By O. Abbas. Dickinson State University.
In this last chapter I also resurrect the question of national health in surance safe adalat 30 mg, because it is on this question that the public debate about health care will turn discount adalat 30 mg mastercard. If a comprehensive program of national health insurance is prom ulgated in the next few The Arguments 5 years discount adalat 30 mg visa, as is almost certain, the structure, prerogatives, and style of practice of the existing medical care system will be frozen for decades. If the outcome is simply m ore medical care, our health will be worse and our well-being as a popu lation will be in jeopardy. Finally, in an epilogue I draw the broad outlines o f a new medicine, which must be calibrated with the future and specifically with the health care needs o f the future. Although most of the points are docum ented, the ultimate test is their theoretical strength. T hree characteristics of medical practice are particularly perplexing to the uninitiated. First, determ inations of the quality of care are made with out reference to the actual outcomes of care to the patient. To use a homely example, most of us judge a restaurant on the basis of the taste and quality o f the food. Seldom do we inquire as to the chefs lineage or education, or visit the kitchen to inspect the ovens and utensils. The quality of means and the results of health care are m atters of different im portance and m agnitude, but the analogy fits. Unlike the quality of food, the regulatory measures traditionally em ployed to control the quality of medical care have focused on who renders it and how, m ore often than on what the results have been. T here is one notable exception, although Florence Night ingale should get similar kudos. Codm an, a surgeon at Massachusetts General Hospital, sought to orient assessment o f the quality of medical care from structural or input evaluation—who did it—to process 6 The Impact of Medicine 7 and end-result evaluation—how and why. T he results revealed shock ingly low quality of care; only 89 of the 692 hospitals could meet the standards established for the study. Limited circu lation of the results aroused so much controversy that Cod- man could not at first get his findings published and then could not find sponsors for further research. He argued that patients should be required to pay only for good results, and that people should be aware of the results of their care. This is a slight variation on the practice in Babylon o f severing the physician’s hand if he failed to cure. He published annual reports that docum ented the results of his care and his methods o f accounting for the results. Cod m an concluded that 183 (or 54 percent) were managed without undue complications. For the rem aining 154 cases that were not satisfactorily managed in his judgm ent, 204 separate judgm ents were m ade to determ ine why problems arose. In most cases (roughly 76 percent), the problems were found to be due to errors in physician care, including surgi cal misjudgment, use of faulty equipm ent, or misdiagnosis. Second, and m ore puzzling than the failure of the medical care enterprise to examine its results, is the paucity of re search on the impact of care on the health of populations. Controlled clinical trials have been used to measure the impact of medical cures for individual patients. But, histori cally, with the surrender of medicine to the scientific m ethod, “population” medicine was relegated to the schools of public health, while medicine went to work on the indi vidual. Consequently, we know something about medicine’s impact on individual patients but very little about the impact of medical care on populations. T hird, there is even less research on the relative impact of 8 The Impact of Medicine personal medical care services and other socioenvironmental factors such as education, housing, air, water, seat belts, and Muzak. In other words, other than some anecdotal and impressionistic evidence, we have virtually no inform ation on the relative weight to assign to the various factors that bear on health, including medical care. First, evidence about the outcomes of medical care, when it is presum ed to be efficacious, is examined. T hen the obverse is examined—when the outcomes are adverse as a result of iatrogenesis, or disease “caused” by the medical care system itself. Next, the placebo effect is assessed, followed by a discussion of the im portance o f caring. The balance of the chapter examines the slender research on the impact of medical care on the health of populations and concludes with a review o f the even m ore sparse work on the relative impact o f medical care and other factors on health. To grapple with this subject, the following definitions de veloped by the W orld Health Organization can be used. T here is also evidence that it is poor in a surprisingly high num ber of instances. The Impact of Medical Care on Patients 9 T he Center for the Study of Responsive Law incorporated much of the research that has been done in its publication, One Life— One Physician. Lewis reviewed the records of the Kansas Blue Cross Association over a one- year period (only two hospitals in the state failed to partici pate in the review). He tabulated the num ber o f elective operations for removal of tonsils, hem orrhoids, and varicose veins, and the operations for hernia repair, in all the hospi tals in each of the state’s 11 regions. Variations for the average rate o f these four elective surgical procedures ranged from a low of 75 operations per 10,000 persons in one region to a high of 240 operations per 10,000 persons in another. Striking variations were also found between regions within each elective surgical category. T he high and low regional incidences (rounded off) per 10,000 persons were: for tonsillectomy, 153 and 432; for hem orrhoidectom y, 11 and 35; for varicose veins, 3 and 7; and for hernia repair, 18 and 43. T here is little doubt, however, that part of the variation is due to the relationship between the medical care provided and the num ber and type o f providers providing it. In the United States, there are twice as many surgeons in proportion to population as in England and Wales. If the results of the H alothane study are accurate, many patients are rolling dice with their lives when they seek care. In general, the research shows that the quality of medical care varies greatly; many instances of poor care can be found. T he data are also remarkable in light of the presuppositions most consumers hold about the quality and reliability o f medical care. Most of the studies in the report judge the quality of care by examining the “processes” of care rather than “outcomes” of care. In other words, the “m anner” in which care was provided is the focus of most o f the studies, rather than the actual “outcomes” o f care. Initially, only 94 of the 141 patients com pleted the battery of studies based on diagnostic X-rays; 77 (or 55 percent) re ceived an adequate work-up based on the intern’s diagnostic impression; but only 37 o f 98 patients, having received diagnostic X-ray examinations, were inform ed whether the findings were normal or abnormal; and only 14 of the 38 patients with abnorm al X-ray results (or 37 percent) ap peared to have received adequate therapy for the conditions indicated. Thus, the study resulted in effective medical care for only 38 patients (or 27 percent). N either effective nor ineffective care was given to 19 patients, or the rem aining 13 percent.
T here is no doubt that the competi tiveness and drive that characterize the ambitious business man and professional drain resources otherwise put to health buy generic adalat 30 mg. Moreover 20 mg adalat amex, the social and ethical concomitants o f success —dinner and cocktail parties generic adalat 20 mg without prescription, and long, liquid lunches, un 136 Medicine: a. But the health problems of those who cannot afford long lunch hours and cocktail parties are often overlooked, and may be m ore severe. From 1947 to 1962, m an-hour produc tivity in nonfarm , unskilled labor increased 60 percent; in agriculture the increase was 242 percent. Given the added hours o f com m uting to the job, for many the actual work week has increased. This results in what one investigator has referred to as “work- stress syndrom e”: A w ork-stress syndrom e m ay be postulated w hich is applicable to a w ide variety o f c u rre n t A m erican occupations— m an u facturing operatives, clerical w orkers, technicians and others. T h is syndrom e includes large-m uscle im m obilization, severe, p ro tracted , tim e-sensory-m otion discipline, high noise an d vib ration levels, an d intense illum ination. It is o ften aggravated by anxiety: ran d o m d angers and needs for im m ediate response associated w ith traffic hazards in com m uting; u n d erly in g an x ieties associated with th e obsolescence o f th e w orker’s skills an d need for constant re tra in in g. But at the same time, a shift to a service economy and proposed reduction in the work week might offset some of the stress. Some scholars, even sympathetic ones, have sought to dem onstrate that poverty and poor health are not inex tricably linked. As H orton and Leslie argue: Ill-health is probably th e g reatest single cause o f h u m an su ffer ing. It is d o u b tfu l if any o th e r single circum stance produces so m uch poverty and dependency, so m uch fam ily disruption, o r so m uch econom ic inefficiency as illness. For example, due to inadequate or nonexistent prenatal care, black children are far m ore likely than white children to be born prem ature. And infants born prem aturely are 16 times m ore likely to die during the neonatal period (the first 28 days o f life) and 10 times m ore likely to be retarded. T here are analytic debating points: does poverty “cause” ill-health or are the two simply found together with more than average frequency, and so on. By almost any measure, the poor are sicker than the nonpoor, and medicine does not cure them, even though the poorest see physicians as often as the m ore affluent. Health is not the product of the multi plication of services and people; it is rather a function of a health-producing environm ent and individual energy. Two of the greatest insults that poverty inflicts are the narrowness of options and vitiation o f energy. T he poor need medical care, but only to achieve a threshold condition, a state that can make other things possible. O f all the factors that might be mitigated, and thus cause m ore rather than less health over the next few decades, poverty is the least likely candidate. As we saw in C hapter 3, an increase in transnational activity, on both public and private levels, will result in health problems that transcend national boundaries at a time when all nations, including the United States, are elaborating and expanding their own medical care systems to the exclusion of the developm ent of a world health care system. Increases in complexity, stress, the size o f organiza tions, and the persistence of work-related stress will present society with new and aggravated health problems. Thus, while certain technological im provem ents such as the rapid developm ent of the com puter offer opportunities to im prove medical care, unforeseen health care problems may arise in the future. Leaving aside em erging health problems, over the next 30 years life is likely to be m ore stressful, faster, and m ore frenetic than it is now. T he diseases of civilization, such as heart disease, vascular disorders, and cancer, will exact an even higher toll because medicine is oriented to ward their cure, not their prevention. Although the health care system will fail to “cure” old age, it will nevertheless continue to lavish resources on the elderly. T he num ber of accidental deaths and injuries will continue to rise (even if in step with population growth), yet medicine engages the problem only after the fact, and poorly when it does. T here is solid evidence that environm ental degrada tion damages health and is increasing in magnitude. But medicine is designed only to repair hum an machinery at a time when the theoretical and empirical evidence is that health is substantially m ore determ ined by social and en vironmental factors. Levels of m ental and emotional disorder may be exacerbated in the future by psychological pressures on the aged as a result o f expanded longevity and expulsion from the job market. But there is little evidence that mental health services have a measurable impact on the incidence of m en tal illness. U nder such circumstances, not only might mental and em odonal disorders increase, their debilitating impact on society is unlikely to be affected by the provision of services. Biomedical breakthroughs promise to improve the tools of the medical care system to treat certain conditions, mostly acute in nature. At the same time, such technological innovations have m ade and will make it possible for the system to expand the present style of treatm ent almost infinitely. T he result has been and will be high costs and m ore concentration on acute conditions by increasingly specialized practitioners. Professionalism in medicine, which heavily influences its reductionist drift and depersonalizes medical care interac- uons, is incompatible with the values of a growing num ber of persons. One result is that the m ode o f adm inistration of medical care, and even its logos, will be increasingly disso nant with em erging hum an values and needs. We choose to live recklessly, to abuse our bodies with what we consume, to expose ourselves to en vironmental insults, to rush frantically from place to place, and to sit on our spreading bottoms and watch paid profes sionals exercise for us. Because this is the way most of us live we need a medicine that repairs us when our systems break down. The assaults on our health are different now, even though our life styles compel medicine to stay where it is. Second, medical care has less impact on health than have social and environm ental factors. And third, given the way in which society is evolving and the evolutionary imperatives of the medical care system, medical care in the future will have even less impact on health than it has now. Most of my argum ent has been supported by findings drawn from conventional research. But the argum ent thus 141 142 The Climate for Medicine far has taken medical care on its own term s— m easuring it by what it tries to do. T here are other powerful, even pro found, reasons why the end of medicine is near, however. Changes now occurring in society will fuel the dissolution of the medical care system and, m ore im por tantly, lead to a redefinition o f health. T here m ust be an accumulation of insight, criticism, consciousness, and politi cal acumen at one end o f a teeter-totter so that the medicine of today, at the other end, can be tipped. Sudden changes can occur—intellectual history reveals the suddenness of some transform ations.
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