other confounding symptoms, you weren’t going to get very good care. And if you had a low probability situation going on, you’d end up with nothing except “I don’t know.”
Sometimes this system does work. In the case of my angiogram, the same cardiologist spent all day, every day, doing them. The day I was booked for mine, there were seven scheduled for him. But if there were any confounding symptoms, he would never have discovered them. My relationship with him consisted literally of three minutes at the start, before I was sedated, and three minutes at the end. He declared my condition at the end of the procedure to be “fine” — and I honestly believe that diagnosis. And look — he was a very nice person. But he was definitely in a rush. He had some six other angiograms to do. Or he would get behind — with predictable consequences.
But he delivered no context for my condition, nor any information about downstream treatment. In talking with him, I actually missed that one of my coronary arteries was 99% clogged, and didn’t understand the outgrowth of collateral arteries that had occurred that had prevented what likely would have been a heart attack that would have killed me. I didn’t walk with any understanding of when I might need another look-see inside my heart to see if other vessels were clogging. I was half-doped up, at any rate. I never really had a chance to understand his perspective that might have helped. Nothing along the lines of “you should’ve seen the last ten people I plumbed. Compared to them, you’re a Boy Scout.” His position had been scaffolded with one thing in mind — maximum, efficient operational throughput. As McKinsey/BCG a solution as I had ever witnessed.
Let’s walk back through what happened in my other history of procedures. My first cardiologist appointment, a referral by my PCP, was actually pretty good. Sitting in the waiting room with a bunch of oldsters who looked like death warmed over had both its good and bad points. On the one hand, I knew I had to be at least nominally in better shape than them. Every single one of them was obese, with a gray pallor that screamed death. But on the other, well, I was in the room with them. My initial nurse in that visit was awesome. Laboring under a mask, she told me I was free to take mine off, and that she thought it was ridiculous. The same with finally the cardiologist when she came to visit. We talked a respectable amount of time — 15 minutes about my condition, and when I left I felt like I had been treated decently and understood.
But the system is inherently fragile, and rapidly goes off the rails when a High Conflict person is introduced. When I was contacted about the first stress test and I requested a check on whether there might have been a mistake in orders, the High Conflict cardiac nurse flew off the handle. Had I actually had a life-threatening problem, the delay in my receiving appropriate diagnostic analysis might have killed me. It is important to realize there was something like a 3 month delay in receiving a reschedule because that nurse decided I was not responding in an appropriate, Authoritarian v-Meme fashion. Which is to mean I should shut up and not respond at all. Orders move down the hierarchy. Feedback does not come back up. Or you get denied treatment.
Further, when I finally did receive the stress test, the nurse (not the same one) at the hospital was not paying any attention to me. She had an algorithm (Legalistic/Algorithmic v-Meme) she had to complete, and that involved some level of minor collapse on my part. They keep defibrillators in the room for good reason. And I’m not saying to remove them. But she simply did not, even with briefing her, process that the test for a fit male at 60 might be run differently than a test for a morbidly obese patient. One of the pieces of advice I now give all my friends in my age cohort is that unless you know the nurse running the test, do NOT assume that she will sort consequences well, and certainly not entertain multi-solution pathways. She has a test. She will run the test. And if you die, well, you signed the release form. Hey, they had the paddles on the wall.
More stuff went downhill from there. Finally scheduling the Nuke Stress Test at least revealed who the High Conflict nurse was. But the fact that any nurse would simply refuse to listen to a patient at the start of a test, with no prior experience, is criminal malpractice. I suspect, but cannot prove she was likely the same person as the first nurse who refused to check on my initial orders. The response of the first radiation tech clearly illustrated the Communitarian/Authoritarian v-Meme split present in medicine. And it’s no surprise that the rebarbative cardiac nurse had to chase around attempting to mask me (this was now in December of 2022) was more proof of her pathology. Especially as masking during procedures for the patient was de facto optional, if not nominally so. In fact, the insistence on masking in general was an amazing memetic sorting tool for all people in the hospital. Of course, in regards to their own situation, they were constrained through hospital policy. But there was quite a bit of elective judgment regarding the patients. For those mask-insistent, it was clear they were low empathy all the way. Most were “just following orders.” But it was also painfully obvious that they reacted negatively to anyone who challenged the authority stack.
One last comment — one can never tell how memetic resonances will work in the context of one’s treatment. I was seriously taken aback when the Coeur D’Alene cardiologist’s nurse in charge confronted me, telling me that I was a difficult patient, and even inferring multiple conflicts with other care providers because of my problems with the one High Conflict nurse. What inevitably happens in conflict is that organizations will close ranks around their lowest level of social development. And in medicine, that is raw Tribal affiliation. You’re either with us or against us. Nothing illustrates this more clearly than the AMA rallying around the recent round of barbaric trans surgeries being performed on youth. All of the trans issue turmoil is a very recent surprise to the majority of the public. Yet the AMA, realizing some small cohort of doctors have been complicit, instead of holding anything resembling an open debate, or even hearing, has closed ranks. Sterilization of children is endorsed by both the AMA and the American Academy of Pediatrics. And trust me, folks — it’s memetic. We’re deep in the Matrix with this one.
What is also interesting is that had I died, the system had covered its tracks the whole way. There would be no inquiry. There is not a level of evidence, in my opinion, to sue for malpractice. There is no timeline in any of this that indicates that time to treatment is even a factor. Other than when my second radiation tech got involved, there was no sense of urgency, and even active neglect in providing timely services — or even explaining to me why there was no rush. A lack of context delivered to the patient is an embarrassing failure of empathy by the medical provider — both emotional and place-taking/rational. Other than the High Conflict nurse, who was egocentrically threatened by my questions, the others were just too busy too care.
I do have to confess — as a doctor’s child, I’ve been raised to expect a high level of care from the medical community. But I haven’t seen this since I turned into an adult. I’m also used to being reasonably charming and charismatic, and building connected relationships with all my service providers. I’m the guy that waves to the garbage man, for chrissakes. None of this made any permanent dent in the medical community, though there were Matrix embeds that I encountered who were interested in the deeper Why of why everything was so fucked up. They knew it.
Finally, one of the most appalling aspects of dealing with medicine was how far south it has gone with regards to anything related to diet and lifestyle. My own PCP is a Seventh Day Adventist, and a very nice person. To be fair, he has only in a couple of incidences recommended some form of veganism to me. But a general incomprehension regarding my own weight loss (I lost 65 lbs. some six-seven years ago) hasn’t helped me much. The fact that I reversed a path that would have certainly led to diabetes is still not interesting to them. I’ve written about how empathetic development leads to higher consequentiality in thinking. Looking at my physicians, and even my revolving door PCPs, which has rotated in basically a constant state of flux for the past (at least) 10 years hasn’t helped with this. They have no history with me, and they are largely overwhelmed.
But this decay in empathy has profound consequences for treatment modalities. One of my favorite stories involves a request I made to one of my PCPs back literally 12 years ago. I’m a big guy — 6’2″, and 255 lbs. I had asked my PCP at the time to write a letter for medical exemption for work for a slightly roomier seat (think Delta Comfort + as opposed to Delta Coach) on flights. I was getting off the plane with severe back pain, and it would take me about two days to heal — especially if it was a long, transoceanic flight.
My PCP physician at the time immediately said “I can’t do that. I’m not going to use my position to give you privilege.” I pleaded with him — what diagnostic test could we do to validate my very real experience? This was no cost to him. But he (and almost every other physician) adamantly refused.
So I looked at him and said “would you give me a prescription for muscle relaxers that I could take after I got off the flight?” He said “that I can do.”
Medicine is going to have to answer whose side it actually is on. The system? Or the patient’s? Right now, the answer is painfully obvious.