the "Green-House" of Healthcare:

For the past 7 years i've wanted to build a greenhouse on the south side of my house. it would reduce my $400-500 monthly winter heating bill, as well as add some beauty and capacity for winter veggies. three years ago i drew up some plans and got started and three years later i'm almost done with the foundation and frame... i call it turtle construction, slow and stead, making sure every nail, screw and piece of cement stands the test of time before another nail, screw or piece of cement is added. that's, of course, the bright side. From another perspective, i'm just a damn slow builder.

The greenhouse is being added on to a Victorian style house built in 1903 that was either constructed crooked or tilted over the years. there is not a single 90 degree angle in that house and the studs are never the same distance apart. as well, the wood used was truly 2 inch by 4 inch, not the smaller versions used today that are still called 2x4's but have shrunk HMO style to something that no longer has any fat or meat left over. pure bone, the new wood.

For the past 7 years i've been doing home construction to "relax" from doctor stuff, learning electrical, plumbing, demolition and framing skills on this tilted, awkward, frustrating, lovely old house. There was something simply elegant about putting in a new foundation, framing up a fresh new structure for the greenhouse, designing "from scratch." But when the greenhouse started butting up against the old house, all the old crooked demons of warped angles, erratic distances, different sized pieces of wood surfaced again and i realized something that felt quite profound.

The House of Medicine is like this 100 year old Victorian house. Crooked, intense, beautiful, frustrating, layers and layers and layers of things built on things built on ideas built on air. Like my house, it sometimes feels like the house of medicine was put right on the ground, with no foundation, no plumbing system, out of date wires. It works. For some people, in the master bedrooms, it works really well. But for many of us, practitioners and patients alike, it's a mess. Learning in it, working in it, receiving "Care" in it.

Out of this mess, I decided to build my own clinic, to start fresh, from "scratch," working with others who shared similar values. Set down the foundation, the frame, fill out the walls with beautiful windows, put on a solid roof and leave the door open for anyone to come in. But like my small greenhouse, it has to butt up against the house of medicine and therein lies all the intricate mess of history. Fortunately we built our "greenhouse of medicine" in such a way that the insurance system is out of range/sight/smell. They could be on another planet for all we care in our clinic. No CPT codes, no coding of visit lengths, no billing office, no checkboxes, no phone arguments over pre-existing conditions or prior authorizations. halleluyah. We only have to deal with labs, x-ray, MRI/CT and the occassional hospitalization. And with most of these external systems, we've had pretty good luck. Lab is fairly standard, x-rays are covered by an independent doc who charges $50-100 per shot, hospitalization has worked out amazingly well with a local non-profit hospital. MRI/CT is a mess, costs $500-3000, but we are working on it and have a potential solution coming down the road.

I know not everyone will agree with the grandiosity and negativity of this perspective of medicine. I don't mean to come off sounding black and white. the house of medicine does have some foundation somewhere. But please hear this criticism from a recent graduate of the system, from someone who has survived it's training programs and successfully built an alternative model that is working, that is making money charging 50-90% less than other operations. Whatever foundation we might have had in the past, similar to my victorian house (that was lifted from it's foundation on the other side of town and moved to it's present location over 50 years ago), large parts of our health system no longer seem to touch the ground.

The ground in medicine is science, research and common sense, connected to a trusting and powerful therapeutic relationship with our patients. Legal fears, Insurance relationships, personal/individual greed, and race/class factors all contribute to our instability as a coherent "house" of medicine.

andru