27 February 2011

"Imaging tests are now responsible for half of the overall radiation Americans are exposed to..."

Lyotard remarks somewhere that its possible for things to seem like they are getting better and better even as they get worse and worse. Perhaps this is especially true in medicine. And the rise of the CT and MRI are likely to blame. In the New York Times, Abraham Verghese discusses the way in which computers have transformed the hospital, hospital practice, and the doctor-patient relationship. He makes several interesting claims, among them this:

Imaging the body has become so easy (and profitable, too, if you own the machine). When I was an intern some 30 years ago, about three million CT scans were performed annually in the United States; now the number is more like 80 million. Imaging tests are now responsible for half of the overall radiation Americans are exposed to, compared with about 15 percent in 1980.

He also observes that:

Of course, we still teach medical students how to properly examine the body. In dedicated physical diagnosis courses in their first and second years, students learn on trained actors, who give them appropriate stories and responses, how to do a complete exam of the body’s systems (circulatory, respiratory, musculoskeletal and the rest). Faculty members stand by to assess that the required maneuvers are performed correctly.

But all that training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be “throughput” — getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge. And the engine for all of that, indeed the place where the dialogue between doctors and nurses takes place, is the computer.

The consequence of losing both faith and skill in examining the body is that we miss simple things, and we order more tests and subject people to the dangers of radiation unnecessarily.

The deskilling process Verghese describes here fits with deprofessionalization models commonly described by sociologists in the 1970s. Deprofessionalization occurs when professionals lose the facility to control their practices. They tend to lose exclusive rights to their work. Their work becomes more routine and thus less obviously "expert".

Ever since the political shift towards deregulation occured in Anglo-America, forces working towards deskilling and breaking professional monopolies in medicine have grown. The rise of PAs and nurse-practitioners, while good for those professional groups, signals not jurisdiction disputes between medicine and its allied sciences, but the movement towards deprofessionalization.

Technology in the hospital has exerted similar pressures. And, of course, insurance companies and hospital administrators, themselves working under crushing structural forces, have placed an ever-firmer boot on doctors and surgeons (especially young ones in training). The phenemena described by Verghese have thus been widely-acknowledged in academia.

But probably no one has been more aware than patients of these changes. And for all of medicine's successes in some areas - e.g. cancer - there has not been a major shift in epidemiological terms. Medicine is good at getting you to age 80. After that it is genetetics and luck.

And getting the patient to 80 only describes a circumstance of health. Ask difficult questions such as how did that patient pay for those medical services, what is the quality of their life in material terms, and what was their experience of medicine like, and the answers will be uniformly disquieting. (Don't believe me? Visit five nursing homes, five out-patient clinics, or five emergency rooms and stay in each for an eight hour period. You will believe me then.)

Curiously, however, few have acknowledged the decline in medical care that has accompanied these trends. Certainly, medical practitioners' unrelenting belief in the progress of science doesn't help. It shuts down critique of the order of things. The mantra appears to be "keep up appearances."

But that places too much blame on medical practitioners. The problem is simply deeper. While technology not only deskills and depersonalizes, it also operates in the service of the illusion that something futuristic is happening in the hospital. It claims that the banality of illness can be offset by the innovative, the mechanical, and the 'screenshot' of the body.

Technology, to crib from Paul Forman, is about "ends, lots and lots of ends". But I think medicine is factually about means. Treatment, the healing process, doctor-patient relationships, placebo effects: these are all phrases conjuring up the notion that the ends of medicine are health and the practices of medicine must thus be means.

Not only does technology disturb those relations, it moves doctors further away from their patients. It alienates doctors and surgeons (and nurses and PAs) from their labor. Technology turns the hospital into a techno-marketplace. The hospital ceases to be a house of healing, and becomes marketplace for manufactuors to sell their wares.

This game costs hospitals. It taxes civilian electrical grids. It stymies the profits of insurance companies. It causes medical school tuition to raise. It drives up healthcare costs. It causes social welfare systems to become insolvent. And probably most important, it costs healthy people.

Meanwhile as the process of deskilling and depersonalization accompanies these empirical realities, few doctors understand what they have given up and few patients realize how little changed their prospects are. Everything looks better, fancier, newer, and flashier. Bright lights, harmonic beaps, and the silent hum of hydraulics all contribute to the spectacle. Ask the tech users what they think and they'll voice disquiet, concern, and worry that their patients imagine too much from all of the equipment.

But for all of those complaints the equipment in the hospital continues to be used. It does little more than measure better what could already be known by the hand and time but that assumes that the medical practitioner has both time and access to the "art" of medicine. They don't. Their time is now managed.

Gandhi once observed that the health of a society was inversely proportional to the size of its hospitals. Depressed? Don't worry, there's a pill for that. But just to be safe and certain that its not something else, why not get a second opinion and some scans first? Everyone will be happier.

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