On an abstract level, all of these arguments are valid in their own ways. However, we do not live in the abstract. We live in real life, 2012 America. The picture is complex. We need to step back, analyze the complexity, and come to grips with what we have become. Because when we analyze this complexity we see that all these answers are at best simplistic. And none get to the fundamental issues plaguing us that form the petri dish for a massacre of this sort.

Two comments kept replaying in my mind:
First, the movie goers were at first amused by the shooter’s appearance. THEY THOUGHT IT WAS PART OF THE SHOW! To have a guy appear in black battle garb in the front of the theater, throw out some kind of smoke bomb, and start shooting seemed like part of the entertainment.
Second, one response of the movie company was to pull the trailer for a soon-to-be-released movie that featured a team of GUNMEN SHOOTING A MOVIE GOERS IN A THEATER.

I am nothing if not passionate about our right to free speech. In my opinion, it is the fundamental right that makes us great. But how twisted have we become when massacres are deemed “entertainment?” What happened to restraint? Good taste? Memorable dialogue? How did we get to a place where parents bring a 4 month old baby out to watch a movie after midnight about death and mass destruction and think they did a great thing by snagging these tickets?

To me the real tragedy, is that we have moved beyond schadenfreud to celebrations of mass sadism. When we are excited to see these images in 3-D and hear these sounds in surround-sound, what do we expect?

Then the movies appear on Netflix and we can purchase the DVDs and watch them endlessly. Of course the images are imbedded in our minds. And worse yet in our hearts. Our children who have been raised with a lifetime of increasingly vivid violent images think this is normal. They think 3-D, surround sound violence is Real Life.

It is useless to then mourn when their version of Real Life imitates what they have been taught is “art.” Please spare me the apologies that violence in theater started with the Greeks and continued through Shakespeare. Classic plays were written with world class dialogue. And the violence was not enhanced with 3-D and surround sound. Most of all, the violence was presented as Tragedy, not Great Stuff.

We need to keep free speech. But we need to exercise this precious freedom for the greater good. Create great art. Argue issues with the Loyal Opposition instead of spewing hate back and forth.

And most of all, stop glorifying vivid images of Shooting as Entertainment.

I want my healthcare “served” in the same way – local, slow, specifically tailored to my needs. In Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal, Drs. Kupfer and Bond (JAMA, July 11, 2012, Vol 308, No. 2) present a model for outpatient care that makes sense to me.

The idea is that doctors, where possible, should present patients with options to determine their needs. Risk-averse patients might try the most conservative therapies first. Those seeking the quickest results might be more interested in more intense, perhaps surgical therapies.

This is really s – l – o – w medicine. It is much easier to simply order a test and then order a procedure. Ironically, the authors note that this can result in higher patient satisfaction scores since the patient might perceive the doctor is “doing” more. If you have ever been treated at an urgent care center, you may have seen this philosophy in action. They have based their model on their conclusion that patients want something tangible from their visit – a prescription…an x-ray result…a lab finding.

Sadly, your PCP who knows your medical history and therefore has the tools to treat you as a Total Patient may not be reimbursed for the task of carefully laying out alternatives and presenting them to the patient for mutual decision making. So, the fast-food model of care has taken hold, to everyone’s detriment.

A complicating factor is that this model of patient centered care requires an informed patient. Patients must be able to read and interpret information. For many, this is an unrealistic expectation. This fact places more responsibility on the doctor to explain, compare, and contrast options for the patient. Can a mid-level provider and/or an M.A. help? Undoubtedly. But it takes time, effort, and training to invoke those options. Busy doctors may not have the time.

It takes time and effort to choose dinner in a locavore, independent restaurant. It is easier – and cheaper – to simply use the drive-through at your generic fast-food joint. And you know that is not healthy. Just as you know you should your food carefully, you know you will be healthier collaborating with your physician to carefully craft your healthcare to meet your needs. Find a physician who understands what Drs. Kupfer and Bond have demonstrated: that physicians need to be sensitive, not simply to lab results, but to their patients’ total being.

“Contact Us” seemed like almost edgy interactivity in those days. I had to defend this decision. After all, the population in this town had little disposable income. How many could get online?

You will be shocked. Even in 2002 – before iPads and iPhones — that percentage of residents who stated they had online capability was 80%. How could this be?

This was a very young population. Median age was less than 20. While few had PCs in their living rooms, most found a way to get online daily by using libraries and other public venues with computers. Even then, it was important enough to them to go out of their way to get online and then connect with their healthcare provider.

Fast forward to today. Ten years later, most of us carry a computer in our pockets. We post pictures and comments to our social media sites and get comments back from friends in real time.

But medicine has been slow to catch the wave. Granted, we are legitimately concerned about patient privacy. But the resistance to utilizing social media is deeper than that. The patient portal has been slow to catch on. I would blame doctors/providers but I note that Google stopped supporting its healthcare vault for lack of interest. The lack of interest in the two-way street of patient/provider communication seems to be itself a two-way street.

I would argue that in this instance, providers need to take the lead. If they use technology so that the patient can easily access an answer to a (legitimate) question, then patients will clamor for more, want to store this growing collection of data, and vaults will be used by most if not all.

I would also argue that with the infinite amount of information doctors must amass and the limited time in their schedules, it is imperative for each patient to be informed about their own care. This must include some level of interactivity that is at least somewhat real time. How to reimburse physicians for the extra work this model necessitates? A topic for another blog.