The Decline of American Medicine
The COVID pandemic has highlighted concerning trends in the way medicine is practiced in the United States. These trends have been present for long time, predating the appearance of COVID, but their pernicious nature has become more apparent under the stresses and anxieties associated with the virus.
The fundamental and most deleterious trend is the decline of the physician/patient relationship. There are many causes for this — some economic, some cultural, some ideological — but the cumulative effect is corrosive.
The importance of the physician-patient relationship has been recognized for millennia, and was alluded to by Plato in Book IV of his Laws:
[D]id you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the dispensaries — practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints? The doctor who treats slaves prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill; and so he relieves the master of the house of the care of his invalid slaves. But the other doctor, who is a freeman, attends and practices upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.
The perception of the physician-patient relationship has changed over time, exacerbated by misunderstanding of its value and role. Individual physicians treating individual patients are not significantly responsible for increasing life spans in developed countries; that effect has more to do with clean water, improved access to food, and technological advances that decrease infant mortality. Nurses are every bit as important to good outcomes for patients as are physicians. To the extent that physicians collectively contribute to increasing life spans by, for example, improving individual outcomes in cancer, this result is ancillary to the more important role of physicians. This role is to minimize the adverse effects that disease and trauma have on an individual patient's ability to live his life in the manner he finds most meaningful. This role is dependent on the values, goals, and personality of the individual patient. It requires judgment, ethical reasoning, individualized attention and commitment, and clinical competence on the part of the physician, and trust and honesty on the part of the patient. These require relationships of the kind that are challenged in our current system.
One set of challenges arises from the inescapable fact that medicine and health care are a business. Over the past decades, the physician-patient relationship has been gradually replaced by the "service line" or "supply chain" model of health care delivery, in which the physician is a fungible part, and the physician-patient relationship an optional accessory. Overall management of the service line or supply chain is often delegated to a non-physician, which creates conflicts and perverse incentives in clinical decision-making. Related to this is a growing number of parties who lobby for their interests to be considered in individual patient decisions. These include insurance companies, hospital administrators, family members, nurses, case managers, consulting physicians, pharmacists, drug companies, etc. We can now add to the list public health bureaucrats, politicians, and ideology-addled academics.
A loosely related phenomenon is the proliferation of guidelines, protocols, and algorithms for management of particular patient complaints or diagnoses. These are, on the whole, beneficial, especially when treated as checklists or recommendations. The mischief arises when they are mistakenly treated as standards of care, often promoted as such by personal injury attorneys, and lead to situations in which individual patient decisions are deferred to remote panels of experts who never the particular patient, and the recommendations of which may not be consistent with that patient's values or best interests.
The intrusion of ideology into the medical profession seeks to redefine the physician/patient relationship altogether. It attempts to legitimize the notion that physician-patient relationship, which had been centered on the goals and values of the individual patient, must now prioritize identity-group interests. This type of ideological malignancy has led to such recent displays as physicians declaring they will not treat patients who are not vaccinated against COVID, or asserting that treatment of a particular medical condition, such as heart failure, should be influenced by vaccination status. Likewise, denying a demonstrably efficacious therapy to a patient solely because of racial or ethnic identity is contrary to human dignity and the moral foundations upon which medicine is premised. Such behaviors are intrusions on the physician-patient relationship, dehumanizing, and grossly unethical, as are recommendations that a particular patient who may be an unfit subject for vaccination receive it anyway because of external concerns.
The practice of medicine is no less vulnerable to ideological pathologies than is any other institution in American life. Politics and submission to ideological abstractions make nearly everything worse. One clear example is the diversity, equity, and inclusion dogma that is seeping into both academic and clinical medicine. The idea itself is based on the most paradoxical bigotry and obvious fallacies. To think a person of a particular race or ethnic group is best treated by a physician of that same race or ethnic group is to indulge the bigoted assumption that the patient is not an individual, but rather defined by racial and ethnic identity. It presumes that all such members of the identity group have similar values, goals, and interests. This is particularly evident when the idea of "lived experience" is raised, since a physician's lived experience may be irrelevant to, or even antagonistic of, a patient's values and interests.
Furthermore, the presumption does not translate well to considerations beyond race and identity, although, if the underlying premise were valid, it should. Experience does not support the idea that an obese physician is the best provider for an obese patient, or that a patient with lupus should be treated only by a physician with lupus. Certainly, one would not expect that psychotic patients do better with treatment provided by physicians suffering from the same affliction. Humanity and basic human decency are much more essential to the practice of medicine than is any affinity for a particular identity.
American medicine is still excellent. It entails a high degree of technological sophistication and scientific innovation. It employs a large number of committed and skilled personnel. However, there are forces actively degrading what should be the central focus and fundamental purpose of medicine, and that is the physician-patient relationship and the dignity and values of the individual patient. These are undermined by the encroaching economic, political, and ideological interests who either do not understand or do not care about the damage they are causing.