Medical Complaints‏

I received this note recently:

The state of medicine in the US is in shambles. The problem is an overshooting in the bastardization of concepts like evidence-based medicine and the patient-satisfaction, which are viewed as something like (fictitious and functional) opposites to "paternalistic medicine". Of course the terms are not even poles of any kind of conceptual spectrum. Some quick clarifications/definitions:

evidence-based: typically the results are based on a *population*. There was this group of people with some condition. We did X to them. Y happened as a result, and here is our statistical confidence on seeing Y when we do X. 

- nothing wrong with this result really, and it sure helps us understand what works *in general*.

guideline: An operational rule book on a particular condition, whose basis strives to be "evidence based" (i.e. the result of those studies), and from which any *care giver* can deviate ("....oh, of course these are no substitute for actual practice with individual patients") at their own legal and financial risk. 

paternalistic medicine: "I am your doctor. I know what is good for you and what is not good for you. Trust me, I will make medical decisions for you. 

patient-centered medicine: "I am the patient. I know what I value, not you, doc. I will make all the decisions on my care, doc. I am a "client", see. What I feel is right is actually best for me.

- implicit is the thought that: "of course the doctor's job is to clarify the entire situation in 7th-grade language so I can make that decision".

- of course years of learning and experience can easily be translated into 7th grade, culture-sensitive language on short notice, so that you (who has every prior experience, including that of end of life issues, your probability of survival, success etc) can make snap decisions on the spur of the moment in real time, leaving open every possible loophole for lawyer and your own hindsight to return to in all legal glory for an aftermath of financial (and maybe criminal) plundering of the care-giver and medical infrastructure (which is what they/it fear, making for some interesting preemptively evasive behaviors). 

doctor: a red-listed species, soon to be replaced by the invasive *care giver*. Originally represented by some Oslerian entity of remarkable learning and clinical skill, that could in most cases stand in for your, priest and lawyer (in terms of advocacy), MRI/CT/US machine and lab (low-efficiency, but passable diagnostic equivalent), pharmacist and dispenser of treatments, as well as mother when you need someone to hear the cry ("Mummy!"). 

care-giver: an invasive species that wears white coats, and is the result of a convergent evolutionary process to fit a common evolutionary niche. Many also carry stethoscopes that they hardly know how to use (in a traditional sense). Protean species that have evolved into this include nurses (now known as the "clinical nurse practitioner", or CNP), and an entirely new 2-yr enlightened group called PA or "physician's assistant", who are non physicians elevated to the lowest calorie doctor standard that "less-money" can buy. Optometrists and even medical technologists wear the white coat and patients mistakenly call everyone "doctor".

- but lo and behold, even doctors are evolving into care-givers these days. your average physician today is no better than a PA IMO.

medical-care: an evolving concept, even a misnomer. At present represented as a combination of interactions between care-givers and infrastructure (MRI/CT/US/lab/pharmacy/OR/ER) and the laws laid down in the unassailable 'guidelines', what the market will bear and legal risk.

- it optimizes patient-satisfaction, care-giver adherence to guidelines and legally supportive documentation.  

common-sense in medicine: an extinct skill, previously referring to medical judgement that considers the vagaries of an individual patient navigating a disease, now to be replaced by a mindless executions of the care-giver, based almost entirely on the guidelines, which are of course justified as they are evidence-based whenever we can have evidence for it, what legality dictates and the workload.

with that we come to the state of affairs: a Procrustean approach where you, the patient, will be fit to a few standardized racks (your feet will be cut off or you will be stretched to make it work), so that the population statistics look great (while each individual differs from the "mean" by about 0.8 std deviations - the standardized mean difference), and you will be bulldozed by interacting with caregivers and infrastructure, suffer at the hands of the insurance companies, and the system will sustain minimal (legal, financial) risk, while perpetuating itself. You will subscribe to dual incompatible illusions that you have both a doctor looking after you in a paternalistic manner (which you desire despite your protestations) while you believe you are the ultimate decision-making/consumer (the satisfied "patient-center" of it all). You will not know better. The numbers will speak well of the well oiled machine. You will be sold short, but will die obliviously happy.

 

This was my response:

 

Medicine and politics is a "target-rich environment," perhaps deserving of an Ambrose Bierce approach. But I think there is a lot more going on, and going wrong, than such definitions allow. The Procrustean pressures are on everything, not just the patient, and are the direct result of the divided loyalties of the medical system. And the problem is much larger than at the interface between patient and doctor.

Is medical care a right? A result of holding a job? A charity?

Is the physician a scientist? A humanist? A technician?

What are we to do with physician extenders?
Is the fact that the majority of ground-breaking studies in pharmacology over the last years are irreproducible important?

Do patients have no responsibility for their behavior or, should they, like bad drivers, suffer financially for their bad statistics? Would such an attitude prejudice their rights?
Is Lee Hood right? Will the physician be the mere moderator in the discussion between the patient, the geneticist and the statistician?

We can explain the disparity between our high health costs and our mediocre life expectancies but what can we do about it?

We have had months of political campaigning yet I have not heard any discussion about medical care. There are complaints about the Affordable Care Act but not a single alternative. Yet there is a defining alternative, one proposed by the self-appointed Hillary Clinton in the 1990s when she offered her health plan along the guidelines of Uwe Reinhardt. It limits health care spending to 10% of GDP. It was her idea then, is it her idea now? And, if so, what does the kind of contraction such a plan implies mean for health care?

In some ways, medicine is a metaphor for the nation, a complicated mix of good will, science and technology, populated by practitioners raised in an environment of outdated principles, receiving information corrupted by economics and politics, serving a naïve patient population with suicidal tendencies and run by grasping non-scientific leaders who refuse to confront significant and basic problems that soon will be exaggerated by the growing demand and a discouraged work force.

Fortunately we all have the audacity of hope to hold on to.