A doomed and dysfunctional medical culture

J.D. Kleinke is a medical economist, health information industry pioneer, and author of the forthcoming Catching Babies. In a dramatic, powerful, and beautifully written post on The Health Care Blog, he captures the essence of what’s wrong with modern medicine.

Kleinke tells the story of Hannah, a family member. She is 39 weeks pregnant (a typical pregnancy is 38 weeks) and has been losing weight. Her baby is small, at the 7th percentile for fetal weight.

Hannah could be experiencing something called intrauterine growth restriction. If she is – and if she continues the pregnancy – her baby could suffer developmental delay and retardation. On the other hand, if she allows the hospital to induce labor, she could end up with a c-section and the numerous complications that often follow this procedure. “The blessing and the curse of modern medicine,” Kleinke writes, “from the NICU to the oncology unit, is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.”

Medicalization, patient preference, and provider prejudice

There’s an inherent conflict between the preferences of birthing mothers (natural childbirth) and those of the hospital staff (minimize risk by whatever means). Does this conflict stem from the hospital’s need to protect itself legally and financially? Kleinke says no. He places the blame on the medicalization of life. (emphasis added)

It would be causally accurate and certainly easy to blame the American legal system for the collision in our nation’s delivery rooms between what patients want and what protocols demand. But our tort system, with its stupefying processes and swarm of venomous creatures, is not the root cause of the problem. Rather, it is a symptom of our own denial, of Americans’ entrenched cultural inability – shared by this author – to accept life on its own occasionally heart-shattering terms. Our medical malpractice system, like much of the post-modern American health care system itself, is a house of broken mirrors for our own worst neuroses as a society; and a big part of these neuroses includes our pathologizing of childbirth, along with our pathologizing of shyness, baldness, the normal effects of aging, dry eyes, twitchy legs, and whatever other little misery we can figure out how to medicate next.

A health care system driven by overdiagnosis and overtreatment

As Americans, we seem hellbent on controlling the uncontrollable; this is why we create so many breathtaking medical technologies and give the world almost all of its breakthroughs in the treatment of cancer, heart disease and other real diseases. But it is also why we grind up tens of billions of health care dollars every year overtesting, overreacting, and overtreating; why we look for someone with deep pockets to blame when things go wrong anyway; and why we demand and expect to get retribution when nature wants – to add insult to our injury – simply to take its own difficult course.

Health care expectations based on fear and dread

[T]he fear of a remote catastrophic outcome outweighed the more likely mildly bad outcomes. These choices are not really rational or irrational, so much as they are differently rational; they are the human calculus of fear and dread winning out over skepticism. From the oversized pre-natal ultrasound clinic at one end of the hospital to the oversized ICU at the other end, patients and their families are driven not by reason, but by faith, fear, guilt, anger, entitlement, and nothing less than what they perceive as the rockbottom meaning of life. And God help anyone who tries to stand in their way, as the hysteria about “death panels” during the health reform debate made garishly clear. With childbirth, all of these forces go into overdrive.

Hannah’s husband and I pace the labor deck. He reminds me that she is carrying the hopes of an entire family. Baby Sam will be the first child in a new generation, and because of that, he has been tagged by name with nothing less than the legacy of a recently deceased uncle who survived the concentration camps and walked from Poland to Israel. Against a landscape of hope that dramatic – and for every family, the landscape is that dramatic – it is difficult if not impossible for anyone to think clearly about imperfectly informed medical choices: not the mother, nor the family, nor anyone on a jury.

The over-medicalized lives of women

This is why Catching Babies morphed, almost against my own will, into a novel. In my earlier work about the economic and political conflicts that define the delivery of health care in the US, I kept noticing that the greatest variations in care – and deepest cultural angst and antagonisms – seemed always to be associated with women’s health: our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable; the almost criminal variations in hysterectomy rates around the country; the uninformed, blanket imposition of one group’s religious values on all women’s reproductive decisions. What started out as an analysis of the health policy problems unique to obstetric medicine quickly escalated into outright drama, if only because nowhere else in our health care system have I found the needs and obsessions of individual providers on such a direct collision course with the needs and obsessions of patients.

A doomed and dysfunctional medical culture

Like Hannah, we all dream of perfect pregnancies and perfect babies, as if they were natural rights. This happy baby dream can be punctured, often in a few messy, terrifying moments, by the harsh and merciless realities of the working OB/GYN’s world – a world shaped by an OB/GYN resident’s disproportionate exposure not to happy baby dreams, but to disaster pregnancies among the poorest, unhealthiest, least insured, most vulnerable women in society. The specialty has learned to cope, barely, by muttering homilies about retrospective diagnoses; by learning to hate lawyers like they learn to hate cancer; and by hoping for the best (maybe) but always assuming the worst – and treating accordingly. Without sleep, without data, one patient at a time. Who would not find great drama in a medical culture so doomed and dysfunctional, and so utterly driven by the conflict between patient preference and provider prejudice.

The doctor’s induced labor in Hannah. The birth was painful and difficult. “Baby Sam” was born “perfect and pink and healthy.”

Kleinke’s book will be published on March 1.

Related posts:
Medicalization then and now
Atypical antipsychotics: Overprescribed, not safer, not more effective
How the pharmas make us sick
Baby RB: Ethical dilemmas of modern medicine
Baby Isaiah: Ethical dilemmas of modern medicine (1)

Resources:

Image: Daily Women Tips

J.D. Kleinke, A Normal Pregnancy is a Retrospective Diagnosis, The Health Care Blog, February 2, 2011

J.D. Kleinke, Catching Babies