Yearly Archives: 2011

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

Posted by on @

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

Share

Recommended (online) reading

Posted by on @

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

Share

When the poor were contagious

Posted by on @

Unsanitary living conditions 19th centuryThe 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

Share

On sabbatical

Posted by on @

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 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)

Share

The Dreams of the Founders of Family Medicine

Posted by on @

Marcus Welby MD on the phoneLaurence 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

Share

Guest post: Guilt-edged

Posted by on @

Bananas with the Globe and MailToday 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

Share

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

Posted by on @

Dr. Joel AngI’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

Share

The misuse of health statistics by politicians

Posted by on @

Rudolph Giuliani prostate cancer[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

Read more

Share

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

Posted by on @

Why is it so hard to reduce US health care costsProfessor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.

The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.

We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors. Read more

Share

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

Posted by on @

Consumer Society by Barry SmartOnce more, from Perpetual Euphoria: On the Duty to Be Happy. This time on our relation to wealth.

Why is it American conservatives deplore European social democracy? Could it be that it doesn’t stimulate consumerism enough to satisfy a free market economy? (emphasis added in the following quotations)

[T]he power of the great upheavals of the preceding century in France, including those of 1936 and 1945, consisted not only in redistributing the social pie, but also in creating new kinds of opulence for the majority of the people: free time, poetry, love, the liberation of desire, the sense of everyday transfiguration. Not being content to manage penury, but discovering everywhere new goods that are unquantifiable and escape the rule of profit, prolonging the old revolutionary dream of luxury for everyone, of beauty made available to the most humble. Today, luxury resides in everything that is becoming rare: communion with nature, silence, meditation, slowness rediscovered, the pleasure of living out of step with others, studious idleness, the enjoyment of the major works of the mind – these are all privileges that cannot be bought because they are literally priceless. Then we can oppose to an involuntary poverty a voluntary poverty (or rather a voluntary self-restriction) that is in no way a choice to be indigent but rather a redefinition of our personal priorities. This may involve giving up things, preferring freedom to comfort, to an arbitrary social status, but for a larger life, for a return to the essential instead of accumulating money and objects like a ludicrous barrier set up against fear and death. In the end, true luxury is the invention of one’s own life, master over one’s destiny; “but everything that is precious is as difficult as it is rare” (Spinoza).

This is not to say that Bruckner fails to appreciate the situation of the poor. Written in 2000, way before the financial crisis, this comment is even more relevant today:

[P]overty 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

Share

Why are we so willing to undergo cosmetic surgery?

Posted by on @

Miss Plastic Surgery finals China
Miss Plastic Surgery pageant, Beijing
A recent article on cosmetic surgery in China observes that, despite the highly publicized death of aspiring pop star Wang Bei (see The death of Wang Bei: Cosmetic surgery as a moral choice), “the ugly side of Chinese obsession with beauty … is a gamble that millions of people are willing to take.” Why is that?

The high rate of cosmetic surgery in Asia has been widely discussed, including an article in The New York Times. What caught my attention in this more recent piece was the postmodern/feminist spin.

Susan Feiner, a feminist economist, offers these comments: (emphasis added)

Parents are caught between a traditional world view and a postmodernist world view. On the traditional side especially, your daughter is your property and potential to social advancement. … On the postmodern side you have this idea that western beauty, this imported beauty ideal, is really a sign of your family’s openness to the future. So those two impulses – a very traditional impulse and the more modern neo-liberalism impulse come together at the moment of submitting your own daughter to the knife. …

On one hand we have all of this acceptance and even approval for women to become doctors and lawyers and political leaders and at the same time what’s been held up to women is this Walt Disney notion of our lives. That really even if you are a doctor or a lawyer or a political leader the best you can really do is to be beautiful and get some wealthy rich man to take care of you, so the best possible outcome for any women is to be both hugely successful professionally and be knock-down beautiful.

Why so much willingness to reshape the body?

What drives the popularity of cosmetic surgery? As bioethicist Carl Elliott notes in one of my favorite books, Better Than Well, medical enhancements, along with body size, are part of the logic of consumer culture: “You cannot simply opt out of the system and expect nobody to notice how much you weigh.” Read more

Share

Bruckner on the family, being gay, and AIDS activism

Posted by on @

The perfect familyI recently read and very much enjoyed Pascal Bruckner’s newly translated book, Perpetual Euphoria: On the Duty to Be Happy (originally published in 2000). Here’s a passage from the chapter “The Fat, Prosperous Elevation of the Average, the Mediocre.” (emphasis added in the following quotations)

[W]hat a contradiction to see in civil unions or in gay marriage with adopted children the forerunners of the disintegration of the family! It is exactly the reverse: it is the familial order that is triumphing over all of us, no matter what group or belief we subscribe to, and it is hard to see any argument, anthropological or other, that we could make against it.

Good point. Lost on conservatives, unfortunately. The new normal in family formation is resisted by those who cling to traditional values, while the traditional value of family prevails.

The paragraph continues with a discussion of conformity and anticonformity, and includes the following footnote:

According to Lucien Sfez, in 1995, 45 percent of literature majors at Stanford said they were gay, a figure that has little to do with reality. The author sees three reasons for this phenomenon: it is cool to say you’re gay and not to have the brutal image of the heterosexual; gays being a minority are protected by labor unions; and finally, gays cannot be accused of sexual harassment. La Santé parfait, p. 65.

The first reason makes sense, the second is irrelevant today, and the third certainly isn’t true in the US.

The footnote appears in connection with a critique of identity politics. “People state their identities only to make others yield, and display them noisily, perhaps out of fear that without them they would not exist.” Later on, however, in a chapter on suffering, Bruckner does not fault those who go public with an identity that features an incurable disease or disability.

The impact of AIDS activism on attitudes towards illness

Read more

Share

Pascal Bruckner on doctors and patients

Posted by on @

Doctor patient relationshipA concise summary of the history of the doctor-patient relationship: It began with reverence and respect for the physician, changed dramatically in the 20th century, is in an unhappy state today, but may aspire to something more satisfying in the future. (emphasis added)

There is no figure more ambivalent than the doctor, who is simultaneously a preacher, a magician, and a healer, the master of both life and death. For a long time the image of him oscillated between two extremes: that of an arrogant practitioner intoxicated by his power and endowed with all the attributes of knowledge; and that of the family doctor, the tutelary divinity of French society who knew how to combine sound, precise diagnosis with friendly advice about what to do. …

Everything changed when medicine became specialized and liberalized. In the hands of a specialist, not only is the human body fragmented, but each part of it is subject to competing authorities. The result of this new status is that in dealing with a physician we oscillate between faith and absolute suspicion. Since he is supposed to know everything, a doctor has no right to be mistaken. … The contemporary patient is a skeptic who does not believe in any treatment but tries them all, combining homeopathy, acupuncture, sophrology, and allopathy, a little like new converts who embrace several religions to increase their chances. Read more

Share

Can pharmaceutical drugs benefit society?

Posted by on @

Goethe quotation: Whatever you can do ...Here in the US, we’re apt to hear about the British health authority NICE (National Institute for Health and Clinical Excellence) when a stage-four cancer patient makes a desperate appeal for access to an expensive drug not in the approved formulary. The British system has been characterized as rationing, and conservative US politicians like to use such incidents to argue against “socialized” medicine, which will surely do away with Granny before her time is up.

There are big changes currently underway in the British health care system, and NICE will actually be replaced by a different decision-making process in 2014. Although health care reform in the US (the Affordable Care Act) rejects the British model, a recent article in the New England Journal of Medicine suggests there’s much we can learn from the British experience.

Why not design drugs to have wider societal benefits?

Of particular interest is the concept of the social value of drugs. The idea is that if a drug demonstrates “wider societal benefits,” the British government would be willing to pay more for the drug. Presumably this financial incentive would lead the pharmaceutical industry to invest more heavily in products with a high value to society.

What might these values be? In discussions of how the new system would work, the only example provided is drugs that benefit the care-takers of patients. The article’s authors, however, suggest a few more: “narrowing health inequalities, advancing children’s life prospects, reducing burdens on social services, increasing tax revenues, and decreasing workforce absenteeism.” Read more

Share

What gets lost in the bureaucratization of medicine

Posted by on @

Medical practice as an artIn a recent issue of JAMA, Dr. Michael H. Monroe recalls how medicine has changed in the mere 14 years he’s been practicing. His desk has a drawer on the lower right where – at the start of his practice — he began collecting articles and stories on the medical humanities and the art of medicine. Over time, that drawer has fallen into neglect.

Addressing a mentor who retired shortly after he began his own practice, Dr. Monroe writes: (emphasis added)

A 14-year career of rounding, teaching, and publishing has not the longevity you had at your “retirement,” but it feels like it’s become an increasingly wearying few years. Concerns of coding, billing, documenting, administration, computers, surveys, rules, regulations, and politics have increasingly occupied my mind and space like an intracranial tumor, slowly compressing my right hand drawer. …

Medicine today is science, and business, and law (perhaps not in that order) but not so much art as it seemed to be even when I started. It is a world of statistics, evidence-based medicine, and quality improvement; of increasing things to count, to codify, and to structuralize. I know why we are counting, why it is important, essential even, and we are doing better, say the numbers, and I mark the progress but still can’t shake the feeling that in medicine, things easily counted need to be distrusted. Despite years of study and numbering, after all, we still haven’t settled the role of vitamins, hydrochlorothiazide, mammograms, aspirin, diabetes control, or almost any other topic in medicine including statistical analysis itself. What I have slowly realized and come to reluctantly is how hard it is to prove that anything is true. … Read more

Share

Patient safety and corporate profits

Posted by on @

Patient safety firstThe Supreme Court recently decided, in the case of Bruesewitz v. Wyeth, that Wyeth Pharmaceuticals could not be held liable for injury to the Bruesewitz’ daughter (following a vaccination) because Wyeth was protected by the National Childhood Vaccine Injury Act.

I was reading an article on this controversial issue in the NEJM when I was brought up short by the following sentence: (emphasis added)

Litigation such as the Bruesewitzes’ can help the FDA in its oversight function by revealing important and previously unknown information about product-related risks, especially during the postapproval period, and by deterring manufacturers from acting irresponsibly and engaging in business tactics aimed at increasing product sales at the expense of patient safety.

Now, I know corporations sometimes put profits before consumer safety (I once owned a Ford Pinto). And I know that, starting in the late 20th century, medicine became driven by corporate profits rather than traditional medical professionalism. (This is not to say that medical professionalism has disappeared. Merely that there has been a shift in values.) But it still troubles me to read a casual reference to profits being more important than patient safety. It’s an acknowledgment that such practices are an everyday occurrence, imperfectly dealt with by regulations and legislation, and are not a matter of what’s ethically right or wrong.

For-profit medicine drives increased use and costs

I believe medicine – which deals with life, death, pain, suffering, and disability – is not just another business like selling consumer goods. (See From MD to MBA: The business of primary care.) Other industries –automobiles, airlines — may need to consider life-threatening safety issues. But the primary focus of those industries is to sell a particular product or service, not to keep people alive and well. Read more

Share

The emotional burdens of patient care

Posted by on @

The emotional pain of doctorsIn a recent issue of JAMA, Dr. Michael Stillman writes about the emotional pain of delivering bad news to a patient he has known through the best and worst of times.

Earlier in my career, delivering bad news seemed like a technical challenge. I would methodically seat patients and their family members facing one another, pause for a moment after reporting that there was an “unexpected finding” on a scan, and search for an opportunity to say that I “wish things were different” and that I would be there to help until the very end. This routine, though slightly stiff, helped anchor me in whatever emotional swell was to come.

Now, however, these conversations just make me sad. …

Patients suffer and die, and a physician must find the balance being feeling her own humanity and maintaining the professional stance that allows her to move on. There are no simple guidelines, although Dr. Stillman suggests remembering the good times his patients have had and focusing on those moments.

Emotional hazards of practicing medicine

I wonder just how aware patients are of the psychological burden of being a doctor. Dr. Stillman writes:

I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many “civilians” would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.

How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction? …

There is simply no way to be a good but distant physician.

Read more

Share

Guest post: A sound mind in a disintegrating body

Posted by on @

Mens sana in corpore sanoIn an attempt to balance my very serious attitude towards the subject of healthism – the idea that individuals should be held personally responsible for their health; an idea promoted at a time of rising health care costs in the “Great Society” seventies, appealing to residual American sentiments of self-reliance and individualism, conveniently distracting attention from social and environmental determinants of health …

I could go on, but as I was saying, in an attempt to provide balance, I offer this guest post by Kate Gilderdale, a writer who valiantly resists healthism propaganda and whose approach to any subject is always liberally laced with humor. Kate blogs at The Jaundiced View (where this post first appeared), and I highly recommend a daily visit (laughter being the best medicine and all).

Mens sana in corpore sano is today’s mantra for many people, but a lot of us only manage to fulfil half the equation at best.

In order to attain the corpore sano required by today’s fanatical health and hotness community you have to devote two or three hours a day to honing the body beautiful so that it contains no lumps, bra overhang or bits that have to be sucked in when you walk past a mirror. This involves lunges, squats, curls, lat pulldowns, pushups, bench presses and eventual death from exhaustion unless you are of that rare elite who are truly in The Zone.

The rest of us get by by avoiding spandex and investing in Spanx, whilst using those three hours not spent at the gym to fill our brains with stuff that we hope will make us appear erudite without being unforgivably elitist.

When it comes to physical exertion, Joan Rivers said it best. “I don’t exercise. If God wanted me to bend over, he would have put diamonds on the floor.”

Any deviations from Americanized spelling (“fulfil”) may be attributed to Kate’s proper British education.

Kitten with barbell

Read more

Share

There’s more to life than the pursuit of health

Posted by on @

Doctor with stethoscopeA few quotations on attitudes towards the pursuit health:

And do you not hold it disgraceful to require medical aid, unless it be for a wound, or an attack of illness incidental to the time of year, — to require it, I mean, owing to our laziness, and the life we lead, and to get ourselves so stuffed with humours and wind, like quagmires, so to compel the clever sons of Asclepius to call disease by such names as flatulence and catarrh.

– Plato, The Republic, 380 BC

Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the flattening out of human experience. I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living.

– Ivan Illich, Health as One’s Own Responsibility – No, Thank You!, (PDF) 1990

After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.

– Lewis E. Foxhall, M.D., The Tyranny of Health, 1994

Thinking that we can make death, illness, or privation easier to bear by preparing for them day and night is a sure way to poison our lives, to spoil the slightest pleasure by imagining its end.

– Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy, 2000

In the past, health was usually understood as the normal state of affairs, and taken for granted as [a] feature of life largely beyond the control of the person or the society. The proliferation of reflexive techniques which promise actually to improve one’s health has transformed the very meaning of the term ‘health’. The advent of such an immense range of popular ‘health-enhancement’ or ‘self-improvement’ techniques has meant that health is now seen more as a positive goal to be achieved rather than the normal state of a person without illness.

– Christopher Ziguras, Self-care: Embodiment, Personal Autonomy and the Shaping of Health Consciousness, 2004 (emphasis in the original)

There have always been individuals willing to point out that the constant pursuit of health is not the be-all-and-end-all of life. This eminently reasonable attitude, however, is increasingly rare among both doctors and patients. We have been educated to believe – primarily by what Ziguras calls “commodified and mediated health advice,” but also by the medical and public health professions – that feeling good and assuming we’re healthy could all too easily be a delusion. How can we be certain some fatal disease doesn’t lurk in the unreliable interior of the body?

We choose to pursue health or to pursue disease

Read more

Share

From healthism to overdiagnosis

Posted by on @

H Gilbert Welch OverdiagnosedIn his new book, Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch enumerates how the cutoff points that determine whether a patient should be treated for a disease – diseases such as high blood pressure, diabetes, osteoporosis — have been creeping inexorably lower over the years.

Take diabetes. The cutoff point used to be a fasting blood sugar level of greater than 140. In 1997, the number was lowered to 126. This immediately created 1.7 million new diabetes patients.

In a highly publicized study that began in 2003, one group of patients with type 2 diabetes received “intensive therapy” to make their blood sugar “normal.” The control group – the other half of over 10,000 patients – received treatment to lower their blood sugar, but not to the new normal level. The trial was stopped in 2008 when it became clear that there was about a 25% increased risk of dying for the intensive therapy group.

Dr. Welch’s comment on this: “If it’s not good to make diabetics have near normal blood sugars, then it’s not good to label those with near normal blood sugar diabetics. Why? Because doctors will treat them. People with mild blood sugar elevations are the least likely to gain from treatment – and arguably the most likely to be harmed.”

High blood pressure (hypertension) was also redefined in 1997. Instead of the cutoff points being 160 systolic over 100 diastolic, the numbers dropped to 140 over 90. This created 13.5 million new patients.

The definition of high cholesterol (hyperlipidemia) changed following a 1998 clinical trial. The definition of “abnormal” total cholesterol fell from 240 to 200. This created 42.6 million new patients, an increase of 86% over the previous number of patients.

It’s the same with the definition of osteoporosis. A bone mineral density X-ray produces a T score. It’s a way to compare an individual’s bone density to what’s considered “normal.” For women, normal is defined as the bone density of an average white woman aged 20 to 29 (a T score of zero.) If your T score is less than zero, it’s assumed you have an increased risk of fracture.

In 2003 the definition of osteoporosis changed from having a T score less than -2.5 to less than -2.0 (i.e., closer to normal). This created 6.8 million new patients, an 85% increase in those now eligible for treatment with drugs that turned out to have significant side effects – as virtually all drugs do. Read more

Share

Megan McArdle: Why are there no new antibiotics?

Posted by on @

Approached by the Antibiotic ResistanceMegan McArdle spoke on antibiotic resistance at the Economic Bloggers Forum yesterday. McArdle is a journalists who writes for the The Atlantic, primarily on economics, finance, and government policy.

Her presentation, “Antibiotics: The world’s most broken market,” was interesting. Notice (in the video below) that she never questions the market-driven premise of pharmaceuticals – and by extension, the for-profit nature of medicine and health care. That’s not her politica/economic persuasion.

Here’s an excerpt from the talk where she discusses the patient/doctor end of the antibiotic resistance problem. What she says is already quite familiar. What’s interesting is her frank description of how doctors behave and how patients in turn regard doctors.

People love to get antibiotics. They go to their doctor and they’re like, “My kid has an earache. Give him antibiotics.” Now the doctor could say, “No we shouldn’t. We should wait and find out if it’s bacterial. Almost all ear infections are bacterial. Due to throat infections. Due to almost anything you can name. But to do that, the doctor has to sit down and deal with an angry patient who may pick up and leave their practice.

If you look at the way that the current insurance industry is organized, right, what do doctors need? They need volume. They get paid by volume. Reimbursements for primary care physicians, who are where a lot – by no means all – but where a lot these vaccines go through, are very low. They’ve made up for that, and you all know this, right. You go into your doctor, and the minute you start talking, your doctor exudes an almost visible — like — desire for you to leave now. So that they can go on to the next patient. So what do they do? They give antibiotics to patients to shut them up. It takes too much time to explain and the risk of losing the patient is high.

Where have all the unattractive people gone?

Read more

Share

Joseph Stiglitz on inequality

Posted by on @

Income inequality waiting onlineGreat essay by Joseph Stiglitz on income inequality: “Of the 1%, by the 1%, for the 1%” in Vanity Fair.

As we gaze out at the popular fervor in the streets [of the Middle East/North Africa], one question to ask ourselves is this: When will it come to America? In important ways, our own country has become like one of these distant, troubled places.

Alexis de Tocqueville once described what he saw as a chief part of the peculiar genius of American society—something he called “self-interest properly understood.” The last two words were the key. Everyone possesses self-interest in a narrow sense: I want what’s good for me right now! Self-interest “properly understood” is different. It means appreciating that paying attention to everyone else’s self-interest—in other words, the common welfare—is in fact a precondition for one’s own ultimate well-being. Tocqueville was not suggesting that there was anything noble or idealistic about this outlook—in fact, he was suggesting the opposite. It was a mark of American pragmatism. Those canny Americans understood a basic fact: looking out for the other guy isn’t just good for the soul—it’s good for business.

The top 1 percent have the best houses, the best educations, the best doctors, and the best lifestyles, but there is one thing that money doesn’t seem to have bought: an understanding that their fate is bound up with how the other 99 percent live. Throughout history, this is something that the top 1 percent eventually do learn. Too late.

Read more

Share

Are the most heavily marketed drugs the least beneficial?

Posted by on @

Prescription drugs symbolIn a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.

For example, harmful effects (like death) may not show up during the limited time span of a trial. Data from trials may be selected – and other data ignored — to produce positive results. This is apt to happen when clinical trials are conducted by the pharmaceutical industry, rather than by economically disinterested parties, such as the NIH or independent academic institutions. Also, the participants in the trial may differ significantly (in age, gender, and health, e.g.) from patients who end up taking the drugs. As a recent article in JAMA put it, “most clinical trials fail to provide the evidence needed to inform medical decision making.”

The Inverse Benefit Law

If you follow pharma news, you will have noticed that many high profile, aggressively marketed drugs turn out to be either ineffective or positively dangerous (think Vioxx, widely prescribed for arthritis, which turned out to cause heart attacks and stroke). Howard Brody, MD, and Donald Light, PhD, have proposed an explanation for this phenomenon. They call it the Inverse Benefit Law: “The ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed.” Or (for those who feel fuzzy about inversion): The more aggressively a drug is marketed, the more likely the drug will cause harm, be ineffective, or deliver little by way of benefit. Read more

Share

Down so low we dare not speak

Posted by on @

Despair and pessimismDue to multiple, largely uncontrollable influences that include both nature and nurture, individual outlooks on the world are arrayed along a continuum from bright to dark. I tend to land on the dark side.

Three weeks ago I read a darkish blog post that made a strong impression on me. I was especially struck by its characterization of the current political/economic climate as so depressing one hesitates to speak of it. I understand that sentiment.

I couldn’t remember where I read it and recently tried in vain to locate it in all my usual web haunts. Then last night it popped up like an old friend. It’s called “The New American Pessimism,” and it’s written by the Serbian-American poet Charles Simic, a Pulitzer Prize winner, among other things. Here’s an excerpt. (emphasis added)

It must be difficult for any hostess nowadays to stop her dinner guests from reciting to each other over the course of an evening the endless examples of lies and stupidities they’ve come across in the press and on TV. As they get more and more wound up, they try to outdo each other, losing all interest in the food on their plates. I know that when I get together with friends, we make a conscious effort to change the subject and talk about grandchildren, reminisce about the past and the movies we’ve seen, though we can’t manage it for very long. We end up disheartening and demoralizing each other and saying goodnight, embarrassed and annoyed with ourselves, as if being upset about what is being done to us is not a subject fit for polite society. …

By the president’s calculation, telling the truth to the American people would doom his reelection campaign, since he would not be able to raise the billion dollars he needs this time around. The kind of people who have that kind of money and will agree to contribute to his campaign know very well what informed voters in a working democracy would to do to them once they understood just who has depleted the national treasury to line their own pockets. No doubt, he and his political party will do anything to avoid the truth and will propose outwardly attractive solutions—like the health care bill that not only expands coverage but greatly benefits insurance companies and does little to reduce healthcare costs. They hope that these kinds of measures will lure the majority of voters who won’t bother to learn the details, but they will also send a clear signal to the moneyed classes that they won’t be inconvenienced in the least. … Read more

Share

Breaking the self-destructive meritocratic spell

Posted by on @

A just societyIntelligent, thoughtful essay by Namit Arora on distributive economic justice: libertarian, meritocratic, egalitarian. (emphasis added)

In Rawlsian terms, the problem in America is not that a minority has grown super rich, but that for decades now, it has done so to the detriment of the lower social classes. The big question is: why does the majority in a seemingly free society tolerate this, and even happily vote against its own economic interests? A plausible answer is that it is under a self-destructive meritocratic spell that sees social outcomes as moral desert—a spell at least as old as the American frontier but long since repurposed by the corporate control of public institutions and the media: news, film, TV, publishing, etc. Rather than move towards greater fairness and egalitarianism, it promotes a libertarian gospel of the free market with minimal regulation, taxation, and public safety nets. What would it take to break this spell?

Read more

Share

What Wisconsin hath wrought

Posted by on @

Wisconsin protestsIt’s time to focus on the corporate CEOs and speculators. … “In U.S. states facing a budget shortfall, revenues from corporate taxes have declined $2.5 billion in the last year. In Wisconsin, two-thirds of corporations pay no taxes, and the share of state revenue from corporate taxes has fallen by half since 1981.” The same is true in other states. These facts must be stressed, repeatedly and aggressively, if the debate is going to shift from cuts in public services and education to demands for fair taxes and the revenues necessary for services and schools. Read more

Share

It’s cheaper to let the sick die

Posted by on @

Free health care clinic draws thousandsUnfortunately, he [Gawande] dismisses what, from the standpoint of reducing total health-care expenditures, is the single most serious drawback to such an approach; namely, the probability that effectively case-managed patients will survive longer than they would without intensive ambulatory care and will thereby offset their reduced frequency of hospitalization with an increase in their time at risk. If an intervention reduces a patient’s frequency of hospitalization from ten admissions annually to five, but simultaneously increases that patient’s survival from one year to two, the intervention is fully justified medically but is a wash from a cost perspective. If it increases that patient’s survival to two years and one month, it’s a net liability. Read more

Share

Complaints about pharma go way back … to ancient Rome

Posted by on @

History of pharmacyIn 1911 the medical profession complained of the “commercialization” of medicine, contending that this led to abuses in pharmacology and the practice of medicine. The Romans failed to check these abuses, which increased as Rome declined. “[I]f we are to avoid such unfortunate deterioration in our own time, we must not shrink from recognizing and resisting the evils which do so easily beset commercialized ages like those of the first and twentieth centuries A. D.” Read more

Share
Skip to toolbar