I’m a Doctor, Not a Magician
I get accused of being a cynic and a realist, especially by people who are themselves self-proclaimed idealists. Why it is wrong to be a realist or cynical is the topic for another day. But I do actually have an idealistic heart and one that would shame the pretensions of even those whose bumpers are festooned with a kaleidoscope of stickers announcing their support for the typical things that pass for idealism nowadays. I just have a different sort of idealism, especially when it comes to the practice of medicine. It’s an old-fashioned idealism to be sure, and one that many may view as being slightly stodgy at best or a throwback to the stone age at worst.
I’m talking, of course, about the difference between reactive and proactive medicine.
In reactive medicine, the traditional model of medical practice, the physician is trained to diagnose and treat the diseases of people who seek him out when needed. This is my idealism and probably why I chose Emergency Medicine as a specialty. Our entire job is to react to medical problems. In this manner I live my ideals in a way that, unless it involves parachuting into the Himalayas, those whose ideals involve freeing Tibet can never hope to do.
Some believe in “proactive” medicine and to a certain extent I can understand and applaud their ideals. Family Medicine, for example, is full of motivated physicians keeping a careful watch on their patients in the expectation of catching and preventing health problems early enough so the treament is a pill instead of a heart transplant. Some work in preventative medicine and struggle to eradicate the common diseases that afflict the human herd.
Idealism is a good thing except when it becomes zealotry at which point (as absolutism brooks no dissent) reason, moderation, and respect for the heretic are abandoned. The hard-core purveyors of proactive medicine long ago passed into zealotry and have never looked back. Many of you have read of my experiences with community medicine at Duke University where the Department of Community and Family Medicine was the beating heart of proactive zealotry and about which I relate the following cautionary tale:
During our orientation as interns, we sat through many conferences extolling the virtues of Community Medicine, the Shining Path of proactivity that involved physicians, mid-level providers, nurses, social workers, dieticians, and various other minor functionaries of the dependocracy in a coordinated effort to bring good health to the to jibbering inhabitants of North Carolina’s urban and rural hinterlands. One such effort involved a pilot project to combat obesity. A local Baptist church was selected as a test site and the obese parishioners were subjected to all manner of testing, nutritional counseling, cooking classes, motivational speakers and everything and everyone that the initial grant money could bring to bear. To say that this group was targeted would be an understatement. They received the full broadside from the great ship of state which, for good measure, came about and raked them from the other side.
You’d think the pounds would have dropped like French soldiers at the sound of gunfire but, when one of the interns tentatively asked if the target group had lost weight, it turned out that the test subjects had no statistically significant weight loss.
There were no outliers. The most lost was a little more than the weight of a couple of pork chops and some actually gained.
Anybody could have predicted this. Most education, like most preaching, is ineffectual. The parson can talk himself blue in the face but the bars will still be open and the fancy women will have no shortage of customers because unless people have some strong personal motivation for change, a motivation which cannot be accessed by the usual uninspired preacher or government scold, they will continue to indulge their immediate gratification at the expense of of some unknowable future punishment.
Late at night, when the motivational speakers have gone home and the skinny lady from the university has stopped trying to extract impossible promises, the siren call of the pecan pie in the refrigerator is irresitable. Pie will out. This simple yet seductive desert will trump our best efforts. When you’re three hundred pounds hoping to lose the fleshy equivalent of a couple of sixth graders, the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.
I am a stocky fellow myself and even though I know better, after approximately twenty years of education and a medical degree I still succumb to the demonic allure of baked goods including that of the very arch-devil of pastry, the apple fritter.
You can lead a horse to water and, if you hold his head underwater, he will eventually drink. But you have to stand there and hold him down. Likewise, we can probably modify people’s bad habits but the level of involvement required is immense. If a small platoon of earnest social workers cajoling and lecturing for a month could only show a couple of pork chops for all their effort and a a couple hundred thousand bucks worth of their time, those are mighty expensive pork chops. So unless you’re willing to swallow the cost of providing everybody in the country who needs one with their own personal trainer to hold their head underwater, well, you need to let it go. People are going to do what they want. They’ll suck down crack, inject heroin, free-base Big Macs, and make love to the pastry cart and nothing short of locking them in a jail cell with Richard Simmons and a crate of lettuce is going to make much of a difference. What little difference it makes is probably not going to be worth the gigantic expense of providing nannies to a third of the population.
It’s probably more cost effective to just say to hell with it and confine ourselves to reactive medicine where at least we can make a difference. Remember, no matter how much you spend, it can all be undone by an 89 cent piece of pie.
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