Losing Trust in Medicine
People are losing trust in medicine. This is a very bad thing. And doctors are taking note. From a column by a surgeon named Pauline Chen published in the New York Times: "I don't rely on the doctor anymore. These days, you have to look out for yourself."
Alas, the column doesn't really explore the reasons for this verity, although she hopes to have further conversation about that with readers of the NYT Web site.
Those words, and the smell of grilled meats, wafted by me at a recent potluck dinner party. My husband and I had tagged along for a summer reunion, where my sister-in-law and her husband joined a group of 40-, 50-and 60-somethings who were visiting their hometown, eager to catch up on their childhood buddies’ lives.
The chatter started as one would expect--five-minute recaps of work, children, parents and summer plans. But as the evening progressed, the gossamer conversations of this boomer crowd seemed to spin into one thread: the state of one's health. Or our parents’ health. Or our children’s health.
And no matter the specifics of each story, they all seemed to revolve around one theme: that as a patient or the family of a patient, you would feel at odds with the very people who were supposed to care: the doctors...
More and more Americans feel disconnected from their doctors, especially compared to a generation ago. And they certainly have less confidence in the profession as a whole. In 1966, a Harris Poll found that almost three-quarters of Americans had “a great deal” of confidence in their health care leaders. That number has steadily dropped over the last four decades, so that today only slightly more than a third feel the same way, the same poll shows.
I suggest the conversation could look into these issues for a start:
1. The erosion of Hippocratic values caused by the influence of utilitarian bioethics leading toward a "quality of life" ethic that devalues the sickest patients and those with cognitive and developmental disabilities.
2. The erosion of Hippocratic values caused by the influence of HMOs and the capitation system of medical economics that result in hospitals and doctors losing money on the sickest patients or those with the most serious disabilities.
3. Bioethics agenda items like futile care theory in which people see stories of doctors trying to refuse wanted life-sustaining treatment.
4. The drive for health care rationing that would be medical discrimination by a more polite name.
5. The erosion of trust in ethical end of life care sowed by the assisted suicide movement.
6. Controversies like the Terri Schiavo case in which some people see a helpless woman dehydrated to death by doctors who willingly remove sustenance and others see a woman forced to remain alive against her wishes in a condition they dread befalling themselves or their loved ones.
I am interested in any of your thoughts on this important matter.
posted by Wesley J. Smith @ 6:10 PM
17 Comments
17 Comments:
7.) A holier-than-thou attitude held by some physicians, in particular those who pick and choose what information to tell patients based on their own ideas of morality.
Case in point: the current regulations being promulgated by the Department of Health and Human Services. If people can't be sure that their doctor is acting in their best interests, it's no wonder they don't trust doctors. By placing their own "conscience" above all else, doctors are sending the message that patients' consciences are somehow worth less.
Perhaps this is too simplistic, but I would say along the lines of your #2. The doctor spends ten minutes max with you in the examination room, and most of those ten minutes, he's looking at you like he wants you to shut up so he can move on to see the next patient.
Being in the hospital is very chaotic for most patients. They rarely have the same nurses every day, and sometimes they have a doctor following them who they've never met before.
There's no relationship there, like there used to be with doctors and patients.
Perhaps it also has something to do with pharmaceutically driven practices, in which the physician barely acknowledges anything your saying, but listens for keywords like "pain," "headache," "sore muscles", and then quickly dispenses a prescription for the symptoms, never EVER taking the time to dig deeper to find the cause. Not only do they seem not to be very competent, they also seem not to care about anything but how many milligrams of drugs they can prescribe in a day.
misty: Thanks for dropping by. That's a very sobering evaluation.
heather: Not simplistic. I think you and misty are dealing with the same phenomenon, that is the managed care system is forcing doctors to take more patients than they can handle. And I believe our education policies pay medical schools to limit the number of physicians trained, at least that occurred under the Clinton Adm.
dr. dredd: I wonder if the situsation is kind of like people's disgust with Congress, but they like their own Congressperson.
The erosion of which Hippocratic values? Abstaining from sex? Not sharing money/goods with teachers? Not teaching medicine for free?
I think if medical school didn't cost anything, we'd certainly have a lot more doctors...
Health care rationing is the elephant in the room. If health-care resources were unlimited, this would not be an issue. Given the situation in the real world, however, I'd suggest that it would be blameworthy not to take questions of distributive justice into account in making health-care decisions.
I take care of my disabled, elderly mother full-time, so I presently have no health insurance. A subsidized clinic takes care of my basic health care needs for now.
My wonderful doctor and I got into a conversation when I asked her whether she had privileges at any nearby hospitals. She said no. She left an urban area in another state and came to my rural area because she had been working over 100 hours a week between the practice and the hospital. She added that now some 80% of US doctors with private practices are choosing not to have hospital privileges for this reason. Hospitals increasingly have their own dedicated rosters of doctors.
She also said that in her former practice, working under other doctors, patients would actually simply tell her, "I need X drug—just give me the prescription," indicating they didn't expect her to take any time to address their problems anyway. That was apparently what they were used to, but it alarmed her. Of course, she was expected to keep the "assembly line" of patients moving herself. There was no time to chat at all.
She told me she was glad to be working at the clinic, because she could take time with her patients and be herself. And so she did with me.
But her comments do raise an interesting question. Those doctors who want to practice futile care theory, utilitarianism, etc., to the detriment of patients all seem to be attached to hospitals—as opposed to being the patient's own doctor in a private practice. That would clearly make a difference concerning attitudes about patients: old Mr. Y in room 323 simply becomes another elderly person consuming medical resources, as opposed to actually being "my" patient.
Perhaps this explains much of the trends we see, Wesley. And burnout in a hospital setting might also explain some doctors' decisions there. I don't think my doctor at the clinic would be likely to say, "Pull K-Man's feeding tube." But an anonymous doctor in a hospital certainly would, or at least would be much more likely to.
And that makes me shudder to think what might be the outcome when my mother ends up at the hospital in bad condition, which will happen one day...
Hi, Wes. I guess I'm in the minority. I have a low opinion of both Congress in general AND my congresspeople...
This is an interesting discussion. I'm a primary care physician, and it's true that there's a pressure to see more patients in less time. However, part of the problem is also that there's also more to do within each patient visit. With so-called pay for performance, the number of guidelines we must follow has grown exponentially. Not everything can be done in a single visit, but there's an attempt to cram everything in there anyway so we can get reimbursed. It's a horrible system.
I think this is also related to K-Man's point about hospital doctors and futile care theory. I'll say up front that there are many cases where I do agree with the withdrawal of life support. The recent case in Rochester comes to mind. The patient in question had a living will; I have no problems following that, even over the objection of a family member who may not truly know how the patient feels. But the problem is that there often isn't a living will, and physicians don't have the time to explore the situation in depth.
I used to have an amazing doctor. He was actually my pediatrician, and I kept seeing him until I was 23, and he was the old sort who listened to patients and actually spent time trying to figure out the problem, so I used to have a very high opinion of doctors. Unfortunately, I got too old for (and he has since retired) and in the last 3 years I've not found a doctor I really like. Most of them have no interest in listening to the patient. I even went to one for a foot injury, and she spent almost the entire appointment trying to convince me that I ought to get the HPV vaccine (she actually tried to make me feel stupid for not wanting to get it, but that only encouraged my stubbornness about it). Like Misty above said, doctors driven by pharmaceuticals.
And like dr_dredd said, a holier-than-though attitude. My view of doctors has darkened (only once in the last three years have I encountered a doctor who actually listened to me and answered my questions without being condescending).
I think all the good doctors have retired or been driven out of Washington State by the ridiculously high cost of medical malpractise insurance.
Thanks all. I like my doctor precisely because he is not a technician. He has told me the most important thing he does is listen.
His associate, while a fine doctor who I like, I don't want as my PCP. We have used him for acute issues, and my sense is that he looks at problems as if it were from a checklist. I also know he will be more likely to prescribe--not that he is a pill pusher. So, for my PCP I have a sort of Marcus Welby. He also knows me and I have the feeling that because of that, if I presented not looking "right," he would notice.
I think it's a pattern of hubris and lack of attention to patients' wishes that has eroded trust in the healthcare system. For instance, I used to trust doctors to make a reasonable determination about my brain's activity level if I were in an accident, and therefore planned to become an organ donor. But, I have since decided against this status, as I do not want doctors rushing to grab my organs after they have declared me to be in a PVS or permanently comatose state after a few days. This is sad, and many others will probably decide against becoming organ donors because of the utilitarian ethics that are being employed by hospitals. I think that the distribution of resources argument is prejudice dressed up in another form, when it applies to denying care for those with severe medical conditions. In such cases, doctors are discriminating against certain actual patients for the purpose of ensuring equal medical care for hypothetical patients. A common argument is, "someone else needs the feeding tube/ventilator to live." Are we suggesting that feeding tubes and ventilators are in short supply when considered in respect to the number of people who need them? And, if someone else needs it to live, isn't that person just as disabled as the person currently using it to survive, and thus subject to the same type of discrimination? And how are people with any disability possibly supposed to trust hospitals if the hospitals endorse utilitarianism/discrimination against us? Honestly, sometimes I get the impression that many in the medical/bioethics profession think that the general public is too stupid to recognize such conflicts of interest.
Also, there does seem to be a trend toward prescribing drugs with extremely dangerous side effects when people's conditions are unclear. For instance, a doctor once suggested that I take medication for a condition that she wanted to diagnose via my reaction to the medication, which, in rare instances, causes a flesh-eating rash that kills you in two weeks. I told her no, thank you, I'll take the orginal problem! (which, it turned out, wasn't the cause of the symptoms I was experiencing)
A variable that must be included is health insurance. Two classes of people exist today and it directly affects how they view doctors: here I refer to the insured and those without insurance. I simply cannot afford to see a doctor as my health insurance is grossly inadequate (hospitalization only). I save all my money to see a urologist once a year (I am a paraplegic). The thought of routine blood work and establishing a working relationship with a doctor is a pipe dream. As I age I know this will likely adversely affect my life expectancy. I can either pay my taxes, put a roof over my head, and work or see a doctor.
Dang, William. Every health care policy I've had over the last several years has offered a free yearly physical. They'd rather pay for, for example, a mammogram every year, than metastatic breast cancer.
(I'm reading that book.)
I have found, no offense anyone, that some doctors are idiots. Sorry, but they are. I could give examples.
I think the internet has only made us aware of how much knowledge there is, and what our doctors don't seem to know.
I am a part time professor and writer--essentially self employed. I have never had insurance that covered a single doctors visit or any medication. I suspect most who do not work for a corporation share my experience.
Years ago I worked for a mom-and-pop through which my health insurance was affordable, but not dependent insurance. My husband's insurance on his job was even worse. I called Blue Cross and said, "Don't y'all have health insurance policies for individuals, not through their jobs?" Indeed they did, and my husband and daughter were covered by a family policy for years. It was cheaper than what I could get through my workplace, and it did pay for yearly physicals. But I know that what's available varies widely by state and over time, and by individual people's circumstances.
Yes, I could get insurance independently. In the state of NY it would cost close to my yearly salary. I could try to get insurance through the national anthropological association but I cannot do so because I live in NY. I have spent a great deal of time on this issue and found no solution aside from moving out of NY.
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