In this week’s New Yorker, Atuk Gawande, the author of the article, “Overkill: An Avalanche of Unnecessary Medical Care is Harming Patients Physically and Financially,” states:
That sounds like iatrogenesis, which simply put, means that it is the cure, the treatment — the care itself — that makes patient ill (Illich, 1974). When a doctor says an illness is iatrogenic, it means that it was the result of a treatment. For example, if someone develops a low white blood cell count (agranulocytosis) from a medication, it would be called “iatrogenic agranulocytosis.”
On the flip-side, in his recent New York Times article, “When Patient’s Don’t Follow Up”, Barron H. Lerner, a physician at New York’s famed Bellevue Hospital, examines the implications of patients failing to get necessary evaluations and treatments. Dr. Lerner focuses on issues of responsibility. He looks at socio-economic barriers to care, systemic issues, and some of the fixes that can help patients follow-up (for example, reminder calls).
Who is responsible for a patient having a bad outcome? For example, consider a patient with high blood pressure, who has a stroke, or a patient who needs a heart evaluation, fails to do it, and has a heart attack. Patients have a right to refuse care, but doctors are responsible for communicating the reasons for a recommendation, and the risks of not doing it. To some extent they also need to follow up with patients who don’t do what is recommended. This kind of confusion compounds when a patient’s health is on the line and a doctor’s sense of wanting to provide good care and avoid malpractice claims comes into play. The result. High anxiety.
From an ethical perspective, things are hazier. Do patients really have no responsibility when it comes to follow-up? After all, non-adherence by patients is a well-known and inevitable phenomenon. If one argues that doctors or their colleagues need to call all people who miss appointments, why shouldn’t we also be calling every day to make sure patients are taking their medications, exercising or adhering to their diets?
Sometimes doctors will order more tests than necessary, and sometimes patients will avoid following recommendations — in both cases, anxiety is one of the culprits for this pair of negative behaviors.
“When there is irrelationship between doctor and patient, it is more likely that there will be irrelationship between the healthcare system and everyone else.”Mark
The doctor-patient relationship is one that is extremely susceptible to the pitfalls of irrelationship. Given the high-stakes of medical testing and treatment, and the terrible costs of missing appropriate evaluation and treatment, the doctor-patient relationship is shaped to varying degrees by apprehension and fretfulness for both parties involved. This basic anxiety twists the doctor-patient relationship into a pretzel, serving no one. This deep discomfort, outside of awareness or described as “dissociated,” often gets expressed in maladaptive behaviors that play out in interpersonal interactions. This is called “enactment,” and, according to the rule of thumb: whatever is dissociated is enacted (Bromberg, 1998; Levenson, 1972; Stern, 1997). The more this shared anxiety is unrecognized and unaddressed, the more it can play out in destructive ways. It seems likely that the doctor and patient relationship triggers overwhelming feelings, among other responses, that lead in part to creating more defenses on the part of each, to protect from being further overwhelmed. The spiral builds insecurity and lack of trust which is enacted through patterns of interaction that cause imbalance and breakdown in reciprocity: healthy and natural interdependence between those who give care and those who are cared for.
We believe that relational health — even relational sanity — occurs and is jointly created when there is a balance of give and take in relationship. This is mutual interdependence. Irrelationship is the opposite of that; we could say it is relational insanity. If a healthy relationship is a state where the people within are willing and able to care for each other in ways that allow them to be compassionately empathetic, intimate, vulnerable and emotionally invested, then irrelationship is the “cure” that leads to poor relationship health. This is because the short-term value of avoiding anxiety seems to outweigh the long-term damage cause by the avoidance. Irrelationship thus becomes the iatrogenic cause of suffering. As they say, the cure is worse than the disease.
Is the medical system itself in irrelationship with the recipients of its care?
Dr. Gawande is a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. His curiosity was piqued when his own patients reported an alarming rate of “unnecessary care.” He begins his article referencing work that reviewed the treatment of more than a million Medicare patients. This research suggested that “a huge proportion had received care that was simply a waste.”
He goes on to state:
The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful… In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.
The unnecessary tests and procedures included: EEGs, CT and MRI scans, and cardiac procedures, among others. Gawande poses the question: “Could pointless medical care really be that widespread?” He says that, “Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another.” Yet, at least in Overkill, he does not address the parallel issue Lerner highlights; there are patients who have an appropriate test or procedure recommended and fail to get it done. The real issue here seems to be about an imbalance in care provision, leading to errors both in terms of excess and deprivation. This arises partly from distortions in the doctor-patient let’s call it irrelationship, of course, embedded within the context of deeply problematic issues with healthcare and society.
But it raises the question: Does unnecessary care suggest irrelationship within the “caregiving” medical establishment itself? Has the dynamic between the medical care system, broadly defined, and the patient become a song-and-dance routine that is about turning the tables, reversing roles between the caregivers and the caregiven? Do patients, especially like those of Dr. Gawande, who know that unnecessary “care” is taking place, do they “take care” of their caretakers by accepting their “care” when they shouldn’t? Do patients like Dr. Lerner’s take care of their beleaguered doctor’s by not showing up, and giving the poor doctor a break? Or do they express dissatisfaction through non-participation, rather than through healthy channels of communication.
Rather than being able to relate as human beings in a professional context, do patient and doctor become two-dimensional caricatures, taking on roles of performer and audience as we discuss elsewhere in detail? To dig deeper, are both doctor and patient in an irrelationship with the healthcare and societal system at large? Can they step out of this irrelationship? Can they possibly think together and relate effectively and intimately about terribly important things? Is relational sanity possible in these circumstances?
“I wish more patients would be up front when they have concerns. Of course, docs have to do our best to put people at ease... even in the shorter and shorter amounts of time our system is doling out for healthcare visits.”Grant
Professional caregivers, Dr. Gawande included, are essentially trained to be ever mindful and suspicious of “doing too little than doing too much.” Dr. Lerner concludes on an ambivalent note, describing a patient who disappears without treating her dangerous high blood pressure. He tries to reach her and finds she has left the country. He persists, asking her contact to let his patient know how important it is to take care of the issue abroad. Sardonically, he concludes, “And then I wrote a note documenting the conversation,” alluding to the anxiety of being wrongfully sued, and the dehumanizing effecting of having to practice “defensive medicine” in order to take care of one’s own needs. From relational to irrelationship again.
Maybe it is time to spread the irrelationship net to include all kinds of interactions that we’ve not yet considered. For instance, doctors and patients are in irrelationship when there is either overkill or underkill — unnecessary care vs. non-compliance, a blurring of the lines between quantity and quality — that leads to overwhelming anxiety. This fosters and sustains a breakdown in reciprocity. It also results in relational imbalance that leads to insecurity in all parties, and triggers powerful defenses against it — that is, irrelationship. Together doctor and patient enact irrelational routines that result in sustained imbalance — and failure — in the larger system. When there is irrelationship between doctor and patient, it is more likely that there will be irrelationship between the healthcare system and everyone else. In the end, everyone suffers.
Bromberg, P. M. (1998). Standing in the spaces: Essays on clinical process, trauma, and dissociation. Hillsdale, NJ: Analytic Press.
Illich, Ivan (1974). Medical nemesis: The expropriation of health. London: Calder & Boyars. ISBN 0-7145-1096-3.
Lerner, B. H. (2015). “When patients don’t follow up,” The New York Times, November 13, 2014.d
Levenson, E. (1972). The Fallacy of Understanding. New York: Basic Books.
Stern, D.B. (1997). Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: Analytic Press.