Map of life expectancy at birth from Global Education Project.

Friday, February 27, 2009

Just some thumb sucking about where medicine is today

When I first began to study medical sociology in the late 1980s medicine was just beginning to undergo a cultural shift that ultimately led to intense self-reflection.

The probability of doctors doing more good than harm didn't really become substantially positive until around mid-century, with the development of antibiotics and other important advances. Finally having a truly effective science of medicine was exciting and in some ways, too seductive, because it led to an era in which medicine was highly reductionist, breaking down the organism into separate pieces and systems and largely ignoring the psychological and social dimensions that are part of an entire human being. Hospitalized people were referred to as "the cirrhosis in room 2010" or "the COPDer in 817." Doctors and patients didn't talk with each other, the doctor just said, you have this and that, take these pills, or maybe didn't even bother to say you have this and that. There was a spate of widely read books that analyzed medicine as an instrument of social control -- Intimate Adversaries, Medical Nemesis, The Second Sickness, Disabling Professions -- and as unengaged with the humanity of patients -- The Discourse of Medicine, the Silent World of Doctors and Patients. None of these were saying that physicians were bad people or didn't want to benefit their patients, but they were saying that the culture and structure of the medical institution were in one way or another defective. Illich came at it from a religio-philosophical perspective, Waitzkin a leftist political perspective, Dundas Todd a feminist perspective, Zola the perspective of disability and the stigma of illness, Mishler and Katz a broader socio-cultural perspective, but one way or another they were all seeing the relationship as too one-sided, as imposing its own values and goals on the people who came in contact with it, to their detriment or disservice.

Fortunately, during the time I have been studying these issues there has been a large and sincere reaction to these criticisms within the profession. Academic medicine has honestly struggled to come to terms with the nature of the physician-patient relationship, the appropriate scope and boundaries of medicine, and how medicine should engage with individual patients, communities, politics and society. But we still have a way to go, both because the old culture is still somewhat entrenched and glaciers don't melt overnight, and also because we just don't know enough about how to heal people instead of livers and stomachs and immune systems. Social science is slippery, because there are too many moving parts -- every person is different even though we're also all the same. But anyway, I do believe that the practice of medicine is getting somewhat better, even as it is becoming more difficult and trying to climb uphill against growing challenges.

I'll continue to try to sort through it all here.

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