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The
Traditional American Medical model as we know it today became
extant in the second decade of the 20th century. Prior to what was called
the "Flexner" report, the standards in the practice of medicine
were quite variable. There were hundreds of institutions and "small
businesses" purporting themselves to be medical schools, and there
was little regulation regarding the quality of the education or the
quality of the graduates of these schools.
After
the findings of the Flexner report became clear to Congress, strict
regulations and guidelines were put to fore in order to create an
environment where the United States would have the best Healthcare system
in the world. The goal was to limit the number of medical schools, have
those remaining medical schools meet high standards of care and education,
and limit entrance to the schools only to what were considered to be the
"best and the brightest".
In
this light began the culture of the "American Medical Model". It
was also at that time that science was able to break through many of the
mysteries of human physiology. Diseases such as diabetes, pneumonia,
syphilis and hypertension, which killed untold thousands of people yearly
worldwide, began to let loose of their secrets. And with this new
knowledge, those thousands of lives were saved each year.
The
"new" American Physician was a Scientist. To separate himself
from his predecessors he eschewed anything which was not
"objective" and quantifiable. It was because of the then new
scientific approach that physicians were able to save many lives, and
improve the quality of many more. The "old style" physicians
depended on qualities of intuition, folklore, powers of suggestion and
belief. The old ways were to be purged, so that the quality of human
existence could improve unimpeded.
Inherent
in this belief of scientific absolutism was the attitude that the patient
knew little or nothing of the evolving scientific discoveries in medicine,
physiology, chemistry and biophysics. Physicians then developed a
"paternal" approach to their patients in order to help them use
the new tools of scientific medicine. This paternalism certainly was not
new as a medical approach, but it did become solidified as de rigueur
because it would be unrealistic to expect a general patient population
with marginal education to have any understanding of the diagnostic and
treatment modalities which were undertaken.
This
paternalistic physician-patient relationship became the standard, and was
generally well received for almost seven decades. Although many a patient
would be frustrated by the usually arrogant, almost always male physician,
the sense of being "cared for" overarched those feelings. People
trusted their physicians because it was felt the physician was beholden to
only the scientific method and the fruits of that method. We trusted our
lives to these physicians and their beliefs without question.
How
did a person with a disease such as Fibromyalgia or Chronic Fatigue
Syndrome fit into this model? What was the physician’s attitude toward
these patients for whom science had little to say in terms of an answer?
Physicians
bolstered by their successes with the diseases of "known cause"
were very uncomfortable with those patients who did fit into disease
categories which were elucidated by the scientific method. Physicians are
an uncomfortable lot to begin with, because of the number of unknowns that
they have to deal with everyday, even in situations where they are dealing
with "well understood" maladies.
When
a patient with Fibromyalgia or Chronic Fatigue Syndrome came to a
physician in those times, there was first an attempt to understand the
pathophysiology of the sufferer’s malady. When attempts to define the
cause of the person’s illness failed, there was often a crisis of
confidence. The American Model of Scientific Medicine had purported to be
able to diagnose and "cure" any disease. In this case, the
situation created an environment leading to "cognitive
dissonance". In order to relieve this uncomfortable state, the doctor
had to either come up with an answer, make one up, or treat the symptoms
so as to make himself and/or the patient feel as something "had been
done".
This
was natural in a paternalistic system. The approach to the patients was
not unlike that of parents toward children: give them an answer regardless
of its validity, and then prescribe medications that mask or ameliorate
the symptoms. This was common practice throughout the 40’s, 50’s, and
60’s. The physician-patient relationship was strong – the patient was
told she had "neurasthenia" or "hypoglycemia" or
"vapors" or "chemical imbalances" or any number of
pseudonymous terms for "I don’t know". But along with these
new diagnoses were popular remedies to alleviate the symptoms of pain,
lethargy, stiffness, and intermittent confusion.
In
1970, the Nixon Administration pushed through the Drug Abuse Prevention
and Control Act. And in 1973, the Drug Enforcement Administration was
founded to enforce federal laws regarding the use and distribution of
"narcotics", as defined by the Drug Abuse Prevention and Control
Act. Many factors led to the 1970 Act and subsequent organization of the
DEA, but not least among them was the common physician behavior of
treating the symptoms of people with Fibromyalgia and Chronic Fatigue
Syndrome with amphetamines, opioids, and sedatives.
Out
of a sense of medical impotence, physicians had by a significant majority
"overtreated" patients with chronic pain and fatigue. Medical
"addiction" was almost commonplace, and many
less-than-scrupulous physicians used the patients’ addictions to keep
them coming back to the office, and to coerce them to pay their bills.
Now let us leap into the latter
1990’s. Many changes have taken place. Patients have become
increasingly sophisticated and educated. Managed Care has
overshadowed and overtaken the individual physician’s judgment.
When once the physician answered to the court of scientific
inquiry, that position is now considered secondary to the
directives of the managed care corporation’s profit margins.
Because
of the exuberance of yesterday’s doctors and the inability of the
Federal Government to control illicit substance use, the Drug Enforcement
Agency has focused increased efforts on legal prescription
"diversion". This watchfulness by the DEA has elevated physician
anxiety regarding the prescription of "narcotic" drugs (as
defined by the Drug Abuse Prevention and Control Act).
What
is the present day physician’s approach to the patient who walks into
her office with concerns related to Fibromyalgia or Chronic Fatigue
Syndrome?
You,
the patient, come into the physician’s office with need for diagnosis
and relief of your symptoms of pain, lethargy, fatigue, sleep disturbance,
concentration deficits and muscle stiffness. Most of your symptoms are
considered to be controlled by the Central Nervous System (consisting of
the brain and spinal cord). Therefore, a neurological evaluation would be
considered appropriate in your case.
The
physician is presented then with her first hurdle. Let us assume that your
physical examination showed "no objective abnormalities" (i.e.,
there is nothing that the physician sees outside of your verbal report of
pain or discomfort). A neurological evaluation might include: EMG/NCV,
MRI, CT, EEG, various blood chemistries and antibody evaluations, Evoked
Potential studies, and perhaps others. The managed care company will
refuse to give approval for these studies because of the lack of
"objective evidence" to justify these expensive procedures.
(Also,
in many cases physicians are reimbursed, or given incentive, not to
perform tests and a percentage of the cost savings are paid to the
physician.)
You,
as a sufferer of Fibromyalgia or Chronic Fatigue Syndrome, won’t be
effected by whether the physician is able to get the tests approved or
not; the results will be "negative" because of the limitations
of the present technologies. Now the physician faces her second hurdle,
what is she going to do with you?
In
the former paternalistic system, it was the physicians’ imperative to
take care of their patients. The patient had placed her trust in the
physician to bring some degree of relief of suffering, and the physician
of the age had an unwavering belief that science, most of all
biopharmaceutical science, while not always providing a care, could at
least quell the extent of suffering. To this extent, the physician-patient
relationship was fulfilled; the patient felt better and the physician also
felt better because he was not rendered powerless or helpless to aid his
patient.
The
present system does not allow anywhere near the same degree of latitude.
CNS (central nervous system) drugs are often expensive, and are not on the
managed care plans’ approved formulary (which means that you, the
patient, are responsible for paying the full price for these non-approved
medications).
An
even more overarching concern on the physician’s part is the DEA’s
oversight of their prescribing behaviors. Most CNS drugs used for
Fibromyalgia and Chronic Fatigue Syndrome are listed as "controlled
substances" by the DEA. The prescribing physician often
misunderstands the extent of DEA involvement. This lack of understanding
is communicated to the patient. "I can’t prescribe that medication
to you because the DEA is watching me like a hawk and I can get into
trouble". In fact, the DEA does not record or have a central database
that is updated on a daily, monthly or yearly basis. While such
centralized databases would be relatively easy to implement and maintain,
at the present time they do not consider this part of mission.
Something
that is more often the case is that the physician does understand the
extent of DEA oversight, but because she doesn’t want to prescribe the
medication at all, communicates to the patient that her hands are tied.
Whether this is because of concern over addiction, or a concern over the
present state medical board position on the use of controlled substances
for chronic conditions, or just the fact that she doesn’t like the
patient, is not communicated.
Therefore,
the nature of the physician-patient relationship is quite different from
what it was. Feeling hamstrung by managed care corporations, the DEA, and
state/county medical boards/societies, the nature of physician-patient
relationship has evolved from the paternalistic to the adversarial.
The
adversarial nature of the physician-patient relationship has its
underpinnings with the medical liability crises in the 70’s. Malpractice
is always in the back of every physician’s mind. However, there is now
an amplification of what can be seen as "competitive" behavior
between the physician and patient. The patient, no longer someone who is
"cared" for, is a consumer of heath care resources, and the
physician is no longer the doctor, but a health care "provider".
You
then come to the physician’s office not so much now to develop a
therapeutic relationship, but rather as a customer. The physician is part
sales person and part business owner (or employee), who seeks to make not
only the customer happy, but also the regulatory agencies which govern her
business (and/or her bosses). As in, for example, a restaurant, if a
single customer is unhappy, it is considered unfortunate. However, if that
restaurant should make the Health Department, the State Tax Franchise
Board, the Alcohol Beverage Control Board, and any number of regulatory
agencies unhappy, then they are out of business. Period.
And
you, the people with Fibromyalgia or Chronic Fatigue Syndrome, are in the
worst situation. You are considered to be inappropriately heavy users of
medical resources, and overusers of controlled substances. Given the
diametric change in the nature of the physician-patient relationship, what
can you do to fortify your position?
You
are a customer, and the physician is the "store". The situation
is more akin to that of Used Car Lot rather than a retail store, in that
bargaining and negotiation skills are paramount. Each side needs to
understand the other’s position and then attempt to find a common
ground, making a "win-win" for both you the customer and the
physician provider.
As
a negotiator, you must have objective facts. This means researching your
condition, finding medical evidence to support your getting the things
that you need, such as diagnostic testing and medications. Your sources
must be from "legitimate" publications and authors (i.e.,
reviewed medical journals or mass media publications that are not
considered "fringe").
But
the scientific aspects of your negotiations are not enough. The major
challenges lay in political and business research. You need to be aware,
and enlighten the physician with whom you are negotiating the results of
your awareness, of the present stands of the State Medical Board, their
county medical society, and the DEA on those things that you want.
You
must also have ready information regarding the rules and guidelines of
your managed care organization. Those include the policies regarding the
drugs which they approve for treating your condition, the tests approved
for diagnosing your condition, and the name and qualifications of the
initial reviewers as well as the medical director of your managed care
plan.
With
your scientific, business, and political knowledge you can sit at the
negotiation table. With the knowledge you have of your
"competitor’s" situation, you should be able to come up with a
reasonable compromise. If not, you must, like in any other type of
negotiative scenario, leave the table and choose not to do business with
that person. However, you must document fully the reasons for your
choosing another physician; else you will be seen as a "doctor
hopper". The physician-patient relationship has changed radically. You now have the information and the insights to tackle the challenges of the new "commercial" relationship patients have with their physicians. By using this knowledge, you should be able to maximize your abilities to seek some degree of relief from your chronic conditions. Copyright © 1998 Thomas W. Shinder, MD. All Rights Reserved.
Thomas
W. Shinder, MD,
is a neurologist-turned-network systems engineer
who practiced medicine in Texas, Oregon and Arkansas before moving to his
present home in the Dallas-Ft. Worth TX metropolitan area.
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