The Crisis in Medicine: A Provocation
A cardiologist argues that contemporary medicine may harm as much as help.
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I was the only one of my group of friends from college to go to medical school—something I thought about often in my twenties, when I was confined to a library cubicle and trying to memorize the names of obscure diseases. During brief and infrequent phone calls to catch up, I’d hear about their lives in Manhattan and Chicago, which seemed to consist, when not trading derivatives, of sipping expensive cocktails. After hanging up, I’d feel bitter and envious. On more than one occasion, I contemplated dropping out.
Probably as a coping mechanism more than anything else, I began to tell myself a certain sort of story. At least I was doing something to better the human condition; my college buddies, friends though they were, were simply manipulating 1s and 0s and making the rich richer. At one point, I remember coming across an interview with Jonathan Safran Foer in the New Yorker. “For a long time, I thought I would like to be a doctor,” he said. “Such a good profession. So explicitly good. Never a waste of time. No obstetrician goes home at the end of a long day and says, ‘I delivered four babies. What’s the point?’” He’s right, damnit, I thought. This sucks, but it matters.
This conviction carried me for several years—through my internship and residency, even past my fellowship. But now that I’ve been out in practice for a few years, it has begun to feel a bit less ironclad. At times, I’ve begun to wonder if medicine may be less meaningful, its mission less unassailable, than we like to let on.
This is, admittedly, a bit of a provocation. Modern biomedicine has, of course, delivered breakthrough treatments over the past century, treatments which have transformed the care of diseases which were once considered incurable. Aspirin for heart attacks. Insulin for diabetes. Potent antibiotics to treat infections caused by highly virulent organisms. These interventions are true marvels of the modern age: they're safe and effective for conditions that affect millions. We should rightfully celebrate such treatments and work to make them widely and freely available.
The problem is that for other types of treatments—treatments which now constitute the bulk of medical care—the outlook is far less sanguine. This seems especially pronounced in my field, cardiology. To take just one example: trial after trial has demonstrated the limited effectiveness of stents for many patients with blocked or narrowed heart arteries. But, undeterred, cardiologists have plowed ahead, depositing these little expandable tubes via catheters into hundreds of thousands of patients every year, committing them to long-term medications, and, quite often, setting them up for a lifetime of continued unnecessary testing.
At times, I even find myself wondering whether we’ve reached a hard limit on progress, at least when it comes to the sorts of “blockbuster” treatments I mentioned earlier—treatments like insulin, which, though it was discovered more than a lifetime ago, has prolonged the lives of and alleviated the suffering of millions.
Now, our most highly-touted novel treatments also seem to have the nasty habit of failing to replicate in large clinical trials. It’s a familiar scene: a “late-breaking” trial at an international medical conference, the audience waiting with hushed anticipation for the big reveal. A two-fold decrease in mortality! A 30% reduction in hospitalizations! The story gets picked up by all the newswires, the TV commercials for drug X (“ask your doctor about…”) start to appear. Never mind that a subsequent trial—or two, or three—enrolling more patients and performed the following year demonstrates no effect. No matter, use of the device will continue to increase, as health care expenditures in the United States inch ever closer to 20% of GDP.
And then there’s the work itself. Consider the transformation that medicine, as a vocation, has undergone. As the sociologist Paul Starr wrote in the 1980s, physicians will come to experience “more regulation of the pace and routines of work.” They will be required to meet “standard[s] of performance, whether measured in revenues generated or patients treated per hour.” Starr was prophetic. These days, the job often resembles middle management: the day to day drudgery, the hours in front of a computer, the electronic health record-keeping systems which inflict “death by a thousand clicks.” The operative term in healthcare now is “productivity”: the work of trying to make people better reduced to the “relative value unit,” or RVU, which, along with the QALY, or “quality-adjusted life-year,” have conveniently allowed us to mathematize human flourishing and suffering.
But wait, you might ask, does any of this really make medicine any less meaningful? Could this not simply be a function of the field’s bureaucratization and corporatization; of the well-known incursion of drug and insurance companies into what should be a publicly funded enterprise for the collective good; of misplaced research priorities; of the “publish or perish” mentality that dominates biomedical research (and therefore results in volumes of low-quality, duplicative work)? These well-known factors are surely responsible for the degradation of the job as well as the experience of the patient, you might say, but they hardly make the job itself worthless.
Perhaps. But I do worry that there may be something deeper going on here. Along with the diminishing efficacy of our treatments and the proletarianization of the work of healing is the nagging sense that we may actually be hurting people. And—critically, depressingly—we may be hurting them just as much as we are helping.
Over twenty years ago, the Institute of Medicine famously estimated that nearly 100,000 patients die yearly in hospitals due to medical errors. An egregious figure, and one that doesn't even really capture the scope of the problem. Giving the wrong dose of a medication, or overlooking a severe allergy—these are certainly elements of the healthcare system’s proclivity to harm. But a more apt descriptor may be what the philosopher and theologian Ivan Illich described as “iatrogenesis”—the tendency of an industrialized society to medicalize all of its inhabitants, to see people as either diseased or pre-diseased and treat them as such. In this way, says Illich, “the medical establishment has become a major threat to health.”
An elderly patient I saw recently had a severe narrowing of one of her heart valves, which had been present for several years. She felt fine but nevertheless underwent an elective catheter-based procedure to receive a new valve. The new valve tore her aorta, and she was rushed to the OR for emergency open heart surgery. Postoperatively, her kidneys failed, rendering her dialysis-dependent. The blood thinners she had been prescribed caused bleeding in her brain and she was wheelchair-bound. What did I have to offer this patient at our first visit following her protracted hospitalization? Perhaps the most important treatment of our contemporary era: combing through her medication list and eliminating extraneous prescriptions (high cholesterol, at this juncture, felt like the least of her problems) and telling her that I was sorry.
The medical meliorist will be quick to cry foul, to say that this is an extreme example, hardly representative; that complications happen. All of this may be true. But even seemingly benign procedures—all of those “routine” heart catheterizations I alluded to above—carry silent consequences, the severity of which we are only beginning to realize.
There are certain boilerplate policy prescriptions that tend to be trotted out in response to these sorts of criticisms. A common one is that this is all simply a problem of supply-demand mismatch. Increase the number of doctors, the argument goes, and you would relieve the pressure that doctors face to churn through patients and overtest and overtreat. It’s a simple problem of elasticity.
But the economics of healthcare are unlike those of, say, automobiles, as Kenneth Arrow argued sixty years ago. In particular, he wrote, “[t]he special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and the efficacy of treatment.” Old illnesses recede, new ones emerge. Complex, high-dollar treatments are hailed as the “next big thing,” only to have their unforeseen and untoward effects discovered years—often decades—later. By then, of course, it’s too late. The funhouse-mirror economics of healthcare will have done its work, where the mere existence of a new therapy and its inevitable increase in supply will paradoxically result in an increase in demand. Hundreds of thousands of devices implanted and drugs prescribed, only to be eventually recalled and pulled from shelves.
So what, then, are our choices? How do we resist these forces, in order to ensure that the work of healing remains meaningful? Because for all its faults—and despite the near-fatal flaws I’ve spent the last couple thousand words enumerating—it’s still hard to imagine doing anything else.
When it comes to medicine, I can speak only to the approach that I’ve come to adopt in recent years: do less. In fact, don’t be afraid of doing nothing at all. As medical students, we all solemnly took Hippocrates’ famous oath, but we would also do well to remember his “rule of thirds”—one third of patients will get better if left alone; one third won’t respond to treatment; and it’s only the remaining third who will derive some (often marginal) benefit from our armamentarium of pills and machines.
Finally, and perhaps most importantly, recognize that ordering tests and performing procedures is no substitute for treating people with dignity, for understanding their station in life and meeting them accordingly. The smallest of interventions, but one that has the potential to be the most consequential. And one, I’m afraid, that may be our only hope.
Akshay Pendyal is a physician and writer living in North Carolina.
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