The Commodification of American Medicine

"We need to keep some parts of our social, cultural, and spiritual life out of the marketplace. We must not convert all gift labors into market work lest we wake one day to see that universal market in which all our actions earn a wage and all our goods and services bear a price."

So said Lewis Hyde in his highly insightful 1979 book, The Gift. Regarding the field of medicine in America, we have very nearly, or perhaps completely, reached this realm. I hear daily in conversations at the hospital: how can the administration pay us X when clearly we are worth Y? As if the work and care of medicine can be fully translated and digitized into some currency. The attempt of course has led to massive payments to nurses and doctors, which administrators publicly lament over, but then take pains to profit off of, being as they are the top of the doctor-nurse-patient pyramid themselves.  

No, the field of medicine cannot lose its gift component and remain medicine. It becomes only a tit-for-tat exchange, and even a battle, for the human body always carries scarcity, even when well. The sick will consume all commodities and still be wanting. In today's medicine, the sick person desperately longs for gift, for love, for human, for divine. When these are missing, no commodity will suffice. 

Stateless Patients

A 30 y/o woman presented to a rural clinic for prenatal follow up: G2P1 at 25 weeks. As I used the ultrasound to check dates, look for anomalies, and measure amnionic fluid, I thought of the patient’s lack of sufficient identification in this country to allow her access to complex OB care. Instead, a volunteer internist was doing her ultrasound. The baby appeared healthy, but I later noted that she had not gained weight for several visits and that she was on prednisone. She had started having joint pains when she first got pregnant, was diagnosed with rheumatoid arthritis, started on steroids, and the labs that she could afford were sent off.

Through translators, the patient reported oral ulcers that were now healed, but no rash. Exam confirmed persistent pain and limited range of motion in the elbows, knees, wrists, MCP and PIP joints. Anemia down to a hemoglobin of 5 had improved to 8.5 with iron and steroids, but the WBC was still low at 2.7. She had negative rheumatoid factor, positive ANA and dsDNA, and negative anti-Smith. The creatinine was normal and urine protein was 3+. She met criteria for lupus.

I explained to the patient how a lupus diagnosis put her and her baby at risk, and the medications had risks as well. I increased the prednisone and asked her to come back in a week, hoping I could get some advice via email as to what to do. Thankfully, rheumatology friends overseas emailed back. We then developed a plan including medications that we could obtain and that were considered relatively safe during pregnancy, hoping to reduce the steroids at some point.

Three weeks after I first saw her, the patient had gained some weight and her joints were nearly normal, though she still had proteinuria. I outlined an ongoing plan for the staff as I left and prayed for her and the baby.

One wonders when helping people who are outside the “system” and its resources for whatever reason, at home or abroad: am I doing the right thing? Am I practicing beyond my scope if no one else will see them? How can I get better at doing this when medical progress seems to require more and more sub-specialization? And how can I protect these people’s privacy and security and still advocate for improved access to care?

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Epidemic of Medical Care

Dr Welch in his NY Times article points out that screening for thyroid cancer leads to more diagnosis but not likely better treatment or better care, but likely harms. 

I think it is very interesting as I think about these questions:

1.  What does a country look like that has too few doctors?  I was recently in Liberia, where the WHO registered 51 doctors for the country of over 4 million persons.  Several of those have died of Ebola.  I worked with facilities in Monrovia, where patients are cared for, babies delivered, simple treatments done by nurses mostly.  Research has shown that having a medical attendant for a delivery dramatically reduces maternal deaths. 

2.  What does a country look like that has too many doctors? This is where Dr Welch and the Lown Institute and the Dartmouth research helps us to understand that so much of our medical care is actually hurting us because of over-medicalization, over-treatment, over-testing, and certainly overspending on healthcare in America. 

In both situations--Liberia and the USA--one thing that strikes me is how invisible this issue seems in the regular everyday life of the people and the thinking of the medical workers.  The Liberian government, even today in the days of the Ebola crisis, still will ponder over your application for a medical license.   Providers wonder if a volunteer doctor will be unfair competition.  As if there was not an absolute desperate need.  And in America, new medical schools are still opening, with a call for more doctors in a "national shortage."  The fish does not notice the water she swims in.

And so it takes certain people, with a special vision, to help the rest to understand that realities of the medical establishment perhaps are different than we think. 

Of Beginnings and Ends

We talk much in medicine about the end of life. How do we know when it will end (prognosis)? How do we prevent death (treatment)? How do we comfort those in their last days (palliation)? But what do we really know about these questions of beginnings and ends?

I notice that many of our discussions focus on the “end of life.” As if life has an end. In all of history, what religion or culture has said that this moment of last breath was the complete end? All connect the life to the living that remain, or those who have “gone” before. Or adding hereafter, look also to that same life going on unseen elsewhere. Who has not been affected by those whose lives are over? Those loved ones we carry with us. Or even the multitude we have not met who impact our lives now in one way or anther: Plato, Freud, Stalin, Jesus? Their lives are “over,” but are they? When did we adopt terms better used in the lab or the courtroom for thinking about the “end” of life when it comes to meaning, being human, or making decisions about “end of life care.” (there we go again)

And for that matter, what does the “beginning” of life mean? Knowing now what the ancients did not, that if you look at a sperm and an egg under the microscope, they have a set time of fusion; does that mean we have defined the beginning of life? How has even the Christian Church been so quick to adopt this moment, ignoring the stories of life formed from dirt, from ribs, at the indefinable “beginning” of time, from a God with life, no beginning and no end?

And as for science, what have we as moderns added with our great stores of knowledge? We still use a beginning and end in the same simplistic way, throwing away what we know to again adopt words from the courtroom or the congress such as autonomy and individual. What of mitochondria that span thousands of generations, truly tying us all together with a single mother of yore. What of Lucy the transitional, of stone tools and an iron age, can we truly say with any authority that my life began with me? What of my own tail that was resorbed, my blastocyst stage (when I was more pond scum than biped)? Or what of toilet training, adolescence, are not those beginnings and ends as well?

So the complexity grows and the discussion could continue as well, encompassing all. Let us, as doctors and otherwise, take off our shoes and bow our heads when we approach issues of beginnings and ends of life. It was wisdom, not foolishness, that made the ancients call in holy men and women at these moments. And if we find ourselves there for reasons of science or otherwise, whether it be the delivery room or the palliative care room, or for that matter the classroom of discussion, may we foster things like silence and awe in ourselves and others and not be limited to only procedures and check boxes. And may we realize how limited we are and how we limit our understanding of life with this vocabulary of beginnings and ends.

It's Easer to Get a Gun than Mental Health Care

by Dora Calott Wang, M.D.  in Psychiatry Today

Mass shootings are a symptom of our broken health care system.

Published on January 12, 2011

 

There will be more shooting rampages, like that which targeted Congresswoman Gabrielle Giffords in Tucson last weekend-as long as it is easier to get a gun than mental health care. Our current epidemic of mass shootings is but a symptom of our nation's broken health care system. Poor access to medical care jeopardizes an individual's health. But when the mentally ill or the seriously distressed can't access care, we are all at risk.

As a psychiatrist, I remember when I once did everything in my power to keep a disturbed patient stable, and society safe. I'd see the patient every day, or hospitalize the patient for months, if necessary. Needless to say, this degree of attention is impossible today, given limited resources, and the fights my staff and I regularly undertake with insurance companies to get even routine care approved.

For decades, the American health care system has prioritized profits, often by excluding the sick. This travesty is now coming to roost, in the form of mass violence, such as the recent shootings in Tucson, at Virginia Tech, and in communities across the country, including my own. Medical care for our most disenfranchised citizens will never turn good profits-yet basic health care for everyone, is necessary for the stability of society.

What does it mean that for kids today, the greatest threat of mass violence comes not from enemy powers, but from fellow disenfranchised citizens? As opposed to the duck and cover bomb drills of my own childhood, schoolchildren today do drills to prepare for shootings. Across the country, uniformed officers with weapons rush onto campuses to tackle imaginary shooters, while students run for cover. In Oxford, CT, helicopters and over 150 officers helped stage an elaborate shooting drill. At Scales Elementary School in Tennessee, little kids cried and wet their pants during a drill. In Dallas, police mistook a drill for an actual attack, and rushed onto campus like an episode of Keystone Cops. What have we come to?

Insurance companies have the ultimate say about how often I see a patient, what medications I prescribe, and if the patient can be hospitalized. In the past, I might have provided services free of charge, in the name of patient welfare, my own professional ethics, or for the sake of public safety. But physicians and hospitals who don't prioritize the bottom line are increasingly put out of business. Even St. Vincent Hospital in Manhattan, after 161 years of practicing good medicine but bad business, is bankrupt, gone. Meanwhile, health insurers are among the most profitable companies on Wall Street. It's a perverse distribution of the nation's precious medical dollars.

My own community's worst mass shooting occurred on August 18, 2005, when five people in Albuquerque were shot and murdered by a man who suffers from schizophrenia. For the prior three days, John Hyde sought help, but was turned away each time. His family called his psychiatrist repetitively, but HIPAA privacy laws prevented communications. On the day Hyde started shooting, he sought help from his insurance company.

Hyde was once kept stable for seven years by an old-fashioned psychiatrist who had personal relationships with patients, and who was available at all hours, like all doctors of another time. But when for-profit insurance companies took control of New Mexico's mental health dollars in 1998, Hyde's psychiatrist found himself paid less, while needing to spend just as much time haggling with insurance bureaucrats, as treating patients. In 1998, practicing the same devoted way he had for 22 years, Hyde's psychiatrist, Dr. Jay Feierman, closed his practice with $50,000 in debt.

After Hyde lost the long-term, committed care of his personal psychiatrist, Hyde fell into a system that operates in today's typical fashion. His care was divided between a psychologist for therapy, a psychiatrist for medications, an Emergency Room for problems after hours (which is most hours of the week), with insurance bureaucrats ultimately at the helm of each medical decision. With Dr. Feierman, at least Hyde knew who to call, if he felt unstable.
Effective treatments for serious mental illness only began with antipsychotic medications created in the 1950's. An older, more primary function of psychiatry-dating from the time of asylums-has always been to keep society safe.

We as a society are only as stable as the least stable individual roaming our streets.
How many more tragedies need occur, before we conclude that our mental health care system no longer functions to keep us safe? When will we learn that everyone needs basic medical care, not just for humanitarian reasons, but for the safety of all of us?

Dr. Wang wrote The Kitchen Shrink: A Psychiatrist's Reflections on Healing in a Changing World. I thought the above piece is very relevant so I quoted it in its entirety.