“Medicine has always been hierarchical, but never has it been so conformist,” writes Dr. Aaron Kheriaty in his latest book, Making the Cut: How to Heal Modern Medicine. He is the Director, Bioethics, Technology, and Human Flourishing Program, Ethics and Public Policy Center. “There are too many thoughtless physicians marching in lockstep to his metrics dictated by vested outside interests that show little concern for sick patients.”
Kheriaty recognizes that many patients are frustrated with medicine. As for reasons why, his list includes “poor communication, long wait times, high costs, barriers to access, and a perceived lack of respect or trust in the healthcare system. One in six people, including physicians, no longer trust doctors, and one in three do not trust the system,” he offered from a recent survey by the American Board of Internal Medicine.
In Kheriaty’s eloquent and honest book, he gives readers a unique look into his journey through medical school, his internship and residency, and his medical tenure at UC Irvine. He describes being present for birth, death, and everything in between in the clinic and hospital setting. As he gets closer to becoming a licensed physician, his eyes are opened to what would become barriers. As he writes, “A humble and realistic acknowledgement of the permanent limits of medicine is a necessary starting point for any sane and sustainable healthcare system. Doctors are not miracle workers, much less gods.”
Trends That Contribute to the Dilemma
- One barrier between doctors and patients is the growing role of technology. The belief that “all human beings are fundamentally interchangeable units” is as far away from what Hippocrates believed as medicine can get. This trend, according to Kheriaty, “makes individuality, diversity of place, culture, custom, and nation a glitch in the machine. Every patient gets the same cookie-cutter care.”
- Another barrier is doctors having to meet certain established metrics in order to receive payment. For example, if you’ve ever had a “wellness checkup,” the brief appointment doesn’t allow you to actually talk about a medical problem. That requires yet another appointment, co-pay, etc.
This checkup works for certain industry groups who have a vested interest in expanding disease categories and widening definitions. Acceptable blood pressure measures, for example, have steadily been lowered while drugs became the primary treatment. This metric that doctors must report often leads to overprescribing medications. Kheriaty states that, “25% of people in their sixties are on five or more long-term meds; rising to 46% in their seventies and 91% of nursing home residents. The evidence for the use of many of these drugs is based on younger, healthier people.
- Physicians face a proliferation of top-down “guidelines” that dictate the management of various illnesses. These also come from state and federal regulatory authorities and public health agencies. “Guidelines really means control of a physician’s behavior by dictating payments and reimbursement for hitting certain metrics. In 1990, the number of available guidelines was 70; by 2012 there were over 7,500. Physician judgement goes out the window of unthinking checklists.”
“The managerial ideology that has taken over modern medicine consists of several core tenets,” writes Kheriaty. “Among these are the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means. And that those with superior scientific and technical knowledge are therefore best placed to govern society.” Following are four guiding beliefs that have greatly contributed to doctors retiring early or feeling like their practice of medicine has been hijacked.
- Technocratic Scientism – The use of studies that yield statistical averages, which apply to populations but say nothing about individuals. No two human bodies are exactly alike, but technocracy treats bodies as interchangeable.
- Utopian Progressivism – The belief that a perfect society is possible through precise application of scientific and technical knowledge, and that the “Arc of History” bends towards utopia as more expert knowledge is gained.
- Liberationism – The belief that individuals and societies are held back from progress by the rules, restraints, relationships, historical institutions, communities, and traditions of the past. All of which are necessarily inferior and therefore we must be liberated from them in order to move forward. The term “better than well” is only gained through hormones, gene editing, or psychopharmacology.
- Homogenizing Universalism – The term creates “turn style” medicine. The goal is to move a patient, whether they are in your office or in the hospital, through the system as quickly as possible.
Dr. Kheriaty is not alone in his opinion that the quality of medical care and a physician’s practice was changing even before Covid. Covid only served to highlight what the mechanization of care was about.
Dr. Joseph Varon writing an article for the Brownstone Institute observed that “Evidence-based medicine was never supposed to mean obedience to a document. Its foundational definition joined the best available external evidence with individual clinical expertise. Good medicine requires their union, applied to the patient’s values and circumstances.
“A doctor trained primarily to comply will eventually stop seeing possibilities that fall outside the approved pathway. A nurse repeatedly punished for initiative will learn to wait. A patient told that every option must first survive a chain of institutional permissions will begin to understand that the system’s first duty is to itself. Once that culture becomes normal, no single villain is required. Everyone can behave properly, every form can be completed, every protocol can be followed, and the patient can still be abandoned. When healers become hostages to the system, healing becomes incidental.”
Finding Ways Out of the Dilemma Will Take Time
The power and number of vested interests that want to keep the practice of medicine just the way it is are powerful. Kheriaty is a realist and cautions that it will take time before what he describes as, “The new parallel institutions of medicine return sovereignty to individuals, families, and communities and strengthen social solidarity. In these new medical models, physicians need to be able to exercise individualized clinical judgment and appropriate discretionary latitude. Doctors should work primarily for patients and only secondarily for institutions.”
Dr. Joseph Varon’s final paragraph in his Brownstone Institute article is a thoughtful ending to this post. “If another pandemic arrives tomorrow, whom will we follow: the patient in front of us or the official who has never entered the room? Will we again allow fear to turn protocols into commandments, uncertainty into censorship, and experts into authorities who cannot be questioned? Will we repeat actions that make no clinical or human sense simply because the correct institution has ordered them?”
“Whatever improvements medical technology claims,
we spend twice as much of our GDP on healthcare as any other nation
and get worse outcomes than most developed countries.” ~Dr. Aaron Kheriaty
Photo credits: Which path to take? – jon Tyson, BP Monitor – Getty images, patient and doctor – nani Chavez, hourglass – Andrej Iisakov