The roots of a health care crisis

It is good to see such prominent health care providers as Drs. Dennis Shubert and Zev Myerowitz recently offering their carefully considered opinions on the causes and cures of our national health care dilemma. I would like to express my own thoughts.

President Clinton was so right (gasp!) a decade ago when he described health care as a system in crisis. It has gotten predictably worse since that time until the system is nearing a state of collapse. No one is happy and yet we do not dare to challenge some of the fundamental assumptions that make the system unsustainable. In a sentence, we continue to expect all the diagnostic testing and treatment we desire with no regard to how much it costs unless we have to pay for it personally.

I see three central and interrelated conundrums at the heart of our impending medical collapse. If we Americans had the political will to solve these puzzles, we might be able to keep health care off life support.

First, is the end of life a problem? Life is a terminal illness. No matter how much preventive medicine, medical and surgical care or even alternative medicine we get, we will all get sick and die. The problem is that a great proportion of our health care dollar is spent in the last days of a patient’s life; often after it is quite clear that the patient has no chance of long-term survival.

Few people, least of all I, begrudge expensive medical care to people who can be helped back to a healthy and happy life. But there is no mechanism for saying enough is enough. Eventually the cost of caring for dying patients will become so high that there won’t be enough money in the treasury to pay for it.

The answer has to come from minimizing the high-tech procedures and hospitalizations for the dying and maximizing hospice care, in-home care and other supportive help. No one should have to die in a hospital surrounded by machinery and strangers because the system does not pay for “non-medical” health care. However, it will take great political will to switch the thundering express train of medical care onto this less invasive track.

The second issue is the gradual elimination of the whole person from medical care. When I first started to practice psychology 30 years ago, there appeared to be a movement toward the biopsychosocial conception of illness. That is illness (and by extension the patient) was defined by interaction of biological, psychological and social factors and not as either a medical or a psychological case. Instead, the momentum has been in the exact opposite direction. More and more of life’s experiences and variabilities are being classified as an individual person.

The problem here is that we have come to believe that for a condition to be legitimate (and paid for by insurance) it must be a “physical” disease with a “medical” name. Thus, headaches become migraine headaches, back pain is a degenerative disk disease, other pains become reflex sympathy dystrophy, carpal tunnel syndrome is fibromyalgia. I would not discard any of these diagnoses. All have their place when used with care and specificity. But these terms have become all-purpose labels that simply rename subjective experiences in pseudo-objective terms. And the process always seems to lead to the same medical interventions of medications and procedures such as injections and surgeries.

Another way to look at this topic is in the distinction between acute disease and chronic illness. The dramatic medical advances in recent years have been in the diagnosis and treatment of serious acute disease. It makes sense to do all necessary medical tests if a patient has had the recent onset of medical symptoms. If investigation reveals a treatable condition, it should be initiated without delay. We’d all expect that from our medical care.

However, chronic illness is a different matter. The longer a patient has had similar symptoms and the more diagnostic treatment procedures he has had, the less likely new and repeat interventions are to yield improved results. Over time, the attitudes, beliefs and behaviors of the patient becoming the more significant issues.

Powerful forces in modern health care seem to conspire to always push medicine toward the acute care model. As I’ve seen too many times to count, patients come with medical charts inches thick with diagnostic test after test and medical intervention after medical intervention. The astounding number of curative procedures, medications and even surgeries by a host of practitioners are all intended to cure the condition as though it were an acute disease. The consequence of this acute care attitude is not only the direct costs of so much redundant and ineffective care. More serious is the psychological effect on some people of reinforcing their beliefs that they are sick or disabled and causing them to seek more and more medical attention. In sum, modern medicine tends to leave the patient out of the health care equation.

This brings me to my third central issue. In present-day medicine, it is much more advantageous to act than to think. Expensive medical tests and diagnostic procedures take the place of reason and judgment. Doctors who still spend a great deal of time in the difficult process of gathering all relevant history, examining the past medical record and thinking carefully before acting can be economic fools. Patients and insurers aren’t interested in paying for this kind of work.

Despite their protestations, medical insurers act as if a penny-wise and pound-foolish system is exactly the one they want. They will pay for health services only if they receive a convincing medical diagnosis and an authorized medical treatment. The more serious the diagnosis and the more invasive the treatment, the more they’re willing to reimburse. Similarly, doctors almost never get into trouble for over-diagnosis and over-treatment.

But let a doctor define a patient’s condition more benignly or psychologically and offer to help the patient cope with what he’s got and an insurance company will be quick to deny any benefit at all. Patients also share the blame for this. For many people, high-tech and expensive medicine promises a magical solution to their problems without any burden of the responsibility or hard work on their own behalf. Besides, many patients today resent any discussion of psychological issues involved in their illness. The common reaction from these patients is, “you’re trying to tell me it’s all in my head.”

The grand result of these three factors is an exorbitantly expensive medical care system with more and more being spent for less and less positive result. As a recent Wall Street Journal article put it, citing the work of Dartmouth physician John Wennberg, “there is little scientific basis for the differences in the way medicine is practiced in the U.S. and little evidence that giving more care always extends lives.” (WSJ, March 21).

Eventually, we will have to change our beliefs about what we expect from health care. We will have to decide what kind of care we give to the dying and how much we want medicine to intervene in our own subjective experiences. We will have to change our current medical insurance hodgepodge into a single system where we all take the responsibility for defining what is paid for as health care through the political process. Above all, we will have to find a way to bring good judgment and good sense back into health care.

Robert L. Gallon, Ph.D. is a psychologist practicing in Bangor.