Archive for the ‘Medicine’ Category

Writing in Foreign Affairs, the Princeton economist Alan Blinder considers the question of job security and falling wages for U.S. workers in light of global competition:

“Many people blithely assume that the critical labor-market distinction is, and will remain, between highly educated (or highly skilled) people and less-educated (or less-skilled) people–doctors versus call-center operators, for example. The supposed remedy for the rich countries, accordingly, is more education and a general “upskilling” of the work force. But this view may be mistaken. . . . The critical divide in the future may instead be between those types of work that are easily deliverable through a wire (or via wireless connections) with little or no diminution in quality and those that are not. And this unconventional divide dose not correspond well to traditional distinctions between jobs that require high levels of education and those that do not.”

Blinder suggests the crucial distinction in the labor market will be between what he calls “personal services” and “impersonal services.” The former either require face-to-face contact or are inherently tied to a specific site. Physicians who treat patients don’t need to worry that their jobs will be sent offshore, but radiologists who examine images have already seen this happen, just as accountants and computer programmers have. He goes on to point out that “you can’t hammer a nail over the Internet.”

The MIT economist Frank Levy makes a complementary argument. He puts the issue not in terms of whether a service can be delivered electronically or not, but rather whether the service is itself rules-based or not. Until recently, he writes, you could make a decent living doing a job that required you to carefully follow instructions, such as preparing tax returns. But such work is subject to attack on two fronts—some of it goes to offshore accountants and some of it is done by tax preparation software, such as TurboTax. The result is downward pressure on wages for jobs based on rules.

These economic developments command our attention. The intrusion of computers, and distant foreigners whose work is conceived in a computer-like, rule-bound way, into what was previously the domain of professionals may be alarming, but it also compels us to consider afresh the human dimension of work. In what circumstances does the human element remain indispensable, and why? Levy gestures toward an answer when he writes that “viewed from this rules-based perspective, creativity [sic] is knowing what to do when the rules run out or there are no rules in the first place. It is what a good auto mechanic does after his computerized test equipment says the car’s transmission is fine but the transmission continues to shift at the wrong engine speed.”

— Matthew Crawford, Shopclass as Soulcraft

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It is an odd thing about us. We expend huge efforts exhorting ourselves to “Say No to Drugs,” then go to the drugstore and buy them by the armloads. Almost $75 billion is spent each year in the United States on medicines of all types, and pharmaceutical products are marketed with a vehemence and forthrightness that can take a little getting used to.

In one commercial running on television at the moment, a pleasant-looking middle-aged lady turns to the camera and says in a candid tone: “When I get diarrhea I like a little comfort” (to which I always say: “Why wait for diarrhea?”).

In another, a man at a bowling alley (men are pretty generally at bowling alleys in these things) grimaces after a poor shot and mutters to his partner, “It’s these hemorrhoids again.” And here’s the thing. The buddy has some hemorrhoid cream in his pocket! Not in his gym bag, you understand, not in the glove compartment of his car, but in his shirt pocket, where he can whip it out at a moment’s notice and call the gang around. Extraordinary.

But the really amazing change that occurred while I was away is that now even prescription drugs are advertised. I have before me a popular magazine called Health that is chock full of ads with bold headlines saying things like “Why take two tablets when you can take one? Prempro is the only prescription tablet that combines Premarin and a progestin in one tablet.”

Another more intriguingly asks, “Have you ever treated a vaginal yeast infection in the middle of nowhere?” (Not knowingly!) A third goes straight to the economic heart of the matter and declares, “The doctor told me I’d probably be taking blood pressure pills for the rest of my life. The good news is how much I might save since he switched me to Adalat CC (nifedipine) from Procardia XL (nifedipine).”

The idea is that you read the advertisement, then badger your “healthcare professional” to prescribe it for you. It seems a curious concept to me, the idea of magazine readers deciding what medications are best for them, but then Americans appear to know a great deal about drugs. Nearly all the advertisements assume an impressively high level of biochemical familiarity. The vaginal yeast ad confidently assures the reader that Diflucan is “comparable to seven days of Monistat. 7, Gyne-Lotrimin, or Mycelex-7,” while the ad for Prempro promises that it is “as effective as taking Premarin and a progestin separately.”

When you realize that these are meaningful statements for thousands and thousands of people, the idea of your bowling buddy carrying a tube of hemorrhoid unguent in his shirt pocket perhaps doesn’t seem quite so ridiculous.

— Bill Bryson, I’m a Stranger Here Myself

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It is a shame, really, that doctors spend so little time in the communities where they practice. If we did, we might come to see our patients from a different angle, as real people on equal terms, capable of returning more than they receive. With greater depth of field, we might more easily grasp their worries and woes, and recognize our failure to help them. We might be fed by their gratitude, motivated by friendship instead of their demands or our sense of sacred duty or the lure of the almighty dollar.

— David Loxtercamp, “Facing Our Morality”

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The ethical dilemmas in medicine are no longer about distributive justice or physician-assisted suicide: these we have surrendered to the stockholders and politicians. For the battle-worn physician, our Waterloo waits in the stack of messages at the end of the day, or in the denied insurance claim we let lapse. We recognize it in unwritten cards of condolence, our cowardice to confront addiction or abuse, the contempt we feel for self-destructive patients, and the encounters we crimp with a blood test or prescription when another five minutes with the doctor would do. How we respond to patients—in mood and action—reflects the core of the physician we are striving to become.

— David Loxtercamp, “Facing Our Morality”

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The strictly medical factors are rarely the most crucial to healing. While a patient’s lifestyle and environment are important elements to be considered in any medical evaluation, traditional medicine nevertheless finds its power by breaking problems down into their constituent parts, isolating individual issues and dealing with them as discrete clinical entities. But the complex, interrelated web of troubles that confront the poor make it impossible for me to treat the medical portion of their lives in isolation. I cannot address James Martin’s hypertension without worrying about his economic status (how is he going to fill his prescription?), his educational level (does he understand the need to take medicines—especially given their side effects—that will not, in the short run, seem to do anything for him?), or his family situation (how does the incarceration of his oldest son or the pregnancy of his daughter affect the hypertension?).

Within traditional medicine, the physician is the central player because he holds the keys to wellness. The doctor who chooses poverty medicine, however, not only finds his own power circumscribed by the same forces that dominate the lives of his patients but also quickly discovers that he is not the most important player on the team. At any given time, it may be the nurse, the social worker, the nurses’ aide, the counselor, or the receptionist who offers what is most needed.

— David Hilfiker, “Not All of Us Are Saints”

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Although pain and suffering are closely identified in the medical literature, they are phenomenologically distinct. The difficulty of understanding pain and the problems of physicians in providing adequate relief of physical pain are well known.

The greater the pain, the more it is believed to cause suffering. However, some pain, like that of childbirth, can be extremely severe and yet considered rewarding. The perceived meaning of pain influences the amount of medication that will be required to control it. For example, a patient reported that when she believed the pain in her leg was sciatica, she could control it with small doses of codeine, but when she discovered that it was due to the spread of malignant disease, much greater amounts of medication were required for relief. Patients can writhe in pain from kidney stones and by their own admission not be suffering, because they “know what it is”; they may also report considerable suffering from apparently minor discomfort when they do not know its source. Suffering in close relation to the intensity of pain is reported when the pain is virtually overwhelming, such as that associated with a dissecting aortic aneurysm. Suffering is also reported when the patient does not believe that the pain can be controlled. The suffering of patients with terminal cancer can often be relieved by demonstrating that their pain truly can be controlled; they will then often tolerate the same pain without any medication, preferring the pain to the side effects of their analgesics. Another type of pain that can be a source of suffering is pain that is not overwhelming but continues for a very long time.

In summary, people in pain frequently report suffering from the pain when they feel out of control, when the pain is overwhelming, when the source of the pain is unknown, when the meaning of the pain is dire, or when the pain is chronic.

— Eric J. Cassel, “The Nature of Suffering and the Goals of Medicine”

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In the secular view, suffering is never seen as a meaningful part of life but only as an interruption. With that understanding, there are only two things to do when pain and suffering occur. The first is to manage and lessen the pain. And so over the past two generations, most professional services and resources offered to sufferers have moved from talking about affliction to discussing stress. They no longer give people ways to endure adversity with patience but instead use a vocabulary drawn from business, psychology, and medicine to enable them to manage, reduce, and cope with stress, strain, or trauma. Sufferers are counseled to avoid negative thoughts and to buffer themselves with time off, exercise, and supportive relationships. All the focus is on controlling your responses.

The second way to handle suffering in this framework is to look for the cause of the pain and eliminate it. Other cultures see suffering as an inevitable part of the fabric of life because of unseen forces, such as the illusory nature of life or the conflict between good and evil. But our modern culture does not believe in unseen spiritual forces. Suffering always has a material cause and therefore it can in theory be “fixed.” Suffering is often caused by unjust economic and social conditions, bad public policies, broken family patterns, or simply villainous evil parties. The proper response to this is outrage, confrontation of the offending parties, and action to change the conditions. (This is not uncalled for, by the way. The Bible has a good deal to say about rendering justice to the oppressed.)

Older cultures sought ways to be edified by their sufferings by looking inside, but Western people are often simply outraged by their suffering—and they seek to change things outside so that the suffering never happens again. No one has put the difference between traditional and modern culture more succinctly than C. S. Lewis, who wrote: “For the wise men of old the cardinal problem had been how to conform the soul to reality, and the solution had been knowledge, self-discipline, and virtue. For . . . [modernity] the problem is how to subdue reality to the wishes of men: the solution is a technique. . . .” Philosopher Charles Taylor, in his magisterial book A Secular Age, recounts how Western society made what he calls “the anthropocentric turn,” the rise in the secular view. After this turn, Taylor says the “sense of God’s ordering presence begins to fade. The sense begins to arise that we can sustain the order [of the world] on our own.” As a result, Western society’s “highest goal is to . . . prevent suffering.”

In Western culture, then, sufferers are not told that their primary work is any internal adjustment, learning, or growth. As Shweder points out, not only is moral responsibility virtually never assigned to sufferers but to even hint at it is considered “blaming the victim,” one of the main heresies within our Western society. The responses to suffering, then, are always provided by experts, whether pain management, psychological or medical treatment, or changes in law or public policy.

— Timothy Keller, Walking with God through Pain and Suffering 

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