The quality of health care depends on many things, but certainly medical education is uniquely significant. Following four years of medical school, the additional years of internship, residency, and fellowship are not simply a time for acquiring the latest insights into the nature and treatment of disease. This is when fledgling doctors imbibe the values and priorities of the medical profession from the attending physicians who mentor them. If attendings have no time to mentor the doctors they are presumably training, the quality of doctors who emerge from such a system will suffer. And if the priority of an academic medical center is to increase profits rather than care for patients, patients will also suffer, first at the hospitals associated with these centers and later as patients of the doctors who trained there. The decline in the residency system for training doctors is the subject of Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
From mentorship to profits
Sir William Osler established his ideal of medical training at Johns Hopkins Hospital in the 1890s. The guiding principle was that doctors should learn to care for patients under the close supervision of highly experienced attending physicians. Right up to WWII, the highest priority of teaching hospitals remained education. Faculty members formed intense mentorships with their students, often lasting a lifetime. Lara Goitein, in an essay/review of Let Me Heal, writes: Read more
Back in June of 2009, when Congress was just beginning to formulate and debate the Affordable Care Act, Atul Gawande wrote an article on the rising (and exorbitant) cost of US health care. He focused on how waste contributes to cost — not just the usual fraud, high prices, and administrative fees, but unnecessary care: Drugs that are not helpful, operations that do not make patients any better, scans and tests that not only have no benefit, but often lead to harm. Waste accounts for a third of health-care spending. More disturbingly, it can cost people their lives.
Gawande used the town of McAllen, Texas to illustrate his case. McAllen had one of the highest costs in the nation for Medicare — twice as high as El Paso, another Texas border town with similar demographics. And it’s not as if patients in McAllen were receiving better care. Compared to El Paso, patient care was similar or worse.
It turned out that many specialists in McAllen had financial stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital. One local doctor told Gawande: “Medicine has become a pig trough here. … We took a wrong turn when doctors stopped being doctors and became businessmen.” Read more
When it comes to how much water we should drink every day, Chinese medicine teaches that we should drink when we’re thirsty. None of this eight-glasses-of-water-a-day business — a misunderstanding of a 1940s US Food and Nutrition Board recommendation that’s been widely exposed (see How much water do we need?). For those who’ve always believed in drinking when thirsty, there’s no longer a need to be aware of our bodily sensations. We can simply wear digitized clothes that will notify us when we need to drink.
Listen to your shirt. Smart clothing could warn its wearers when they need a drink. Xsensio, based in Switzerland, is developing textiles that look for signs of dehydration by measuring body temperature, sweat and skin conductance. Sensors also take air temperature and humidity into account. As a person becomes weary and thirsty, the shirt will send alerts reminding them to drink – useful for sporty types.
We are told “as the person becomes thirsty the shirt will send alerts reminding them to drink”. Isn’t that what the sensation of thirst does? Talk about pointless, redundant and wasteful technology. For their next trick, how about a hat that reminds you to breathe?
Well, interesting you should mention breathing. Read more
Let me begin by quoting a paragraph from Gyorgy Scrinis, a lecturer in food and nutrition politics and policy at the University of Melbourne. This is from a chapter called ‘Nutritionism and Functional Foods,’ which he contributed to the book The Philosophy of Food. Scrinis went on to publish an entire book on this subject, Nutritionism: The science & politics of dietary advice.
Just prior to the following paragraph, Scrinis has been discussing the dietary advice, from the 1960s to the 1990s, that it was better to eat margarine than butter. (Added emphasis in this and the following quotations is mine.)
The “mistake” of inadvertently promoting transfat-laden margarine is one of several mistakes, revisions, and backflips in scientific knowledge and dietary advice over the past century. Other cases include advice regarding dietary cholesterol, eggs, low-fat diets, and vitamin B. Yet these revisions do not seem to have tempered the sustained and confident discourse of precision and control that continues to pervade nutrition science, nor the willingness to translate limited and partial scientific insights into definitive population-wide dietary advice. I refer to this nutritional hubris as the myth of nutritional precision, as it involves an exaggerated representation of scientists’ understanding of the relationship between nutrients, foods, and the body and a failure to acknowledge the limits of the nutrient-level perspective. At the same time, the disagreements and uncertainties that exist within the scientific community with respect to particular nutritional theories tend to be concealed from, or misrepresented to, the lay public.
I always thought the main function of the hippocampus was to convert short-term memory into long-term memory. It’s one of the first regions of the brain damaged by Alzheimer’s. If your spouse can’t remember something you discussed 20 minutes ago, you start to worry.
The hippocampus also plays an important role in spatial memory and navigation. That’s why you unfortunately hear of Alzheimer’s patients wandering away from home and not being able to find their way back.
Here are more articles of interest I’ve come across recently while reading NEJM, JAMA, and New Scientist. These items all relate to for-profit medicine.
Bulleted titles in the following list link to the individual items below. Under References I indicate the accessibility of articles: OA means open access, $ indicates a pay wall. Note that emphasis in quotations has been added by me.
When I want to know more about a medical condition, my first Internet destination is the Mayo Clinic’s website. It seems both reputable and decidedly non-alarmist.
Each condition is organized into a series of information packets: definitions, symptoms, causes, risks. There’s invariably a section called “Preparing for your appointment.” Without fail, it recommends that you make a list of your symptoms. Here’s an example:
Before your appointment, make a list that includes:
Detailed descriptions of your symptoms
Information about medical problems you’ve had in the past
Information about the medical problems of your parents or siblings
All the medications and dietary supplements you take
Questions you want to ask the doctor
Once you’ve begun interacting with your doctor, it can be easy to forget something you’d intended to ask.
I was somewhat surprised, then, to learn that some doctors are decidedly irritated when a patient brings a list to an appointment. Dr. Suzanne Koven discusses this in a Perspective piece in NEJM: The Disease of the Little Paper. Read more
What follows are items I found interesting in magazines I’ve recently read. Normally I would have tweeted these links, but since I was on vacation from Twitter (see My Twitter vacation), I decided to create a type of blog post called Reading Notes (see Blogging and my Twitter vacation).
The bulleted titles below link to the specific item. There’s more detail on the articles I mention under References. OA indicates open access. $ indicates a pay wall. Note that emphasis in quotations has been added by me. Read more
A complaint one often hears about electronic medical records (EMRs) is that the doctor pays more attention to the computer than the patient during an office visit. Among nations using EMR, is this a characteristically American problem?
I read an illuminating letter to the editor recently that compares the doctor/patient/EMR experience in the US and Canada. The letter was from Dr. Alan B. Astrow, a hematologist/oncologist who practices in Brooklyn, NY. He writes: (emphasis added)
Many American physicians agree that recording patient data electronically has interfered with “a deeply human, partly intuitive and empathetic process,” and has led to inefficient care. Since no one wants to revive illegible paper charts, however, the indictment encourages us to ascribe these harms to the price of progress.
A Canadian physician friend, though, says he uses an electronic record that does not disturb his rapport with patients. He also sees more patients hourly than American counterparts without compromising quality.
Why the difference? American physicians must choose from five levels of service when submitting bills. Of necessity, we tend to include extraneous information to justify higher levels and satisfy potential insurance company audits. Canada has only two levels, so doctors’ notes are short and succinct. Read more
I came across the following sentence in The Positive Thinkers, a book originally published in 1965. It strikes me as a good example of how the meaning of health has changed. (emphasis added)
Health is ordinarily regarded — when it is “regarded” at all, for ordinarily the point of being healthy is to be able to forget about it — as a means to other things; healthy men are those able to pursue their ends.
Health is hardly something we’re able to forget about today. We live in a culture where it’s commercially profitable to constantly remind us of widespread, proliferating risks. The conscious, highly intentional pursuit of health is a mark of social status for which we expect to be admired and envied. We “regard” it all the time. Read more
[I don’t seem to be able to display that image anymore, but here’s a link to what I’m talking about.]
This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this. Read more
The final post in this series on interrogating inequality is about another possible clue as to why we no longer seem to care about inequality. It’s from the book Excellent Sheep by William Deresiewicz.
The role of elite institutions of higher education
In his book, Deresiewicz argues that elite educational institutions reproduce a class system, exacerbate inequality, retard social mobility, and perpetuate privilege. Not only is the elite class that’s created by these institutions “isolated from the society that it’s supposed to lead.” It runs society for its own exclusive benefit. (emphasis added)
Our educational system, it’s been suggested, is what America developed in lieu of a European-style social welfare state to mitigate inequality. Instead of “handouts,” opportunity. And once upon a time, it worked as advertised. Both the unprecedented expansion of public higher education and the equally unprecedented opening of access to the private sort were instrumental in creating a mass middle class, and a new upper and upper middle class, in the decades after World War II. But now instead of fighting inequality, the system has been captured by it.
I mention this not simply as another possible clue, but because the article (Rebooting Social Science) that prompted me to write this series of posts appeared in Harvard Magazine. That may or may not be relevant to the attitude it expresses towards inequality, an attitude I found troubling. Read more
Continuing my discussion of interrogating inequality, here is another post with a possible clue as to how we came not to care. This one considers a rather wide expanse of history
We have neglected to cultivate a culture that cares
I recently struggled through the book Governmentality: Power and Rule in Modern Society by Mitchell M. Dean. The book is very clearly written — the publisher calls it “exceptionally clear and lucid,” and it is. The book is intended, however, for experts already familiar with Foucault’s writings and lectures, particularly those on governmentality.
I frequently found myself in a fog, but I persisted. I was hoping to find ideas that would explain the changes that produced the contemporary self, including why we have become a society that fails to care about increasing inequality. And I did find a brief reference to this development in a section where Dean asks: “Where do our notions of ‘care’ come from?” Why do we think the state should care for the welfare of its citizens? Read more
How did we become a society that passively accepts the injustice and discrimination inherent in inequality? How did we come not to care? It would undoubtedly take me a very long time to adequately address that question, but in this and the next two posts I offer a few small clues.
We are each the stars of our own lives
First up is Pierre Rosanvallon’s recent book The Society of Equals. In a review of the book, Paul Starr mentions what may be an impediment to a society of equals: We see ourselves not simply as individuals, but as unique singularities. (emphasis added in this and the following quotations)
The story that Rosanvallon tells here is that as new forms of knowledge and economic relations have emerged, people have come to think of their situation in less collective ways. Since the 1980s, he writes, capitalism has put “a new emphasis on the creative abilities of individuals,” and jobs increasingly demand that workers invest their personalities in their work. No longer assured of being able to stay at one company, employees have to develop their distinctive qualities—their “brand”—so as to be able to move nimbly from one position to another.
As a result of both cognitive and social change, “everyone implicitly claims the right to be considered a star, an expert, or an artist, that is, to see his or her ideas and judgments taken into account and recognized as valuable.” The demand to be treated as singular does not come just from celebrities. On Facebook and many other online sites millions are saying: here are my opinions, my music, my photos. The yearning for distinction has become democratized.
Rosanvallon does not criticize the society of singularities, with its “right to be considered a star.” Since it’s now a fact of life, we need to figure out how to deal with it. Read more
In a previous post (Interrogating inequality: An annoying article) I discussed an article about a group of interdisciplinary scholars who were “interrogating” the societal consequences of increasing inequality. While the group included individuals with backgrounds in psychology and history, it was dominated by academic scholars who specialized in economics, business, and public policy. (The first three individuals quoted in the article are a professor of business administration, a professor of management practice, and a senior lecturer at Harvard Business School.)
The concluding comments on inequality were offered by a professor of social policy. This particular individual “recently revealed” that he had given up on his long-term research on the social effects of inequality (a project he’d started in the 1960s) because there were no “convincing conclusions.” In other words, research had not been able to provide statistical proof that inequality is in any way harmful to society as a whole. As one of the social scientists put it: (emphasis in original)
The problem is, there is no consensus in the research on the consequences of inequality.
May I suggest that a more significant problem is that social scientists ask the wrong question. As Tony Judt writes (emphasis added): Read more
The previous post, this post, and the next four were provoked by an article that made two assertions I found troubling: one, that there is no consensus among researchers on the consequences of inequality, and two, that evidence of a “causal relationship” between income inequality and health is unclear. In the last post, I discussed those assertions and quoted Daniel Goldberg on whether health behaviors determine health. To continue …
Ground control, we have causation
Over the past few months, since I first read that annoying article, I keep coming across accounts that offer evidence of the harms that result from inequality (particularly in childhood), as well as actions that doctors and politicians are willing to take to address the problem. We’ve known for some time that there was a correlation between poverty and health. Now we’re finally discovering the mechanisms, the causation. Read more
I recently read an article that really annoyed me. It was called “Rebooting Social Science: The interdisciplinary Tobin Project addresses real-world problems.” I began to realize that I wouldn’t see eye to eye with this article when I got to the section that discussed the “real-world problem” of inequality. The section was titled “Interrogating Inequality.” Not “addressing” inequality. Interrogating. Shades of “doubt is our product,” as I’ll explain.
One of the scholars interviewed for this article characterized inequality as “the most contested of contemporary issues.” The evidence cited for said contestation was the lack of agreement on whether inequality contributed to the recent financial crisis. Some claim that it did. Others, however,
dismiss this argument, viewing rising inequality “as little more than a hiccup” or even celebrating it as “a favorable development … in the progress of American capitalism.”
As it turns out, the real issue being “contested” by these “social scientists” (economists, not sociologists) is not whether inequality exists or whether it’s just a hiccup or an inevitability of capitalism. No. (emphasis in the original)
The problem is, there is no consensus in the research on the consequences of inequality.
No consequences? What about childhood trauma, increased rates of disease, shorter lifespans, human dignity? Well, it turns out those things may affect individuals, but what these researchers are looking for are societal consequences. For example, is there a relationship between inequality and economic growth? Evidently, if we cannot detect a decrease in economic growth, there’s no reason to alleviate inequality. And it seems social scientists disagree among themselves about the quality of the evidence on that issue. Read more
The August issue of The Journal of Medicine and Philosophy does not have a specific theme. The nine articles address a number of quite interesting issues, among them:
How existential psychotherapy can offer powerful insights to patients recovering from severe mental disorders such as psychosis
How a preference in athletics for natural talent over artificial enhancements (such as doping) may reflect “unsavory beliefs about ‘nature’s aristocracy’ ”
How rich, educated, white males may be just as, if not more, vulnerable to threats posed by physician-assisted suicide and voluntary active euthanasia than members of marginalized groups
When the decision is made not to administer artificial hydration and nutrition, can the responsibility for the patient’s death be attributed to the underlying pathology, even when that is not the cause of death
The right to procreate: Is it possible for prospective mothers to wrong prospective fathers by bearing their child
Note that the articles in this journal are not open access and that I have added the emphasis in the following extracts and abstracts. Read more
The August issue of Social History of Medicine contains eight original articles:
Late 19th/early 20th century food adulteration in an increasingly industrialized and globalized world and the search for safety standards
The shift in cancer education in the 1950s, no longer downplaying post-operative recovery
The 20th century shift in British veterinary medicine towards small animals (dogs, cats), as the need to attend to horses declined (open access)
How complaints about the quality of London drinking water in the 18th century reflected the new popularity of bathing for health and social attitudes towards bathers from the lower classes
A re-evaluation of the prevalence of venereal disease at the time of the World War I (open access)
How quacks preyed on people with hearing loss in mid-19th century Britain
How the 1975 TV play, ‘Through the Night,’ portraying what it was like to experience breast cancer treatment, registered with medical professionals and activists who complained of ‘the machinery of authoritarian care’ (open access)
Did Axel Holst and Theodor Frølich actually develop an animal model of experimental research?
There are also a large number of book reviews, including:
Writing History in the Age of Biomedicine by Roger Cooter with Claudia Stein
Emotions and Health, 1200–1700 by Elena Carrera (ed.)
The Age of Stress: Science and the Search for Stability by Mark Jackson
Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution by Robert Baker
Jill Lepore has an article in a recent New Yorker called The Disruption Machine: What the gospel of innovation gets wrong. Her target is Clayton M. Christensen’s book The Innovator’s Dilemma and, specifically, disruptive innovation. As usual with Lepore, her essay is personable and well-argued. What I liked most about it, though, was its brief discussion of how unfortunate it is that professions such as higher education and medicine are being privatized (if they’re not already) and administered to maximize efficiency, making profits more important than students or patients. (emphasis added) Read more
In the 1890s, bicycles became safer and more comfortable to ride (detailed in this Wikipedia entry on the history of the bicycle). This may have something to do with the increased number of women who were attracted to bicycle riding. (There’s a correlation, but the causation is undoubtedly much more complex.)
Some celebrated this development. Susan B. Anthony, for example:
Let me tell you what I think of bicycling. I think it has done more to emancipate women than anything else in the world. It gives women a feeling of freedom and self-reliance. I stand and rejoice every time I see a woman ride by on a wheel … the picture of free, untrammeled womanhood.
In the July issue of Journal of the History of Medicine and Allied Sciences:
A comparison of 19th century public health measures and the contemporary approach to the AIDS pandemic
The conflict between the medical profession and religion in their attempts to portray habitual drunkenness
The understanding of dementia paralytica in the Netherlands at a time when psychiatry was attempting to establish itself as a medical profession
Adelle Davis’ role in creating the ideology of nutritionism.
There’s also a commentary on the Adelle Davis article, an ‘In Memoriam’ for Sherwin B. Nuland, and reviews of ten books (of which I’ve featured here only two).
Thanks to h-madness (a great blog) for bringing my attention to this new issue. Somatosphere (a most excellent blog — highly recommended) often covers this journal, but I haven’t yet seen the July issue there, so I’ll go ahead and post these abstracts. Note that all articles (other than their abstracts/extracts) are behind a paywall. (emphasis added in what follows) Read more
The theme of the June issue of Medicine & Philosophy is disagreements among bioethicists. This is an interesting topic in its own right (see the extract from the Introduction to the issue below), plus there are a few articles that especially appealed to me. The discussion of cognitive enhancement appears to argue for a more tolerant attitude toward enhancement drugs based on an attitude of humility, plus toleration and transparency. There’s also an article that points out how we assume the art of clinical medicine is an innate skill and that, as a result, we fail to teach it.
Note that nothing is this journal is open access (and also that I have added the emphasis).
Bioethics was born in the 20th century out of an attempt to cope with rapidly and radically developing medical technologies, especially as they arose around the time of the Second World War. Albert R. Jonsen, one of the founders of bioethics, writes in reminiscence:
New techniques, from antibiotics to transplanted and artificial organs, genetic discoveries, and reproductive manipulations, together with the research that engendered them, presented the public, scientists, doctors, and politicians with questions which had never before been asked. (Jonsen, 2000, 115; cf. Jonsen, 1998)
But more importantly, bioethics arose as well due to major cultural changes that marginalized previous approaches to moral issues in health care and that brought into question medical ethics as an enterprise grounded in the medical profession. Read more
The shortage of pharmaceutical drugs is a serious problem in the US. The number of drugs in short supply has tripled since 2007. In an article in The New York Times, Sabrina Tavernise reports that the number of drugs in short supply in 2012 was 456. The types of drugs affected cover a very wide… Read more
Animal species are going extinct at a rate thousands of times faster than was the case before there were humans. And this is a conservative estimate. At least half the tortoises and turtles, a third of the amphibians, a quarter of the mammals, and an eighth of the birds on this planet face a risk… Read more
In a recent essay on climate change, Zadie Smith touches on matters not usually mentioned in connection with this topic. “What’s missing from the account,” she says, “is how much of our reaction is emotional.” Smith is the mother of two young children. She imagines how, in the year 2050, she would explain to a… Read more
Chris Hayes sometimes gets dismissed as just another commentator on a failing liberal TV network, but I found his book Twilight of the Elites a perceptive, well-written account of how American meritocracy perpetuates inequality. Hayes recently reviewed the book Young Money: Inside the Hidden World of Wall Street’s Post-Crash Recruits by Kevin Roose. The book… Read more
The pharmaceutical industry is in the business of making profits. It’s not in the business of improving the health of individuals or populations, nor does it care about the cost of health care, even as those costs spiral out of control in the US. This is hardly news, I know. The behavior of pharma, along… Read more