Society places a great deal of value on modesty.

I’m starting to wonder if modesty is so great.

Why is it so shameful to speak of one’s positive qualities? Is it hurting anyone? Is it rude? Insulting? Or do we refrain from recognizing the things we do well out loud because we’re worried about what other people think?

What do you think when you hear someone talking about their accomplishments? Do they think too highly of themselves? How highly should they think? Do they think they’re better than you are? What if they valued your accomplishments as highly as they valued their own? What if they were as honest about their shortcomings as they were about their accomplishments?

I think I’d rather be around people who are equally generous with praise towards themselves AND others than with people who go out of their way to avoid saying anything positive about themselves. I’ve given compliments to people who said, “No, I could never be as ­­­____ as you." How does denigrating oneself make the compliment any more meaningful? If someone is critical of the amount of praise he gives himself, might he not judge you by the same standard?

I often find myself checking my thoughts when I start to compliment myself. Don’t get a big head. You’re too self-absorbed. There are plenty of people out there who are doing better things.

Then I start to feel like I’m not good at anything. And that’s when I start to dislike myself. At times, I start to hate myself.

Who does that benefit?

***

I got defensive the other day when some people at the table were criticizing a classmate for complimenting people too much. They felt like the compliments were disingenuous, that he must have some ulterior motive.

Apparently, this was irritating.

Maybe he did have an ulterior motive. Maybe he just wanted people to like him. Is that a crime? What I DO know is that the guy sends an email out to all of his classmates every holiday to wish them well. I don’t know what else he’s getting out of it, but I DO know that he’s not saving any time by writing those emails.

They were also commenting on his tendency to ask all these questions after lecture. No one said this explicitly, but they weren’t exactly complimenting him on his curiosity. At least one person did say: “Hey, at least he doesn’t waste your time by doing it during lecture.”

I got upset. The poor guy meant well. He wasn’t wasting anyone’s time. He wasn’t being rude. Hell, he took time out of his day to do something that we probably don’t do enough for each other. Who are we to say how others should tell us that we’re valued?

I think, deep down, I wondered: How often do I do something and mean well, only to be the subject of ridicule at a group dinner?

By the way, the other day a 14 year old kid was shot in the head at Easton Shopping center.

Kids are killing each other, and we’re complaining about someone giving too many compliments.

I just watched this clip on YouTube:

http://www.youtube.com/watch?v=826HMLoiE_o

So much energy and emotion invested in dinner. I was wistful when I watched this video, because I realized something: the more developed of a world I live in, the more removed I am from the activities that sustain me, and the harder I have to work to find a point in what I'm doing.

For much of the day, I am inert. I drive to class. I eat lunch, and sit at a table. I go to the library to study, and sit (for up to five or six hours at a time). I drive home, and sit in my car. I eat dinner, and sit at my dining table. I study some more, and sit in front of my computer. Then I go to sleep. Somewhere in all of this "inert time" I have to make time to exercise. So I drive to the lake and run in circles for an arbitrary amount of time, not necessarily accomplishing anything (except, perhaps, to clear that restless feeling or to de-stress). I think of what drives me to finish that last lap around the lake, when I'm sweaty and my legs hurt and I'm breathing hard. Maybe I'll feel disappointed for not finishing the run, or I won't get as much of a runner's high. But often times I have to remind myself: what's the point?

This guy doesn't have that problem. He's in better shape than I am, and he'll probably live longer, provided that some disease doesn't get to him first. But if he doesn't keep running each time he's on the hunt, he's going to starve to death. He's got plenty of motivation.

Because everything is so convenient, I forget to appreciate. I wake up in the morning and make store-bought eggs and coffee. I don't know the name of the guy who gathered the eggs, or where the eggs came from. I don't know how long it took for the coffee tree to grow, or how much effort it took to harvest the coffee beans, or to roast them. I don't think about any of it, because all I have to do is throw the coffee in the espresso grinder, tamp it in my espresso machine, and turn the machine on. Sometimes I'm too lazy to chop up my own veggies, so I buy them pre-cut. And when it's so easy to get food, I find myself in the strange predicament of having too much food. I don't struggle to find enough food; I struggle to not to eat too much of it. Or I try to figure out how to keep the whole chicken I cooked from going bad so I don't have to throw it out.

This guy is probably not going to waste any of that kuru. He appreciates it way too much, not just because of the effort required to hunt it down, but because he spent hours watching it run for its life. To be honest, I'd have a difficult time killing a cow. But I'll eat a steak. And I don't appreciate it nearly as much as I should.

Yesterday, I got bored. So I called my friends, and we walked around Whole Foods. Not because we needed to buy food. We just needed to burn up time.

I'm trying to imagine explaining that concept to the guy who just spent days finding his dinner.

I used to think that those who make the biggest impact on society are the ones who change the system. They recognize that an institution is unjust, or wasteful, or unethical, or just plain isn't doing enough, and they roll up their sleeves and make big changes. I believed that welfare institutions were imperfect solutions to a problem that shouldn't exist in the first place. We wouldn't need suicide hot lines if people had more support from friends, clinicians, or family. We wouldn't need homeless shelters if everyone had a job. Volunteering at a free clinic was kicking pebbles compared to health care reform.

Now I’m beginning to realize that policy isn't enough.

We need those who strive to change the big picture. Hell, they probably make the biggest contributions. But the people who are making the big changes are too few, and while the changes they make are enormous for one person, for an entire world, it's barely a dent. Paul Farmer has moved mountains by treating TB and AIDS in Haiti, Peru, and Russia. But there is still Darfur. There is still South Africa. There is Honduras, and the Dominican Republic, and the ghettos in New York City. God forbid he stop. But it's not enough. Drugs will still be expensive. People will still murder others because of their ethnic background. And a majority of people will look at Paul Farmer and think, "What a great man doing great things. But that's not for me."

I am sure that those on high have their hearts in the right places. And we need them for their political and diplomatic clout. But they have other things to worry about, like "how can I get enough votes for this bill," and, "I don't want to piss off the drug industry lobby," and, "if I vote for this bill I might lose my constituents." In their conference rooms, they sit face-to-face with the educated and the affluent, not the HIV-positive drug addicts or the single mother who can't afford her antidepressants. The policy-makers worry about budgets and program efficacy, not how the person stranded in their home at 1 in the morning is going to make it to the emergency room for a psychiatric evaluation.

Policy may open doors, but it doesn't necessarily show people how to find those doors. Policy-makers can't make someone spend a few hours a week helping a kid with their homework. They can't make the CEO of a drug company agree to take less money for a bonus so that a homeless man can afford retroviral drugs to manage his HIV. They can't make someone listen to their next-door neighbors problems. And as long as that gap remains, people will continue to fall through the safety net, and as long as people continue to fall through the safety net, we need people waiting below to catch them.

Who?

Every day that I work the hotline, I am reminded that we did not evolve to be individuals. If you believe in natural selection, you must believe that society exists because it gives us the greatest advantage in survival. Yet, somehow, we have evolved into a population that defines its rules of conduct by what we don't have to do for each other, rather than what we should do for each other. Don’t kill, don’t steal, don’t hurt anyone else. Everything else is optional.

When I was growing up, my parents never stopped encouraging me to thrive. They jumped at the chance to enroll me in ballet classes and piano lessons. They drove me to gymnastics or swim team practice. The only thing I had to worry about as a kid was catching the school bus on time and surviving high school (not necessarily a small feat). I almost always had health insurance, either through my parents or through school. When I wasn't insured, Dad was always ready to foot the bill. If I needed counseling? No problem, I'd go to the student health center. If I needed to go to the hospital in the middle of the night? No problem, my RA would drive me. Even now, if I'm worried about paying the bills, I have Sam at the financial aid office. If medical school is driving me nuts, I have Patti at the wellness center. I have everything that I need to do well. I'm on track for a cushy job, and if things get tough on the way there, I'm surrounded by people who can help me.

But I had to do well in college to get here. And I had to do well in high school to get to college. And I couldn't have done that without Mom doing laundry and cooking every meal for me. I couldn't have done it without Dad making sure I had a roof over my head, or paying for college. And I wouldn't have wanted to do it if Mom hadn't taped my report cards on the fridge and listened to me talk about what I learned in AP history, or if Dad hadn't checked my math homework and talked with me over coffee about life, the universe, and everything. I wouldn't have wanted to if they hadn't reminded me constantly that I could.

My life hasn't always been easy...no one's is. But I always had encouragement. I always had a safety net. And I always took for granted that I'd be taken care of.

The other day on the hotline, I spoke with a young woman I'll call Jenny. Jenny's mother was a homeless drug addict, and Jenny had been living with her grandmother since she was a baby. Jenny's grandmother had just died. Her father didn't want her to come visit. She felt like her aunt didn't want her around. She was homeschooled, and she was lonely. I kept thinking, hang in there, you'll graduate from high school, and then you can live your life however you want. But when I asked her if she was thinking about college, she said, "I don't know." 

There was a way for Jenny to get to college. The infrastructure was there. She could look up the college online. She could ask her home school teacher for help. The government would give her money if she couldn't pay. But she had to feel like she could before she would even want to try. She needed someone to show her how to register for the SATs. She needed someone to help her fill out the FAFSA, because she probably doesn't know what a W-2 or a 1040 is. She needed someone to drive her to campus, and to take her shopping for her dorm room. She needed someone to tell her that she deserved better. Each step that my parents or my teachers helped me through when I was in high school was a struggle for her. Those steps can add up. College must have seemed impossible for her.

Life lands people in shitty situations. There are people without jobs. The health care system is imperfect. There are people who don't have enough support from friends, clinicians, and family. Someone should change that. But these thoughts are of no use to me when I'm trying to figure out how my caller can get counseling without health insurance, or get access to meds, or get to college. So I thank my lucky stars when I find a free clinic, or a food pantry, or a non-profit that will get them through this month's utility bills. I do a little fist-pump when, after asking if they are insured, they tell me that they have Medicaid.

In short, I thank my lucky stars that there are people who take responsibility for others, even if they don't have to. It's so easy to say, "It's not my responsibility." And even during our hotline training, they tell us that we need to know when to walk away from a problem. But it's not my problem, because I wasn't diagnosed with paranoid schizophrenia. It's not my problem, because my mother doesn't happen to be a drug addict.

It's not my problem because it didn't happen to me.

But it could have happened to me. If everyone else were so busy saying, “It’s not my responsibility,” where would I be?

During one of my hotline shifts, I received a call from a woman who had just lost her health insurance, had run out of her anti-depressants, and, because of her insurance status, couldn't get an appointment for a new prescription. She told me, "I don't know what to do. I can't go on like this." Fortunately, there was a free clinic in her area, and though she was skeptical when I told her about it, she finally agreed to go.

Now, my caller was not thumbing her nose at a free clinic. She was skeptical because the billing people at the hospital told her that no matter where she went, she would run into the same problem—no insurance, no appointment. No appointment, no prescription; and no prescription, no medicine. She had become convinced that this was true, so by the time I spoke to her she was doubtful that the free clinic could help her. The people she spoke to at the hospital had to have known about the free clinic, she said. Weren't they trained to know about this sort of thing?

The call frustrated me. It's so easy, I thought. Just pick up the phone and call. I had worked at free clinics before, and while it's no picnic to be seen (sometimes you have to wait all day; sometimes you don't get a spot), you do have access to a physician who can write you a prescription. The drugs will either come from the free clinic's pharmacy or from a local drugstore, and the physician will prescribe an affordable, generic drug.

Then it occurred to me: It was easy to have this remarkably clear perspective of what to do. I had been exposed to free clinics, so I knew how they worked. At the time of the call, I was sitting comfortably in a room with a flat-screen TV, separated from the problems of my callers by miles of telephone line. No financial worries. No medication worries. No depression to make me feel that I "couldn't go on this way anymore."

My caller, on the other hand, was a different story. Anyone who couldn't afford their medication would worry. But she was dealing with unmanaged depression that made her situation seem far more daunting—even hopeless. On top of that, the most reasonable avenue for help—a hospital—not only denied her an appointment; it told her she would be denied appointments no matter where she went. So when I asked her why she did not want to call the clinic, her answer made sense. Each door that shut for her was one more nail in the coffin. She called the hotline because she was beginning to believe that there was no way out. A free clinic? Too good to be true.

No health care system is perfect. People may argue that the principles on which private healthcare industries thrive—free market, competition, and most of all, profit—enable the healthcare system to develop and flourish. But that doesn't change the fact that there is a population that struggles in the system, and the population is too large to ignore. I cannot accept that such expensive healthcare, and healthcare riddled with bureaucracy, is the price we must pay for quality.

We seem to take for granted that healthcare is so expensive. We accept that it’s unreasonable to pay out of pocket—we rely on health insurance to foot the costs, because we understand that we could go bankrupt trying to pay the bills. Indeed, the crux of health care reform rests on our patronage of health insurance; the goal of the Patient Protection and Affordable Care Act is to expand coverage to 32 million more Americans by 2014.

It’s a reasonable concept, health insurance. It may take someone years to pay off a triple-bypass surgery. But if a group of people dump their money into a pot, each person can dip into the pot to pay bills that they otherwise couldn’t afford, provided they don’t dip into it too often. The people who do dip into the pot more often – those with “pre-existing conditions” – compensate by dumping more money into the pot and paying higher premiums.

The problem, however, is that health insurance has entrenched itself so thoroughly as the middle man in healthcare that it now determines how doctors treat their patients, and who can and who cannot be seen at a hospital. One of my professors, an oncologist, admitted a patient for chemotherapy and later received a call from the patient’s insurance company; the company was demanding to know why the patient was spending the night in the hospital. When my professor explained that his patient had just been diagnosed with Hodgkin’s lymphoma, the company, not wanting to reimburse the hospital, asked if he could send her home after the chemotherapy instead of keeping her overnight. Indeed, if the insurance company felt that his treatment was unreasonable, they could have withheld his reimbursement, and the hospital would have had to make up for the cost.

For those without insurance who are turned away from hospitals, the problem seems less complex. If people want affordable healthcare, they should buy insurance.

But there are the not-so-fortunate people with pre-existing conditions. Diabetes.  Heart disease. BMI’s that are too high. (For the record, in high school, my BMI indicated that I was borderline overweight. Never mind that the 10+ pounds I packed on were from weight-lifting.) There are the people stuck in limbo—recently unemployed, or who just graduated from college. And there are the people who are insured, but get tangled in the red tape. One of my friends suffered a back injury after a car wreck but couldn’t get a hospital appointment because her health insurance policy didn’t cover car accidents. The only way she could get an appointment was if she brought cash, then received compensation from her auto insurance. Unfortunately, that would take weeks to months, she didn’t have the cash, and the pain was excruciating.

Yes, something must be done about health insurance. But I’m more curious to know:

Why does healthcare cost so much, period?

It’s the high cost of care that spawned our dependence on health insurance in the first place. On a national level, we are concerned only with overall healthcare spending. We blame the rising rates of obesity and diabetes for increasing the demand for care. We blame the increasing cost of insurance for emptying the pockets of patients. We blame Medicare and Medicaid for draining our tax money. We blame the drug industry for inflating costs and blocking generics from hitting the market sooner.

But this doesn’t help me understand why a visit to the doctor’s office cost over $200 out of pocket, even though the only thing the doctor did was feel my lymph nodes. It doesn’t explain why I need to pay $400 for an x-ray. It doesn’t explain why an MRI costs $3,000.

Who sets these fees? The hospitals. How do hospitals determine compensation for procedures? Here is an excerpt from Atul Gawande’s book, “Better”:

The notion of a [fee schedule], with services and fees laid out a la carte like a menu from Chili’s, may seem odd. In fact, it’s rooted in ancient history. Doctors have been paid on a piecework basis since at least the Code of Hammurabi; in Babylon during the eighteenth century B.C., a surgeon got ten shekels for any lifesaving operation he performed (only two shekels if the patient was a slave). The standardized fee schedule, though, is a thoroughly modern development. In the 1980’s, insurers, both public and private, began to agitate for a more “rational” schedule of physician payments. For decades, they had been paying physicians according to what were called “usual, customary, and reasonable fees.” This was more or less whatever doctors decided to charge. Not surprisingly, some of the charges began to rise considerably. There were some egregious distortions. For instance, fees for cataract surgery (which could reach six thousand dollars in 1985) had been set when the operation typically took two to three hours. When new technologies allowed ophthalmologists to do it in thirty minutes, the fees didn’t change. Billings for this one operation grew to consume 4 percent of Medicare’s budget. In general, payments for doing procedures far outstripped payments for diagnoses. In the mid-eighties, doctors who spent an hour making a complex and lifesaving diagnosis were paid forty dollars; for spending an hour doing a colonoscopy and excising a polyp, they received more than six hundred dollars.

This was, the federal government decided, unacceptable [...] so the government determined that payments ought to be commensurate with the amount of work involved. [...] In 1985, William Hsiao, a Harvard economist, was commissioned to measure the exact amount of work involved in each of the tasks doctors perform. It must have seemed a quixotic assignment, something like being asked to measured the exact amount of anger in the world. But Hsiao came up with a formula. Work, he determined, was a function of time spent, mental effort and judgment, technical skill and physical effort, and stress. He put together a large team that interviewed and surveyed thousands of physicians from some two dozen specialties.

They determined that the hysterectomy takes about twice as much time as the session of psychotherapy, 3.8 times as much mental effort, 4.47 times as much technical skill and physical effort, and 4.24 times as much risk. The total calculation: 4.99 times as much work. [...] Overheard and training costs were factored in. Eventually, Hsiao and his team arrived at a relative value for every single thing doctors do. Some specialists were outraged by particular estimates. But Congress set a multiplier to convert the relative values into dollars, the new fee schedule was signed into law, and in 1992 Medicare started paying doctors accordingly. Private insurers followed shortly thereafter.

There is a certain arbitrariness to the result. Who can really say whether a hysterectomy is more labor-intensive than cataract surgery?

Arbitrary, but at least there is an effort to be systematic. But this only determines the reimbursement schedules for insurance companies, not the fee schedules set by hospitals, which, most of the time, are higher than the reimbursements. In the end, the hospital or practitioner decides whether or not to accept insurance, and it is the hospital that ultimately decides how much the procedure will cost. Of course, one must take into account overhead costs (about 20%) and security for the uninsured patients who are seen in the ER (about 15%). But hospitals also set their fees based on how doctors expect to be compensated. Gawande writes:

I got a second interview for a surgical staff position at the hospital in Boston where I had trained. It was a great job—I’d be able to do general surgery, but I’d also get to specialize in surgery for certain tumors that interested me. On the appointed day, I put on my fancy suit and took a seat in the wood-paneled office of the chairman of surgery. He sat opposite me and then he told me the job was mine. “Do you want it?” Yes, I said, a little startled. The position, he explained, came with a guaranteed salary for three years. After that, I would be on my own: I’d make what I brought in from my patients and would pay my own expenses. So, he went on, how much should they pay me?

After all those years of being told how much I would either pay (about forty thousand dollars a year for medical school) or get paid (about forty thousand dollars a year in residency), I was stumped. “How much do the surgeons usually make?” I asked.

He shook his head. “Look,” he said, “you tell me what you think is an appropriate income to start with until you’re on your own. If it’s reasonable that’s what we’ll pay you.”

Can it really be that simple? Can it really be that I need to fork over $400 for an x-ray or $3,000 for an MRI because the radiologist wants to get paid 300K a year? Can it really be that, if someone without insurance undergoes a series of surgeries, he could go bankrupt because the surgeon expects to make half a million a year?

I realize how extreme my idealism is. Medical school is expensive, and it’s four years out of a future physician’s life. But really, how accurately does compensation reflect the investment? Is there even a way to measure such a thing? Business school is only 2 years, but if someone does well in the corporate world he or she could end up making three times as much as a family practitioner. Hard work alone does not guarantee a good salary—we must work hard in the right field, and we must know the right people. An employee can lift as many crates as he wants in a factory and work ungodly hours, but he won’t make anything higher than $40,000 year if he’s lucky. I could devote up to seven years of my life to a PhD and become a professor, but even if I was tenured, a $100,000 a year salary would be on the high end.

I used to think that doctors charged as much as they do to keep up with cost of practice—medical school debt, malpractice insurance, space and equipment rental. But, one or two years into their specialties, family doctors make an average of $172,000 a year. Even with malpractice insurance, (about $40,000 a year), they are able to pay off their medical school debt. They have houses. Some of them have houses with pools. They have cars. And yet, family practice is seen as the butt of the specialties, because some specialists can make over three times as much. Physicians make the money they do because it is what they expect to make, not what is required to stay in practice. And no one is going to ask them to lower these expectations, because medicine is a respected field. Those who go into the field must make an investment, and god forbid we put a dent in our population of qualified physicians.

But what motivates someone to study medicine? What would happen if cardiologists were paid $160,000 a year instead of half a million? Would we see a drop in the number of cardiologists? Would see a drop in the quality of cardiologists? Considering our shortage of primary care physicians, I’m inclined to believe so. And while I find this disheartening, I understand that I would be naive if I expected people to go into medicine without thinking about money. That’s the driving force of the free market: if you want people to work hard, you need to offer them the compensation.

But is money always the most alluring compensation? If it was, why are universities able to keep their professors? Why are high schools able to keep their teachers? Why does the military keep bringing in enlistees—people paid far less than physicians, but who are ultimately willing to sacrifice their lives? And why can’t we expect the healthcare field to attract people for the same reasons? What would happen if a radiologist were paid the same as a primary care physician, and not paid per procedure but a flat yearly salary? Would our healthcare system collapse? Or would we just select for those who care less about the money and more about the discipline of healing?

• Fat is not the main culprit in obesity
• Dietary fat and cholesterol are not the main culprits in heart disease
• Eating things that spike your insulin -- white flours and sugar -- predisposes you to heart disease and obesity
• In lowering fat consumption, Americans have raised their refined carbohydrate consumption (high fructose corn syrup and starches are used to compensate for the taste you lose in low-fat products)...and this explains the obesity and heart disease epidemic