Recently I had dinner with several primary care physicians who had just read Anatomy of an Epidemic. They had heard of my interest in this book and they asked to discuss it with me.These are physicians I have known for many years and in my opinion they reflect everything that is good in medicine. They are dedicated, caring, and humanistic. But the conversation reflected for me everything that is wrong with the modern practice of medicine. Although there are the ways in which psychiatry is different from the rest of medicine, there are ways in which it is similar and I am not sure we can expect much to change if we do not address some of these similarities.
Saying we do not like the medical model will not make that model go away. I do not think we resolve these problems simply by declaring that emotional distress is not a medical concern. If psychiatry were to whither and die, there would still be physicians out there who will prescribe psychiatric drugs. There will always be companies promoting their products, be it in the traditional or alternative realm.
Medicine is structured and funded in a manner that perpetuates and promotes a model that does not always serve us well. For graduating medical students in the U.S. today, one of the most competitive residency programs is Dermatology. It is required that a student is in the very top of her class to even be considered for one of these treasured spots. I am not against this specialty; skin after all is the largest organ. But I do not think it is a passion for reducing the suffering of those afflicted with skin diseases that drives this competition. It is the salary, the life style, and the thriving business of cosmetic dermatology that drives this. Although U.S. medical school tuitions are extremely high, this training is still subsidized by the taxpayers. Is this really where we want our money to go?
The New York Times had an article yesterday about the cost of colonoscopy. It is far more expensive in the U.S. than anywhere else. I know that colonoscopy improves the chances of discovering colon cancer and the best way to treat this type of cancer is to discover it early. However, we do not know if other tests are as good as colonoscopy in detecting early cancers. We do know that gastroenterologists are among the highest paid physicians. The article reported that in the past ten years since these tests have been highly promoted there has been a push to do them in facilities where the charges are higher than in doctor’s offices where many believe they can be done as safely. They reported how there are companies that have formed that advise doctors on how to set up facilities that allow them to maximize their reimbursement rates.
A couple of weeks ago, The New York Times wrote another article on how drug companies have access to deep data bases on doctors’ prescribing patterns. Some argue that this will help to improve the practice of medicine but others are concerned that this will allow the companies to fine tune their marketing pitches. Psychiatry is far from the only branch of medicine where ineffective and sometimes dangerous drugs have been over promoted and over sold.
If it was up to me, primary care physicians would be the highest paid and highest valued. After all, they are the lynch pins of the system. If you have a pain in your body, you need to go to them to begin the process of figuring out what ails you. They need to know about everything. They are the ones who see you through.
But in the model we have today, they are forced to see patients for 15 minutes or less. It is a grind. When I was a child, everyone in my family saw Dr. K. He was a revered person in our family and he addressed more than our aches and pains. We heard all about his family and he knew much about ours. When I was accepted into college, my grandmother was most excited to share this news with him. When I was in medical school, I remember being aghast when I went with my grandmother to a visit and heard the loudest heart murmur I have ever heard when he let me listen to the stethoscope he had placed on her chest. The medical care may have been less sophisticated back then but he cared for my grandparents into their seventies (and my grandfather lived to his nineties).
My modern day Dr. K’s peppered me with questions about what they could do other than to give their unhappy patients SSRI’s and their sleepless patients hypnotic drugs. They feel enormous pressure to prescribe. But they did not just talk about psychiatric medications. They feel the same pressure to give people antibiotics. These original “magic bullets” are so over-prescribed that we are raising a generation of superbugs for which we have no treatments. People go to the doctor expecting something and we spend an enormous amount of resources just trying to explain to people why no treatment may be the best course of action. That strikes me as a strange use of resources in a system we are not able to afford or sustain. The medicalization of sadness and despair is just a subtype of a pattern of medicalizing and needing to fix every ache and pain.
When I was a younger physician, I had a somewhat patronizing view of Dr. K. I bought into the notion so prevalent for so many years, that technological advances would save us. But what I have observed in the 30 years since I have been a doctor is that despite our advances, we seem to be getting sicker. The biggest advances in increasing the life span may have happened when we reduced infant mortality. Primary care physicians spend a lot of time trying to treat conditions that are man made. We are so good at growing food that we have found clever ways to get people to eat more and this has led to a growth industry in diet related ailments. We do not prize the relationship in medicine. We prize the procedure. We prize the drug.
Sera Davidow had a recent poignant post about her experience with a miscarriage. She was not looking for a pill. She was looking for a doctor to listen. She was looking for a doctor not to eliminate but to acknowledge her pain. My colleagues know this and yet something has gone wrong. Perhaps this is not exactly lost but it is tremendously undervalued. If we do not address this in a general way, I am not sure the focus solely on psychiatry will have enough impact.