Friday, January 06, 2006

Paternalism-It's All About Power-Maybe?

In my "Etiology" post on this blog on Jan 3 I put forth, for your consideration, my six causes for the current crisis in US organized medicine. The first I noted was paternalism. In today's essay I will explore this complex controversial issue to be followed by future essays on my other five causes of our real-time current US medical meltdown. Paternalism has always been associated with healing from historic physician-priests, shamans, to contemporary white-coated "MDieties" who deign to receive the supplicant patient so that magical, mysterious and most importantly secretive cures can be administered to the eternally grateful patients. Not only are the cures known only to the healers but a secret specialized language is developed among the healing fraternity. Unfortunately this paternalistic model is based on power dynamics that infantalizes patients keeping them forever dependent on their doctors. I once published perhaps an extreme statement that "the best medicine is simply helping people to become themselves". Now mind you, if you have the misfortune of being born with a huge hole in your heart, or a truck driving 60 miles per hour hits your body broadside, or you develop a life threatening disease like cancer or a stroke you need a highly skilled technical physician pronto!- or stat! as they say in medicine. At that moment in time "becoming yourself" is a silly issue. But a large proportion of medical encounters (>70%) are not that at all. Most rather relate to physical symptoms and diseases that are attitude, behavior and lifestyle related or for example having a "toxic boss". Well, anyway, paternalistic systems (another example being organized religion) begin to fail when two related things happen-when patients become educated and when they become mature. They henceforth expect or even demand that their doctors relate to them as adults who can actually think. Regarding the neo-educated mature patient the internet has dramatically and profoundly changed the doctor-patent relationship. At least 88.5 million US adults will use the internet for health information over the next five years accessing no less than a whopping and growing- 20,000 health related websites. In some cases especially intelligent, persistant or sometimes desperate, computer literate patients will know more about current science and options for diagnosis and treatment for their disease than their doctors. This is a very painful transition for paternalistic docs who don't have the maturity to work with a educated patients. So the era of co-decision is now upon which also places more responsibility on patients some of whom fear that "burden" or even worse "abandonment". In addition to the internet the free market which I will write about in a future essay -if it is truly free-(currently it is not e.g.- largely a physician monopoly and AMA restriction of trade) allows patients to choose all sorts of providers who they can relate to as adults. US organized medicine is trying. For example to see what the AMA says about paternalism you check out this site.http://www.ama-assn.org/ama/pub/category/12037.html .But I remain convinced that this rhetoric is not matched by the AMA's or its members' real practices. After all there is a lot of power and big money at stake which is perpetuated by paternalism and dependent patients. But I recognize it ain't easy for any of us to grow up. Let's hear from you on this difficult but necessary transition for all of us. For any excellent essay on "deconstructing paternalism" I highly recommend http://www.sma.org.sg/smj/4303/4303sf2.pdf from of all places Singapore:)

5 Comments:

Anonymous David Boulton said...

Good piece. I enjoyed it.

I think the 'paternalism' of medicine is a younger brother of the 'paternalism' in our approach to the 'health of learning' in general. The paternals assume that 'what' they know and have to teach or dispense is more important that how well the 'patient' / 'student' is learning, first-person, about 'what' -ever it is. We are wholesale choking the life out of our natural learning abilities and medicine is one of the forces in the unconscious conspiracy to perpetuate the disease. Having said that I think it's distracting to go very far into the blame game. There are many vested interests in perpetuating the health and learning disabling status quo. They are not 'evil', they have weak 'ethics' and are following the "American way". I think those of us who want to help change these misleading directions have to recognize that we are seeing the trajectory of cultural history and that it has a lot of inertia. We have to find the points of 'greatest leverage' to influence that inertia and generate value case propositions that attract, connect and resource the people and organizations who are committed to those points of shift. In the final analysis the solutions to our problems are not just scientific, political, economical or educational (as education is defined today) - rather they depend on our 'social learning' - on 'critical mass' learning on a wide social scale.


All the best,

David

10:30 AM  
Blogger Cervantes said...

Indeed Blake. While the public consensus of the culture has moved away from medical paternalism to the idea of patient-centeredness and shared decision making and all that good stuff, the reality has not begun to catch up with the rhetoric. Actually I think this is really true of most patients as well as most doctors. Patients tend to perceive themselves as making their own decisions, but then their rationale just turns out to be that it's what their doctor thought best, and they really can't get any deeper. Patients who challenge their doctors or ask too many questions are still largely unwelcome in the examining room.

I am actually doing empirical research on these issues, which I will talk about in due course.

10:34 AM  
Blogger Blake said...

Thanks for feedback from my partner Cervantes and a person I hold in very high esteem David Boulton who founded http://www.implicity.org/
dedicated to stewardship of childhood literacy-a likely key to human survival. Cervantes we are in cinque on this one-PATERNALISM-Good luck with the research. David-I agree with your points of leverage and critical mass theories to effect change.I do not believe personally in bloody revolutions but I'll help a bloodied or bleeding patient :)

11:09 AM  
Anonymous C. Corax said...

My encounter with noxious paternalism was when I had Lyme disease. I was going to the on-campus clinic for my health care at the time. Of the three different doctors I saw during the unpleasant episode, two were paternalistic &^%#*@s determined to tell me that I wasn't ill. Honest to goodness, one of them twisted everything around to make me out to be a hysterical menopausal woman. "Well, a woman your age...." is an exact quote when I told him I had had bad fever sweats on one night. The other paternalistic doc kept giving me incorrect info about deer ticks--everything he told me, I had to correct. He was furious. Tough. I knew what I was talking about.

The third doctor, the one who right away admitted he didn't know what was wrong with me, was the one who did the necessary tests that found the Lyme. My problem with him was a nurse who was outraged when I questioned something the doc did. I ended up cussing her out something awful when I insisted on speaking to the doctor, not the nurse, and she picked up anyway.

When I was finally better, the good doc told me that the reason they gave me so much grief is because the month before, some guy showed up telling them he had Lyme. When they told him he didn't, he had threatened to sue the various doctors. Of course, I didn't go in telling them what I had, nor did I threaten to sue anyone, fer cryin' out loud. I went in not knowing what was wrong until tests indicated Lyme...and the bad docs STILL insisted I couldn't possibly have it.

After that, I asked a friend I'd known for years to be my PCP. Best medical decision I've ever made.

5:22 PM  
Blogger Blake said...

c corax-thanks for sharing. Glad you finally found a doc you like.Sometimes it takes some time. Hope you are feeling well :)

8:52 PM  

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