While Congress grapples with making health insurance more available for all Americans, a leading specialist on health policy and medical technology told a AAAS seminar that there also is an urgent need for health care professionals to change the way medicine is practiced.
Stanley Joel Reiser
Stanley Joel Reiser, clinical professor of health care sciences and health policy at The George Washington University, has devoted more than three decades to the study of how technology affects the delivery and quality of health care in the United States. He argues that doctors have become adept at treating disease but often at the expense of truly understanding the needs of their patients.
“In modern medicine, we often treat the disease fully and the patient partially,” Reiser said. “That is a formula for inadequate medical care.”
Reiser, the author of a landmark monograph in 1978 on the rise of technology in medicine, spoke at a 7 October seminar co-sponsored by the AAAS Archives and the Chemical Heritage Foundation's Center for Contemporary History and Policy. He is the author of a new book, “Technological Medicine: The Changing World of Doctors and Patients” (Cambridge University Press).
Modern doctors have become “geographers,” Reiser said, seeking illness in places throughout the body where visible evidence of disease the formation of lesions can be located. Each introduction of new tools of medicine such as stethoscopes, X-rays, and sonograms helps reinforce the urge to find pathology at the physical level, he said. That same mind-set is at work in the newer technologies that allow health professionals to search for damage at the level of genes and chromosomes.
The stress on finding the physical sources of illness through use of diagnostic instruments, Reiser argues, has become the accepted model for medical intervention. “This thinking is so pervasive, it’s virtually invisible,” he said.
But Reiser argues that there needs to be an alternative approach, one that considers illness as an interaction between patients and the environments in which they live and work. “Illness occurs when we can’t adapt adequately to the environment that surrounds us,” he said. Illness is a pastiche of personal experiences and reactions, he said, with each person responding individually to disease organisms and other health challenges. The stresses of daily living, including how we are treated at work, how well our marriage is holding up, how well we are succeeding in school, can influence how we cope with disease or chronic illness, Reiser said.
Within that adaptive model of disease, the social and humanistic sides of medicine have struggled to gain traction against the rise of technological medicine. That rise has changed the relationship between doctors and patients, Reiser said, and the change has affected both parties. Just as technology has encouraged doctors to view patients as vessels of disease, he argues, so has it left patients with sometimes inflated expectations of what medicine can do for them.
Technology also been the principal driver for increased health care costs, Reiser said. In the 1960s, before the dawn of truly high-tech medicine such as kidney dialysis, 1 out 20 dollars of GNP was spent on health care, he said. It rose to 1 out 6 dollars by 2006 and is heading toward 1 out of 5, he said. Part of the increased spending on health care can be attributed partly to higher incomes the more money you have the more you can spend on health care and partly to broader access to health insurance, which also encourages spending, Reiser said. But the most significant factor by far, he said, is “the use of technology to treat illness.” He said studies suggest that one-half to two-thirds of all health care costs are technology-driven.
“If you don’t understand exquisitely what technology does in medicine,” Reiser said, “then we will have a difficult time sustaining reform in a satisfactory manner.”
Reiser sketched some of the ways in which technology has changed the doctor-patient relationship, even as far back as 1819 when the stethoscope was introduced as a tool that allowed doctors to listen to the sounds of the body. “The whispers of the body became more important than the voice of the patient,” he said. As the doctors began to pay more attention to the sounds of the body’s organs, the first steps toward what Reiser calls “therapeutic distancing” had begun.
In early 1896, the public’s response to the first X-ray of a human being, a ghostly picture of a hand, was a mixture of awe and fear. Stores in London soon promised their customers that they sold undergarments that were “X-ray proof.” The technology is now overused, Reiser said, and many doctors do not even recognize a person’s lifetime X-ray exposure can have a cumulative effect on cells.
The advent of costly new technologies also can have economic impacts, leading to de facto rationing of health care, Reiser said. That is particularly the case when a technology is first introduced. In 1961 at the Seattle Artificial Kidney Center, which pioneered kidney dialysis, it cost patients $10,000 a year for services. That was comparable to the cost then of a luxury car or a college education, and it meant that many who might have benefited from the new technology were simply unable to afford it.
As the American health care system expanded in breadth and complexity, thanks to the introduction of many new tests, tools and therapies, the patient information generated by the system became more diffuse and difficult to manage. One possible solution: yet more technology in the form of computerized, electronic medical records. The advent of such records has been widely viewed as a positive development, Reiser said.
“The only technology that doesn’t fractionate things but brings them together is the [electronic] medical record, he said. Such a record could help doctors keep track of a patient’s cumulative X-ray exposure, for example, and help ensure that the medical records of patients are available no matter where they move. Proponents also tout the records as a way to help eliminate duplicative tests and reduce health care costs.
But even that technological innovation has been oversold, according to Reiser, and may not provide the sort of cost savings and efficiencies envisioned in the various health care reform proposals being considered by Congress. “Too much weight has been put on a very good innovation that is still in development,” he said.
As Reiser sees it, health care reform must proceed on two fronts. Congress is dealing with policies that government can impose to make the existing health care system work better. But Reiser called for more fundamental reforms by medical professionals willing to consider new therapeutic approaches that recognize the complexity of illness and health as experienced by individuals. In doing so, he said, the natural tendency to rely heavily on technology would be diminished as other paths of analysis what we eat, our mental state, where and how we live come to the fore.
“The reform of policy and the reform of practice must go hand in hand,” he said.