This course has not only opened my eyes to the clear issues and complications of today’s healthcare system, it has led me to realize my role and responsibility as an individual in improving this broken system. In the first half of the course, it was very informative to learn about the inner and outer machinations of what is now a highly corporatized market and how it compares to other healthcare systems around the world. However, as the course progressed it was even more intriguing to investigate how the U.S healthcare system has evolved into one of commercialism and consumerism and why its components have become social institutions.
In the article, “Does Investor Ownership of Nursing Homes Compromise the Quality of Care?” Harrington et al. sought to investigate if investor ownership affects quality of nursing home care. The study examined almost 14,000 nursing home facilities across the U.S and measured the institutions’ quality based on a range of measures including health outcomes, physician services, patients’ rights maintenance, and nurse staffing ratios. The study even controlled for confounding variables that could have muddled the relationship between investor ownership and quality being investigated. The results showed that investor-owned nursing homes had ~40% more deficiencies in all categories of quality of care than did non-profit and public facilities. Interestingly, investor-owned facilities had lower nurse staffing in each occupational category (registered nurse, licensed vocational nurse, licensed practical nurse, etc.) than the other types of facilities. The study concluded that investor-owned nursing homes provided lower quality care than do non-profit or public facilities.
In the New York Times article, “A Quiet End to the ‘Death Panel’ Debate,” Paula Span draws attention to the recent change in Medicare policy that reimburses physicians for holding end-of-life discussions with patients; this policy change thus promotes an important conversation that can ultimately help alleviate issues for the patient, their loved ones, and the nation’s budget. Over the years, medical care and its professionals have evolved to focus on “curing” a patient of their condition often irrespective of the patient’s comfort and quality of life, and this tendency of health care providers to order more tests and procedures rather holding a transparent conversation with the “nearing-the-end” patient has contributed to a less compassionate health care system and increased health care expenditures. Encouraging a discussion of end-of-life options for a patient and not a declarative “death-panel” respects the wishes of patients and their loved ones, improves communication in an egalitarian doctor-patient relationship, and ultimately reduces the need for unnecessary scans, tests, procedures that contribute to elevated health care costs.
In Robert Zussman’s excerpt, “The Patient in the Intensive Care Unit,” the issue of patient dehumanization in the U.S health care system is especially prevalent in hospital intensive care units (ICU). Zussman argues that the dehumanization of the patient results from the disease endured but also at the hands of the practice of health care professionals. Many of the people that are admitted into a hospital’s ICU with unstable vitals, but ICU doctors and nurses often work tirelessly to stabilize a patient’s heart rate, blood pressure, respirations at the expense of the patient’s personhood. Zussman made the shocking comparison of ICU medicine to veterinary medicine suggesting that there is no longer any doctor-patient communication and that the “treatment” does not require thinking of the patient at the contextual level; diseases and conditions reduce people to intubated and unresponsive vessels hooked up to organ-pumping machines. Zussman also argues that because of the lethal nature of the patient cases that they treat, ICU doctors are often less thorough in their patient’s physical examination and are less empathetic health care providers than doctors in other hospital departments. This distinct difference in treatment is demonstrated in ICU doctors coining the term “GOMER” to describe undesirable ER patients and the reduced use of talking and touch when diagnosing an unresponsive patient.
In the excerpt, “The Rise of the Modern Hospital,” Charles Rosenberg illustrates how hospitals have made the transition from being a “microcosm” in a 19th century community to a national institution by the early 20th century. Rosenberg also describes how this transformation of the hospital setting was driven by technological advances and rise of internal bureaucracy. He also begins to touch upon certain social determinants of healthcare, as referred to as “social location” that persisted along with the new hospitals’ development.However, the idea that “changed expectations” of the hospital setting on both the physician and patient ends had largely contributed to the transformation was a novel argument that was particularly interesting.
Rosenberg argues that as medicine changed drastically in the latter half of the 19th century, so did patients’ expectations of medicine and this thus provided “medical men” the ability to claim an identity with raised authority in social hierarchy and even over science itself. Rosenberg reiterates this notion with the statement, “The growing complexity and presumed efficacy of medicine’s tools seemed to make the centrality of physicians in decision making both inevitable and appropriate.” This must have begun the medical care norm of the patriarchal relationship between the doctor and the patient, which was a big transition from what used to be a community with diffused medical knowledge and skill and not as much power to the physician. Rosenberg concludes that the initial driving force of scientific advancements in medicine continues to raise people’s expectations of medicine while simultaneously increasing costs of medical care; however, the issues of rising health costs and persisting patient dissatisfaction does not seem possible to solve with our current health care system’s preferred aims for scientific innovation and profit maximization.
In the excerpt “How Doctor’s Think” from Marketing, Money, and Medical Decisions, Jerome Groopman demonstrates how big markets like the pharmaceutical industry largely influence what becomes a medicalized condition by aiming sales tactics at physicians and a patient-consumer audience. Groopman details the experiences of endocrinologist Dr. Karen Delgado and how Big Pharma has pushed their testosterone product by exploiting hormonal related aspects of aging as medicalizable conditions. Pharmaceutical representatives often lobby for the sales of their products by bribery and bullying physicians into changing the way they normally practice and treat patients. Pharmaceutical companies also push for the medicalization of certain profitable conditions by creating ads that are directed to their potential consumers. The advertisements often list vague symptoms that feel applicable to much of the audience and recommends that they ask their doctor about their product. By directing sales tactics at physicians and marketing to potential patients, drug companies wield power in shaping what becomes medicalized and how it can be treated.
In the New York Times article, “Pediatricians Are Asked to Join Fight Against Childhood Hunger,” Catherine Saint Louis commends the American Academy of Pediatrics (AAP) for its new policy that addresses the issue of food insecurity as a major contextual factor that influences U.S population health. She draws attention to how food insecurity has been found to cause many behavioral problems and hospitalizations for developing children. She also states that the lack of proper nutrition for these children contributes to the rising costs of health care. Saint Louis argues that the negative health outcomes in children from food insecurity amongst families is due impart to the medical practice of pediatricians. Saint Louis draws on claims from Dr. Chilton of Children’s HealthWatch that pediatricians do not adequately research childhood hunger; it has also been difficult to get the physician community to focus on the issue of food insecurity and the negative health effects it causes for their patients. The academy now urges pediatricians to screen their patients for food insecurity using a screening method that inquires if in the past year, money for a lasting food supply was a concern the parent(s) had encountered. If it is incorporated into standard routine of the doctor check-up process, this proposed screening method is helpful in that it removes the communication barrier experienced by parents that may be embarrassed to admit food insecurity and to seek help from a medical professional.
Patricia Rieker et al. in “Understanding Gender and Health – Old Patterns, New Trends and Future Directions” discuss the gender gap in longevity and overall health in the United States and at the global level. Women have shown higher life expectancy than men, and this pattern is consistent across different countries. Although clinical research had previously focused on solely biological mechanisms to explain the health disparities between the sexes, Rieker emphasizes that the size of this gender gap is a result of complex interactions between social and biological factors. Rieker and Bird propose a multilevel constrained choice model to explain how individual choice in addition to actions performed at the family, work, community, and government levels shape the differing health outcomes of males and females. I found it very interesting that men, who are normally thought to have more privilege in today’s society, actually have a short life expectancy than women. They discussed how this intriguing paradox could be a result of social and biological determinants. For example, men may feel social pressures to fulfill masculine identities and engage in more risky behaviors than do women, which leads to negative health outcomes. However, biological mechanisms come into play as men may be more genetically apt to abuse alcohol and other deleterious substances. The discussion provides for a new area of health consciousness; a better understanding of the differing constraints experienced by the genders can help propel prevention and interventions necessary for improving overall population health.
In their article, “Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence and Policy Implications,” Phelan et al. elaborate on the historically prevalent theory that socioeconomic status (SES) is intimately linked with health outcomes. They provide compelling evidence as to why this association has persisted despite the ever-changing diseases and risk factors encountered by our developing population. It was of no surprise that “flexible resources” such as knowledge, power, and social connections that exist at the individual and contextual level were at the center of their proposed fundamental cause theory. However, it was interesting that they found that SES-related health disparities were more prominent for diseases that had recent progress in treatments than the level of disparities found for diseases that did not have new found knowledge or interventions. These findings supported their fundamental cause theory on the basis that those of high SES are better equipped to seize these newly developed medical treatments. They claimed that strategies that aim to reduce these SES-related health disparities must reduce disparities in socioeconomic resources and the strategies must include interventions that are equally distributed across SES groups.
Each class and article has revealed to me a new level of intricacy and topic of inquiry that govern the healthcare system that we live in today. In my naiveté, I did not realize that as a buyer of health insurance that I am a “patient-consumer” with very little choice or power as a pawn in what has developed to be a corrupt market. I want to believe that when I visit a hospital or doctor that there are no hidden motives that govern how they treat me; however, this hopeful illusion is quickly dissolved by arguments like Quadagno’s Stakeholder Theory and Timmerman’s discussion of the shift in medical professionals’ actions in favor of self-interests.
I am bewildered by the fact that in our system one man has the power to upcharge a life-saving drug from $13.50 to $750 per pill, that people can be “too poor” for private insurance and simultaneously “too rich” for Medicaid, and that some people are forced to file for bankruptcy due to medical bills that would have been otherwise alleviated if the individual were not two years shy of 65 years-old. How has our country’s policies evolved to let hospital “chargemasters”, Big Pharma executives, and other providers in our multi-payer system gain this level of power and influence over our quality of healthcare?