The medicalization of life

Mar 16, 2010 By H. Gilbert Welch

Here's a question that's not being asked in the health-care debate: How much medical care do we want in our lives? It's something we should be discussing.

Start with the two life events we all experience, birth and death.

My profession has gotten pretty good at terrifying (and operating on) during what should be one of the greatest experiences in life. And we are equally proficient at dragging the elderly through all sorts of misery on the road to death.

Too harsh, you say?

Consider this. Two of the most common tests performed on pregnant American women are obstetrical ultrasound and electronic fetal monitoring. After reviewing experimental studies involving more than 27,000 women, the Cochrane Review -- an independent, international collaboration that summarizes evidence for medical procedures -- found that routine late-pregnancy ultrasound "does not confer benefit on mother or baby."

But it does do a good job of scaring expectant parents. Among other things, it finds minor anatomical abnormalities (like "bright spots" in the heart or ) that have been associated with feared genetic disorders such as . Less than half of maternal-fetal medicine specialists reported using the test to screen for these disorders in 2001; now almost all do. The problem is that the minor anatomical abnormalities are about 30 times more common than the genetic disorders they have been associated with.

That means most parents who are told after an ultrasound that their child might have serious problems are told so needlessly. Not surprisingly, this leads to a lot of unnecessary heartache and extra testing. This has led one of the founders of the technology to write that its routine use has crossed the line and now causes "more harm than good."

The story is no better for electronic fetal monitoring during labor. Largely confined to teaching hospitals during the 1960s and '70s, by 1999 -- the last time the federal government examined the topic -- electronic fetal monitoring was used in 83 percent of all U.S. births. After reviewing experimental studies involving more than 37,000 women, the found that the monitoring had no effect on the need for neonatal intensive care or, more important, infant survival.

It did lead to slightly fewer seizures, but also to a lot more Cesarean sections -- on the order of 100 extra C-sections to avoid one seizure.

The increase in fetal monitoring is part of the explanation for why the beginning of life now involves major surgery one-third of the time.

There is even more medical care at the end of life. Although most Americans say they would like to die at home, the most common place of death is still the hospital.

A hospital is not a peaceful place. The prevailing paradigm is intervention, not comfort. Nowhere is this more true than in intensive care units. They tend to be busy, noisy, frenetic and frightening places. There are lots of monitoring devices, which lead to lots of uncomfortable procedures. The ICU is not a good place to die.

Yet they are being used more and more for this purpose. Between 1995 and 2005, Dartmouth Atlas data show a 25 percent increase in the proportion of Medicare patients spending time in the ICU during their last six months of life. The average number of days spent in the ICU went up even more -- by 43 percent.

Furthermore, a startling number of doctors can be involved with care at the end of life. A third of Medicare patients cared for by "America's Best Hospitals" (as designated by U.S. News & World Report) were seen by 10 or more physicians during their last six months of life. That's right, 10 or more. It's hard to imagine how that can ever be good. These may be our best hospitals, but they are certainly not our best deaths.

So the most fundamental life events -- birth and death -- increasingly involve more and more medical care. Why should you care about this increasing medicalization of birth and death?

Simple. Because it exemplifies the medicalization of life. Everyday experiences get turned into diseases, the definitions of what (and who) is normal get narrowed, and our ability to affect the course of normal aging get exaggerated. And we doctors feel increasingly compelled to look hard for things to be wrong in those who feel well.

Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment -- and some of them are harmed by it.

And it's big part of the reason why medical care costs so much.

There are many areas in which medical care has a great deal to offer. But it has now gone well beyond them. There may have been a time when the words "Do everything possible" were indeed the right approach to . But today, with so many more possibilities for intervention, that's a strategy that is increasingly incompatible with a good life. We all need to be a little more skeptical and -- to really be healthy -- willing to ask "Why?"
___

ABOUT THE WRITER

H. Gilbert Welch is an internist at the Department of Veterans Affairs in White River Junction, Vt., and professor of medicine at the Dartmouth Institute of Health Policy & Clinical Practice. He is the author of "Should I Be Tested for Cancer? Maybe Not and Here's Why." He wrote this for the Los Angeles Times.

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CynthiaY29
Mar 17, 2010
This comment has been removed by a moderator.
rachielondon
2.7 / 5 (3) Mar 17, 2010
I would say this person is more worried about the insurance company's profits, like medicare for example.

" Dartmouth Atlas data show a 25 percent increase in the proportion of Medicare patients spending time in the ICU during their last six months of life. The average number of days spent in the ICU went up even more -- by 43 percent.

A third of Medicare patients cared for by "America's Best Hospitals" (as designated by U.S. News & World Report) were seen by 10 or more physicians during their last six months of life. That's right, 10 or more. It's hard to imagine how that can ever be good. These may be our best hospitals, but they are certainly not our best deaths."

But I do agree we have many things in health care that needs fixing.
We should be more worried about all the people dying because of misdiagnosis and undiagnosis, over a 100,000 people a year just in the US. After we solve that lets worry about the medical care we don't need. huh?
deatopmg
1 / 5 (2) Mar 17, 2010
This is an excellent article! Medicalization (yes it is a word cynthiay29) of the natural birth process is a disgrace but the Industrial Medical Complex doesn't care, it's about making money not about peoples health.
We are so ready to blame the insurance industry for the rising cost of health care but their take is minuscule compared to the medical industry's. The real reason for health care in the uS costing up to twice as much as in the other developed countries is at least three fold: Lawyers running amuck, the medical industry (especially big pharma) being a gov't granted cartel (w/ the classification of every real or imagined ailment), and people wanting to be treated for these ailments.

The solution: any and all contacts between lobbyists and/or their agents and gov't employees, including elected officials, and/or their agents shall be posted on a specific website within 24 hrs and shall include time, duration, the names of all present, and the location of the meeting.
marjon
1 / 5 (2) Mar 17, 2010
The only real solution is to get the government and industry out of the medical care business.
When consumers choose who to pay and what to pay, the industry must accommodate or go out of business.

Another point, in any of the recent uproar from the democrats about health care, how much was addressed to the actual costs of the care at point of service? Much rhetoric exists about the cost of insurance, but not much about the actual cost of the product.
Now MA proto-Obama governor is proposing price controls as MA state health program is going bust.
Wage and price controls NEVER do as intended. That has been demonstrated over and over and over...
marjon
1 / 5 (2) Mar 17, 2010
Follow up:
"The state's stubbornly high health costs are partly the result of intrusive government regulations that stifle competition in the insurance market and strict mandates on what services insurance must cover."
"insurance companies are required to sell "just-in-time" policies even if people wait until they are sick to buy coverage. That's just like the Obama plan."
http://online.wsj...652.html
JayK
3 / 5 (2) Mar 17, 2010
Just to point out that marjon probably isn't the best person to be listening to in a discussion on medicine:

http://www.physor...812.html

There it is comparing HIV to other communicable diseases. And here it is trying to act like it has a valid opinion on anything else. Wonderful.