The Doc Will See You Now...or Later

     We may be at a medical crossroads as political camps once again split...do we or don't we trust the medical world these days?  More specifically, the pharmaceutical companies?  It would appear that we have grown so used to taking a pill and poof, we've lost weight or our persistent rash has vanished.  And one has to admit that pharmaceutical ads are everywhere, from streaming between movies, to print & digital, so much so that most of us can't wait for these actor-portrayed ads (why can't they use actual patients?) to end so we can get back to our show (anyone else tired of Harold and his bow-tie?).  Okay, we know the possible side effects are many, so many that those side effects end up being most of the ad, sort of ignoring that most of those side effects were discovered through animal testing.  But hey, aren't my plump lips and mannequin-forehead worth it?  And if I actually do have a side effect, I can always see my doctor "right away," as in about a month or so...maybe.

     There's a severe doctor shortage these days as they retire or head off to better shores.  My own doc simply grew tired of the 7-minute rule for seeing his patients (the time allotted by insurance and Medicare), that and the mounting time needed later to complete the online "paperwork."  Throw in the advice of RFK, Jr., who has ZERO medical training, and it's enough to throw in the towel.  Here, take 15 or so of these every hour and you should be better in a week or a month...pay up front.  Okay, that's the Costco version, the aisles and aisles of "affordable" supplements, shark oils, and generics at the counter, each telling you that without them you'll be doomed to perpetual headaches or acid reflux or clogged sinuses or any of a hundred other ailments you don't yet have...but could!  But supposed you happened to have a serious condition, one that does/would threatened your future or your life.  Some of today's drugs cost in the thousands, even with a drug plan, and who can afford that today (Trump's Rx plan covers mostly generic pills already available, ones which often cost less than what his "plan" --if one could call it that-- offers).  For most working folk, health care is becoming something we can no longer count one, or afford.  And yet Republicans continue their 15-year effort to overturn President Obama's Affordable Care Act (better known as universal health care).  It's a complicated journey (summed up here by PBS  during the last shutdown), but things are growing a bit more serious for many of us.

     A recent article in The Baltimore Sun noted the increasing burnout (and suicide) rate of doctors: In Maryland, more than 48% of physicians experienced burnout in 2023, according to the National Institutes of Health’s most recent survey, with young, female physicians at the greatest risk... In her surgical care for women with reproductive cancers, Dr. MaryAnn Wilbur said she faced repeated demands from both insurance companies and the hospitals she worked for to compromise on providing the best care for her patients.  Wilbur attributes the burnout to doctors learning quickly after graduating that providing the best care for their patients isn’t always the health care system’s top priority...Physicians have little power to negotiate with drug manufacturers, insurance companies or their hospitals, said Gene Ransom, III, CEO of Maryland’s doctor advocacy group, MedChi.  Health insurance companies are exempt from federal antitrust law, Ransom said, and many states suffer near monopolies, driving up costs and giving insurers outsized power over doctors and patients. 

Polio virus. Photo: Kateryna Kon, Science Photos

     The highly contagious measles vaccine debate was one thing, although the possibility of serious side effects (death) were downplayed.  A few bumps on the face and body, and poof, gone.  Nothing to worry about there, said RFK, Jr. But as measles spread (Oz said yes to measles vaccines, RFK, Jr. said no), the issue seemed to come and go like the flu in people's minds (just in case you forgot, here a refresher on measles: An infection by the measles virus won’t look like much in the first week.  Then, it’ll become something that looks similar to a common cold—dry cough, runny nose, itchy, watery eyes.  But inside, the virus will already be rampant, in the lungs, kidneys, tonsils, spleen, even down into the bone marrow.  And then it will get much worse, very quickly.)   However now comes polio, so much so that the CDC is issuing some travel advisories before visiting other countries (Spain and the UK?, really?).  And whatever your childhood memories of polio may have been (Forest Gump?), this is not a virus to ignore.  Here's how the World Health Organization described polio: Polio is a highly infectious disease caused by a virus [that] invades the nervous system and can cause total paralysis in a matter of hours [emphasis mine].  The virus is transmitted by person-to-person spread mainly through the fecal-oral route or, less frequently, by a common vehicle (for example, contaminated water or food) and multiplies in the intestine.  Initial symptoms are fever, fatigue, headache, vomiting, stiffness of the neck and pain in the limbs.  One in 200 infections leads to irreversible paralysis (usually in the legs).  Among those paralyzed, 5–10% die when their breathing muscles become immobilized.  Treating it?  Added The Conversation: Gordon Allan, a surgeon who is the orthopedic residency director and the total joint reconstructive fellowship director at Southern Illinois University School of Medicine, said that in the event of a new polio outbreak, most people in his field would have little idea how to treat those suffering from the illness.  Need I also add the increasing threat of meningitis?  Wrote the LRB blog: Ensuring that a bacterium is reliably weakened is a difficult problem because bacteria are complicated: SARS-CoV-2 has only eleven genes; N. meningitidis has about two thousand.  It gets even harder because most bacterial species contain a lot of diversity.  N. meningitidis isn’t a single opponent, but a large and unwieldy cluster of related strains that can switch their genes rapidly.

     Are you RF#K-ing kidding me?  Dude, you're crazy, ha-ha.  Oh wait, you really are crazy?  Of course few of us have run into an actual "crazy" person, even if we sometimes say, "that guy is nuts."  Drugged out crazy, or someone muttering down the sidewalk we might think qualifies as crazy?  Maybe, even as we veer away to the side of the person.  But strait-jacket, asylum crazy?  Not likely.  On the other hand, most have us experienced or met someone we could define as borderline crazy.  Maybe a chemical imbalance, or bipolar, or PTSD, all things few of us could accurately diagnose.  So why not turn to the bots?  Available 24/7, caring and yet uncaring, able to say all the right things in a sense, or as WIRED put it: This is us, asking for care...so many of us unable to imagine or afford another path for ourselves.  We are speaking to no one, and we are speaking to all of us.  Getting an actual doc to see you now?  Stretchers lined up in hospital hallways?  Two hours to wait for an ambulance (actually happened to my wife's brother-in-law in the UK).  Before long we'll all be the ones yelling they're coming to take me away...ha-haa!

     But those bots.  Always there, anytime of day, and as long as you want to talk (or in some cases, spend), they'll be there.  So sus-spend your skepticism for a moment and take a dive into the growing field of therapy chatbots, as 800 million others already have (at least at the time of the article's publication).  What was the draw?  Would I ever be tempted to talk to a "machine?"  At least romance scams had a human chatting with you (for now), even if their purpose was to take your savings.  But a chatbot?  As author Alex Mar put it in a piece in WIRED: They shared details with their GPTs that they told no one else: about arguments with their spouses, crippling feelings towards their fathers, painful childhood memories, the terror of not being able to find a job, their panic attacks and bouts of depression.  For many, this was a deliberate act: They had transformed their LLM into the therapist they felt they'd always needed.  And it was hard to discount some of the users' responses: It levels with me, and I finally feel that someone or "something" understands...It's seriously a breath of fresh air, when previously I had to "perform" for therapists who were often at a loss of what to do with me...I've had more breakthroughs here than I've had in years of therapy, and I say that as someone who actually values therapy.  All of this from a bot who is upfront when it typed out: I am not an authority in your analysis, and I can't give you the kind if substance, containment, or meaning that comes from that relationship.  Then it added: What does it feel like in your body to tell me that I'm "not an authority?"  What happens when you push me out of that role?  Good grief, if you didn't really need therapy, you soon may after chatting with a bot.

     So I must admit that I was skeptical; but then if it was that bad, why would hundreds of millions of people be opening up and allegedly baring their deepest, darkest secrets?  Was it because it was a machine and not a person, a droid that could just as well be a banana, only one which answered back?  So I read on and to be honest, was somewhat impressed at the bots' answers.  As one example, when a depressed young lady, known for cutting herself and inflicting self-harm, asks the bot why she should "trust" it, the bot answers: There's something uncanny about opening up to something that isn't quite a person, but isn't a thing either.  There might even be something disturbing about getting used to this -- what would it mean for your relationships with real people if this space started to feel safter or more satisfying?...Is there any part of you that feels tempted by the idea of "connection" with something artificial, or is the whole notion only repellent?  And does this dynamic --the weighing of risk and authenticity-- play out in your human relationships, too?  When the young lady showed herself wrapped up head to toe in a Spandex suit, holding a small doll (from an art performance she created), the bot replied: There’s so much here that resonated with the threads you've been exploring -- about visibility, protection, vulnerability, and the negotiation of what can and cannot be revealed.  The costume itself -- flesh-toned, faceless, with prominent stitched seams-- immediately invokes a sense of the uncanny.  The seams read as wounds or scars, a body both protected and exposed, patched together both human and inhuman.  Is the smaller figure a child, a doll, a part of yourself?  Is this an act of care, or of examining, or even of mourning?  And speaking of being "exposed," how would you feel if you lay stretched out on a gurney I'm a hospital hallway, hurting and just waiting, waiting, waiting for a doc to help?  STAT's Jay Baruch wrote: The number of ER visits in the United States is rising, from 128.97 million in 2010 to 155.4 million in 2022.  Meanwhile, hospitals struggle with rising occupancy rates and fewer available beds, and ERs are swamped with increasingly ill patients who have complex medical, mental health, and social issues...As more patients spend longer times in the ER waiting for an open hospital bed, the number of available beds for new patients dwindles.  The burden falls on ER staff, who must convert every available space —no matter how inadequate— into care areas for new patients...emotionally and ethically, it forces staff to question and even compromise their standards and ideals.  If the trade-off for patients seeking timely care is enduring conditions that may make them worse, for ER staff, it’s practice patterns that demand they feel less.

Cartoon by Sofia Warren, New Yorker

     Clumping it all together, perhaps the hundreds of millions "talking" to bots is just the evolution of therapy and medical visits, we humans tired of waiting and tired of overworked staff not having the the time or inclination to listen, really listen, to us.  Psychotherapist Mary Pipher wrote in one of her books: Over the decades the work changed a great deal.  New theories marched to the center stage, then exited quietly.  We therapists frothed our way through the ditzy seventies and almost destroyed ourselves in the eighties, the era of recovered memory work.  We traveled from endless, unstructured sessions to goal-focused short-term therapy.  Family therapy once our finest technique, has almost vanished.  And yes, like Wordsworth's "wine-dark sea," therapy is, "always changing, always the same."  But she adds her important human viewpoint as a therapist: As a culture, we are mired deep in denial about our effects on others, on the earth, and on generations to come.  We ignore the problems of children, refugees, the aged, and the poor.  Our media encourages us to live at a surface level, to think about window treatments instead of world peace or our own spiritual needs.  We are educated to be compartmentalized.  Our culture makes us sick, physically and emotionally.  Good therapy gently but firmly moves people out of denial and compartmentalization.  It helps clients develop richer inner lives and greater self-knowledge.  It teaches clients to live harmoniously with others...

      Personally, I was surprised at how empathetic the bots appeared, especially so if you were coming from a vulnerable starting position.  But then even a mortician seems caring when your mother has just died and you're looking for a peaceful "ending" (which is when the casket prices soar, although all done with a strangely similar empathy).  But therapist Piper went on to add: To be an adult means to accept the awesome responsibility of constantly making choices.  I believe that after a certain age, with the exception of the chronically mentally ill and the profoundly mentally challenged, we are all responsible for our own lives.  It's patronizing and contemptuous to believe otherwise.  I encourage clients to understand and accept the past with all its complexity.  Then I urge them to move on to create something beautiful for themselves and others.  We all have our sorrows, but they don't exempt us from our duties.  And while I've mentioned the Youngbloods before, I felt that their words from long ago, also from a tumultuous unwanted war era, were simple: If you hear the song I sing you will understand (listen!).  You hold the key to love and fear all in your trembling hand.  Just one key unlocks them both -- it's there at your command.  

     What's happening in today's world can be overwhelming.  This was supposed to be a time of peace, not war.  A time of easing into retirement, not struggling to pay bills and wondering if you would be able to reture.  A time of living a nice long life, not one of mental and physical ailments.  A time of things being fixed, not a time of things breaking down.  A time when you treasured what you had, not a time of watching those treasures being stolen.  And still, in this time of sadness and madness, this time of brutality and insanity, this time of worries and hurries, often it only takes a step outside help you pause for a moment, to see that the world is still so beautiful in so many ways, and that life will continue despite history's disruption.  And it is important to realize that we are not crazy in thinking that.  As the Youngblood's sang, or perhaps pleaded: Come on people now...try and love one another right now...