Sunday, March 19, 2006

How Much of Our Health Do We Really Control?

The topic of how much of our health that we really control is, for me, probably one of the most difficult concepts that I will ever write about on this blog. Since Medical School in the late sixties up to the present I struggle with this central issue. I have concluded there are no easy answers now or likely ever? So I invite lots of dialogue on this from you.

I became interested in this issue because of my interest in psychiatry (never became a psychiatrist) , mind-body medicine , and more recently consumerism in medicine. Issues surrounding patient dependency on "MDieties" and the evils of excessive paternalism always intrigued me. Yet to this day, I remain plagued-almost haunted- by the notion that, as a doctor, my first moral principle was beneficence- to actively do good for my patients- to intervene on their behalf using my technical skill and knowledge that they could never hope to possess?

I scoured the medical literature for evidence on what % of illness was self induced through individual or collective human behaviors verses the roles of genetics.?I became interested in the psychology/sociology of accidents - still believing today that most are avoidable. I became interested in issues surrounding the environment and workplace (my chosen specialty) and how much control especially the disenfranchised really had over this?

This led to my interest in the fundamental dilemma of self- determination verses fatalism or pre-ordination and its association with belief in God verses existential self.

On a more practical note I studied the concept of Health Locus of Control (HLOC) a theory developed in @ 1976 which sought to quantify how much an individual believed health was under their own control (see

I read the late Susan Sontag's book Illness as a Metaphor (1978) where she chastised the mind- body movement accusing it of "affirming the primacy of secular spirit over matter" and inducing guilt in those who contracted cancer for example- the disease which ultimately took her life too soon! Yet I personally think Sontag was wrong in her indictment of mind-body.

Now we have consumerism in medicine which is encouraging patients to become educated, to ask questions of their doctors (see Cervantes Stayin Alive blog-Tues March 14-"Don't Be Afraid to Ask Questions") and to become co-decision makers with their doctors. This latter point is a huge tectonic shift in the heretofore paternalistic doctor-patient relationship.

Here is where I personally stand today. I like the model of the doctor as a the teacher. To me the best medicine of all is "helping people become themselves". I loathe the concept of victimhood. Yet, in the end, genetics is real, viruses and bacteria are real, environmental and workplace biological insults are real, natural and man-made catastrophies are real , some accidents I suppose just "happen", and certainly social injustice is VERY real.

When I consider the above external realities my ideas about helping my patients achieve "the gift of themselves" yields to my sense of moral obligation as a physician to offer the hand of benevolent paternalistic intervention to my patients to the best of my abilities with the knowledge and skills that contemporary western medical education and my years of practice have afforded me.

Please let me hear from you. I really need your input, your stories, your hopes your fears on this topic of importance to all of us.Thanks


Anonymous Barry Millis, OD said...

The physician as teacher is appropriate but fraught with difficulty in a "time is money" culture. Educating patients to be responsible for healthy behavior requires lots of time to overcome all the aquired prejudices and preconceptions. Just watch the reaction from laymen when you discuss Norton Hadler's book, "The Last Well Person". There is general disbelief that so many of the "accepted" tests and procedures may actually be useless or harmful. As long as the system is money-driven, there will not be enough physician-teachers to make a difference.

8:03 AM  
Blogger systemdoc said...

this is a good exposition of the "hippocratic tradition" with the physician as the priest-like guide to other humans who experience illnesses is a symbolic way - the physician is thus the mediator between the physical and metaphysical world - certainly a long way from applicability to our currently paradigm-polarized world, with an overly materialistic/commercialized medical culture, where the human connections have been washed out - yet, this relinkage to people is a part, or precondition to a political reconfiguration of the health care system

bob pero

11:10 AM  
Blogger Blake said...

Barry - Thanks for posting a comment my dear friend. I hope you share your many keen insights often! You are probably correct for now. $ still rules supreme! But the inevitable collapse of our US Health Care system is here or imminent. Then the doctor-patient relationship will change?:)

11:26 AM  
Blogger Blake said...

systemdoc- bob pero- Thanks for posting on Critical Condition! Hope you do so often. You are a great thinker and strategically placed.I struggle constantly with physician as teacher verses priest verses technician? verses ? Whitman said we contain multitudes? Whatever identity dominates surely we are still people trying desperately to connect to people. Visit here often.Need your input!

11:34 AM  
Blogger stoney13 said...

How much? Hell who knows! Too much wory and stress over who's going to win "American Idol" is what's wrong with people today! All the stress in the world won't get one thing done! Why worry? There's only two kinds of problems! Those you can fix, and those you can't fix! Fix what you can and fuck what you can't!

Worry and stress kill! Get over yourselves, people! Before you decide to take on the world, remember thet the worlds a heavy place! And if the job is so easy, WHY"S IT ALWAys OPEN??!!!

10:51 AM  
Blogger Blake said...

Hey stoney13-Yes-one of my favorite phrases is "before you save the world first you must savor it" Stoney13- looking forward to another creative riff/rant on your own blog but thanks for visiting here! What are your views on health care?

3:08 PM  
Blogger Cervantes said...

It is a real challenge for the physician, I think, to manage the tension between patient autonomy and the exercise of expertise. After all, what we are buying from you is presumably your superior knowledge, and that creates a fundamental inequality -- and yet it's my body and my life that is on the line, so I need to take responsibility, and I should get to choose.

In fact, patients differ a lot on what they want from this relationship. Some really do want to be relieved of the burden of responsibility -- they just want to be told what to do, and they don't have the time, energy or inclination to inform themselves about their situation.

Others want to make their own decisions, but as the physician you strongly feel they are making a mistake. You feel responsibility for their well-being, so you are very strongly tempted to be directive, or manipulative, or whatever it takes to get them to take the antiretrovirals or have the surgery or whatever it may be. Beneficence wars with autonomy.

And then there are those patients who want to be well-informed, who will understand what you say and take it to heart, who want your best advice, and who will make then make their own choices, ones that you feel are at least defensible and that you can live with even if they aren't what you would have done. Here you have a genuine, functional partnership. But is that really the norm? Can it ever be? How would we have to redesign medical education, the medical institution, and the rest of society, to make it really happen?

However challenging that may be, it ought to be our goal, anyway. Maybe it will always be the Holy Grail, leading us on a quest we can't fulfill.

6:34 AM  
Blogger Blake said...

Cervantes- Your analysis is excellent:)Absolutely- I tell myself and my physician colleagues that each patient wants and maybe deserves a different relationship. Mature doctors however, dare I say, do tire of excessively dependent personalties as mature people also in general tire of these folks.Your third model of a general functional partnership (adult/adult) is the ideal goal. How to achieve it? Personally I think it all begins in childhood and what we are taught about authority figures and dogma/openmindeness.So early childhood neuro-education is critical for doctors-to-be and patients:)

2:17 PM  
Anonymous Stephen Kriz said...

I think the link between mind/body and overall health are very highly correlated. If a person eats a good diet, exercises regularly (4-5 times per week), has a strong spiritual life (for me a strong Christian faith, but it doesn't have to be that) and a strong and supportive circle of friends, I believe 80-90% of disease and illness can be avoided. That, I think, is why I am very healthy and my sister, who is divorced, has no faith life, eats the wrong things and never exercises is chronically ill. Good luck with you blog - the U.S. medical system is desperately ill.

Stephen Kriz

7:44 AM  
Blogger Blake said...

Thanks stephen kriz-Appreciate your sharing your own formulae for good health.I am especially interested in your spirituality as a source of health. Many studies have been done in this area and are continuing. I hope you visit here again. Best Wishes and Be Well

6:05 PM  

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