Are Americans Over Medicated

By Herbert Ratner, Professor of Preventive Medicine and Public Health at the Stritch School of Medicine, Loyola University, Chicago, and Commissioner of Health of Oak Park, Illinois. From an interview by Donald McDonald, Dean-elect of the College of Journalism of Marquette University, one of a series in connection with a study of the American character by the Center for the Study of Democratic Institutions.

 

The United States is the best place in the world if you have a serious illness, but one of the worst if something minor is troubling you. This is only one of three striking paradoxes about American medicine, and they can be attributed to our failure to develop and maintain a sound, dynamic philosophy of medicine and to teach and practice medicine accordingly.

It is generally recognized that America is the most overmedicated, most overoperated, and most overpopulated country in the world. It is also the most anxiety-ridden country with regard to health. As an action-minded people, we feel more comfortable doing something or having something done. Thus we impose our life-saving drugs and techniques, intended for serious ailments, on minor, even trivial, illnesses–illnesses that are self-limited and that, except for occasional symptomatic relief, do better without interference from a physician.

To put it in its broadest perspective, we make health an end in itself. We have forgotten that health is really a means to enable a person to do his work and do it well. Modern medicine–and I am thinking of patients as well as of physicians–is geared not really to health but to the hypochondriacal. Our preoccupation with health is shown by the medical columns in newspapers, the health articles in popular periodicals, and the popularity of the television programs and gale of books on medicine. We talk about health all the time. Yet, for the most part all that has been accomplished is an increase in imaginary illnesses. The healthy man should not be wasting his time talking about health; he should be using health for the work he is meant to do, work that good health makes possible.

Americans tend to look upon health, as upon so many things, in materialistic terms. They think of health as something that can be bought, rather than a state to be sought through an accommodation to the norms of nature. We have become increasingly a paying animal as if health were solely a commodity of the market place.

And here is a second paradox: we are the world’s wealthiest country–yet one of the unhealthiest. We are flabby, overweight, and have a lot of dental caries, fluoridation notwithstanding. Our gastro-intestinal system operates like a sputtering gas engine. We can’t sleep; we can’t get going when we are awake. We have neuroses; we have high blood pressure. Neither our hearts nor our heads last as long as they should. Coronary disease at the peak of life has hit epidemic proportions. Suicide is one of the leading causes of death (fourth between the ages of fifteen and forty-four). We suffer from a plethora of the diseases of civilization.

Much of this situation results from our having forgotten nature. As an example, take the healthy appetite. It is an extremely sensitive biological mechanism which, if it is not perverted or seduced, can protect us from overnutrition, undernutrition, malnutrition, avitaminosis, and other nutritional ailments, without the need of our becoming chemists, calorie counters, apothecary jugglers, or vitamin and food faddists. We also have muscles and they beg for exercise. But they don’t get exercise in this push-button and car-transported civilization of ours. Hippocrates, the father of medicine, said a long time ago–almost twenty five centuries ago–that use leads to health and disuse to disease and premature disability.

To Hippocrates, the first step in restoring or maintaining health in a person was regimen. In his famous “Oath” he expressed this with the word diet, which in his time had the general meaning of mode of life. He was concerned with the work, rest, eating, sleeping, and recreation of the patient. He had a sound approach to the whole person because he recognized and accepted the psychosomatic nature of man. He also knew that nature did the real curing. That is really why regimen was so important to him. That was his first line of attack. His second was medicinal. And then if those two failed, he turned, when indicated, to surgery as a final recourse.

But in the drama of medicine as it is seen by the public today, the surgeon is the top man. He is the one you practically enjoy paying because he is “doing something” to you, if not for you. He is doing things you can see and feel and talk about, and this is something that our activist culture can readily appreciate. We go to the surgeon first–too impatient to give nature a chance, even the chance to unfold her story.

The tradition of medicine, which began with Hippocrates, recognizes that nature is the prime physician on any case, and that the doctor’s role is to work with nature, to assist, support, and minister to her. As a matter of fact, the very word “physician” is derived from the Greek physis, which means “nature.” If I had to define medicine I would define it as the art of doing for nature what nature would like to do for herself if she could. The physician cooperates with nature’s forces, which are ordered to health. Walter Cannon, the Harvard physiologist, in his book, The Wisdom of the Body, named these forces “homeostatic,” that is, tending to maintain a relatively stable condition within the body.

When a person faints he falls to the horizontal position, a position that is curative. Nature accomplishes this all by herself. Now when a person feels faint, we usually get him to lie down. A doctor, if called in to handle a simple faint, has only to remove that which is preventing nature from doing her work. He unprops the patient who has been inadvertently propped up. Fainting is an instance where nature’s homeostatic forces are working to get the patient well; these forces are an immediate counteraction to what has happened to the patient.

Another example: the body reacts to poison with vomiting and diarrhea as a means of getting rid of the poison. Now what does a doctor usually do for the poisoned person? He uses emetics and gastric lavages to empty the stomach, and moves in with drugs to produce diarrhea. However, a patient can be vomiting and having diarrhea with such frequency that he approaches a state of shock. The doctor, if he forgets he is only the assistant to nature and zealously takes over the stage, may so add to what nature is already doing well that he actually throws the patient into shock by the vigor he adds to nature’s forces.

The goal of nature is health. When nature cannot accomplish this goal, the physician must take action, at times dramatic and radical action. But since so many diseases are self-limited, the physician has to develop the kind of wisdom that will enable him to keep his hands off when he should, or to tread lightly.

This kind of wisdom is becoming more and more necessary. In our medical journals now we are repeatedly finding articles on what is called “iatrogenic disease.” Now iatro is Greek for “physician,” and genic means “to generate.” One medical journal recently devoted an entire issue to this topic of physician-generated diseases. Such reporting is a testimony to the honesty of physicians, as well as to their interest in getting papers published. Many more go unpublished.

One of the leading causes of dermatological disease, for example, is overtreatment; in fact, overtreatment may be the leading cause of dermatitis in this country. It goes something like this. A person uses a home remedy or patent medicine on a skin condition which more often than not makes it worse. The doctor who then sees the inflamed area tends to prescribe a stronger medication which results in a further insult to the poor skin. Then the dermatologist comes along and if he isn’t wary he makes his contribution to the furthering of the inflammation. Now if it is true that more dermatitis is caused by overtreatment than by any other cause, and then, if, by fiat, no treatment were permitted for such dermatological conditions, we would achieve more cures than if we were treating them, even though there would be a small percentage of cases that would definitely benefit from appropriate therapy.

The way tranquilizers are often used today is another example of treatment for the sake of treatment. Together with the barbiturates and the stimulants, they are the most misused drugs in the United States. We consume them in fantastic amounts. For many they are used as a panacea to solve personal problems, and are practically replacing the function of the virtues in striving for a sane and well-ordered life. One of my former students, an internist then in the Air Force, told me it took him months before he found out why there were no tranquilizers available for some of his hospitalized patients. When a shipment. came in, the medical officer in charge of this large Pacific post distributed the entire supply to all of the secretaries under the illusion that this would achieve harmony.

We are becoming a pill-swallowing civilization. None of them are innocuous, and the damage they do frequently far outweighs the good they intend. One of the nation’s most respected clinicians, Maxwell Finland of Harvard, in a recent Shattuck Lecture which dealt in large part with the unsalutary effects of the antibiotic age, concluded his address with a most intriguing suggestion. He first called attention to a notice published in 1855 by the Massachusetts Medical Society: “The Treasurer announced he had received the sum of one hundred dollars from a member of the Society for a prize for 1857…on the following theme: ‘We would regard every approach toward the rational and successful prevention and management of a disease, without the necessity of drugs, to be an advance in favor of humanity and scientific medicine.’” Finland then followed with the proposal that “this theme, documented with acceptable facts, would be a most appropriate one for a future Shattuck Lecture…” Perhaps it would be asking too much of pharmaceutical houses, which offer many association prizes for drug advances, to subsidize a yearly prize for the elimination of drugs.

I am, of course, fully cognizant of and full of admiration for the tremendous advances in medicine, whether in heart surgery or brain surgery, in antibiotics and immunizing agents, in psychopharmaceutics, in public health, or in other areas. These advances are translatable in terms of large numbers of people who in many instances would otherwise be dead. My point is that we are also increasing morbidities and anxieties. We do much for the dying but less for the living, and in some instances we directly convert the living to the dead by therapeutic misadventure.

Hand in hand with our failure always to give nature a chance is our failure to recognize the true role of the physician. Most medical schools, for example, are confused about their basic purpose. We do not know any longer whether our goal is to turn out physicians or research men. This is an age of research scientists. It is through them that the medical schools get their present glory and money. It is here that the ego of the scientist is satisfied by publishing papers. But today the medical schools are having a harder time getting applicants. We are losing them to the physical sciences where there is plenty of glory and lots of money and outer space to move around in. This is what happens when we compete with the physical sciences on the wrong grounds, when we fail to pose the inner man against outer space.

We forget, in the competition for medical students, that the true and chief function of the medical school is to turn out physicians, that is, artists, not scientists; professional men, not high-level technicians. We should appeal to students as humanitarians, not as technologists; as makers of health in the suffering rather than pursuers of truth in the laboratory, which calls for a different bent of mind. The difference here is between art (to make) and science (to know), and involves a delicate distinction, one easily misunderstood. It relates in its bad aspects to looking at people as guinea pigs rather than as human beings, as statistics rather than as persons.

The prime cause of medical schools’ science orientation is the tremendous amount of research money which is available to them from government, foundation, and pharmaceutical sources. It is common knowledge that we have more research money available than we have worthy researchers and worthy research ideas, and this available money seduces. Research scientists, rather than good teachers and practitioners, have become the sought after commodity for medical schools. This has all kinds of grave implications for contemporary medicine, which is moving away from the individual patient-physician responsibility toward the mass medicational approach, an approach that usually turns out to be mass manipulation by well-subsidized, overly committed scientists backed by powerful public relations departments of wealthy national health agencies.

The confusion is now affecting the premedical curriculum, which we are shortening to make the M.D. degree competitive in time with the Ph.D. degree. But we are streamlining the educational process in the wrong direction by stressing the technological at the expense of the humanities. We have gone a long way since the famous reply of Sydenham, a great English physician, to Sir Richard Blackmore’s question about what medical books he should read. Sydenham simply answered, “Read ‘Don Quixote.’”

And so we have a third paradox: at the same time we pay lip-service to the concept that we have to treat the whole person, and at the same time we pay our respects to the psychosomatic complexity of the human person, we concentrate increasingly on test-tube and technical know-how courses and substitute sketchy survey courses for a true liberal arts education. We act as if in the cure of the sick human being–and remember the word cure comes from the word care–the highly technical, assembly-line medical center is superior to the private physician’s office, and as though the mechanically sensitive laboratory procedure is superior to a humanly sensitive person, the broadly educated family physician.

Medicine is, of course, complex. I know of no generation of physicians since the time of Hippocrates that did not respect the complexity of medicine. It is true, also, that today we have more proximate scientific knowledge; for example, we know that a certain mosquito carrying a certain parasite causes malaria. But Hippocrates, who did not know about the mosquito or parasite, and had no microscope, had to master some very complicated knowledge in order to handle malaria. He had to know about swamps; he had to know about the winds (malaria means “bad air”); he had to know where to build a city in relation to a swamp; he had to know geography, geology, meteorology, and astronomy.

Today, we say we have to know a bewildering array of synthetic drugs, but if one goes back to the time of Galen and to the Galenic formulas uup through the nineteenth century, one finds there was a multiplicity of natural drugs to be known then. Today we have to know more chemistry, but yesterday they had to know more botany–and they also had to know how to compound drugs.

Without additional knowledge, a contemporary medical graduate would probably flunk out of medical school at the time of either Hippocrates or Galen. Even in the late sixteenth century Harvey had to discourse for one full hour on any one of Hippocrates’s aphorisms in order to graduate. Most of these aphorisms are deceptively profound. I don’t think the modern medical student could comment adequately for an hour on many of them. In many areas of bedside medicine, his knowledge would be inadequate compared to that of the Hippocratic physician. For one thing he would be lost without a laboratory.

The modern medical school is really not much different from the veterinary school. It could, for the most part, just as well have the horse for its subject. There are only a few medical schools in the country that give a course in how to communicate with patients, for instance. I know of only one school that gives a course in the philosophy of medicine, that is, analyzing the nature of medicine in terms of its elements, causes, and principles. Hardly any medical schools, with the exception of an occasional Catholic medical school, have a satisfactory course in medical ethics, and, since medical ethics are primarily based on the natural law rather than on denominational teaching, this is what every medical school should be doing, with great advantage to the performance and to the public image of the physician.

We have to come back, finally, to the need for a sound philosophy of medicine, to a comprehensive answer to the question, “What is the nature of medicine?”–and to all of the auxiliary questions: What is the physician’s work, nature’s work, their relationship? What is the role of science, art, and experience; the role of the patient; the significance of homeostatic forces for man as a social animal; the concept of the normal; the nature of a profession? All these questions and others lead to answers that have profound significance and consequences for medicine, especially for American medicine.