Editor's Note
Searching for the Simple
On July 4, 1845, Henry David Thoreau trudged through a second-growth forest on the outskirts of Concord, Massachusetts, and settled into a two-year experiment in living on the shore of Walden Pond. Fleeing the “lives of quiet desperation” of his fellow townsmen, he built his cabin, grew his vegetables, and wrote daily in a journal that would become the book Walden. The most compelling of his motivations was to strip away the trappings of civilization in search of a purer existence, “As you simplify your life, the laws of the universe will be simpler,” he wrote.
With the publication of Walden in 1854, Thoreau became the spiritual guru for generations of future cultural refugees, from the hippies of the 1960s to executives who walk away from high-powered careers to everyday daydreamers, all of whom are seeking a simpler existence. Indeed, the yen for simple seems universal. This month, we take a walk in the health care woods searching for simplicity.
Patients are longing for simpler health care. Their hospitalizations generate 20 statements headed by the words “this is not a bill.” Congress approves a Medicare drug plan that features a mysterious “donut hole” understood only by math Ph.D.s and that spawns 60-some statewide plans, leaving octogenarians vertiginous as they sift through their choices. Every phone call to a clinic or insurer involves negotiating a multi-step voice messaging system that would test the patience of even the most Job-like patient. And explanations of their medicines and medical problems seem as opaque as astrophysics to patients. No wonder programs are sprouting up to lead patients through the health care labyrinth.
Physicians, too, yearn for the uncomplicated. I suspect all practicing physicians rail audibly or inaudibly against the complexities of today’s practice of medicine. The inherent complexities of analyzing and fixing as intricate an organism as the human body are imposing and getting more so as medical science expands. Yet doctors rarely complain about that; it’s a given that they understood when they signed up. The calls for simplicity from physicians become deafening, however, when the focus is the administrative and financial details of medical practice—pharmacy formularies that seemingly change with the wind, reimbursement and coding rules that would baffle a Supreme Court justice, the disease-management “suggestions” from third-party payers, nursing home pharmacists, and even Walgreen’s. Attempts to measure what physicians do hold peril and promise, and whether the current moves toward pay for performance and quality measurement will simplify or complicate the doctor’s day remains to be seen.
Physicians’ responses to complexity vary. Some have embraced computerized solutions to handle paperwork and automate quality evaluations. Some try to pare their practice to the essentials. Some look longingly northward, imagining that Canada’s seemingly simpler solution offers a better way, though this month’s interviews with Canadian physicians working in the United States suggest otherwise. And some retire, the Arizona variation on Walden Pond.
A few years ago, I re-read Walden, expecting to revisit my youthful admiration for the rebel Thoreau. Instead, I came away with a sense that he was a detached, uninvolved critic, carping at a distant society he had abandoned and offering no real-world solutions. We can walk in the medical woods and sniff the air, but true simplicity, when engaged in a complex world, may be one big daydream.
Charles R. Meyer, M.D., editor in chief
Dr. Meyer can be reached at
cmeyer1@fairview.org