V. Reichman is right in pointing out that healthcare has gotten off track in its goal to provide patient-centered care by focusing a little too heavily on the biomedical model; Dr. Brewster’s examples further show that the push towards biomedical predominance is not just because of provider insistence. Thus, several points that underlie the patient-physician (and many times, family-physician) relationship from a psychosocial perspective are consistent with two pervasive cultural mindsets in American society. 1) Americans want to have problems solved, which proves messy for a field that has uncertainty like medical biology and 2) Americans, by-and-large, are uncomfortable with death.

The fact that most Americans want a definite answer, or solution, for their health problems creates several problems for providers. First, preventative care is devalued because it involves treating a problem that either doesn’t exist or won’t exist. So, getting patients to buy into preventative care is challenging, and payment schemes don’t reward providers for trying hard to encourage a commitment to prevention. Second, often times patients are frustrated that a surgery won’t “cure” their problems. Recently, my grandfather was hospitalized for chest pain. He had such severe blockage in his arteries that by-passes were impossible because there was no place to by-pass to. While some stents were put in place, he left the hospital frustrated because he couldn’t be ‘cured’ by a single surgery. A by-product of providers receiving such esteem for the ability to treat complicated disorders, many patients feel that physicians can solve all their health problems no matter the stage of their illness. The outcome for this mindset could be patients being sicker before they seek treatment, or an exacerbation of the biomedical model for treatment at all costs. Third, if patients are frustrated that their provider is not “pulling out all the stops”, they may resort to readily available information on the internet to treat themselves, or demand certain care from their provider. The patient demand for procedures has contributed to the exponential increase in healthcare costs.

My second point, America’s uneasiness with death, fuels the malpractice culture and excessive use of expensive life-prolonging treatment. Death is always seen as something to avoid no matter the circumstances, sometimes with a poor ‘life quality’ being preferred to death in the minds of both patients and their families (and providers too). Many times families of unconscious or comatose patients insist on life-sustaining treatments because death is a ‘bad’, ‘evil’ thing that is not talked about sufficiently in society and is unequivocally a bad outcome. Further, when death does occur in the medical environment, there is the urge on behalf of families to determine blame for this terrible event, whether it is negligent or not. Perhaps if death and healthy grieving strategies were more common in conversations in our culture, ‘life-at-all costs’ would be a mantra that lessens in importance. Sadly, the palliative care options in the healthcare industry have been slow to catch on among patients and their families for this reason (among others), not to mention potential undervaluing from insurers and providers alike.

While doctors can’t fix everything, they can do something. Physicians alone cannot change society’s beliefs, values, or healthcare preferences. However, they can still make a difference by taking the time to sincerely discuss their patient’s demands and end-of-life issues. While treating one less patient a day to make room for effective discussions with patients and their families may affect physicians’ wallets, so do malpractice suits and reductions in insurer reimbursements when unnecessary tests are done in excess. Physicians need to take the lead in preventing the situations Dr. Brewster offers, before the situation that “doctors can’t fix everything” becomes “doctors can’t fix anything”.

The dominance of the biomedical paradigm and the continual emergence of new technology misleads us to demanding more medical solutions, either for things which are natural – like some aging processes and death, and for things some things which are better addressed on a preventive level through community means. As a society we expect everything to have a scientific basis and a scientific cure. Ultimately, that proves both myopic and expensive: we develop conditions we could have avoided with a better, and cheaper, focus on prevention (for which the responsibility should lie with both patient and physician), and we pay billions more to treat their distal effects instead of their proximal causes (such as behavioral, social and economic ones). Even more than a fiscal restructuring, a cultural revision of the role of and the management of our expectations from medicine could improve how we deliver and acess healthcare.

I don’t think the medical field uses the same definition of “life” that many patients, especially those with chronic, non-life threatening conditions use and it is THIS discrepancy that leads to an adversarial relationship between doctor and consumer.

The woman demanding the CA-125 is concerned about her life’s quality, which includes her appearance and self image, and the standard of care ignores.

The woman with pain isn’t having her pain addressed. Doctors are looking for a disease to cure without treating her symptoms and her quality of life is deteriorating.

The 94-year-old’s son was unwilling to live with guilt that would damage his quality of life for years later.

If quality of life would be included in standard or care, much of the anger and frustration would be eased, if not eliminated!

This is a heartfelt and meaningful post.

I believe many of our troubles in health care today are because we look at the issues you raise through a financial lens. We talk about things like cost when we should really be talking about what it takes to, as you say “find doctors that we trust and follow their recommendations.”

It’s not so much a question of rethinking our expectations of the health care system. It’s instead about repositioning medicine, patients, and their families at the center of health care. And recognizing that who pays for health care, and how they do it, is secondary to these important issues.

I have some related thoughts here: http://bit.ly/1641Wf

Many thanks,

Evan Falchuk