Balance of Power

In researching a novel I am writing I have been reading about the history of the treatment of depression.  As often happens, I ran into an historical issue with echoes of the future.

Here’s an interesting paragraph from Howard Kushner’s book American Suicide.

“While asylum superintendents [in the 1840s] were as much captive of bourgeois ideology [the conviction that the insane could be reformed and that the suicidal could be cured] as were other social reformers, they were influenced on a daily basis by more parochial concerns.  Not least of all, these men sought stable employment in the medical profession at a time when, buffed by competing medical sects, medicine promised neither prestige nor a regular income.  A career as an asylum superintendent offered a solution to the contradictions between humanitarian desires to help others and a quest for economic security.  Like most professionals then and now, these asylum physicians saw no conflict between an increase in their professional power and the improvement of the condition of the patients they served.  Indeed, they viewed the former as essential for the latter.”  (Bold letters are my addition.)

Let’s look at that second-to-last sentence.  Professional physicians see no conflict between increases in power and the improvement of patient condition.  Conflict may not be quite the right word.  Maybe correlation is a better one.  Professional physicians see correlation between increases in power and improved patient condition.  Up to a point the statement is historically accurate.  There was no conflict in the eighteenth and early nineteenth centuries because as trained doctors from legitimate medical schools began to have more influence than the untrained barber-surgeons and apothecaries, patient health did get better.  Education and science eventually led to treatments that truly helped people.  This resulted in a medical profession which, unlike that of 1840, had great prestige and good income.

Since those early days of medical professionalization, however, power has shifted.  The turn away from paternalism toward autonomy has shifted the balance.  Regulation, legislation, and an omnipresent media have shifted it further.  Power, which used to be in the hands of doctors, for better or worse, is now in the hands of regulators, administrators, and the patients themselves.  The question is, does the decrease in physician power correlate with a change in the health of patients?

The answer, of course, depends on who you ask.

You could ask Timothy Quill and Howard Brody, who would tell you they doubt extremes of patient power increase the well-being of patients.  In 1996 they wrote the following in the Annals of Internal Medicine: (Ann Intern Med. 1996;125(9):763-769)

“At one extreme end of this [patient autonomy] spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician’s exercise of power and influence inevitably diminishes the patient’s ability to choose freely.”

You could ask the Physician Regulatory Issues Team at CMS, which claims that the power of regulation, in the form of government money, improves the condition of patients:

“Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients.” (http://www.cms.gov/Outreach-and-Education/Outreach/PRIT/index.html?redirect=/prit/)
You could ask Drs Bell, Wilkes, and Kravitz, who may say that the power of advertising is not improving anyone’s condition.  They found that “A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media.”  The Journal of Family Practice [1999, 48(6):446-452]
You could ask Louis Goodman and Tim Norbeck of Forbes, who would probably say that regulations are not increasing patient health.   “…Physicians are already spending 22 percent of their time interacting with insurers on formularies, claims, billing, credentialing, pre-authorizations, and quality measure data.  The workload can only increase with the new [ICD-10] codes.” http://www.forbes.com/sites/physiciansfoundation/2013/11/05/healthcare-is-turing-into-an-industry-focused-on-compliance-regulation-rather-than-patient-care/

You could ask the people of Florida, where doctors abuse their power of the prescription pad.  They would say that absolutely, regulation has improved the condition of patients.  An article in the New York Times reported that “New laws are also cutting off distribution [of prescription painkillers]. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” http://www.nytimes.com/2011/09/01/us/01drugs.html

Balance of power is important in health care, just as it is in government and marriages.  No one will argue that giving physicians full power to do anything they want is a great idea.  But we need to be careful about how much power we take away.

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