Restoring care to health care
It is no surprise to say that a crisis in health care has been brewing for many years. What is surprising is how quickly the meltdown has occurred. Much of the reason lies in the extraordinary control corporations now have in the system.
Patient dissatisfaction is at an all-time high. Health care is not a coherent system, but a hodgepodge of corporate fiefdoms whose central aim is to maximize profit for the benefit of investors. To achieve this objective, time-honored clinical decisionmaking by doctors is being curtailed.
Arbitrary regulations, supervised by a burgeoning bureaucracy of technocrats, have now invaded every precinct of clinical judgment, whether the question involves a drug prescription, the need for a specialist, the propriety of an emergency room visit, or the advisability of hospitalization. Far worse than deprofessionalizing doctors, the current system of managed care is depersonalizing patients.
The industrialization of medicine requires two elements: the standardization of the product and the interchangeability of its parts. It must be said that this process preceded Wall Street's takeover of health care. It relates also to the longstanding marriage of medicine to reductionist science and to evermore sophisticated technology.
In the modern medical paradigm, each patient is a statistic similar to any other patient with the same illness. Science, in accounting for endlessly diverse biological phenomena, ignores individual uniqueness in order to abstract the underlying operating mechanisms.
What modern medicine proclaims as decisive are the biologic commonalties, while individual differences are given short shrift. If all patients have similar and interchangeable parts (organ-transplant programs sanction such a simplistic notion), the field is rendered ripe for corporate control.
How did we get to this point?
The crisis began in the very heartland of medicine. Doctors were seduced by financial incentives.
At first, unquestioning third-party payers provided an open till. Care was fragmented among superspecialists, with multiplication of mindless procedures, encouragement of uncalled-for office visits, and exposure of patients to a glut of unnecessary surgical interventions. Each test or procedure was converted into a profit center.
Yet, while America was spending far more for health care than any other industrialized country, over a sixth of the population was denied even rudimentary health care.
Someone was needed to control and manage doctors. The logic presented to the public was that only competitive, investor-owned health maintenance organizations (HMOs) - working to generate profit by cutting costs - possessed the financial discipline to stem inflation of health-care costs. Implicit in this corporate logic was that sickness could be regarded as a commodity, and that a patient can behave as a sovereign and knowledgeable consumer of health-care services. Neither assumption is correct.
Consequently, HMOs amplified and aggravated the many inhumanities that prevailed in the fee-for-service system. There are many highly skilled and caring doctors trying to practice humane medicine, but it is becoming extraordinarily difficult to do so. Many doctors are losing heart.
In market-driven medicine, the primacy of the patient yields to the perverse accountability of investors, bureaucrats, insurers, and employers. For-profit health care demands that the doctor perform as gate-keeper to ration or deny care. In these circumstances the patient-doctor relationship is undermined by suspicion that any advice is determined by the corporate bottom line.
For-profit health care is essentially an oxymoron. The moment care is rendered for profit it is emptied of genuine caring. This moral contradiction is beyond repair.
The elusive properties of mind and spirit that account for each person's uniqueness find scant sympathy in the current state religion that worships business efficiency. Nor do these properties enter the scientific equation.
AFTER all, empathy, kindness, altruism, benevolence, insight, joy, suffering, sadness, tragedy are outside the purview of molecular biology and accounting.
Patients will not acquiesce to the ultimate alienation of being reduced to standardized objects. No one will accept for long being merely identified by their illness, or seen as nothing but an assemblage of broken down biologic parts.
Patients crave a partnership with physicians who are as sensitive to their aching souls as to their malfunctioning anatomy. They yearn not for a tautly drafted business contract, but for a covenant of trust between equals earned by the doctor while exercising the art of caring.
A few years ago, shortly before his death, the essayist Anatole Broyard wrote:
"I wouldn't demand a lot of my doctor's time. I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh.... Without some such recognition, I am nothing but my illness."
*Bernard Lown is professor emeritus of cardiology at the Harvard School of Public Health and chairman of the Lown Cardiovascular Research Foundation in Brookline, Mass. He is also the co-recipient of the 1985 Nobel Peace Prize, which he accepted on behalf of the International Physicians for the Prevention of Nuclear War.
