Tag Archives: health care

Academic medical centers: Education or profits?

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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

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US healthcare: Atul Gawande has some good news

gawande-mcallen-texas-update

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

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Reading Notes #2 (For-profit medicine): Cancer drugs. Expensive doctors. Health care monopolies. Dental care.

fear-of-dentist

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.

FOR-PROFIT MEDICINE

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The patient with a list of questions

patient-with-list-of-symptoms2

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

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Reading Notes #1: Health care inequities. Overdiagnosis. The Doctor/Patient Relationship

benefits-harms-annual-mammography-screening

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

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Electronic medical records, for-profit medicine, and the doctor-patient relationship

emr-for-profit-medicine-doctor-patient-relationship

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

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Drug shortages: “We are talking about people’s lives; this is not a cell phone contract”

iv-fluidThe 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 range and include such things as cancer drugs and nitroglycerine used in heart surgeries. The situation is quite disruptive for hospitals, doctors (especially oncologists), and patients.

IV fluid shortage threatens patient care

This year, in addition to drug shortages, there is a nationwide shortage of IV fluid. Intravenous therapy is essential for treating dehydration and electrolyte imbalances, for blood transfusions, and for delivering medications such as those used in chemotherapy. IV fluid is a hospital staple.

A recent JAMA article quotes Erin R. Fox, director of the Drug Information Service at the University of Utah in Salt Lake City: (emphasis added in the following quotations)

“It’s maddeningly frustrating that we don’t have these basics.” … Fox said that although shortages of drugs, particularly sterile injectables, have become common in recent years, it is unheard-of to have a shortage of such a basic supply. …

Why is the supply chain so fragile that it creates a national crisis? asked Fox. …

“Physicians, nurses, and pharmacists are working together to minimize the harm to patients, but it is really a challenge,” she said.

Read more

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For U.S. health care, some are more equal than others

death-rate-after-surgeryThe Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

  • The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
  • Read more

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The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

general-health-checkups

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling. Read more

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Two children visit their doctors: Social class in the USA

Rick Santorum, responding to Obama’s statement that “the middle class in America has really taken it on the chin,” said that he would never, ever, stoop to using the word “class.” (Dorothy Wickenden in The New Yorker)

Sociologist Annette Lareau has done extensive field work that involves unobtrusively inserting herself (or her field-worker assistants) into the homes and daily lives of families (treat us like “the family dog,” she recommends). Her observations have led her to identify a difference in the parenting styles of families from different social classes. Middle-class families practice what she calls concerted cultivation: parents teach their children skills that prepare them to engage successfully with the social institutions of adult, middle-class life. Working class families value natural growth: parents give their children a great deal of unstructured time in which they must use their own creativity to plan and execute their activities.

rich-poor-children-social-inequality

Lareau’s work is described in her book Unequal Childhoods: Class, Race, and Family Life. Originally published in 2003, it was updated for a 2011 edition. It’s a wonderful book. I think of it whenever people argue – as they frequently do in the US – that America is the land of equal opportunity, therefore those who fail to exert themselves sufficiently have only themselves to blame.

I’d like to cite two stories from Lareau’s book that relate to health care. Read more

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What pediatrics can teach us about addressing adult social determinants of health

patient-centered-medical-homeAttending to the social determinants of health is especially important for children, since children’s experiences – of poverty, poor nutrition, trauma, abuse, neglect, the prenatal environment – can affect physical and mental health for an entire lifetime. As the authors of a recent commentary in JAMA write: “Pediatrics … continues to evolve clinical practice aimed at addressing social determinants because of children’s exquisite vulnerability to the deleterious effects of the social and physical environment, especially the aggregation of social factors associated with poverty.”

The occasion for the commentary – titled Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics — is the imminent implementation of the Affordable Care Act. The medical home (also known as the patient-centered medical home) is a concept that originated in pediatrics. The basic idea is that when a team of providers — physicians, nurses, nutritionists, pharmacists, social workers – work together, they can best meet the needs of patients. The Affordable Care Act has several provisions designed to establish and promote medical homes, and the authors of this commentary (two pediatricians and a family medicine practitioner) ask: What has pediatrics learned about addressing social determinants that can be translated to medical homes for adults. Read more

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A culture of health needs a market for health

Determinants of healthThis feels encouraging: Two Viewpoint articles in a recent issue of JAMA (The Journal of the American Medical Association) on improving population health (both behind a paywall, unfortunately).

Population health

What is population health? Apparently it depends on who you ask. If you ask those with a financial stake in the health care delivery system, population health means improving the health of patients who currently use (i.e., pay for) the system. You get a different answer if you ask those involved in public health, community development, or social services. They believe “population” should include everyone in the entire geographic community, whether or not those individuals are able to use or benefit from health care services. They also believe “health” should include quality of life and economic well-being – measures that prevent disease in the first place – and not just conditions addressed by the medical model of disease.

What I especially liked about Stephen Shortell’s article – Bridging the Divide between Health and Health Care – was its economic realism. I dearly wish that those with a financial interest in the health care industry, as well as politicians who control health policy, would acknowledge that the way to improve health is to address its social determinants. But trying to change the hearts and minds of stakeholders is like pushing against the tide. Read more

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Healthy lifestyles: Social class. A precarious optimism

Social determinants of health. Marmot, WilkinsonContinued 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

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Healthy lifestyles: The unfortunate consequences

Healthy lifestyles yoga poseContinued 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

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Healthy lifestyles: The antecedents

Healthy lifestyles yoga poseIn 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

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

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

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

Abnormal psychologyContinued 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

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

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.

Blog topics and their connections

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

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

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.

Blog topics and their connections

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

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

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.)

Blog topics and their connections

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

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

Romney: Repeal & Replace ObamacareI 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.

Read more

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What is healthism? (part two)

Apple and stethoscopeIn 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

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What is healthism? (part one)

Apple and stethoscopeThroughout 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

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

MicroscopeHere’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

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Recommended (online) reading

Woman reading computerI’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.

Read more

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On sabbatical

Self-reflectionI’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 write about the history of medicine, starting with the Enlightenment and the transformation of medicine into a science in the 19th century. I want to think about what light that sheds on the 20th century. Read more

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The misuse of health statistics by politicians

Rudolph Giuliani prostate cancerComparing five-year survival rates for the US and England is fundamentally misleading. Prostate cancer is overdiagnosed in the US. Many men who receive a diagnosis do not have cancer or will never develop symptoms, let alone die from the disease. The estimate for the US is that 48% of men diagnosed with prostate cancer do not have a progressive form of the disease. In England, on the other hand, testing is performed after symptoms appear, so a diagnosis is much more significant and meaningful. Read more

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

Why is it so hard to reduce US health care costsA 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

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Bruckner on the family, being gay, and AIDS activism

The perfect familyThe 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

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Pascal Bruckner on doctors and patients

Doctor patient relationshipMedical 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

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