Thursday, January 28, 2010

The Kubler-Ross Stages of Grief in the State of the Union Speech: Four out of Five Ain't Bad

During its medical career, there were a number of times when the Disease Management Care Blog had to break bad news to patients. Sometimes it was a life-threatening condition, an incurable disease or something that was going to involve a lot of time, money, pain or hardship. During those difficult times, the DMCB also recalls witnessing many textbook displays of the '70's pop psychology Kubler-Ross stages of grief. This says that when persons are confronted by tragedy, coping involves initial denial, followed by anger, then bargaining, then depression and finally acceptance. While these are supposed to serially happen one at a time, the DMCB remembers patients and families not only shifting back and forth, but displaying two or more stages at the same time and sometimes never reaching acceptance.

And so it was during the discussion of health care reform during President's State of the Union Address last night. While the DMCB was distracted by a Supreme's head shaking 'not true' disagreement, the frozen impassivity of the Joint Chiefs over repealing don't-ask-don't-tell and how almost eerily alive Mitch McConnell (R-KY) looked, that didn't stop it from 'medicalizing' the SOTU.

What is the bad news ailing our President? It's the tragedy that landmark and historic legislation is not going to happen. Our President is grieving. The stages of his coping were visible during the speech and can also be discerned in the italicized text of his remarks below.

I didn't choose to tackle this issue to get some legislative victory under my belt. And by now it should be fairly obvious that I didn't take on health care because it was good politics. I took on health care because of the stories I've heard from Americans with preexisting conditions whose lives depend on getting coverage; patients who've been denied coverage; families –- even those with insurance -– who are just one illness away from financial ruin.

To the DMCB, this opening paragraph sure looks like denial. The President did everything he should have done and the facts on the ground support his point of view. How, he asks, could this be? Is there some sort of mistake?

After nearly a century of trying -- Democratic administrations, Republican administrations -- we are closer than ever to bringing more security to the lives of so many Americans. The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care.

This look and it sure sounded like anger over the widespread injustice, the spectacle of insurers getting away with it and the pain of having defeat snatched from the jaws of victory.

And by the way, I want to acknowledge our First Lady, Michelle Obama, who this year is creating a national movement to tackle the epidemic of childhood obesity and make kids healthier. Thank you. She gets embarrassed.

Hey, he points out, I'm willing to include the participation of the First Lady in a very worthy wellness cause. Is this a good will gesture? The start of bargaining?

Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office -– the independent organization that both parties have cited as the official scorekeeper for Congress –- our approach would bring down the deficit by as much as $1 trillion over the next two decades.

The DMCB thinks that by reminding everyone of the merits of what he's willing to trade: access and reduced deficits. He is setting the stage for the pitch to follow.....

Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering, "What's in it for me?"

What's in it for me, indeed. This and the following paragraph continue with the bargaining. He's signalling his willingness to negotiate and once again reminding the listener about what's at stake:

But I also know this problem is not going away. By the time I'm finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans, and neither should the people in this chamber.

By now, we should be seeing some signs of depression....

So, as temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Let me know. Let me know. I'm eager to see it.

This has been interpreted as a willingness of the part of Mr. Obama to listen to the ideas of the Republican opposition. While that may be true, the DMCB wonder if this rhetorical 'let me know' is the sign of a bitter realization: if they are going to let him know, he's going to have listen and maybe even adopt some of their suggestions. It's well camouflaged, slightly angry, but still a remarkable admission of frustration. That is sad, espeically because the tone suggests he doesn't believe he thinks he'll see anything he'll really agree with.

Here's what I ask Congress, though: Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done. Let's get it done.

Unfortunately, the DMCB notes that this section of the speech appeared to end on a note of negotiating. That may be the sign of a good politician. However, from an admittedly armchair-ish pop-psychology point of view, the DMCB did not hear a post-defeat and Clintonesque 'the era of big government is over' style acceptance.

Of course, the stages of denial, anger, bargaining and depression may be enough to motivate the White House to get a bipartisan deal done. However, the DMCB found that patients did better once they accepted reality and dealt with it. That may, or may not be true in Washington DC in the coming weeks.

Is four out of five enough? We'll see.

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