By Matthew Holt

JD Kleinke has been one of my favorite people in health care for at least a decade (or probably more!) notwithstanding his barrages at all and sundry (sometimes including me) on this very blog. He’s been a little quiet of late, but that silence is over. He’s out with a new novel called Catching Babies. It’s a topic I’m thinking about a lot! As you may know I’m less than 2 months from being a first time dad, and Indu (my Health 2.0 partner) is similarly close to being a first-time mom. Both me and my wife read Catching Babies in pre-publication and it’s a tour de force of health policy and medical soap opera–Health Affairs meets Grey’s Anatomy–wrapped up in the complex world of childbirth. Now the book is out and we’ll be having JD at the  Health 2.0 Spring Fling in San Diego in a fireside chat about the book with Amy Romano (@midwifeamy). but I thought I’d take the chance to interview JD about the book and his previous and next steps. Here’s a (heavily edited) version of our IM chat–Matthew Holt

Matthew: You’re well known to THCB readers as a medical economist, policy wonk, and health IT entrepreneur geek from way back.  The obvious first question – why a novel of all things?  Does your shift to fiction imply that you’ve lost touch with reality?

JD: Lost touch? That would imply that I was ever in touch with reality in the first place!  You may recall that my very first book tried to argue that managed care was a necessary evil for the good of us all, including providers.  That the harshness of commercial managed care was the change agent we needed to get hospitals and physicians to modernize. I suppose that turned out to be fiction as well!

Matthew: OK so you’ve always been a bit of a dreamer, I might say the same thing about the health care IT ventures you’ve been involved with. But some of them, like Solucient and HealthGrades, are now pretty successful!  And Catching Babies is not just a novel – it’s a great story – but it also has more powerful things to say about a dozen health policy problems than as many treatises on the exact same subjects.

JD: Thanks for the kind words about the story, and if that’s true, it’s powerful as a policy document precisely because it is a novel.  For better or worse, this is how all of us, as human beings, relate to even the most abstract health care policy, or new technology, or business idea.  Every health policy is ultimately a patient, and every patient is ultimately a story.  Medicare coverage is extended for a new treatment because a Congressman’s mother once needed it. The crazy quilt of health benefits mandates at the state level exist because someone in each of those states got sick, was stuck with the bills for treatment, and took his case to the state senate either directly, or via the front page of the largest Sunday paper in his state. If you look back at the news building up to the passage of health reform, you’ll see that public opinion probably crested in support, when President Obama took the stage with the sweet lady from Ohio with cancer who couldn’t get health insurance.

Matthew: On the other hand, fiction still seems like a stretch for a hard-headed, corporate health care data guy like you – even if you do live in a city getting more and more famous for eccentric, creative types.

JD: Ha!  Portlandia is another story, literally.  Actually, it’s a great TV show – but you’re right. Writing fiction is art, not craft. And producing readable fiction turned out to be a much bigger effort than producing credible medical information, which explains why this book took so many more years to churn out than the others.  As for the dozen health policy problems you see in the book, well, that’s no coincidence. Catching Babies started out as non-fiction, as a book of essays on some of the weirder things I’ve uncovered about womens’ health and obstetric medicine in my research and as part of my health informatics work.  The original working title was “God’s Eggs.”  It was going to be a survey of the complex collisions between reproductive medicine and religion, and each was originally based on what are now the core clinical cases in Catching Babies. You know – the Muslim twins, the pregnant Mormon with the heart defect, the Catholic doctor doing the abortion.  You’ve probably noticed in all my work that I’m fascinated by the deep philosophical conflict at the heart of even the simplest health care problems – the conflict between opposing values and beliefs and rhetoric that makes every discussion in health care so freighted, so fraught with emotion and anger.  No other industry in America is burdened with so much bickering, screaming, accusations of bad faith.  And this is nowhere more true than in obstetrics, reproductive health, womens’ health, and childbirth, all of which runs smack into the biggest questions of all: religion, rights, privacy, freedom, equity, the very meaning of life.  Throw all that emotion and angst into the mix, and you can’t help but end up with drama, with the stuff of narrative fiction.

Matthew: But the drama, at least as you render it in Catching Babies, seems to be more about the providers than it is about the patients.

JD: Yes.  And it could just as easily have been focused on the patients.  But as I started writing, I found the doctors, nurses, and midwives more interesting, if only because, unlike the patients, they have deliberately chosen this medical chaos. And they choose to live in it every day.  So my question has to be: why? That’s probably the core impetus for why Catching Babies morphed into a novel.  In obstetrics, especially the high-risk cases, patients’ stories are of course wildly dramatic and emotional – they swing back and forth between the extremes of our biggest hopes and worst fears – and they end up with happy endings or horrendous heartbreaks. But I came to find the doctors’ stories even more compelling, more extreme. I have gotten to know several OB/GYNs personally, several during the bizarre and brutal rituals of their residencies.  And I was morbidly fascinated by those rituals and how OB/GYN residency seemed designed explicitly to turn these generally caring and compassionate people into either martyrs or monsters. I witnessed incredible heroism among these doctors, and I also witnessed incredible cruelty and callousness.  And the harder I tried to understand the origins for these extremes in clinical behavior and attitude, the further it led into the realm of literature. The drama of the group, the unconscious acting out of old wounds, the psychology of compulsive behavior, transference and projection, the quest for spiritual wholeness, the random act of kindness or sadism by humans pushed beyond their limits – these elements are what makes for the world’s great novels.

Matthew: But you did keep the health policy elements alive and well, just beneath the surface of the story.

JD: Yes, thanks, I tried. I suppose because those elements are in fact the protagonists in these caregivers’ dramas, especially when you look at, say, the struggle over integrating midwives into the system, or the struggle over even acknowledging home-births.  It doesn’t help that most of the physicians in the system are flying blind, or flying backwards, thanks to a dearth of data and a culture gridlocked by defensive medicine.  So much of OB medicine is practiced with little or no evidence to support it, other than “this is how we do it” or “we do it this way because of the fucking lawyers.” Sorry, Matt – I don’t know if you can run that – but “fucking” seems to be the universal modifier for “lawyer” among OB/GYNs.  Anyway, the underlying presumption of almost all OB medicine is always: what will go wrong.  This is the essence of what I wrote about in my “Normal Pregnancy” piece here on THCB.  If we pathologize childbirth in America – and I certainly believe we do, and I fully understand both sides of this bitter argument – then this is where it originates, with OB/GYNs who are trained, insured, and “fucking lawyered” up to assume the worst and proceed accordingly.  Small wonder that this then becomes the staging area for so much of their own pathologizing as caregivers.  And without giving anything away, that’s the real theme of the novel.

Matthew: The wounded healer theme?

JD: Exactly.  These doctors are not just trying to heal women and catch their babies. They’re trying to heal themselves and their mothers, trying to catch themselves.  The good ones, anyway. The bad ones – well, I don’t want to give anything away.

Matthew: But there’s more. I know you well enough to say that there is clearly a little bit of you in this book. So, what about the author?

JD: I’d be insulting you and my readers if I pretended there isn’t a lot of me in this book.  I’d always heard that serious fiction isn’t fiction at all, except for its particulars, that it’s merely a channeling of the author into the story, even if it’s on another planet.  So yes, the labor and delivery floor can feel like another planet, but I am very much right there in the bigger story.  Like its central character, I came from a difficult family.  My mother suffered from disabling chronic illnesses her whole life, beginning in her early childhood, and they were exacerbated by her pregnancies with my sister and me, a fact made clear to me at a young age, and something that shows up on page two of the book.  Looking back at what I know now, I am certain she had severe post-partum depression – though we will never know of course.  This is why I have always been a bit of a crusader about the progress we’ve made in mental health diagnosis and treatment in the past few decades, and why I have been accused of going too easy on the drug industry in all of my work.  If the drugs we have now had been around when my mother was suffering in the 60s and 70s, her life and my childhood would have been radically better.  It wasn’t until I was well into the writing of Catching Babies – with a central character who is a hyper-vigilant OB/GYN with anhedonia, cut off from his biological family, haunted by his childhood, and completely over-involved with the well-being of his patients – that I realized this was probably why I was writing this book in the first place.

Matthew: But that’s not why you initially set out to write a book about womens’ health.

JD: Not at all, not consciously.  But in retrospect, eight years later, that’s clearly why I did.

Matthew: Maybe that is why you, like those characters, ended up in health care in the first place?

JD: Yes. And it’s why I have spent my career obsessed with trying to improve the functioning of the health care system, trying to increase patients’ access to care, trying to mobilize medical data about what does and doesn’t work.

Matthew: Talking of mobilizing medical data…

JD: Please don’t ask me about that.

Matthew: Well you were foolhardy enough to agree to be here, so I’m asking.  The last time I interviewed you for THCB, you were running a non-profit institute and working on a personal health records platform.  It was 2008, if I remember correctly.  And you were in the middle of a big legal fight with Dossia, the consortium of major employers funding that work.  But you couldn’t give us any details about what had gone wrong.  Have you and Dossia kissed and made up?  Can you talk about it now?

JD: No.  I couldn’t talk about it then, and I can’t talk about it now.  Omnimedix was a great idea, another dream, and it no longer exists.  End of story.  I’ve moved on, so have the many great people who worked for Omnimedix and stuck it out until the end, and so has the entire personal health records industry.  That was 2008, and now we have Google Health and Microsoft HealthVault, so the world has moved on too.

Matthew: So what is next for you?  Now that Catching Babies is behind you?

JD: Returning emails and sleeping.  Writing a book is like kidnapping yourself, especially as it launches. When you are in an actual writing zone, which is where I spent most of 2003, 2005, and 2010, the book takes over, and you abandon everything except the bare essentials.  But with the book finally out this month, I am ramping back up, working with several very cool health IT start-ups, and catching up on some other writing projects that have simmering on back burners for too long.

Matthew: And what’s next for Catching Babies?  I think the cover will quote me as saying we’ll be seeing this on Thursday nights.  It’s a medical drama, set in a teaching hospital, with a constant influx and outflow of doctors in training and patients in crisis.  Ready for primetime?

JD: I can’t talk about that either!  Actually, I could say that I am in discussions about a potential TV series based on the book with some people in the business.  Who knows.  Entertainment isn’t quite health care, but I can already tell that it has its own dysfunctions.  Who knows.  I learned a long time ago not to count on anything except surprises.

Matthew: OK, thanks for the chat–we’re looking forward to seeing you at Health 2.0 in San Diego in a week.