My favorite iconoclasts are Peter Skrabanek and Thomas Szasz. Skrabanek was a general practitioner who authored Death of Humane Medicine and Rise of Coercive Healthism. Szasz, a psychiatrist, who volunteered that he entered psychiatry to unveil its pseudoscience, is the Voldermort of psychiatry – he who must not be named (may be Voldermort is the Szasz of muggles). He wrote several books including “Myth of Mental Illness.”
Neither believed in nominative subtlety. The title of their books gave it away. Both Szasz and Skrabanek had a point. The point was simple. Be careful. Don’t allow the medical profession to medicalize the broad coastline of normality – the dog ears of the bell-shaped curve.
Skrabanek was a socialist, Szasz a libertarian. Neither was against medical care for the sick and poor. Skrabanek was urbane, Szasz went for the jugular. Both were prescient. They predicted modernism’s medical epidemic: overdiagnosis.
I’m a pseudo iconoclast. I look for real ones. I recognize them a mile off. They are straight shooters. They are humane but do not wear sentimentality on their sleeves. So it was not hard to spot Vikram Khanna, the author of Your Personal Affordable Care Act. Khanna is an ‘in the trenches’ foot soldier who has worked on the wards, worked with insurers and worked as a regulator. He has a mission, like Skrabanek who he worships. To fight healthism.
Healthism is not the promotion of health but the medicalization of everyday life in the pursuit of perfect health.
It starts with a simple logic. If we catch disease early we will prevent complications. True, if we know who has early disease that will progress. But we don’t. We have to cast the net wide, wider the earlier we want to intervene. The trouble is when we throw the net we accuse innocent bystanders of a disease they never were destined to have.
Healthism is collateral damage for our preemptive strike.
Khanna blames the medical establishment for healthism. He has a point – up to a point. Physicians have internalized medicine’s inherent limitations as their personal failings. That’s the easy part, to say we suck, whilst drawing our pay check. It is an odd self-flagellation that is not only morally pleasing but financially rewarding. Buddhist Lamas fast when they transgress. We feast.
The difficult part is to articulate our imperfections. To admit we don’t know. To say that it is better we stick to the sick rather than prod our stick amongst the healthy in the hope of finding the sick. To say, yes I missed that your vague chest pain was because of aortic dissection but were I to have flagged it, I’d have to flag a thousand others who don’t have aortic dissection and, quite frankly, society doesn’t have the resources for that. That requires intellectual and moral courage. Tortured introspection is easier.
But is it better that one sick person is not diagnosed early than ten healthy people are falsely labelled with disease? I am not sure
It takes two to tango. The public doesn’t want aortic dissection to be missed. Death from aortic dissection is avoidable because it is treatable. Avoidable and preventable are two of the most capacious words in the medical lexicon. They can’t be unproven. They have propped up industries. The public has consented to healthism, implicitly. Because one person’s avoidable is another person’s overdiagnosis.
Khanna meets midway. He urges Americans to run, to exercise, to eat judiciously. He pithily advises “eat less, eat less crap.” If people look after themselves they will avoid the physician and defer the grim reader. He internalizes avoidable and preventable, not by placing the onus on the medical profession, but on the individual.
He is a rugged individualist, a determinist, a Calvinist. If you smoke you must pay. You should not diffuse the costs to those who chose not to smoke, he opines.
I agree with Khanna –to a point. Personal responsibility should be encouraged. But irresponsibility should not be punished. To what extent will you punish irresponsibility? Will you ask bungee jumpers to pay for their detached retina whilst covering Whipple’s procedure for fitness freaks who have the misfortune of pancreatic cancer? Will you not cover a person’s injuries if attacked by a Grizzly bear whilst hiking in Yellowstone National Park because they should have known better and stayed at home?
Propensity for risk is the tapestry of our society. Some climb Everest. Some smoke 20 cigarettes a day. Let it be. Freedom lies in not fretting over your neighbor’s cholesterol and how it might impact your insurance premium. Freedom lies in letting it go. Freedom costs. Healthcare costs are higher in a free society precisely because idiots are free to do what they want to do.
Khanna is right but Skrabanek is really right. The job of doctors is to heal the ill not hound the well. We can cure the pathology of the body not the pathology of society. Let’s keep it that way.
Saurabh Jha, MD is a radiologist at the University of Pennsylvannia. His opinions do not reflect the views of his employer.