This NYT magazine article came out a few weeks ago, but I only had a chance to read it this past week since I’ve been gallivanting around in Spain and Morocco. The author writes about her father’s long struggle with disability and declining health at the end of his life and the impact of this struggle on her mother’s life. The story briefly goes like this: he has a stroke and suffers some neurological damage. Her mother becomes a caregiver. He develops a hernia that needs surgery, and in a pre-operative exam, a cardiologist tells him that he needs a pacemaker for his slow heartbeat, or he can’t have the surgery. He had previously said no to the pacemaker, but now his wife, exhausted and stressed out, says yes. Over the next few years, he completely deteriorates mentally and physically, but his heart keeps going thanks to the pacemaker. The author and her mother try to get the pacemaker turned off, but they are always refused. Eventually he dies of pneumonia. About a year later, his wife dies of a heart attack.
The article focused on the financial incentives that encourage overtreatment, and I won’t argue with that. It is a sad truth of the system that we have put together. But I think there are also broader cultural and emotional forces at play.
The guiding principle of American medicine is to do whatever is possible to extend a patient’s life. Our most basic instincts tell us that this is a good thing: life is precious, so why not do anything possible to save a life? I think many of us, even those in a medical profession, have an often blind faith in modern medicine’s ability to diagnose and cure. We have faith in science: that we can use observation and experimentation to answer questions rationally and systematically. We have faith in knowledge: that mankind has amassed a deep understanding of how bodies work and how they break down. We have faith in perfect execution: that the smart, hard-working people who care for us always correctly and appropriately apply their expertise. Thus, we tend to think, “There must be something that can be done about my illness, and whatever it is, I want it.”
From the provider’s point of view, it is probably gut wrenching to admit ignorance or impotence. What was all that training for if I can’t even tell my patient what is wrong with him? For a physician under pressure, the easiest thing to do is probably to prescribe whatever treatment will work in the short term—to solve the problem right in front of him without thinking of the bigger picture. I think it’s too cynical to attribute a doctor’s decision-making purely to economic incentives. Maybe the cardiologist insisted on the pacemaker to make money. Or maybe he just did what he saw as his part in fixing the problem. The patient had a problem with his heart, and the pacemaker corrected it. This is one of the unintended consequences of highly specialized, reductionist medicine. The primary care physician who knew the patient and his wife understood the family’s struggle and considered the impact of the pacemaker on the lives of both people. He opposed it.
Doctors have an impulse to do what we know, what we can. React and treat rather than synthesize and analyze. This is briefly alluded to in the article, but for me it was the most heartbreaking part: we are losing the social side of doctoring, where healing can happen without medical treatment—healing “that is more than a financial transaction or a reflexive fixing of broken parts.”
Which is why good primary care physicians are so desperately important!
