The Health Culture

A new blog on the self

Posted by Jan on June 6, 2013 @ 5:08 pm

I’ve started another blog called Basic research on the self. My intention is to write there about the social and cultural history of the self, aided by insights from sociology, anthropology, philosophy and psychology (especially critical psychology). This is a subject that relates to a number of topics I’ve written about here.

A while back I grouped together my interest in psychopharmaceuticals, cosmetic surgery, happiness/positive psychology, and self-help and labeled these topics “psychological and physical conformity.” When I’ve written about these subjects, I’ve talked about the way things are today. In my new blog, I’d like to step back and ask: How did the society I live in end up valuing self-actualization, self-improvement, and maximized happiness – as well as an impossibly ideal notion of physical appearance — above all else?

That question also relates to a number of my other interests here — healthism, the social determinants of health, inequality, neoliberalism. It’s much easier to convince people they’re personally responsible for their health and well-being (including their socioeconomic status) if they’ve already developed a self-concept based on the ideology of the self-contained, autonomous individual.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: psychology & psychiatry

Healthy lifestyles: Social class. A precarious optimism

Posted by Jan on October 8, 2012 @ 2:22 pm

Continued from the previous post, where I noted that the Lalonde report — despite its good intentions — was followed by an emphasis on healthy lifestyles and personal responsibility for health, as well as increased health care costs.

Personal responsibility and social class

In Why Are Some People Healthy and Others Not?, Marmor et al, writing in 1994, were disappointed that the Lalonde report had not effectively prompted governments to address the underlying causes of health and disease. One reason for this, they believed, was that health policy reflects public opinion. If the public holds traditional views on what makes us sick (pathogens), what prevents disease (medical care), and what we can do to be healthy (take personal responsibility), new policies that include social determinants are unlikely. Those who are on the forefront of professional, scientific opinion may very well understand the importance of social determinants, but public opinion changes slowly. Without an education program, such as the relatively successful anti-smoking campaign, the public is unlikely to endorse change.

This is certainly true, although I believe there’s also something more fundamental at work here, namely, how a society accounts for the different life outcomes of its citizens. In Unequal Childhoods: Class, Race, and Family Life, Annette Lareau describes the assumptions people make when they hold others personally responsible for their life circumstances.… Read more

Filed under: Health & Medicine, History of Medicine, Politics & Issues
Tags: health care, healthism, healthy lifestyles, history of medicine, inequality, lifestyle, politics, social determinants of health

Healthy lifestyles: The unfortunate consequences

Posted by Jan on October 8, 2012 @ 1:48 pm

Continued from the previous post, where I discussed the expansion of universal health care prior to the 1970s, how this created a growing demand for health care, and the problem health care costs posed for governments, especially when the economy suffered a downturn in the seventies. One response to the situation was to consider new ideas. Rather than limit strategies to what could be done by the health care industry, why not directly address the underlying causes of disease by considering social determinants of health.

Canada’s Lalonde report

In 1974, Canada produced the Lalonde report. It has been described as

[the] first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.

The US Congress emulated this thinking in 1976 by creating the Office of Prevention and Health Promotion. The US Department of Health, Education, and Welfare began publishing the document Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The response in European countries — caught in the same bind of greater demand, increasing costs, and the financial consequences of a deteriorating economic landscape – was similar.

The common thread in these new perspectives on health was the assertion that health could be improved — without increasing health care costs — if we concentrated on such things as the work environment (occupational health), the physical environment (air and water pollution, pesticides and other carcinogens in food), genetics, and healthy lifestyles. The approach was broad: the environment was considered at least as important as the promotion of healthy lifestyles.… Read more

Filed under: Health & Medicine, History of Medicine, Politics & Issues
Tags: health care, healthism, healthy lifestyles, history of medicine, inequality, lifestyle, neoliberalism, politics, social determinants of health

Healthy lifestyles: The antecedents

Posted by Jan on October 7, 2012 @ 6:02 pm

In the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.

Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.

A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified.… Read more

A more equitable future? US reveals its true intentions

Posted by Jan on September 24, 2012 @ 5:42 pm

Why is it so hard to convince policy makers worldwide to address the social determinants of health, including poverty, hunger, and income inequality? Judging by the excerpt below, we shouldn’t count on the US to champion this cause any time soon. It’s from a document called “The Future We Want,” issued by the Rio+20 conference last June. The US requested changes to the document, indicated in bold (additions) and strike-outs (deletions).

Eradicating poverty is the greatest global challenge facing the world today and an indispensable requirement for sustainable development. In this regard we are committed to free humanity from extreme poverty and hunger as a matter of urgency.

We recognize that promoting ~~universal~~ access to social services can make an important contribution to consolidating and achieving development gains.

We strongly encourage initiatives ~~at all levels~~ aimed at ~~providing~~ enhancing social protection for all people.… Read more

Filed under: Politics & Issues
Tags: inequality, lifestyle, neoliberalism, politics

Profit-driven medicine: Satisfying patients at the expense of their health

Posted by Jan on July 29, 2012 @ 5:55 pm

Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal bit.ly/MN7Yan JAMA Highly satisfied patients had worse outcomes

— Jan Henderson (@HealthCulture) July 26, 2012

Why would patients who report greater satisfaction with their health care be worse off medically? This JAMA article, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, offers an explanation that makes sense. It points to the commercialization of health care – treating the patient as a consumer – as the villain. (All quotations in what follows are from this article.)

The patient (consumer) satisfaction survey

In the US, many doctors are evaluated and rewarded based on patient satisfaction surveys. Motivated to produce high patient satisfaction scores, doctors are inclined to order more diagnostic tests. Why? It’s more than a simple desire to please the patient.

When physicians’ performance evaluations and incomes are tied to patient satisfaction, the situation becomes ripe for overuse and misuse of diagnostic and therapeutic procedures because it allows the physician to rationalize decision making in terms of patient satisfaction.

Pleasing a patient is a conscious, individualized choice. Rationalized decision making can easily become an automatic habit that requires no additional thought.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: corporations, doctor/patient relationship, health care, hospitals, pharmaceuticals

On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part

Posted by Jan on July 20, 2012 @ 2:34 pm

Continued from parts one, two, and three.

A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.

Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: corporations, cosmetic surgery, disease mongering, doctor/patient relationship, health care, healthism, healthy lifestyles, inequality, lifestyle, medicalization, neoliberalism, overdiagnosis, pharmaceuticals, politics, psychology & psychiatry, risk, social determinants of health

On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections

Posted by Jan on July 18, 2012 @ 11:14 pm

Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.

If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.

Healthism

~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.

“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable.… Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political

Posted by Jan on July 17, 2012 @ 11:02 pm

Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.

The social determinants of health

Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.

The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment.… Read more

On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine

Posted by Jan on July 16, 2012 @ 8:58 pm

It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.

Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.

Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)

Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are.… Read more

Guest post: The unemployed as the waste products of the success factory

Posted by Jan on July 15, 2012 @ 11:07 pm

Pierre Fraser is an author, essayist, and PhD candidate in sociology at Université Laval. We share an abiding interest in healthism or, as Pierre would say, santéisme. For the original version of this post, see L’individu devenu déchet. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

Unlike some countries these days, America seems to have little difficulty tolerating the idea of multiculturalism. An explanation for this, perhaps, can be found in the American ideology of success. This ideology acts like a suction pump, removing any alternative explanations of how the world should work. This myth is contagious. The American dream – you can be whatever you want to be – circles the globe like a very powerful trademark.

In the myth of the self-made man, everything is possible. So powerful is this belief that nothing seems able to deter it. Contact with this idea creates the equivalent of an addiction. Every addiction, however, has its downside. We forget that every day “two types of trucks leave the factory: one type goes to the warehouse and department store, the other to the landfill. We have grown up with a story that considers only the first truck and ignores the second. ” [1]… Read more

Filed under: Politics & Issues
Tags: inequality, politics

SCOTUS, the Affordable Care Act, and an ugly American tradition

Posted by Jan on July 5, 2012 @ 2:38 pm

I thought I had exhausted my need to read or listen to anything more on the Supreme Court decision on the Affordable Care Act (ACA). I read something today, however, that made me realize I hadn’t been paying close enough attention. It was an article published by The New England Journal of Medicine called The Road Ahead for the Affordable Care Act

The author, John McDonough, points out the significance of the upcoming November elections. In particular, he clarified for me why recent mentions of ‘reconciliation’ are not just referring to how the ACA was passed in 2010.

In January 2013, if Democrats hold the White House and Senate and regain control of the House, the ACA will be implemented mostly as constructed. If Republicans capture the White House and Senate and retain House control, the ACA will face major deconstruction early in 2013. Republican leaders will attempt to use Congress‘s budget-reconciliation authority to enact extensive repeal — and will need only 51 Senate votes, with no filibuster threat. If control of the White House and Congress is divided between the parties, then conflict over the law will persist. Thus, the November elections increasingly feel like a referendum on the ACA.

Filed under: Health & Medicine, Politics & Issues
Tags: health care, inequality, politics

What is healthism? (part two)

Posted by Jan on February 20, 2012 @ 3:20 pm

In part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health.… Read more

Filed under: Aging Dying & Death, Arts & Media, Health & Medicine
Tags: health care, healthism, healthy lifestyles, history of medicine, inequality, lifestyle, medicalization, overdiagnosis, politics, social determinants of health

What is healthism? (part one)

Posted by Jan on February 20, 2012 @ 2:20 pm

Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”

In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.

Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.

One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.

This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself. … Read more

Filed under: Health & Medicine, History of Medicine, Politics & Issues
Tags: health care, healthism, healthy lifestyles, history of medicine, inequality, lifestyle, overdiagnosis, politics, social determinants of health

Guest post: Is the prevalence of depression related to the modern empowerment of the individual?

Posted by Jan on February 19, 2012 @ 2:13 pm

Pierre Fraser is an author, essayist, and (currently) a PhD candidate in sociology at Université Laval. Just as his most recent book (Tous Malades !: Quand l’obsession pour la santé nous rend fous) was being published, I met Pierre on Twitter, where we discovered our mutual interest in the subject of healthism. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

This translation would have been impossible without the invaluable assistance of Jan Henderson (PhD in the history of science and medicine from Yale). Her work allowed me to revisit the original French text and enhance it, and in this sense, we followed the injunction of Karl Popper : the duty of clarity. I hope our collaboration will continue, because Jan and I are particularly concerned about the healthization of society, and we try to understand how health has become a social value. Feel free to send us your comments (Jan Henderson, Pierre Fraser).

Pierre Fraser, 2012

When a medical clinician examines a patient, she first determines the presenting symptoms, considers which bodily functions might account for those symptoms, arrives at a diagnosis, and provides the most appropriate treatment. But what if the presenting symptom is depression? As Alain Ehrenberg points out, “depression, like any mental illness, is not a disease that can be assigned to a part of the body.” [1] In fact, as Ehrenberg goes on to say: “when psychiatry can discover the cause of a mental illness, as happened with epilepsy, it is no longer a mental illness.” [2] Such has been the dilemma of the history of psychiatry.… Read more

Filed under: Health & Medicine
Tags: psychology & psychiatry

Why medicine is not a science and health care is not health

Posted by Jan on October 30, 2011 @ 9:00 pm

Here’s something I read recently in a blog post (The Limits of (Neuro)science at Neuroskeptic) that started me thinking:

Will science ever understand the brain? …

The notion that humans are complex and hard, while nature is easy, is an illusion created (ironically) by the successes of reductionist science. Some of the biggest questions facing mankind for eons have [been] answered so well, that we don’t even see them as questions. Why do people get sick? Bacteria and viruses. Why does the sun shine? Nuclear fusion. Easy.

I started to write a simple reply, but it grew into the following.

Medicine is an applied science, not a pure science

It may be true that understanding the human brain is only an order of magnitude more difficult than understanding any other aspect of human biology. I’m uneasy, however, about putting ‘why people get sick’ in the same category as ‘nuclear fusion.’ Particle physics is a science. Questions can be asked and (usually) answered under the controlled conditions required by the objectivity that characterizes science.

Medicine is the application of certain sciences (molecular biology, biochemistry, medical physics, histology, cytology, genetics, pharmacology, neuroscience) to – ultimately — individuals. Each individual is the product of a unique, lifelong sequence of social, cultural, economic, and psychological (as well as physical, chemical, biological, and genetic) influences. To this day, we don’t really know why some people get sick and others do not. To my mind, that makes medicine an application of science – like engineering – not a science in itself.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: health care, inequality, lifestyle, politics

Recommended (online) reading

Posted by Jan on September 30, 2011 @ 10:04 pm

I’m still on “sabbatical.” Mostly reading. Thinking about what I most want to write about. I know what my interests are — the problem is, I have too many. Meanwhile, here are some blogs I enjoy reading.

Thought Broadcast by Dr. Steve Balt

Psychiatry is a controversial topic these days. We (speaking for myself, anyway) love to criticize the overprescription of psychopharmaceuticals, the medicalization of the slightest deviation from “normal,” and those psychiatrists who are eager to take “gifts” from the drug companies whose products they subsequently prescribe and promote.

I suspect people relate to psychiatry more readily than to the science of medicine. We’ve all known moments of slippage along the spectrum of mental health. We’d all like to understand ourselves better, something psychiatry used to promise before it tried to reduce us to the chemical interactions inside our brains.

Dr. Balt writes about all of this. What I especially like about his blog is his compassion for patients and his honest assessment of the psychiatric profession. His writing has a quality like Gawande’s: He maintains a strong personal presence without straying too far into the overtly personal.

To get a sense of Thought Broadcast, read Dr. Balt’s My Philosophy page. A recent post I’d recommend: How to Retire at Age 27. It’s on psychiatric qualification for disability. His point is that labeling (and medicating) someone as disabled does nothing to solve underlying social problems. It concludes:

Psychiatry should not be a tool for social justice. … Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest. More importantly, it harms the very souls we have pledged an oath to protect.

Filed under: Health & Medicine, Politics & Issues
Tags: cosmetic surgery, doctor/patient relationship, health care, medicalization, neoliberalism, politics, psychology & psychiatry, social media

When the poor were contagious

Posted by Jan on August 10, 2011 @ 10:28 pm

The Western world first industrialized in Great Britain, prompting vast numbers of inhabitants to move from the agricultural countryside to urban centers. Living and working conditions were deplorable. Andrew Mearn wrote in 1883 of the “pestilential human rookeries … where tens of thousands are crowded.” He continues:

To get to them you have to penetrate courts reeking with poisonous and malodorous gases arising from accumulations of sewage and refuse scattered in all directions and often flowing beneath your feet; courts, many of them which the sun never penetrates, which are never visited by a breath of fresh air, and which rarely know the virtues of a drop of cleansing water…. You have to grope your way along dark and filthy passages swarming with vermin. Then, if you are not driven back by the intolerable stench, you may gain admittance to the dens in which these thousands of beings who belong, as much as you, to the race for whom Christ died, herd together.

Pretty graphic. Roy Porter’s comment on this passage: “Historians still dispute whether industrialization raised or depressed wages and living standards – something, perhaps, impossible to measure.”… Read more

Filed under: Health & Medicine, History of Medicine, Politics & Issues
Tags: history of medicine, inequality, politics

On sabbatical

Posted by Jan on July 23, 2011 @ 7:24 pm

I’m taking a break from frequent blogging – want to take time to read, do some research, reflect, and think about what I most want to write about next. At the moment, my inclination is to concentrate on the history of medicine, starting with the Enlightenment, followed by the transformation of medicine into a science in the 19th century. I want to consider what the past might be able to tell us about the present.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

Medicine is not an abstract science, like quantum physics or mathematics. Scientific biomedicine may have its foundations in the research laboratory, but the practice of medicine takes place in the real, everyday world of doctors, patients, nurses, lab techs, clinics, hospitals, professional associations, patient advocacy groups, drug firms, insurance companies, politicians, the Internet, and the health advice columns of the Sunday papers. It takes place in a particular place at a particular time, and in a social, economic, political, and historical context.

To understand our dissatisfactions with and hopes for medicine – both as patients and practitioners – it helps to examine that context. And the context is easier to see if we step back from the immediacy of the current situation and consider the recent history of medicine. The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time.

“Not to know what happened before one was born is always to be a child.” (Cicero) Or, to expand on that a bit: “He who cannot draw on 3,000 years is living hand to mouth.” (Goethe)

Filed under: Health & Medicine, History of Medicine, Metablog
Tags: corporations, doctor/patient relationship, health care, history of medicine

The Dreams of the Founders of Family Medicine

Posted by Jan on June 23, 2011 @ 4:07 pm

Laurence Bauer has been an ardent, longtime advocate of family medicine. Among other things, he is Chief Executive Officer of the Family Medicine Education Consortium, a not-for-profit corporation that encourages and supports collaboration among Family Medicine Residency Programs and Departments of Family Medicine.

Larry and I met thanks to our mutual interest in Marcus Welby, MD. The practice of medicine has changed dramatically since Dr. Welby inspired doctors to become practitioners of family medicine. Yet each time I talk to Larry, I’m reminded of today’s dedicated students and physicians who want to practice comprehensive care with the same concern for the whole person that Welby expressed for his patients. This remains a timeless value of the medical profession, and for Larry, it’s important to keep that value alive in an age of narrow subspecialties and corporate medicine.

Family Medicine as a specialty (a three-year residency after medical school that includes the study of internal medicine, pediatrics, obstetrics-gynecology, psychiatry, and geriatrics) emerged in the late 1960s. Those who initially endorsed family medicine wanted to change the direction of medical culture and influence its future. In the words that follow, Larry addresses those early visionaries. I’d like to thank him for allowing me to share his thoughts.

The Dreams of the Founders of Family Medicine

When poetry strays too far from music, it atrophies. When music strays too far from dance, it atrophies – Ezra Pound

As Family Practice emerged from the field of General Practice, it is important to realize that many in and out of medicine told the founders they would not succeed. The cynics believed that the dominant forces in medicine were too entrenched and there were too many societal forces working against the idea of a generalist renaissance in medicine. “Real” medicine of the future aspired to something more worthy. Real medicine involved care of hospitalized patients and was informed by the scientific and technological advances associated with sub-specialty medicine. Anyone could care for the people “out there”. But the founders dreamed big, bold dreams; they were a determined and visionary group.… Read more

Filed under: Arts & Media, Health & Medicine
Tags: doctor/patient relationship, medical profession, tv

Guest post: Guilt-edged

Posted by Jan on June 12, 2011 @ 2:33 am

Today was in need of humor. Here is another guest post from Kate Gilderdale (the original can be found here), who blogs at The Jaundiced View.

I found a website that lists (in a most unfortunate typeface) 29 types of humor. I’d say Kate’s writing combines – not always in the same post — wit, irony, understatement, repartee, satire, and that je ne sais quoi that can only be acquired by growing up in the British Isles. The word urbane also comes to mind. At any rate, I find that Kate’s posts brighten my days.

Guilt-edged

I know you can have Catholic guilt and Jewish guilt but you really don’t need religion to make you feel that whatever goes wrong is somehow your fault.

I feel guilty when I go through customs even though I am scrupulous about not bringing in anything illegal. I feel guilty when I go the dentist in case I haven’t flossed in the approved manner. I feel guilty when I try to defend my decision not to be tested for a disease I haven’t got, or don’t know I’ve got, or might have because at some point I’ll have to die of something – simply because I’d rather not know.

Now The Globe and Mail Life section reveals I could be guilty of hastening my demise by eating fruit. See The New Enemy in today’s paper, which warns that bananas are the arch enemy of the serious dieter and “that the high fructose content makes grapes and cherries as unhealthy as a plate of cookies.” Or not. Depending on which ‘experts’ you believe.… Read more

Filed under: Health & Medicine
Tags: healthism, healthy lifestyles, lifestyle

Is a liberal arts education good preparation for being a doctor?

Posted by Jan on June 9, 2011 @ 2:58 am

I’ve written before about doctors and the arts. In 1980 the cultural historian G. S. Rousseau, citing the techo-scientific nature of modern medicine, claimed that doctors no longer maintained the rich tradition of physicians as humanists. “Until recently, physicians in Western European countries received broad, liberal educations, read languages and literature, studied the arts, were good musicians and amateur painters; by virtue of their financial privilege and class prominence they interacted with statesmen and high-ranking professionals, and continued in these activities through their careers.”

Contemporary evidence contradicts Rousseau’s claim that physicians are no longer practitioners and connoisseurs of the arts. We may not personally encounter a doctor with her cello or recognize one painting en plein air in the little free time doctors have these days, but doctors write books that ascend the best-seller list, and many more write thoughtful, provocative blog posts. The poetry of doctors is published in medical journals and is available online in modest chapbooks. Nearly every major city throughout the world has an orchestra staffed by the medical profession. And the American Physicians Art Association encourages and assists physicians with art organizations and exhibits.

Is a liberal arts education valuable to physicians?

I have many unanswered questions about doctors as practitioners of the arts. I’d particularly like to know if the long-standing tradition of physicians as humanists has changed over the past half century. Higher education has definitely changed since the mid-20th century. In particular, there’s less emphasis on the value of a liberal arts education. (On this, see the excellent book, Not For Profit: Why Democracy Needs the Humanities, by Martha Nussbaum.) Has this affected physicians, either in their satisfaction with their careers or in their understanding of patients?… Read more

Filed under: Arts & Media, Health & Medicine, History of Medicine
Tags: medical profession, visual art

The misuse of health statistics by politicians

Posted by Jan on May 29, 2011 @ 1:35 am

[This post contains links to the New York Times. If you position your mouse over a link, you can view the destination URL at the bottom of your browser.]

When former New York City mayor Rudy Giuliani was seeking the Republican presidential nomination in 2007, he used to give a campaign speech that referred to prostate cancer and health care. His sound bites were turned into a radio commercial and included the following:

I had prostate cancer five, six years ago. My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.

What’s wrong with this picture? Several things.

The numbers themselves – the 82 and 44 percent — were incorrect. Chances of survival are typically stated as the prospect of living another five years. According to the National Cancer Institute, the five-year survival rate for prostate cancer in the US is 98.4%. For England (according to the United Kingdom’s Office of National Statistics), the number is 74.4%.

Where did the lowly 44% for England come from? Giuliani’s health care adviser started with the number of people who have prostate cancer and the number who die (called incidence and mortality rates): how many people have the disease in a given year and how many die from the disease in that year. From those numbers he came up with a five-year survival rate. This is not possible. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” according to the Commonwealth Fund.

Comparing apples to oranges

Filed under: Health & Medicine, Politics & Issues
Tags: clinical medicine, health care, politics

Why is it so hard to reduce US health care costs?

Posted by Jan on May 26, 2011 @ 3:23 am

A modern version of the Hippocratic Oath, the Physician Charter, commits physicians to work toward “the wise and cost-effective management of limited clinical resources.” But there’s little physicians – or anyone else – can do to change the behavior of politicians, insurance companies, pharmaceutical companies, or other entrenched stakeholders. It would indeed be heartening to see a visionary, public-minded physician emerge as a leader of the medical profession in the fight to solve this important and extremely difficult dilemma.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: health care, medical profession, overdiagnosis, pharmaceuticals, politics

Bruckner on the good life, money, and the unequal world of work

Posted by Jan on May 22, 2011 @ 12:55 am

Poverty in developed countries may never be overcome, simply because the rich no longer … need the poor to get rich. … The misfortune of being exploited has been succeeded by the still worse misfortune of no longer being exploitable.… Read more

Filed under: Politics & Issues
Tags: happiness, inequality, politics, psychology & psychiatry

Why are we so willing to undergo cosmetic surgery?

Posted by Jan on May 13, 2011 @ 4:15 pm

Members of traditional societies accepted being told when and how to reshape their bodies. Their decision was binary: either participate or leave the group. In contemporary society, each individual is responsible for choosing and effecting her own reshaping, thus demonstrating her fitness for membership within a given field. Hierarchical position depends on displaying attunement to the field …. including what kind of body counts as right. The right body demonstrates having made the right assessment of capital, and thus becomes a potent display of rights to participation and position.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: cosmetic surgery, gender, neoliberalism, politics

Bruckner on the family, being gay, and AIDS activism

Posted by Jan on May 12, 2011 @ 3:29 pm

The seriously ill, the traumatized, and accident victims, strong in their common weaknesses, manifest their freedom with regard to what had previously put them in the category of subcitizens, those receiving assistance. They are fighting against the segregation that made them lepers, bearers of bad news. They are fighting to remain members of the human community.… Read more

Filed under: Health & Medicine, Politics & Issues
Tags: death, health care, psychology & psychiatry

Pascal Bruckner on doctors and patients

Posted by Jan on May 8, 2011 @ 12:12 am

Medical science’s individual servants are crushed under the weight of its promises, becoming commonplace and losing their authority; they are simple service providers who can be sued – often justifiably, moreover – if they commit an error. While the medical researcher, the scientist, and some surgeons whose skill amounts to genuine artistic genius retain immense prestige, in many cases the doctor is now seen only as a repairman who gets the machine running again until the next breakdown.… Read more

Filed under: Health & Medicine
Tags: doctor/patient relationship, health care, medical profession

Population health

Personal responsibility and social class

Canada’s Lalonde report

The patient (consumer) satisfaction survey

Healthism

The social determinants of health

Moral healthism

Medicine is an applied science, not a pure science

Thought Broadcast by Dr. Steve Balt

Is a liberal arts education valuable to physicians?

Comparing apples to oranges