“Medicalization”

EPSON DSC picture
 

I have just carefully read through several editorials in the January 16, 2018 issue of JAMA, the Journal of the American Medical Association. This issue reflects a growing enthusiasm among medical editors for what’s generally called a “focus issue.”

Since I’m not an editor, I have only a vague idea of how this works. In my mind’s eye, I see the editor sitting at a very large, cluttered desk with accepted but unpublished manuscripts piled by subject. As a pile grows to a threshold size, say seven and three-quarters inches, the editor says, “Aha! A focus issue.” Then he or she gathers up the pile and says to the staff, “Print all these together in 6 or 8 weeks, and we’ll be done with them.”

Readers know that I have no intention of writing about the focus of the issue, which happened to be obesity. What I do want to reflect upon are the social changes that have moved obesity from a straightforward statement about body composition to a medical problem worthy of a focus issue of JAMA, arguably one of the most prestigious medical journals in the world.

When I was a kid, turning to a dictionary definition of the assigned subject provided an easy “out” for starting an essay. I hope I’ve become a bit more sophisticated; now, I’ll turn to Harvard Magazine instead. I quote from the issue of April 23, 2009: “There are perhaps few academic topics of equal interest to scholars of history, law, anthropology, neuroscience, and literature. But this was part of the point when scholars of these disciplines gathered on April 22 for a symposium on medicalization—a phenomenon, they argued, that has infiltrated nearly every facet of modern life.” Not exactly stirring prose, but I’m sure you see the point. Or do you?

Beginning roughly in the mid-1970s, when faced with really tough social-behavioral problems, particularly those that have serious health consequences like alcohol abuse, drug addiction, and obesity, Western society has declared them medical problems.

This process, “medicalization,” relieves broad swaths of professionals from dealing with insoluble problems. Physicians, however, seem to willingly accept the process. We seem to say, “Give us your obese, your addicted, your anxiety-ridden… Send these to my clinic, to my hospital, I lift my stethoscope beside the golden door.” Not only do we engage in this altruism, we campaign to make their diagnoses “official” and billable, and then try to find treatments.

Lest this sound a bit negative, the Harvard conference attendees catalogued the forces that help to drive the trend toward medicalization:

  • “the very existence of health insurance (costs are only reimbursable when associated with a definable medical condition
  • death certificates (the need to give a name to what caused a person’s death)
  • research funding (funding is more likely for problems defined as diseases)
  • drug trials and approval
  • and even a desire to wash one’s hands of blame for one’s condition (for instance, by considering obesity a disease that assails people rather than the result, at least in part, of one’s own actions and lifestyle).”

As I become more senior in the medical community, my awareness of the importance of communication, both among doctors and between doctors and patients, continues to grow. How long will the medical community continue to accept the process of medicalization before we say, “Look, we can help to manage the physical consequences of behavioral problems. If you are too heavy, we can replace your worn-out joints, get your cholesterol and blood sugar down, and help with your blood pressure. But we can’t modify your behavior; you have to decide to do that.”

Sending off the final draft

U2.JPG

 

This is Monday, January 08, 2018. About 3 PM on Friday the 6th, I sent my (new) publisher the final draft of a new book, a memoir-conversation with my long-time friend and double-sculls partner, Bernie Witholt. It’s like sending a youngster off to prep school. Someone else will look at her and correct a word here, or delete a comma there. She’s not ready to graduate yet. She needs proofing, formatting, and a pretty cover. But she’s largely out of my hands.

Over the weekend, I have thought a lot about her. I would like to introduce her. How about just three paragraphs in which Bernie describes his first symptoms?

I was one of some 150 people at a Zurich Stock Exchange Symposium on new high-tech startups emanating from the ETH and other Swiss universities. I came in late and, finding no seat, stood leaning against a steel railing. I did not feel good and I wondered why a few of my students, seated only a few meters away, did not jump up to offer me a seat.

About an hour after the meeting started, after the first two or three talks, I felt a strange rattling in my chest. This was new and quite unsettling. Was this a heart attack? What else might it be? I felt weak, eager to sit down, but there were no empty seats. The next speaker had just started. I looked around; no one else seemed to hear the rattling. I leaned harder into the railing. After ten or fifteen minutes the rattling subsided; the speaker finished his presentation, and I felt better.

With the rattle gone there seemed to be no reason to leave immediately, and so I stayed. The meeting ended a few hours later. I had no interest in chatting with other participants, but had some juice and left. This meant negotiating stairs from the auditorium level up to the higher street level. This was unpleasant. When I reached my car, I sat contemplating what had happened. Whatever it was, it did not seem trivial. I decided to go home this time, but to go to the emergency room of the University of Zurich hospital if it happened again.

Her name, unless the publisher decides to change it, is “240 Beats per Minute. Life with an Unruly Heart.”

Sending her off has left me with what people in my generation called “post-exam letdown.” As we advanced academically, end-of-semester exams became more and more important. At least, we thought they did. Performance on exams determined where we went to graduate school, medical school, or law school. And then, once in a graduate or professional school, better exam performance would mean a “better” post-doc, internship, or clerkship.

As a result, we studied intensely and after all the bubbles were filled with #2 lead pencil and the blue-books turned in, we crashed. Or, at least, we deflated. So it is with sending off the final draft. Even though now, it’s just a matter of hoping that people will like her.

I have neglected my blogging in the push to get her ready. Now that she’s out the door, I’ll take a deep breath and get back at it. Next week.