Posted by: notdeaddinosaur | March 18, 2012

Reclaiming “Medical” Care

Once again, we have people shifting words around to mean whatever they want them to mean, even (especially?) when a word itself means little or nothing. Today I am discussing the word “health”, specifically in the context of the phrase “health care”.

What, precisely, is “health”? The simplest definition would be “the absence of disease”. You can toss in the word “wellness” in the same context, with the connotation of well-being, in the sense of “not sick”.

According to a recent New York Times Op-ed about overdiagnosis as a flaw (hat tip to Dr. Bob), the idea that you need a doctor to confirm that you are indeed “not sick” is a relatively new development:

It was [Richard] Nixon who said, “we need to work out a system that includes a greater emphasis on preventive care.” Preventive care was central to his administration’s promotion of health maintenance organizations and the war on cancer. But because the promotion of genuine health — largely dependent upon a healthy diet, exercise and not smoking — did not fit well in the biomedical culture, preventive care was transformed into a high-tech search for early disease.

So that’s when it started!

In the past, doctors made diagnoses and initiated therapy only in patients who were experiencing problems. Of course, we still do that today. But increasingly we also operate under the early diagnosis precept: seeking diagnosis and initiating therapy in people who are not experiencing problems. That’s a huge change in approach, from one that focused on the sick to one that focuses on the well.

I agree. In fact, beyond a very short list of conditions (blood pressure screening for atherosclerosis; pap/HPV screening for cervical dysplasia; some kind of screening for colon cancer, be it universal colonoscopy or some kind of fecal test; and a surprisingly few others) in which early diagnosis has proven to extend life, I would argue as a physician that you should NOT be consulting with me unless you felt something was wrong with you.

In discussing problems with coordination of care, Dr. Stephen Schimpff writes (via KevinMD):

We don’t have a health-care system; we have a medical-care system, one that was developed to care for patients with acute problems…

I agree with this statement. However I disagree with Dr. Schimfpp (and lots of other people) that this is a bad thing. I am a medical doctor. I have been trained to provide MEDICAL care. What exactly is “Health Care” anyway? As noted above, “health” is indeed “largely dependent upon a healthy diet, exercise and not smoking”, therefore I submit that fostering these things is more in the purview of Public Health, as opposed to the private medical care of individual patients.

Think about it: doesn’t everyone know that poor diet, lack of exercise, and smoking are bad for one’s health? If not, shouldn’t they? Shouldn’t it be a matter of public policy to see to it that this basic information is promulgated to the general public? Hey, it was Surgeon General Luther Terry in 1964 who first warned the American people about the dangers of smoking. Eating a healthy diet requires things like access to fresh food, which is more a commercial issue than a medical one. Regular exercise — mainly walking — is more a function of city and regional planning, addressing sprawl and the over-dependence on cars than of anything I’ve been trained to do.

I don’t provide “health care” because there is no such thing, and I hereby reject the term “Health Care Provider” in order to semantically reclaim the terms that are rightfully mine and my medical colleagues’: Doctor of Medicine, Family Physician, and Healer.

 

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Responses

  1. It would be great if the complete list of conditions that should be checked even if one feels completely healthy were available to everyone, together with an indication of how often those things should be checked. Thank goodness that the complete list is a very short one.

  2. You are completely correct. There is so much abuse of language that covers deep conceptual problems. I cringe every time I hear “wellness”, which has now become a synonym for “health”.

    I also am not a “health care provider”. I’m a certified nurse midwife — but then, “midwife” is another highly abused term.

  3. Once we begin redefining terms, it becomes a slippery slope. Replanting the flags on the peak is no small feat. Especially when your climbing against an avalanche.

    There is much discussion now about relabeling patients. Are we clients, customers, consumers, partners, managers? ePatients? Activated Patients? Participants? When did “patient” become an inaccurate word? Or a derogatory word? I’ve come late to the discussion. Maybe I missed the explanation. Maybe tomorrow the debate will make perfect sense.

    Today I don’t much care what we patients are called so long as it’s respectful and everyone uses the term the same way.

    It’s time to stop playing with our words. Terminology in flux creates keyword hell for doctoral students. And I used to love libraries so….

  4. And if somebody calls me a “provider” one more time I may just lose my religion.

  5. Boy oh Boy do I agree on this one.

    I sometimes feel that much of my day is spent reassuring perfectly healthy individuals that they are not harboring some undiagnosed disease (usually cancer) that will claim their life before I’m able to diagnose it, without actually being able to give them that reassurance with the 100% certainty that is being expected of me. This, accompanied by the expectation that I have the ability and the responsibility to catch all disease in its earliest stage in all patients. Even if I do that, there must have been something I did or did not do that caused it in the first place.

    All of which leaves us open to malpractice claims as patient’s expectations continue to grow and exceed the realities of medical care. And in the end, this push for earlier and earlier diagnosis leaves us caught in the void between the onset of disease and its clinical manifestation, covering our tails, practicing defensive medicine rather than good medicine, documenting obsessively and ordering mostly unnecessary tests. Because if all disease can be prevented, then we doctors must be to blame when disease appears.

    Medical care needs a reality check. This wonderful article in the Times and this great blog post are a step in that right direction.

    Thanks as always for your writing.

    Peggy

  6. And, on the other end of the stethoscope, I would like to reject the term “health care consumer”. Applied to me by my insurance company of course. I don’t recall ever saying, “Something hurts which shouldn’t. I think I’ll make an appmt. to consume some health care.” But that’s how we’ve been labeled now: consumer and provider. It’s just wrong.

  7. It would be great if the complete variety of conditions that must be checked whether or not one seems completely healthy had been available to everyone, together with a particular indication of exactly how often those things ought to be checked. Thank goodness which the complete checklist is a really abruptly one.


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