THIS BLOG FIRST APPEARED ON THANKSGIVING, 2008.
THANK YOU FOR CONTINUING TO READ IT!
My book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available! Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities
THIS BLOG FIRST APPEARED ON THANKSGIVING, 2008.
THANK YOU FOR CONTINUING TO READ IT!
A recent study by Matthew Toth and Lauren Palmer from the Research Triangle Institute (RTI) evaluated the impact of the Center for Medicare and Medicaid Services (CMS) Financial Alignment Initiative (FAI) on access to primary care by those people who are eligible for both Medicare and Medicaid. These people are called “dual-eligibles” and represent about 13% of Medicare recipients. The FAI aimed to increase coordination of care, and the authors discovered that it did increase primary care access, to some degree, in 6 of the 9 states in which this demonstration project was implemented. In one state where it did not, Washington, eligibility for the program required people to have multiple morbidities (chronic diseases), and so the authors speculate that it increased access in other states for “healthier” dual eligibles.
There is nothing wrong with this study, or the program it
studies, insofar as they go. But it raises two major issues. The first is that the
program is yet another example of how the federal government continues to
tinker around the edges of a completely flawed healthcare system by
experimenting with one program after another that might possibly help, to
some degree, a small portion of our population. This is not to say that the
people who were studied, those eligible for both Medicare (by age or
disability) and Medicaid (by poverty) are not deserving of better access to
care and care coordination; certainly, they are. But we all are. Because we
have some people who are eligible for Medicare and some people who are eligible
for Medicaid and lots of people who are eligible for neither, and many people who
are uninsured, and many more are grossly underinsured, we have fragmented our
population and made financial access both unwieldy, far from comprehensive, and
incredibly expensive. If this study (maybe) shows that the improvement in
access was more for those “dual-eligibles” without multiple morbidities, is
this bad? Well, it’s bad that they weren’t getting coordinated care in the
Here I need to take a break, before going on to the second issue, to put in a word or two for our medical insurance companies and large hospital systems. They are not doing badly. Indeed, the outrageous excess cost of our health system, two to three times (or more) per capita than other OECD countries despite leaving large numbers of people uncovered, is due almost entirely to their profit-taking. They are doing well, thank you, along with the drug manufacturers, even while rural and inner-city safety net hospitals are going broke taking care of poor and uninsured (and sick) people, and millions of Americans go without care or receive inadequate care. The words – I’ll go with two – are rapacious thieves.
The second issue is that while financial access, being covered by adequate insurance, is very important, it is only part of the picture. The other part is having doctors (or other appropriate clinicians) who are available to see patients. This is the other area in which the US (and, in fairness, a few other countries including Canada) are failing. Have you tried to get an appointment to your primary care clinician lately? Maybe you can get in easily, but if so you are the exception. Most people have to wait weeks or months. If they go to the ER, they wait many hours, even for urgent or emergent problems. It would be good to be able to see a doctor who knows you, and knows your history, right? Instead of someone in an Urgent Care Center. I can answer all of these for people I know (or me) and the answers are not positive, and these are folks who are well insured and live in a major metropolitan area, not in a rural one or an inner-city health care desert! In Canada, there are suggestions that the way to fix the wait is to – wait – privatize health care! Hah! Come on down and see how that works here!
Why is it that people cannot get appointments to see primary care clinicians? Shouldn’t there be enough? Years ago on Saturday Night Live, Don Novello portrayed a character called Father Guido Sarducci who offered a “5-minute university”, where you were only taught what you would remember years later anyway. For Economics, it was “supply and demand”. So if there is so much demand for doctor visits, especially primary care visits, why is there not enough supply to meet it? This is, as you would guess, kind of complicated
Obviously, there are not enough primary care clinicians, either as a whole or as a percent of all physicians. If there were enough, you could call your doctor and get in today if you were sick or had a worsening problem. Like on TV (pick your favorite FP/GP show). So we don’t have enough. This is all about money. To some degree, it is about doctors wanting to make as much as they can. This results in far too small a proportion of graduates entering primary care, since they can make two or three times as much in some other specialties, which is enough to convince even many who liked the idea of primary care that, especially with their debt load, they liked anesthesiology more. We are at about half the percentage of primary care that we should be. For this I blame the system that pays other specialties so much more (or primary care so much less). In addition, the distribution is poor – not enough doctors in rural areas, or certainly poor urban areas, but all concentrated in more wealthy urban and suburban areas.
Ultimately this is all about the corporatization of health care, and the treatment of providers as widgets in a factory. Put this many in clinics, make sure that they are totally booked and have no room for anyone who needs to get in on short notice, put others in the hospital, put others in urgent care or ERs. Have no flexibility in the system because if you have the capacity to expand when needed, that means that at other times you have down time, and that is unacceptable for making maximum corporate profit. Of course, this is not good for your health, which is better when you can see a doctor who knows you, especially when you are sick and couldn’t plan two to eight weeks ahead of time (or more!) to make an appointment.
Creating doctors and other health professionals takes many years, and cannot change on a dime, but it will never change if that change doesn’t start. If we care about people’s health and healthcare, we need to dramatically decrease the difference between what primary care and other specialist income so it doesn’t discourage students from choosing primary care. We need to ban for-profit corporations (or ostensibly non-profit systems that act like for-profits) from being in our health system at all. All of health care and its components should be about ensuring better quality health for our people, not making money for businesses.
The usual pattern in the US is to have funding for public services cut by politicians who are receiving money from private corporations, to the point that they do not function well at meeting public needs. Then those same politicians say “privatize!” and they do and the cost goes way up and the public needs are still not met, because, well, that’s not what private enterprise is there for. (See this good video by Brittlestar on why privatization is not a good choice for Canadian healthcare.)
Jimi Hendrix said “Castles made of sand fall into the sea eventually”. But our health care system is not built on sand. It is built on rocks of intransigent corporate profit, and it is not going to change without a fight. You and your health don’t count as much as big business making money. So there. Pick up the gauntlet, and fight for yourself, your family, your community.
In The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture, family physician Gabor Maté presents a new formulation for understanding health and illness. Perhaps it is fair to call it a paradigm shift. Maté’s formulation implies that those of us who work in health care should be practicing differently. What might such a healing practice look like?
Firstly, the healer takes the side of the patient and the family – against the toxic culture that surrounds us. One component of the toxic culture that Maté identifies is capitalism, the valuing of corporate profits over human life, the relentless drive to extract private wealth while killing our ecosystem. Under capitalism, in order to stay financially solvent, pregnant women stay on the job until they go into labor. They return to their workplaces within weeks of giving birth. The stresses of working while pregnant, or the infant’s need for nurturing and attention, receive little attention.
Another component of the toxic culture is patriarchy, the control exerted over women and children’s bodies by men. In its ugliest form, this takes the form of sexual abuse and rape. Maté presents a number of case examples of how such past events become manifest as disease, not just psychological but also physical. The author, activist, and playwright V, who wrote The Vagina Monologues, recounts to Maté how abuse by her biological father led to her endometrial cancer.
Maté reviews the scientific basis for how our toxic culture leads to disease. As manifested by behaviors seemingly as trivial as not picking up a crying infant to crimes such as sexual abuse, the toxic culture of contemporary capitalism, patriarchy, and white supremacy leads to trauma.
What is trauma? As I use the word, “trauma” is an inner injury, a lasting rupture or split within the self due to difficult or hurtful events. By this definition, trauma is primarily what happens within someone as a result of the difficult or hurtful events that befall them; it is not the events themselves. (p. 20)
This trauma then leads to the somatic and psychological dysfunction that becomes manifest as both bodily and psychiatric disease as well as problematic behaviors such as attention deficit and addiction. Of note, this account of disease is dynamic, changing over time. Rather than an entity that one possesses (e.g. “my cancer” or “my bipolar disorder”), Maté views disease as a temporal process with roots in the toxic culture within which we all live, as well as in events that might not even be subject to conscious recall.
Thus Maté seeks to transcend conventional biomedical modes of analysis. The biomedical paradigm is reflected in traditional medical education. Premedical students must take basic science classes such as biology, physics, chemistry, and organic chemistry as prerequisites for medical school. In the conventional medical curriculum, medical students learn basic sciences such as anatomy, physiology, pathology, and pharmacology before they learn clinical medicine. The biomedical paradigm is reductionist in the sense that it seeks explanations in more and more fundamental levels of analysis: Thus, the search for genes that cause this or that disease, or dysregulated neurotransmitters as explaining this or that psychiatric disorder.
The biopsychosocial model was formulated by the psychiatrist George Engel in the 1970s in opposition to the biomedical model. Engel incorporated the atoms, cells, organs, cognitive and emotional factors, and social influences such as family, community, even the nation-state into the model. (See figure.) As such, the biopsychosocial model is all-encompassing and potentially powerful in its explanatory reach, but the details of its workings, i.e. the underlying mechanisms were insufficiently fleshed out by Engel.
Indeed, the role of large-scale social forces on health and illness has long been the concern of social medicine. Social medicine practitioners take a step back and examine the root causes of why the people become sick. The social medicine practitioner continues to ask questions until she gets down to the fundamental causes of illness—the social structure. The late Paul Farmer was a practitioner of social medicine. Howard Waitzkin, Alina Pérez, and Matthew Anderson provide us with a how-to manual on how to become a social medicine practitioner in Social Medicine and the Coming Transformation.
While Maté views himself as working within the biopsychosocial and social medicine paradigms, his contribution is to elucidate the epigenetic, psychological, neurologic, and immunological mechanisms by which oppressive social structures and the toxic culture of “hypermaterialist, consumerist capitalism” (p. 198) become manifest as disease.
As well, Maté critiques the reductionist program of behavioral psychology, originally formulated by B.F. Skinner, who derived his theories of behavior modification via rewards and punishments through experiments with pigeons caged in boxes. Maté is particularly critical of the child-rearing practices based on operant conditioning principles, e.g. advising parents not to comfort crying infants lest they feel “rewarded” for their “bad behavior.”
In discussing contemporary practices relating to the treatment of the young or the treatment of pregnant mothers-to-be, Maté references ethnographic accounts of the practices of cultures more in touch with nature, as well as how other mammals besides humans raise their young.
Maté reviews many cases to illustrate his points, but he also references his own failings. He attributes his touchiness about his wife not picking him up at the airport to fears of abandonment stemming from being placed under the care of strangers when he was an infant when the Nazis occupied Hungary. He regrets how his workaholism led to his absence from his children’s lives when they were small. By pointing to his own flaws and sharing how he is still trying to overcome them - he holds out hope for the rest of us to heal ourselves also.
In the Structure of Scientific Revolutions (1962), Thomas Kuhn described how paradigm shifts work in science. Normal science under the old paradigm, e.g. the Aristotelian view of the cosmos with the earth at its center, seems to work well enough, but there are just a few anomalies that cannot be accounted for. Over time, these anomalies and contradictions accumulate – until somebody, e.g. Copernicus, comes up with a new way of looking at the data. The new way of looking at things works much better, of course, and has much better explanatory and predictive power.
When I introduce medical students to family medicine, I often reference chapter five, “Philosophical and Scientific Foundations of Family Medicine,” from the 2009 edition of McWhinney’s Textbook of Family Medicine, the last edition before Ian McWhinney’s death in 2012. In chapter five, McWhinney discusses the paradigm shift in medicine - from the biomedical model to the biopsychosocial model – in the Kuhnian sense. Of course, the reductionist, biomedical paradigm continues to advance medicine. Take a look at the studies reported in any issue of the New England Journal of Medicine. In the clinical setting, however, we need to do a better job of understanding our patients’ pasts, their emotional lives. Organized medicine needs to do a better job of ending the hypermaterialist, consumerist capitalism that is making our patients sick.
I have advocated for the biopsychosocial model during my own medical and teaching career, though I will admit to (following Farmer) emphasizing “structural violence” sometimes and (following Waitzkin) “social medicine” at other times. (Farmer actually left out the “psycho” part and called his own approach “biosocial,” Pathologies of Power, p. 19.) Maté puts the “psycho” back into the biopsychosocial.
What does the practice of biopsychosocial medicine, informed by The Myth of Normal look like? How do I envision practicing medicine within the new paradigm?
Firstly, I will need to examine my own faults and shortcomings – similarly to how Maté subjects himself to self-scrutiny. In order to be an effective instrument of healing, I must first work on healing myself. Maté suggests how one might engage in “compassionate self-inquiry” (p. 431).
Secondly, I will pay more attention to the social lives of children. Are they given the opportunity to play freely? Do their parents have the wherewithal to bond with them? Do I encourage parents to respond meaningfully to their children’s emotional needs?
Thirdly, I will work on adopting a trauma-informed stance with patients. A first approximation will be to ask about adverse childhood experiences (ACEs). Many of those who share their illness narratives with Maté tell him, “None of my doctors ever asked me about that.” I hope to help patients recognize the roles that their illness plays in their life trajectories. I hope to help them heal.