Health Reform: It's Cultural Expectations Stupid!

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.

Kevin Sack, “Screening Debate Reveals Culture Clash in Medicine,” New York Times, November 20, 2009

For at least three years, starting with Voices of Health Reform and more recently with Obama, Doctors, and Health Reform, I have been writing American Culture and American’s Health Care Expectations profoundly influence the health reform debate. This is no secret, but you don’t hear much about these cultural expectations in the media or in the Congressional debates. Now that the august New York Times has brought up the culture issue, perhaps I can talk about it again.

Although Americans are in a funk right now over the economy, unemployment, and the national debt, they retain their belief in the powers of modern medicine. This belief explains why so few Americans believe they are “over treated” or that doctors do “too much.”

If anything, people feel doctors don’t do enough. Americans expect doctors to prescribe a drug, order a mammogram, do a pap smear, or refer them for a CT or MRI scan. Americans expect access to the best, to the brightest, and to those death-preventing, life saving, or function-restoring, even sexual-preserving technologies.

And why shouldn’t they? America has the best high medicine in the world. The media talks incessantly of the latest medical advances, of lives miraculously saved, of erectile dysfunction resurrected, or people diagnosed with some rare and exotic disease. Hospitals market their high-tech wares on television – robots that perform surgery, gamma knives that cut like a laser to the cause of the cancer, surgeons that operate bloodlessly and non-invasively.

There is plenty of hype and hope abou modern medicine’s wonders. Expectations run high.

And to doctors, there always some mythical future lawyer out there who might ask, “Why didn’t you do this procedure, doctor?” “If you had, wouldn’t my client be alive and well? Didn’t you know this test was available?” “Why didn’t you discuss all the options with my client” "Why is there no record of your having done so?” "Why and Where do you go to medical school?" "Didn't they teach you what to do?"

Besides, in the words of the New York Times reporter, “For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.”

The reports of the federally-sponsored and paid-for Preventive Services Task Force on new rules for mammography and pap screening are raising the specter of government health care rationing. And, in the minds of the public, it may be a stick in the eye to the concept of comparative research effectiveness and the government paying only for “what works.”

Medicine is highly personal and emotional. It does not lend itself to detached objectivity or to “scientific based evidence.” As Sally Fields says in her TV Boniva ads, “It’s my body, and I’m going to take care of it.” This might be paraphrased in the present health reform climate to read, “ It’s my health, and I don’t care what the government says. I am going to do what I consider best for me.”