Vox Populi

"The voice of the intellect is a soft one, but it does not rest until it gains a hearing."

Freud, "The Future of an Illusion"

The health care debate is dispiriting, and not only because the Democrats' handling of the issue has been inexpert. The celebrated town hall format is primarily a test of who can yell the loudest within view of the most media amplifiers. More than ever I'm convinced that most Americans are not ready for health care reform.

A generation or more has become accustomed to access to whatever test or treatment they (oops, I suppose I should say "their physicians") want, regardless of the actual evidence for its effectiveness, and for the majority of those who do have medical coverage, the 40 million plus who don't are a statistic, not a tragedy, and certainly not worth endangering the system for.

Shocking, isn't it, that anyone could propose putting a price on life? Life is infinitely precious. We would pour untold billions to treat the loudest town hall crier. No limits--for those brazen enough to seize the wealth that is. If none is left over for those who were too busy or distracted to make the meeting, well, that's the American way.

The Hippocratic injunction to "First, do no harm" is being aired a great deal. True, but if one adheres to this too closely, one never does anything. Any intervention carries the risk of harm. And there would be harm, or at least perceived harm, in the event of health care reform, inasmuch as some people, both patients and doctors, would no longer be able to pursue indisciminate testing and treatment.

Politicians aren't able to highlight this unpalatable fact, of course, just as weight loss programs steer clear of the cruel realities of diet and exercise. We spend too much money on health care, and we do so inequitably. Redressing this would indeed involve lifestyle changes, hunger pangs, and sore muscles from time to time. We're not ready to change--yet.

I get tired of signs saying "Don't touch my health care." In many cases the gray-haired person holding the sign has Medicare precisely because the government does touch his health care in a generous sort of way as it is. "His" health care is being funded by my taxes. And for those with private health insurance, their care may be paid for by my premiums. After all, I'm healthy overall and don't use many benefits. Isn't the whole concept of insurance tantamount to (gasp) socialism? Maybe we should rewind eighty years and stipulate that people can have as much unregulated health care as they want, but only what they can pay for out of their own pocket. Now that would steer well clear of socialism, even if people would be dying in the streets.

Questions of populism also arise from an NPR article describing a website aiming to publish patients' ratings of their doctors. Actually I think this is generally a good thing, but mainly because it would enable patients to avoid the relatively few really subpar physicians out there. Obviously most doctors, as with all human pursuits, occupy a large middle range of good-enough-but-not-great, and patient surveys are unlikely to make fine distinctions here.

I have a certain horror of statistics, but I suppose it may be more accurate to throw out the lowest and the highest ratings of a given physician; the former could just be from a crank who didn't get the Xanax he wanted, while the latter could be from a patient who got on famously with the doctor because their kids go to the same school. Truly bad doctors usually share the same kinds of vices: they don't listen, they are rude and arrogant, and they don't exercise good judgment. A patient should beware of looking for a kind of popularity contest that could reveal the "very best" doctor in his area; he should content himself with finding the good-enough doctor who will do an able job.

There's that idea again: not the best care (at all costs), but good enough.

Rationing

As a postprandial no-show affords a little time for reflection after a hectic morning, I think about all the folks I see in this clinic, one after another until they become a blur, who are indigent, unemployed, and unable to obtain Medicaid or Medicare. This is rationing. We already ration health care, and this is how we do it, by the vicissitudes of finances and the job market.

Yes, they are seeing me, but they are very limited in their access to medications, psychotherapy, and other specialized services, such as psychological testing or substance abuse treatment. This is rationing, merely done haphazardly.

I suppose the health care mess boils down to two issues: social justice, and living within our means. Part of social justice is protecting the minority against the majority, always a challenge, by definition, in a democracy. Word is that resistance to reforming health care is growing, and Obama may fail in this as Clinton did. Why? Because most people still have health insurance and are more or less content with their coverage; they don't want to risk this in order to cover the uninsured. They enjoy seeing doctors who can bar no expense in arranging for testing and treatment. Social justice?

The perpetual refrain these days, from economists and myriad other experts, is that we can't go on this way, that is, spending a massive amount of GDP for medical results that, while spectacular in isolated cases, are merely mediocre on average. But if we are spending medically beyond our means, it appears that the public is not willing to stop yet. Perhaps we have not yet hit rock bottom; perhaps the system is rotting but not yet rotten enough. Perhaps reform is not possible until one or more of three things happens: the majority of people are actually uninsured, the majority of people are personally dissatisfied with the system, or the out-of-control medical-industrial complex really does throw the general economy into chaos.

I'm not an expert, so hopefully I'm wrong.

Flies in the Ointment

A. In this week's New York Times Peter Singer (a philosopher who, like gadfly Socrates I suppose, makes it his practice to publicly point out inconvenient truths, like the contingency of world poverty and the role of animals in our food supply), makes the incontrovertible case for rationing health care. The sad thing (for our cherished vision of ourselves as rational creatures) is that this is still a case that has to be made.

Health care is an expensive commodity, particularly with respect to end-of-life care and the cutting-edge or experimental treatment of severe conditions. I'm no economist, but I think most would agree that resources, ultimately, are finite. How could we think that health care could not be rationed? The question is merely how it can be most justly rationed. Isn't every other commodity rationed? Is everyone guaranteed an Ivy League education, or a private jet? The point is not that life is not precious, but that given limited resources it cannot possibly be infinitely precious (in dollar terms). If it were, we would be spending 100% of GDP on health care.

(Addendum: Jacob Weisberg has a pertinent article in Slate that looks at the health care system, and prospects for reform, as reflections of American culture and values).

B. Somebody in psychiatry (besides me) has some sense. Allen Frances, M.D. the chair of the Task Force that developed the DSM-IV, published in 1994, has written this scathing criticism of the process under way to produce the DSM-V by 2012. He points out the generally haphazard, secretive, and underfunded nature of the endeavor, but his two bigger points are these:

1. Practical knowledge in psychiatry has not increased sufficiently in the past 15 years to justify radical revisions of diagnostic criteria. Research in neuroscience has generated oceans of theoretical information, but none of this yet alters what a psychiatrist can practically do for a patient in the office. So wholesale diagnostic changes amount to what Frances aptly likens to merely rearranging the furniture.

2. The addition of milder, "subthreshold" conditions threatens to greatly expand the prevalence of "mental disorders," which will in turn generate numerous "false positives" and play into the hands of both pharmaceutical companies eager for new "patients" as well as those eager to criticize psychiatry's imperialistic tendencies. There is already plenty of controversy over exploding diagnoses such as bipolar disorder and ADHD; to codify a wider purview for these in DSM-IV would merely fan the flames.

Psychiatry may be well-intentioned, but it is forever trying to advance farther than its secure knowledge base justifies, and at times it seems like one colossal hammer that is hallucinating nails wherever it looks.

As full disclosure and on a personal note, I would add that soon after I was accepted for my psychiatry residency at Duke in 1995, I received in the mail a warm-off-the-press edition of the DSM-IV signed by none other than Allen Frances, who was chairman at that time. He would agree (and has often volunteered) that the DSM-IV is a flawed instrument, as it would have to be; we just haven't advanced enough yet to radically improve upon it.