Feb 17 2023

It’s Not Possible – Until Suddenly It Is

There are a couple of recent stories that remind me that perhaps the most powerful thing in the world is political will. Often politicians and motivational speakers will say something along the lines of, “We can do anything, if we put our minds to it.” While this sounds like feel-good pablum, I think there is some truth to it (with a bunch of caveats regarding “anything”). We (collectively) have a great deal of ingenuity, technological savvy, institutions and methods of change, and resources. What we often lack is collective will.

But occasionally the stars align, pushing political will beyond some threshold, and magically the impossible becomes possible. The first of the two recent examples I referred to above is the incorporation of telehealth into medical practice. As both a doctor and a computer nerd with an interest in medical informatics, I have long pushed and hoped for a greater incorporation of telehealth for managing patients. But this was not something that I as an individual (especially working for a large institution) could do much about. I was told that it was being discussed and worked on, but there were many difficult obstacles.

First, we need the technology to have secure video and audio remote communication.  This technology would need to exist on the patient end as well as the clinician. Second, insurance companies would need to pay for such visits. In order to be universal, this would likely require state mandates. We would also need to carefully assess the effectiveness of online health visits to be sure there were no unintended negative consequences. Ideally, states would also offer licensure reciprocity for online visits, otherwise patients who see doctors across state lines would not be able to be seen online.  And practices need to carefully track the effect of telehealth on their financial bottom line. After years of exploration I was told more years of negotiation and study were required, but this might work eventually (just don’t hold your breath).

Then the pandemic hit. Suddenly, literally within days, we had a telehealth system up and running. It turns out the technology was already in place. On the patient end all it requires is a smart phone and downloading an off-the-shelf app, or a computer with a webcam. It was a little bumpy at first, but the system rapidly improved. States suspended licensure restrictions across states and mandated insurance coverage.

In the end all of the positive outcomes of telehealth were realized, but none of the fears. Especially after the COVID lockdowns ended and patients could voluntarily be sorted into those visits ideal for telehealth and those who need a face-to-face meeting, the system is fantastic. Patients with difficulty traveling no longer need medical transport and a day-long saga just to sit in front of their physician for 15 minutes. Not all patient visits require and exam, and some limited examination can be done over video (I can do an entire mental status exam on video, for example). Many visits are focused on medication management, and don’t require any exam. Many patients love the option and are happier, it’s a cost-effective option, traffic and parking demands around medical centers is reduced, and the no-show rates for patients with difficulty traveling plummeted. States are waffling on licensure reciprocity, but I hope they will realize soon this is a net benefit for their constituents (again, it only requires political will).

The only thing that changed between, it will take years of study and slow adoption – to – having a good-enough system up and running in days, with steady improvements from there, was the necessity created by the pandemic.

The second example is also born out of necessity. The war of aggression of Russian against Ukraine has created an energy crisis in Europe. There were predictions of energy shortages, spiking prices, and economic meltdown. This has galvanized political will in Europe to do two things – conserve energy, and accelerate the transition to energy independence through green energy options. They were helped by a mild winter, but Europeans have collectively made an effort to be energy conscious, and as a result reduced their natural gas use by 24%. This allowed them to keep their gas reserved high. This is also partly due to higher energy costs, although most countries gave subsidies to temporarily limit these price increases. Even still, it shows that high fossil fuel costs is a good motivator to conserve.

Also, European nations accelerated the adoption of wind, solar, hydroelectric, and nuclear power (mainly by keeping nuclear plants open).  According to one analysis, they may have accelerated the green transition by up to a decade. Dependence on fossil fuels has actually decreased, despite warnings of a coal boom. Energy produced by wind and solar for the first time exceeded energy from fossil fuels in Europe. It has not been all good. Scrambling to deal with a sudden crisis is never the best way to do things. Poorer countries who could not afford the subsidies for the citizens have been hit hard.

But it is a proof of concept – the timeline for reducing carbon emissions from the energy sector is very much a choice. It mainly depends on how much we are willing to invest up front, how much we are willing to work together, and what our priorities are. And it should be looked at very much like an investment, that will pay long term dividends. If nothing else the Europe example shows us what’s possible.

I do like to occasionally fantasize about what the world could be like if the majority of people were just reasonable. I try very hard not to define “reasonable” as “thinks like I do”. That’s not what I am talking about. But what if we collectively agreed to not make war against each other and instead use diplomacy to resolve differences. Think of what we could do with all the resources that are currently funneled into the military. (Hey, I said this was a fantasy. I’m not saying this is practical today.) Imagine if there were broad agreement on minimal human rights and the proper role of science in determining what’s real and how to do things. Just those two things could transform the world.

Think of all the big problems we face today. Mostly the limiting factor in fixing these problems is not the availability of technology or resources. It comes down to political will. Sometimes political will takes a crisis. But sometimes it is a slow revolution – a generational change that suddenly makes something possible. But it also requires a system of government that allows for the translation of popular political will into action. That’s something else we’re working on, and itself requires collective political will.

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