Map of life expectancy at birth from Global Education Project.

Monday, January 27, 2014

What I can't really figure out

Not sure whether you uncredentialed rabble are allowed to read this, but here's a thumbsucker by Abeezar Sarela, a British surgeon, in BMJ, which is the jumping off point for this post.

It used to be, before the Great Humanitarian Cultural Revolution of the '60s (which lasted from 1964 to 1972), that everybody took it for granted that you went to the doctor, he (and it was he) told you what to do, and you did it. "Doctor's orders." In the formulation of Talcott Parsons, that was an obligatory social exchange. If you were sick, you maybe got out of some responsibilities, but that was only morally acceptable if you took on the full responsibility of obeying the doctor.

Well then, lots of smart and humane people, including notably among many others my mentor Irving Zola, started to question that. There are tradeoffs that come with medical interventions -- risks and side effects -- and we ought to have a say in making them. Doctors may be are motivated by financial incentives that we have a right to question. They aren't just writing prescriptions, they're deciding if we can get time off from work, receive disability compensation, have sex. Once we started to audio record physician-patient interactions we discovered doctors giving people lectures about morality and responsibility. This is our body, our life we're talking about and we ought to be the ones in charge. Medicine was viewed by men as patriarchal; oppressive in terms of gender, race and class; imperialist in trying to colonize more and more domains of life and classify difference as disease. You get the idea.

So we saw the rise of patient-centered medicine. It's supposed to be about us, as whole people. Doctors need to understand our lives and our values, and respect our goals and preferences. Even that turned out to be too weak and now we have shared decision making and concordance -- the doctor is supposed to do what we want. And we've had forests laid to waste publishing studies showing that they don't.

Sarela gives us a wake-up call. The whole point of going to the doctor, the reason they make the big bucks, is because they're experts and we aren't. It's hard enough for them to figure out what treatment is likely to be most effective, let alone tell us to do it. And the fact is, patients don't want to decide, for the most part. They don't have the requisite knowledge and they don't trust themselves. When doctors try to push decision making off on patients, patients often feel abandoned.

So exactly how we can be empowered in our dealings with physicians is far from clear. If my auto mechanic tells me the reason my car won't start is because I need a coil, I'm not about to say no, please replace the fuel injectors. That would be idiotic.

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