OP-ED

Clinical Man *

Pharos Cover Art

In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1)  I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging:  homo clinicus.

An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.

Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.

There has been a progression of terms for this new species. First, there was the “early sick” then “the worried well.” That was followed by “the worried sick.” We now have arrived at a definable new species that differs from pre-clinical man.

Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, “An apple a day keeps the doctor away.” That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That’s the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough.”

Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.

Medicine and man have evolved in a symbiotic manner ­­– like the whale with those little fish that swim in and out of the whale’s mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man.  Big medicine needs clinical man and clinical man needs big medicine. That’s just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don’t forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.

Clinical man goes to the doctor when not sick. That’s part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.

Here are a few of the characteristics of clinical man:

  1. Knows his cholesterol level within 10 milligrams percent.
  2. Has been biopsied in at least one non-palpable organ by age fifty.
  3. Has been biopsied in a palpable organ by age forty.
  4. Has had at least one major orifice endoscoped within the past twelve months.
  5. Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
  6. Never goes more than twelve months without medical contact.

How did this evolution from an avoidance of medicine to medicine becoming a necessity occur?  It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.

It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors.  Preclinical man will soon be extinct.

1.         Meador CK. The Last Well Person. New England Journal of Medicine 1994; 330: 440 –41. ­­
2.         Thomas L. On the Science and Technology of Medicine. In: Knowles J, editor. Doing Better and Feeling Worse: Health in the United States. New York: W.W. Norton; 1977: 43.

* The term Clinical Man includes both the male and female gender.

Clifton Meador is a professor of clinical medicine at Vanderbilt. Clinical Man originally appeared Oin The Pharos of Alpha Omega Alpha Honor Society, November 2011. Republished with the author’s permission.  

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44 replies »

  1. Heads up, fellow commenters. I came across a must-read for anyone following this thread. Oliver Sacks — the real one played by Robin Williams in Awakenings — is dying with cancer. This link to his personal experience, in his words, is one of the best pieces of prose I have come across lately. It’s not quick or shallow. But it’s worth whatever undistracted time it takes to read it. This is highly recommended reading. Satisfaction guaranteed.

    Here’s a snip:

    On Monday, February 16, I could say I felt well, in my usual state of health—at least such health and energy as a fairly active eighty-one-year-old can hope to enjoy—and this despite learning, a month earlier, that much of my liver was occupied by metastatic cancer. Various palliative treatments had been suggested—treatments that might reduce the load of metastases in my liver and permit a few extra months of life. The one I opted for, decided to try first, involved my surgeon, an interventional radiologist, threading a catheter up to the bifurcation of the hepatic artery, and then injecting a mass of tiny beads into the right hepatic artery, where they would be carried to the smallest arterioles, blocking these, cutting off the blood supply and oxygen needed by the metastases—in effect, starving and asphyxiating them to death. (My surgeon, who has a gift for vivid metaphor, compared this to killing rats in the basement; or, in a pleasanter image, mowing down the dandelions on the back lawn.) If such an embolization proved to be effective, and tolerated, it could be done on the other side of the liver (the dandelions on the front lawn) a month or so later.

    New York Review of Books, April 23 issue.

    http://www.nybooks.com/articles/archives/2015/apr/23/general-feeling-disorder/

  2. Dear PreclinIcal Woman,

    Good for you. You’re an inspiration. The wisest doctor I’ve ever know once said that people should stop worrying about what’s going to kill them and start enjoying the journey. Ironically, if we follow that advice we may live live longer AND live better,

    Cheers,

    Tom

  3. This is very much in keeping with my perspective as a 71-yr old ornery female who has avoided all the marketing. No hospitalizations, scopes, prescriptions, tests, annual exams. Something will kill me eventually but it won’t be overtreatment. “I will live the time I have. I will not spend my days prolonging my years”

  4. David,
    You are feeding the deluded obsession of the Clinical Man described in the original article. Why does a patient need A1C if they check FS blood sugar appropriately? How often would A1C be drawn? Surely not more frequently than every 3 months or so.

    I would be interested to know why the values for desirable serum cholesterol have been going down again and again. Could this be something todo with Big Pharma’s powerful presence in Washington?

  5. Thank you John. The company provides labs at discounted prices and not health insurance. “peace of mind” comes from knowing that you can get an A1C lower than insurance companies will support on a monthly basis. If you are in support of healthcare then you would agree that people who are as old as you may need to have healthcare a lower cost, right?

  6. No mention of signs or symptoms.
    WTF? Trolling for business on a Sunday evening?
    The comment illustrates the point of this post.
    You’re in the wrong line of work, David (at the hot link to New Century Labs). If you’re pitch is “peace of mind” you should be selling life insurance, not health insurance.
    Thanks.

  7. Scenario 1: You have insurance, you see your doctor to get some lab tests but when you get your bill you notice that your insurance company didnt cover it…. Why you ask because your doctor thinks you’re not at risk for this type of lab test. Now you are stuck with the full bill.

    Scenario 2: you dont have insurance and you need to get labs done, you go to the clinic see your doctor, order some labs and now you have a massive bill, doctors bill plus co-pay–Yikes!

    Scenario 3: you have a high deductible and you must pay full price until deductibles are met.

    Scenario 4: you ask your doctor for a particular type of lab test he or she argues that you don’t need it, leaving you with no peace of mind as you walk out their doors.

    Solution: http://www.newcenturylabs.com
    Providing you with lab tests from the top diagnostics companies and the lowest costs with fast and secure results.
    This is an approach to Modern day healthcare

  8. Clifton,

    High praise keeps coming in for my reposting of this article.

    (Tazia, pls excuse my misspelling of your name in previous comment.)

    Cheers

    tom

  9. Clifton– a great post!

    “An apple a day keeps the doctor away” perfectly describes how people use to think of medical care (something to be avoided, if possible))

    Now, they take perfectly healthy 14-year-olds for a “full physical” and boast about how many specialists they see.

    Thank you.

  10. An important thing to remember is that medical care can only deal with about 20-25% of the things that can kill you before age 85.

    The rest is simply beyond the reach of physicians.

    Cheers,

    Tom

  11. This is a good point, but I wonder if self-directed care would increase or decrease utilization? I think it will depend on the person and the level of advertisement.
    GERD, for instance, has gone direct to consumer. Now you can get treated without physician contact or endoscopy, but you also miss the opportunity to explore the causes. As Larry The Cable Guy will tell you: Now you can eat anything you want and not get heartburn. Perhaps reducing the amount of beer and BBQ ingested will have other positive health effects when the immediate symptoms are not masked. Perhaps your body was trying to tell you something. So has the liberation of the PPI reduced medical utilization, or expanded market share and introduced new problems?
    I’m sure there are counter examples like getting vaccines at pharmacies, which is a good thing.

  12. Clifton,

    Here is but one response to the post:

    “Super interesting find Tom, and I couldn’t agree more”. This came form a CEO of a health company.

    If you’d like to discuss my number is 479-957-4902.

    Cheers,

    Tom

  13. Clifton, I posted a link to this on my blog. I’m getting one of the best responses to a post on my blog in five years. Your concept really touched a nerve with my readers.

    Congratulations.

    Cheers,

    Tom

  14. You’re correct about fear to a point.

    ACA is more about leveling the insurance playing field than anything else, but all insurance really does depend on fear — accidents, loss, injury, life, fire, theft, etc. And how SCOTUS rules on King v Burwell also casts a shadow of fear over thirty-plus millions who stand to lose premium subsidies.

    But in any case, some ten to fifteen million previously uninsured people have been able to hedge their fears by being insurance, in many cases for the first time.

  15. To Clifton Meador,

    Excellent article. Congrats. May I have your permission to post a link to this in my blog, Cracking Health Costs?

    cheers,

    Tom

  16. Mortality is, without exception, a universal clinical fact. Something tells me if we prepared better to die, it might result in a better and longer life.

  17. I think that health care, medicine, public health, molecular biology are just starting. You have been around during the birth of the TOOLS. Lucky us. I think you will be amazed, if you live long enough, at how well you will feel, how happy you will be, how much energy you will have, how fast you will heal, how long you will live, how few diseases you will have, how little mental disease there will be, how smart you will be, and what a great memory you will have. Just hang in there…..well, a little longer please.

    The challenge is to take our brains with @10^8 neurons and try to extract meaning from our twenty thousand genes and their twenty thousand proteins and probably a similar number of small molecules, all interacting in this giant ball of complexity, each affecting the other. Someone, tell us what it means, help! We will get there but the first paragraph may be a giant exaggeration.

  18. Make that the illusion “we could prevent and anticipate most medical issues”.

    We cannot.

  19. This is really true!

    Today people are not bothering to live. They are just afraid they will die….

    …and they will.

  20. Our constant obsession with prevention definitely appeared with the possibility to prevent and anticipate most medical issues, we all want to live and be as healthy as possible, let alone be immortal ( think of those new companies that propose to freeze you and to wake you 50 years later…. I read that a few months ago, still wonder if it was true )
    Youth and health quest are the driving force of Mankind.

  21. Pre-Clinical Man knew when his muscles ached his day had been active.
    Clinical Man only knows if his Fitbit passes 10,000 steps.

    Pre-Clinical Man sought out new experiences in the hope of a good memory to take with him through life.
    Clinical Man seeks out experiences in the hope of collecting enough likes, clicks, and upvotes in order to understand whether a memory is good or not.

    Pre-clinical Man saw life through his own eyes as one continuous, uninterrupted experience.
    Clinical Man sees life only through the interrupted, captured, and static images on Instagram, Facebook, and Twitter.

    Preclinical Man was too busy chopping wood and carrying water to worry about his health.
    Clinical Man is too busy recording, documenting, and uploading his life into interactive apps which are all to willing to illuminate his every shortcoming in health, life, and love.

    Preclinical Man lived and died.
    Clinical Man experiences something that is not quite either.

  22. Very good point. I think the biggest problem with the society today, is that people get scared way too easy about a possible diagnostic. And the worst thing is that people look for medication online. They surf online and read sites rather than go to doctor for a specialized diagnostic.

  23. I would like to know how we get so many mutations, copy number variations, deletions, palondromes, et al, in most of our big illnesses. There are very few single gene problems. What is causing these? Is it our emvironment? Are we sniffing volatile carcinogens from millions of square miles of asphalt? Etc. Or, are our error correcting mechanisms, like P53, really imperfect and during mitosis we are making mistake after mistake?

    But, if either is true, why aren’t we apparently evolving rapidly? How are we keeping the germ line cells from changing rapidly?

  24. Thomas Szasz once jibed that the final, ultimate px would be the “Humanectomy.”

    Yeah, Dr. Mike, “a pill for every ill.” And, off-label, there’s surely “an ill for every pill.”

  25. Sorry but have to disagree at least in part. It may be nice to think that we are not on the hook for this shift in social thinking, but the medical-industrial complex clearly bears some responsibility for this. Phama and Physicians have colluded to make sure that everyone knows there is a pill for every ill. And the Insurance-Physician cabal has made sure that the barriers to getting that pill are minimal. And our overselling of some of the preventive services of dubious value (annual physical) have been driven by profit motive and have provided the opportunity to upsell to a variety of pills for a variety of ills for which medicinal treatment is a poor choice.

  26. Great post, and especially appreciated coming from an MD. I have long felt this way and I can assure you that there are still some of us pre-clinical men/women out there albeit a disappearing species. I do agree that it is terribly hard to remain in this camp with the constant barrage of prescription drug ads, screening campaigns, disease mongering, etc. It is literally depressing at times. I stay away from the medical-industrial complex and fear the day that I may have to succumb to it!

  27. How did we get here?

    Our obsession with early diagnosis, prevention, etc.

    Why do we have such an obsession?

    Because we can not handle man’s inherent imperfection. Religion cushioned our discomfort. But now religion has been replaced by scientific determinism.

    This is a social phenomenon. The medical-industrial complex is a consequence, not cause of this phenomenon.

  28. I definitely want to read comments here as they come in. This is a great line…

    >> Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough.” <<

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