The paradox of healthcare - I

Cure the disease or the person?

I love watching old hindi movies especially the ones in monochrome…the period, especially the 60s & early 70s of Indian cinema. The one intriguing thing that I almost always noticed in the hindi movies of that time would be when the family doctor would come visiting the house of an ailing person. The doctor walks in with his handheld bag, the size of a typical picnic basket, is friends with the head of the family and aware of the family’s health history and also the family’s circumstances. He is not just a doctor but part of the family’s inner circle having seen & known the past & present generations of the family from close quarters. Though his/her screen time would be short-lived but the doctor always seems to be calm, composed and very reassuring.

During my school days, whenever I would fall sick, I wanted a doctor like that to come calling on me at home just like in the movies. Of course it never happened!

This practice of house calls by general or family physicians has, for all practical purposes, ceased to exist in most modern day societies. But why am I writing about the house calls of doctors? Read on…

The disease and the person

Around 2016, we were looking to get the cataract surgery done for my father. He had been postponing it for several years and as a result his cataracts had turned hard making the surgery a little complicated. Now my father was by no means your ordinary patient. He had read & researched extensively on hard cataracts, modalities of surgery and risks associated and had a dossier of articles & reports ready for the doctor consultation.

We fixed up his appointment with the head of ophthalmology at one of the largest hospitals in the city. The following exchange happened:

Father: I have cataract in both the eyes…so I was..

Surgeon: (interrupting) We can do the surgery. You take the dates from my secretary. You have to get admitted in the morning. My secretary will explain everything. Anytime next week…

Father: But, I am having this trouble with dry eyes.

Surgeon: That has got nothing to do with the cataract. We can do the surgery.

Father: Everyday I need to put medicine in my eyes several times because of the dry eyes. What do you advise?

Surgeon: (Disinterested, peering at his computer) We can do the surgery.

Father: Also my cataract is quite old and hard?

Surgeon: (again peering at his computer) See you can decide about the surgery & let my secretary know.

On the way back from the hospital, my father who is generally quite vocal, was unusually quiet. I asked him what did he think of the surgeon and the surgery plan. He said, “This doctor is only concerned about the surgery. He is not concerned about me.” I was a little confused as being concerned about the surgery is being concerned about the patient. Isn’t it? It is the cataract surgery that my father was looking to get done. That statement got me thinking.

The eye surgeon, being a department head and all, must have been highly qualified, an expert at doing the surgery and may also be what in the industry is called a Key Opinion Leader (KoL) in the field of ophthalmic surgeries but to my father it didn’t matter. What is missing here?

Such incidents are commonplace in India today. Ask any patient/caretaker who has had to deal with doctors on a regular basis, not withstanding Covid-19 times, and they will tell you a story no different from ours. Doctors & surgeons have seen a massive erosion of patient trust & confidence in the last decade or so, a decade which also witnessed the most amount of cutting-edge breakthroughs and developments in medical sciences. Why is the medical profession failing to satisfy the patients?

“The answer seems to lie in a historically constrained and presently inadequate view of the ends of medicine. Medicine’s traditional concern primarily for the body and for physical disease is well known.” wrote Dr. Eric Cassell. ¹ - Confused? I was too. So I dug deeper.

The biomedical model of illness

The modern medicine or health model is based on the biomedical model of medicine which has been the dominant view of medicine for almost the entirety of 20th century. This model views human beings as biological organisms (materialism), to be understood by examining their constituent parts (reductionism) using the principles of anatomy, physiology, biochemistry and physics. Disease is seen as a deviation from the biological norms, caused by some identifiable physical or chemical event & intervention involved introduction of a corrective physical or chemical agent. ²

Per this model, an illness is always explained with one or more physical malfunctions at a lower level of organization. An infection is explained with the invasion of parasites, a metabolic disorder with a genetic mutation, a psychiatric disorder with an imbalance of neurotransmitters, a speech impairment or a physical disability with neuronal damage and so on. ³

Now that you are reduced to a combination of your body parts (and organs), a disease is considered, in this model, as a breakdown in the normal functioning of the bodily process which needs to be fixed or repaired just like a car needs repair of the defective part before it hits the road again!

As if this mechanistic view of a person’s body isn’t enough, this ‘reductionist’ healthcare model is obsessed with objective, biological signs of a physiological disease. A physiological disease means that resulting from an organ or system malfunctioning in the body and that which can be objectively measured, screened or observed by means of hard data viz, blood markers, CT/MRI scans, scopies etc. Basically it means if you are ill you need to have some observable proof of it in terms of some test report or observation! Your doctor will not write out a diagnosis or a prescription until she/he sees an evidence of a ‘disease’ irrespective of the subjective description of the illness/symptom/pain that you may report as a patient.

(In case you have not noticed, doctors always talk about ‘disease’ while patients talk about ‘illness’)

Lets say you show up at a doctor’s clinic or OPD clinic in India telling him about a low-grade fever you have been having for sometime. You have been popping the usual paracetamol to bring it under control but to no avail as the fever returns once the medicine’s effect wears off. On consulting, your family physician asks for a battery of tests to run, continues the paracetamol until the tests reports are out. The next few days or weeks is spent on detecting the ‘disease’ before any diagnosis could be made. If the tests reveal nothing unusual, the doctor will send you home saying there is ‘No disease’ which means there is no problem which means you are ‘healthy’. This may seem like an oversimplification, but I hope it hits the point home - it may be important to diagnose the disease but lack of objective evidence may not always mean absence of illness for the patient.

We have all become too attuned to this model for almost a century now. Health is being increasingly misunderstood as an absence of disease and medicine is something that restores the human being to health. You, the patient is only a receiver of these medicines without much say in the treatment or cure. And doctors, hospitals, the apparent middlemen between you and good health, are deemed to have the exclusive role & knowledge (benevolent paternalism) of delivering the cure.

Getting back to my father’s story, I totally understand the clear picture now. For the surgeon in this case or the overall healthcare system - the focus is not the patient but the disease! The system is tuned & trained to look for the disease and to, by way of medicines or other interventions, cure it. Your physician is trained to prescribe you medicines for a disease. Your surgeon is trained to operate on your organs or body parts. As you can see, the current healthcare model, possible doesn’t understand what it means to get patients healthy in the truest sense (unless you are one of those who believe that having no physical disease is the same as being healthy).

(By the way this is also why you see hospitals in India only do what may be called as ‘disease management’ for a patient with no semblance of restoration of ‘health’. More on this topic in a separate post!)

The resultant ramifications of this flawed biomedical model is so far reaching that the more I think about it, the more I am able to make sense of the ‘non’sense that we see in our healthcare in India today.

The biggest of this is how patients get dehumanized when they enter a hospital system. They lose their identity from Mr. or Mrs. so & so but the patient in room 203 or the patient with a bilateral bankart tear. Their hopes & fears are nullified as if they never existed or they don’t matter because, as you have just learnt, it is the disease that is important, not the person!

As for the doctor who never came home to look me up, Dr. Francis Peabody in his address to the Harvard Medical School shared this, ⁴

When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience but even when when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life. He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline. What is spoken of as a "clinical picture" is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears. Now, all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital.

End of Part-1 of this article. You can expect the concluding part of this article to hit your mailboxes in the next 10 days.

I also published an introductory post on this topic. You can read it here: The goal of medicine

1. Cassell, Eric J.. The Nature of Suffering and the Goals of Medicine. Oxford University Press.

2. Mehta N., (2011), Mind-body dualism: A Critique from a Health Perspective. In: Brain, Mind and Consciousness: An International, Interdisciplinary Perspective (A.R. Singh and S.A. Singh eds.), MSM, 9(1), p202-209

3. Rocca E., Anjum R.L. (2020) Complexity, Reductionism and the Biomedical Model. In: Anjum R., Copeland S., Rocca E. (eds) Rethinking Causality, Complexity and Evidence for the Unique Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-41239-5_5

4. https://depts.washington.edu/medhmc/wordpress/wp-content/uploads/Peabody.html