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Volume 2, Issue 1
Spring 2006:

Healthcare as though People Mattered

Jeff Kane, MD

Cell 2 Soul. 2006 Spring; 2(1):a5

A half-century ago, my father handed our family doctor ten dollars for a house call. Today that might not cover the man's car expenses.

When we talk about the current "crisis" in healthcare, much of what we mean is its surreally increasing cost. The average American spent more than $5,000 on healthcare last year, an amount thirty-five times more than in 1960. In 1960, one dollar of every twelve spent for anything went toward healthcare. By 1980, healthcare's share was one of every seven dollars, and its appetite continues to grow. (According to the U.S. Center for Disease Control, we spend a larger share of our gross domestic product on healthcare than does any other major industrialized country.)1 At this rate, my inner cynic tells me, we'll eventually buy nothing but healthcare: we'll live in packing crates then and shop in dumpsters, but at least we'll enjoy the most opulent healthcare technology in history.

That expense might be worth it if it made us commensurately healthier, but it doesn't. International studies rank the United States thirty-fourth in infant mortality2 and twenty-third in life expectancy3. We're not just paying too much; for all we pay we're getting even less.

Of course, experts have been addressing this hardly inconspicuous disparity. I recently observed that process in an online healthcare reform chat group. I'd expected a passionate discussion, but what I found was people drily exchanging numbers. Deflated, I looked up the group's roster. Of sixty-two members, almost all were administrators or economists. In fact, I was the only one identified as either a patient or active practitioner.

What can we possibly be thinking when we omit healthcare's only obligate participants from the reform discussion? Evidently we believe the crisis consists only of economics. Through that lens, doctors and patients are simply business vectors, agents engaged in the transfer of a "product" — health — from a "provider" — a doctor or other practitioner — to a "consumer" — a patient. (God help us, that is exactly the vocabulary of the current discussion.) So it is that almost all our healthcare reform talk is limited to who pays for what.

To those of us who inhabit the examining room, patients and physicians, healthcare isn't at all like a business transaction, exchanging money for widgets. Often involving major life crossroads, the encounter is tinged heavily with emotion, intensity, and intimacy. It's this "human element" — underemphasized in practice and utterly ignored in healthcare reform discussions — that's the actual nucleus of the healthcare crisis.

We spend too much for too little because we routinely apply expensive, often hazardous technology where simple human contact would suffice. This unbalanced style doesn't result from a dark plot, but from a broadly held cultural contradiction: while we virtually worship our technology to the point that we consider it one with healthcare, we bridle at the dearth of personal contact.

As glamorous as our healthcare looks in popular media, the real-world version leaves much to be desired. In a nationwide survey of more than 2,000 adults conducted in 2004 by Harvard University, the federal Agency for Healthcare Research and Quality and the Kaiser Family Foundation, 55 percent of respondents said they were dissatisfied with the quality of health care, up from 44 percent in 2000; and 40 percent said it had declined in the last five years. Dr. Drew Altman, president of the Kaiser Family Foundation, interpreted findings this way: "…when they talk about quality of health care, patients mean something entirely different than experts do. They're not talking about numbers or outcomes but about their own human experience, which is a combination of cost, paperwork and what I'll call the hassle factor, the impersonal nature of the care."4

We support a healthcare system that assays our serum sodium with stunning precision but hasn't a clue to our lives — the nature of our suffering, the meanings we make of our situation, its effect on those around us, or what we ourselves can do to change things.

I limit my practice to facilitating cancer support groups, it's fair to say I listen to patients for a living. In our meetings, participants both praise and disparage their healthcare. Their grumbles hardly ever concern the impressive new MRI machine; they're uniformly about personal interaction. They say, "I was treated like a number" or, "Why wasn't the doctor interested in my diet or how my life is going?" or, "The doctor kept her back to me, typing her computer notes." "When I was in the hospital," one said, half-facetiously, "I was poked and probed and ultraviolated, but I was never touched."

When I cite such comments to others, they usually reply, "Oh, that's nothing. Let me tell you this one." Everyone's got a story about impersonality in healthcare. Of course, there are instances of humane treatment, and they delight us as much from their novelty as their benefits.

Americans are dying — and not so figuratively — for more personal contact in their healthcare. In fact, millions are shopping elsewhere, reaching outside standard medicine to "complementary" and "alternative" disciplines. A large-scale study found that visits by the general public to complementary and alternative medical ("CAM") practitioners increased from 34 percent in 1990 to 42 percent in 1997.5 Another study found that 376 out of 453 cancer patients had used at least one CAM therapy as part of their treatment.6 In 1997, Americans made an estimated 629 million visits to CAM practitioners,7 an astonishing fact considering that most of these practices, unreimbursed by standard medical insurance, require cash payment. Each year since 1997, people have paid more out-of-pocket to CAM practitioners than to medical doctors.

This shift in patient interest is obviously no fad, but a major social movement. And it baffles the experts who think solely in terms of numbers. Why are acupuncture needles and herbs suddenly more popular than doctors' prescriptions? Have patients flipped out? Is science passé? The studies published on the subject just crunch more numbers, so their conclusions are all over the field. Seeking some plausible view of this situation, I conducted my own research…on a single subject, myself.

I admit it: I, a licensed medical scientist, make use of CAMs. I've visited acupuncturists, body workers, imagery practitioners and others. (I doubt that places me outside the pale, having read a study revealing that medical doctors' relatives use CAMs even more than the general public does.) When I ask myself what's attractive about these practices, I realize that for me, anyway, their technologies are less compelling than their common style, one which contrasts starkly with that of standard medicine.

First, the pace is slower. Whereas the national average duration of a medical encounter is between ten and fifteen minutes, I never leave CAM offices in less than ninety minutes. These practices move leisurely and deliberately, while the medical visit, even when congenial, feels hurried. During these longer CAM appointments, the practitioner and I, having more sustained contact, get to know one another better.

Second, assessment is more individual. If two patients present to me, a medical doctor, with a cough, fever, and chest pain, I'll probably diagnose infections and prescribe antibiotics for both. But if two people visit an acupuncturist with the same symptoms, they'll be asked about their sleep patterns, what foods they eat, and so on, and receive altogether different treatments. Standard medicine all but defines patients as equivalent physiologic units, while hardly any non-medical discipline sees people that way. On the contrary, CAM practitioners generally seek symptoms and signs that exquisitely individualize the person. Where medical encounters tend to make me feel generic, CAMs encourage me to reflect on my uniqueness.

CAMs utilize more physical touch. I was trained to palpate abdomens and percuss chests only to seek abnormalities. But non-medical disciplines commonly feature touch as treatment. Chiropractors, body workers, yoga instructors, reiki practitioners and others routinely touch therapeutically. Not everyone likes being touched, but those of us who do almost always feel better for it.

CAMs usually require more personal involvement in treatment. As your medical doctor, all I might ask from you is to take the pills I've prescribed. Even though I'll suggest you exercise or eat less or stop smoking, I won't lean on you heavily to do so because, having been trained to see patients as passive and static, I don't have much faith in your flexibility. It's a rare CAM practitioner, though, who doesn't require changes in clients' habits. And since you've usually paid cash, you'll tend to take instructions seriously.

Whether CAMs are more or less effective than standard medicine in treating disease is irrelevant here; my point is that unlike standard healthcare, CAMs emphasize relationship. Slower pace, more personal assessment, more touching, and greater involvement in treatment connect the sick person to the practitioner and to his or her own life. (I admit I generalize. I know a few CAM practitioners with all the intimacy of pine posts; but that's their own personal limitation, not the natural ambience of their calling.) We're not as attracted by crystals and chakras and meridians and flower essences as we are by human contact.

As a medical doctor reading this, I might ask why it isn't enough for me to diagnose and treat patients' diseases. Is it my responsibility to get involved in their lives?

Well, usually, yes. (Actually, I'm already involved. I defy those who stick their fingers into people professionally to say with a straight face they're not involved with them.)

We need to be involved because disease and healing don't exist separately from someone's life. For example, indisputable connections link style and sickness. I've been asking my medical colleagues, "What proportion of your patients' conditions originated in lifestyle?" Most answer somewhere in the majority, connecting emphysema with smoking, type two diabetes with obesity, cardiovascular disorders with unhealthy diet and inadequate exercise, AIDS with needle use and unsafe sex, and so on. That doesn't mean all disease emanates from lifestyle, but within our society an unhealthy chunk of it does. Yet now, in this twenty-first century, when we know how to clone ourselves and survive in space, we have only the barest inklings how to modify disease-causing ("pathogenic") behaviors.

TIME magazine offered a radiant example a couple of years ago when it featured a major story on type two diabetes. The cover photo was of an eleven-year-old girl who'd developed mysterious symptoms eventually diagnosed as type two diabetes. This is traditionally a disorder of overweight middle-aged people, but recently more children have joined its ranks. The article mentioned that this girl weighed two hundred and twenty pounds when she was diagnosed. Then it proceeded to a discussion of diabetes' physiology and treatment.

Hang on, I thought, wait a minute. How does an eleven-year-old come to weigh two hundred and twenty pounds? Why is this article about diabetes and not pathogenic behavior? What are the roles of social pressures, genes, poverty, ignorance, adverse experiences, and intent, for example? Lacking that knowledge, we're painfully ineffective at detouring these lifestyles. We'd love to intervene before the person's biochemistry has irreversibly changed, but as things now stand, we're limited to leaving American Heart Association flyers on the waiting room table and replacing them when they turn yellow.

If that's one good reason we physicians need to find ways to intervene meaningfully in our patients' lives, another — and this might surprise you — is that most medical visits are for incurable diseases. We call these diseases "chronic," meaning long-term, but they'd be short-term if we knew how to cure them. That is, "chronic" is a euphemism for "incurable." Only a few of those who suffer from arthritis, diabetes, cancer, and most cardiovascular, autoimmune and neurologic disorders will enjoy cures. We physicians can often treat their symptoms, but we can't treat their emotional ordeals because we just don't know much about them.

Untrained in addressing emotions and hating to feel powerless, we respond in the only way we know, which is to write prescriptions. The sicker a patient is, the more medications he or she is likely to take. It's not unusual to see a declining older person on twenty or more potent chemicals, some of which can be hazardous in combination.

There is no doubt our healthcare system will change, along with everything else in this universe. A century ago, doctors still bled patients and routinely administered purgatives. As advanced as we believe we are now, a century from now we'll look primitive, too. People will marvel that we lacked the tools to reverse pathogenic behaviors and to address the emotions that constitute chronic suffering. The first step on the path to a sustainable healthcare future is recognizing exactly what our problem is. It is not simply expense, but the inappropriate use of expensive high-tech in place of low-tech therapeutic human contact.


References:

1 http://www.cdc.gov/nchs/data/hus/hus04trend.pdf#027

2 http://www.unicef.org/sowc03/tables/under-5.html

3 http://www.who.int/inf-pr-2000/en/pr2000-life.html

4 Carey, B. In the Hospital, a Degrading Shift From Person to Patient. New York Times, August 16, 2005.

5 Eisenberg, DM, et al. Trends in Alternative Medicine Use in the United States, 1990-1997. JAMA 1998;280:1569-1575.

6 Richardson, MA, et al. 2000. Complementary/Alternative medicine use in a comprehensive cancer center and the implications for oncology. Journal of Clinical Oncology, Vol. 18, Issue 13: 2505-2514.

7 Wolsko P et al. 2002. Insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey.
Arch Intern Med 162(3):281-7.

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