Visual Rhetoric

Advances in medical technology have resulted in substantial gains in life expectancy, especially in developed nations (Roser 2016). However, the healthcare system in the United States is not effectively prepared to handle the massive influx of patients with age related cognitive deterioration and their goals to live comfortably at home and be free of pain. Not only does the current healthcare system stress quantity rather than quality of care, but it also is heavily biased towards acute medical intervention and short term increase in life instead of comforting patients and relieving their pain (Meier 2015). Doctors and hospitals are incentivized to provide more treatment, even if it is less beneficial to patients. However, patients with terminal illnesses do not want aggressive treatment to prolong life, but rather to enjoy their remaining time in comfort (Delude 2015). These issues become more evident in the context of dementia and its underlying diseases, such as Alzheimer’s, which are currently incurable despite the considerable improvements in medical technology and treatment.

Alzheimer’s disease, a progressive neurological disorder that afflicts about five million Americans today, affects the entire body (Mitchell et al. 2012), leaving patients incapacitated and bedridden. Patients gradually lose track of where they are, what is happening, how to dress themselves, who their family is, finally becoming immobile, incontinent, incoherent, and catatonic. As a result, an Alzheimer’s diagnosis is extremely emotionally distressing because it constitutes a loss of identity and of personhood. However, the long trajectory of cognitive decline means that many patients who are diagnosed with Alzheimer’s disease will likely continue to survive for many years, and sometimes even decades (Delude 2015).

When asked, three out of four people say they would prefer to die at home, receiving comfort care only and with no intrusive interventions. Yet most people fail to discuss end-of-life wishes with their families, and only one in four actually prepares advance directives. So when the end nears, most families don’t know what their loved ones would want. Meanwhile, doctors are trained to defeat death, not allow it to happen. In addition, the current payment system creates perverse incentives for sending dying patients to hospitals, where the default mode is acute care. As a result, many people receive unwanted and expensive end-of-life treatments that exacerbate, rather than alleviate, pain and suffering (Delude 2015).

The purpose of the healthcare system should be to best use medical technology to help patients with dementia achieve their goals of comfortable, at home care that provides relief from pain. End of life care is supposed to be supportive and less intrusive in nature. Though dementia is terminal illness, the process of eventual death takes an exceedingly long time. Consequently, patients are more likely to pass away due to the clinical complications from interventional care and being bedridden rather than from the disease itself. In contrast, hospice is a more effective form of treatment because it provides a refuge from unwanted end of life interventions. In hospice care, patients forgo curative treatments but receive care focused on comfort, managing symptoms, relieving pain, emotional support, and enhancing the quality of the time they have left (Delude 2015).

Though hospice seems ideally suited to providing the type of care that advanced Alzheimer’s patients need, it can be a challenge to be admitted. A physician must certify that death will come within six months, a requirement that stems from the early days of hospice when it was primarily designed for cancer patients. However, it is significantly more difficult to predict with reasonable accuracy when a patient with dementia will likely die than it is for a patient with cancer, a disease that has a relatively well understood trajectory towards death. “Alzheimer’s prognosis is so variable that most people who need hospice care won’t get it because it’s not clear they are dying until the last week of life,” says Diane Meier, a geriatrician at Mount Sinai Hospital in New York City. In addition, patients are also required to show ongoing decline in order to continue to receive hospice care. Patients who live longer than six months must reapply; those who stabilize and stop getting worse are no longer eligible for hospice. Ironically, hospice patients often do improve, because palliative care alleviates medical problems caused by the side effects of intrusive medical interventions. By providing loving and meticulous care, patients lives are extended and, in a cruel paradox, their eligibility for hospice is jeopardized (Meier 2015).

The hospice Medicare benefit was set up in 1980s for terminally ill patients. As a result, Medicare considers hospice only as a short term solution and has implemented a cumulative benefit cap per patient. The inherent problem with financing hospice care for dementia patients specifically is that their “end of life” care often lasts far longer than the six month period that Medicare will reimburse. The majority of expenses are taken up only in the beginning of care, when the patient is first admitted, and at the end, when the patient is dying. In between, however, daily expenses are typically lower. Despite the expense curve, hospice benefits are paid out at a constant rate, which eats into the benefit cap. Consequently, hospices must discharge long term patients once the benefit cap is reached. This ineffective administration of funds severely limits the care that patients wish to receive. Many patients who outlive their prognoses and would have benefited from continued palliative care provided by hospice services are forced to resort to invasive hospitalizations and aggressive medical treatments as families struggle to pay for or provide comfortable, at home care consistent with the goals of patients (Meier 2015).

Unfortunately, the current healthcare system does not offer a clear way to continue to care for patients who have been discharged from hospice (Delude 2015). In order to make palliative care more accessible to the ballooning aging population, the hospice Medicare benefits program must be revised such that benefits payments are not paid at a constant rate. Rather, benefits should be reduced during the period when the patient is in stable condition and hospice expenses are lower. This allows patients to remain longer in hospice care and in the comfort of their own homes.

As clinicians become more reliant on the technical aspects of care, less attention is given on supporting patient and their families. Adjusting doctor training protocols and reimagining the home as a place of medical treatment are key aspects in changing the healthcare system for the better. It is imperative that doctors in medical school be trained to take the time necessary to explore the goals and values of patients and best utilize their expertise and medical technology to help patients achieve their goals. The medical system is primarily built around hospitals and clinics and the payment system mirrors that. Though a growing number of hospitals now provide palliative-only care to dementia patients, most who need that care are not actually in hospitals, but rather in their own homes, nursing homes, and retirement communities (Meier 2015). Because reimbursements are predominantly given to hospitals and clinics, most doctors do not have any financial incentives to provide at home care. Reaching these patients will require new federal policies that include the home as an effective location of health care and reward doctors for meeting patient needs where needed (Delude 2015).

References

“Advanced Dementia: State of the Art and Priorities for the Next Decade,” by Susan L. Mitchell et al., Annals of Internal Medicine, January 3, 2012.

“A National Study of Live Discharges from Hospice,” by Joan M. Teno et al., Journal of Palliative Medicine, August 7, 2014.

“Fixing Medicare’s Hospice Problem,” by Cathryn Delude, Proto Magazine, January 28, 2015.

“Long Last Moments,” by Cathryn Delude, Proto Magazine, January 28, 2015.

“Troubled Passage,” by Diane Meier, Proto Magazine, February 15, 2015.

“Alzheimer’s Disease and Dementia Are Different,” by Angela Lunde, Mayo Clinic Expert Blogs, September 27, 2007.

“Alzheimer’s and Dementia,” no author listed, Alzheimer’s Association, nd.

“What is the Difference Between Alzheimer’s and Dementia?,” no author listed, Alzheimers.net, nd.

“Medicare Hospice Benefits,” no author listed, Medicare.gov, nd.

“Life Expectancy,” by Max Roser, Our World in Data, 2016.

Important Terms and Definitions:

• Dementia: a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.
• Alzheimer’s Disease: a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain.
• Palliative Care: care designed to relieve pain or alleviate a problem without dealing with the underlying cause so patients remain in comfort.
• Hospice: a home providing palliative care for the sick, especially the terminally ill.
• Medicare: the federal health insurance program for individuals who are 65 years or older.

Imagine you’re a physician walking through the halls of your hospital. You come across a nurse ordering pizza for her colleagues over the phone. Just as she’s about to hang up and put the phone down, she hears something and raises the handset back up to her ears, just catching the person on the other end reading back her order to make sure it’s correct. Two days later, walking down the same aisle, you see the nurse on the phone receiving medication orders from your colleague. She writes down the order and at the end, she says, “Alright, doc. I’ll get that done.” and hangs up the phone to finish her work.

While this situation seems absurd, John Nance, the author of Why Hospitals Should Fly, recounts this exact exchange in his interview with Proto Magazine. As a pilot since the 1960s, flying for the Air Force and for commercial airlines, his work in connecting the disciplines of aviation and medicine were instrumental in paving the way for Gawande to write his own book, The Checklist Manifesto. While Nance’s work attempts to convince hospital administrators, Gawande takes a different approach in order to help those actually in the medical field to recognize their own humanity.

Physicians, and particularly surgeons, often think of themselves as the infallible commanders of the medical world. The “Miracle on the Hudson” is an excellent case study in team dynamics, and Gawande contrasts how aviators and surgeons deal with unexpected problems. Captain Sullenberger and First Officer Skiles had never worked together prior to that fateful flight. Yet, in the face of a dire situation, they were able to work as a seamless team to address every issue that arose. That seamlessness was no coincidence. Before every flight, the pilots brief each other as to what their specific roles are: who is the pilot in command, who will handle radio communication, etc. The checklist that they followed to ensure that everything was taken care of before the start of the flight was instrumental in the successful outcome of the flight, despite the flock of geese that knocked out both of their engines.

One of the key takeaways can be beautifully summarized by this, “The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with… and lets it rise above to focus on the hard stuff.”

Gawande masterfully weaves this thread of “immense complexity” through anecdote after anecdote describing a diverse set of disciplines where checklists have made an impact. Importantly, he doesn’t forget to mention that checklists are simply tools – they can’t replace a surgeon after all.

Gawande opens the first chapter by contrasting the “dry prose of a medical journal article” with the miracle it describes. Immediately, he builds credibility by reassuring the reader that this book isn’t that. Rather, it shows exactly how he approaches the rest of the book. His linguistic style shows no signs of purple prose. Rather, he seems approachable and conversational in tone. It seems like he’s talking directly to you and just telling a story.

Gawande’s argument that the point of checklists is to help reduce cognitive strain resonates with me. Whenever someone asks how hard it is to fly a plane, I respond by saying that flying the plane is the easiest part of being a pilot. The hard part comes actually from doing all of the other things that the pilot needs to do, while flying the plane.

I remember one particular flight with my instructor that I think readily  illustrates the value of a checklist. My instructor asked me what I would do should the radios fail in mid flight. Immediately I begin to go through all of the possible modes of failure of the onboard radios in mind. I begin to panic. What would I do if the radios failed? The obvious thing to do, I say, is to check if we’re transmitting and receiving on the correct frequency. It could have somehow been changed accidentally. He says that it looks good – nothing amiss there. I ask if there are any other electrical issues; are other instruments behaving strangely? No, he replies, just the radios. I tell him that I would reset the electrical system anyway just to make sure. I think to myself, is anything wrong with the antenna? Did it shear off as a result of high winds or a rock during our takeoff roll? Not likely; we probably would have noticed earlier if that was the problem. I move on to explaining that we should squawk 7600 on our transponder to let air traffic control know that we have radio issues and have lost communication. I glance down at the paper below me, frantically looking for the light gun signals. That’s how the tower can communicate to aircraft without two-way radios. But no one bothers learning these anymore, not when modern electronics have become so reliable. I don’t find them, and so I sheepishly tell my instructor that I’ve forgotten what the light gun signals mean. He laughs it off and asks me, “Did you check if you’re headset is still plugged in? It might have come loose from the turbulence and bumpy ride we had earlier!”

That’s what a checklist is for. It’s so that we don’t overlook the stupid little things like checking if our headset has become unplugged from the intercoms. It’s so that we can focus on flying the plane. When you learn to be a pilot, you’re not learning how to fly a plane. Rather, you’re learning how to deal with the plane when things go completely wrong — and things do go wrong. Likewise, surgery itself isn’t too difficult. However, the training of a surgeon is to know how to deal with everything when it goes wrong.

Most people don’t realize just how easy it is to actually get lost. I was flying back towards Mansfield after a cross country flight to Keene, New Hampshire. Before I left, I noted that a Temporary Flight Restriction would be in effect surrounding Gillette Stadium around the time I would be flying back. I called ATC to ask them if the TFR was currently active, and after a brief pause to double check, they let me know that it was indeed active. In order to avoid the airspace, I flew a couple miles further south than the direct path, not even that far, but just enough to skirt around the edge. That little change completely threw off my sense of direction. I now had no idea what I was looking at and I couldn’t see where the airport was. I had a GPS, so I wasn’t too nervous, but in that moment I realized that without my tools, I would have no idea where I was. I searched outside to see if I could spot 290 snaking its way around. After a few minutes of flying straight ahead and double checking with the GPS, I finally found it. I knew that if I continued following the highway southwest, I would eventually come up to the airport, which just happens to be right off the highway and next to a lake on the other side. Airports tend to look like large clearings in the normally wooded landscape of Massachusetts.

As a pilot, being able to see the value of checklists firsthand is an invaluable convincer to support the use of checklists wherever possible.

While the overt premise of the book appears to be exalting the value of the checklist through anecdote after anecdote, the true reason that this book succeeds is through the masterful use of the connecting thread that ties those anecdotes together and shows how so many diverse disciplines, all with the commonality of immense complexity can greatly benefit from a well designed checklist. Gawande’s poignant reminders serve to show that surgeons, although in a role apt to believe in their infallibility, can also make mistakes and likewise benefit from a checklist to help guide them.

We all get hit with a bout of nostalgia every now and then as we remember and reminisce at the halcyon days of yore. Yet as human beings, I don’t think that our nature can allow us to ponder these things for long without thinking forward at what is to come. Obviously, we are finite creatures and will one day perish, not only as individuals, but also as a part of the collective identity of humanity. It is indeed a disturbing thought, however we must realize the beauty in the ephemeral. The fact that things wilt and weather makes them all the more precious.

As much as I love delving deep into philosophical discussion, it’s just as important to consider the implications of what goes on at the surface of human life. We are by nature social creatures and crave contact with others. Coupled with the fact that we love being in the company of others who share our opinions, the rise of social media was inevitable. It allows us to connect with an immense number of people who are just like us. These groups are commonly referred to as “echo chambers,” where our opinions, whether correct or not, are amplified. These are essential for advertisers looking to make a meaningful impact, but are even more useful when spreading ideologies. Politicians and news organizations constantly tap into social media to influence the beliefs of people all over the country. What I think is particularly dangerous about this is the degree to which social media has infiltrated the opinions of uneducated people. It is essential to the function of the country that we elect competent politicians. When poorly educated and highly opinionated people are responsible, the results cannot be good. When one company is able to use its algorithms to control the influx of news to the population, when they show more conservative news to right wing voters and more liberal news to left wing voters, the echoes are further amplified. Today’s political scene is the most partisan since World War I started in the early twentieth century. Rather than spreading people apart, it is our duty to bring them together, to unify the public into one cohesive America.

I recently read Eugene Wei’s excellent (although I may say, quite lengthy) post about the fundamental nature of humans — that of status seeking monkeys. His theory of why people use social media is really able to explain why some networks succeed while others don’t, and why the demographics of each are the way that they are.

Dossier

“Status as a Service (StaaS),” by Eugene Wei, February 19, 2019. https://www.eugenewei.com/blog/201—9/2/19/status-as-a-service. This lengthy blog post goes in depth into the rise of social media and how it adapts to our fundamental being as “status seeking monkeys.”

When I was in the eighth grade, my teacher had a poster stuck on the wall that explained the meaning of happiness. I believe (though I am not fully sure) that the quote was from Johnny Cash.

When I was 5 years old, my mother always told me that happiness was the key to life. When I went to school, they asked me what I wanted to be when I grew up. I wrote down ‘happy’. They told me that I didn’t understand the assignment, but I told them that they didn’t understand life.

Johnny Cash

This quote really got me thinking about the meaning of life, the universe, and everything. Of course, we already know that the answer is 42, according to the Hitchhiker’s Guide to the Galaxy. But in all seriousness, I have struggled to find an adequate response to that question. Scientifically speaking, we are no different than any other creatures, or even inanimate material for that matter (pun intended). As a result, I find it quite surprising when people claim that humans were created to spread good throughout the universe. With regard to religion, there are many truths that are evident in unconventional places. Modern religion is highly monotheistic and speaks of a God that cares deeply for the welfare of the human world. Yet there is still evil in the world. In Hinduism, for example, there are a multitude of gods that, just like those of the Greeks, treat humanity like pawns on a chessboard. As a result, it is to these gods that Hindus pray, asking for protection and other favors. On top of all of this is the fundamental being of existence, the Brahman. No one ever prays to him, nor are there any temples built to honor him. The reason for this is that the Brahman is so fundamental that he does not care for humanity nor for the universe. Whatever happens in the universe is completely irrelevant. Why is it that in monotheistic religions such as Judaism, Christianity, and Islam, that God is so concerned with humanity? In the grand scheme of things, we are absolutely nothing. This is question that really has no simple answer, yet it warrants a discussion between all of the faiths.

As the slithering seasons come and go,

As the ceaseless tides ebb and flow,

Time marches on with blatant disregard

To human history and its heavenly bard.

Literature is a gleaming window;

Love, satire, gallant deeds, what a show!

Black symbols, merely ink on a blank page,

Scrawled down by many, an undying sage

Enthrall generations of humanity

With no more than subtle allegory.

I wrote this poem as our second term at Mass Academy neared an end, very much surprised at how fast time seemed to fly as we struggled together. 

My goal then was to compose a sonnet in the Shakespearean style, however, it proved to be quite difficult. I maintained the verse structure of the two quatrains and the rhyming couplet, but I did not use iambic pentameter or the abab cdcd efef gg rhyme scheme. I morphed in the style of the Petrarchan sonnet, but again took many liberties to ease the creative process and simplify the style. For example, this sonnet is not about unrequited love nor does it introduce a problem and end with a solution.

Literature is extremely important because it is, as I mentioned in the above sonnet, “a gleaming window.” I very intentionally chose the word gleaming because of its meaning with regard to a shiny, reflective, quality. We tend to embed ourselves in the stories that we hear. Literature opens a new world in our imaginations; worlds in which we can be heroes or villains. Stories bring back our childhood. We need that.

We often don’t recognize, and thus don’t appreciate, the extent of our prosperity in the United States. We take for granted the liberties and privileges that are associated with being in a prosperous nation. However, our forgetfulness does not absolve us the responsibilities of providing a relevant education to the next generation.

When we think of education in the traditional sense, it often involves learning about science, math, social studies, and literature. However, education, in it’s fullest form includes much more. Being “educated” isn’t about having multiple college degrees, or having a wealth of knowledge. Rather it is about having a wealth of experiences that enrich our souls and provide us a sense of understanding and compassion for humanity. This type of education is far more challenging to come by, especially in the U.S.

The American education system has begun to resemble an assembly line. Teachers work quickly to include materials deemed important. Standardized tests are a form of quality control. “In the past decade, the line has been sped up, the workers are asked to add more bells and whistles, and the raw material at the beginning of the line have decreased in quality” (Alan Rosenberg). This system is ineffective and defunct. Modern society demands a passion in building a brighter future with the tools we have. Innovation is not an esoteric art; rather, it’s the simple cooperation of sapience, ingenuity, and imagination.

The term sapience has extreme significance. It represents the philosophy of ideal knowledge and intelligence. And in fact there are three steps in the hierarchy of understanding: first, there are the facts. When we have simple understanding of facts, such as the population of the United States, they have knowledge. But is that really true comprehension? No, it is nothing but memorization. Children consider themselves “smart” when one student can recite many unrelated or random facts, or maybe knows the definition of some complex term. The next step is the ability to connect those facts together to begin gaining more knowledge. This is called intelligence, and it is what we do in high school. This stage is the compounding stage, where more background information allows more understanding. Part of the satisfaction of learning is in noticing the connections between seemingly unrelated aspects.

While being able to relate facts together and having a deeper understanding of the world is important, the final step is the application of knowledge and intelligence to our lives — to improve the lives of others and to create a lasting legacy. This is called Sapience. Sapience is touching the lives around us in many different ways as a granger does to the landscape.

At this stage, I surmise that one can truly be called “educated.”

Joy is a fleeting emotion. It is the small bubbles bursting at the surface of a boiling cauldron of the sticky soup of pain, of adversity, and of hard work. But without the thick, gurgling broth that the bubbles slowly rise through, joy would be worth absolutely nothing. The difficulty of the journey is what gives true value to every bit of happiness that we relish. At the very end, when we are able to look back and reflect on the progress of our lives, I think that we all hope, whether or not we are considered successful by others or consider ourselves successful, that we can be in peace knowing that every living moment was used to squeeze out hard work and passion. The utmost judgement of life is that we pushed ourselves to our limits and that we worked to our fullest potential.

It is the ephemeral element that, I think, adds value to our lives. The fact that everything is in constant flux allows our limited time to become our most valued asset.

Change is an essential component of nature. Without it, the entire earth would be a homogenous lump floating through the empty void of space, as it is from the ever changing sea of brine that life was born. Without change, the human race would not have evolved and progressed as it did throughout the ages. Revolution after revolution, we things get better and better as we realize the flaw in our old selves. This cycle repeats until the end of time and the Day of Judgement is upon us. All of us have a small desire to impart change in the world; to craft our wondrous legacy and build a better and more harmonious world. However, few get around to actually doing anything. The rest of us wander aimlessly among the large masses, living content and complacently, engulfed by popular society. From watching adults while growing up, they seem to despise change. Wanting to keep the old habits and customs alive so that no effort is needed to go through the world. Their energy is exhausted and their souls depleted. The energy from the soul is what powers human ingenuity and creativity. The passion for curiosity comes not from any external sources, but purely from the search of new ways to express the raw and unkempt emotion that resides within each and every human in existence. Though we do not know what is beyond death, we do know that life is ephemeral and fleeting. As a result, it benefits no one to keep the soul within its indefinite prison; let it escape, let it go free and float away, drifting away on the soft breeze. Why not?

Salty froth ebbs away with the tide
As the water seethes about the jagged rocks.
The sun dims, succumbing to a graceful swoon.
Without a noise, a gentle breeze slowly creeps in
To quiet the insolent water and sooth the hot sand.

Human beings are bizarre creatures, not only in terms of evolution as in Sapiens, but also in terms of our societal structures and unique linguistic creations. Of all the beasts on Earth, only human beings are capable of sophisticated and abstract language. Yet, of all these beasts, only humans struggle to convey heartfelt messages. We stand silent and reserved when near a person we admire, while inside we are screaming. We are afraid to speak when it really matters, when whatever we say can really change our lives. However, we blabber on incessantly when saying a simple word or two would suffice. Language is one of our greatest creations, nevertheless, it has complicated our discourse to point of maelstrom, to a point where a simple message becomes turbid with convoluted implications. The fear of being spurned hinders our ability to express our hearts’ most profound desires. It is that fear that must be dissolved in order to further our lives most precious aspirations. However, I do not doubt the power of words and the freedom they bring to human cognition. Their cogency does not come from the speaker, but from the listener. The power of words is a direct result of their ability to make the listener indulge in the contemplation of their meaning.

But words are things, and a small drop of ink

Falling, like dew, upon a thought, produces

That which makes thousands, perhaps millions, think.

Lord Byron

Dossier

“Sapiens,” by Yuval Noah Harari, 2014. This book goes through the history of humankind based on the premise that humans’ ability for fictive language and effective group communication is our only fundamental advantage.

A small boat adrift somewhere in the seven seas,
Lost among the sugary stars and slithering waves.
The night pierces my heart like a black dagger,
Alone with naught to break the inky silence.