Steven G. Ayre, MD
Unmanageable as the many problems besetting the medical profession are these days, there is one particularly important problem which has to do simply with the matter of nomenclature. Confucius said that the beginning of management is to call things by their proper names. Doctors, it is said, do health care. In actual fact what it is that doctors do should more properly be termed “disease management.” Using terminology more accurately descriptive of the activities performed could begin to make matters more manageable.
The prevailing paradigm of doctor-patient interaction in contemporary health care is one wherein the doctor plays the active role – questioning for the existence of disease, examining for signs of it, determining the appropriate diagnostic label, and prescribing what he has been trained to consider as the proper treatment for the diagnosed condition. Much of the time, the prescription medications recommended are things which simply ameliorate the symptoms of the condition itself, rather than doing anything to alter the actual disease process itself. The patient’s role in all this is essentially a passive one: to take the medication as prescribed.
To be sure this all constitutes a gross generalization, and it is accepted that all generalizations are false – including this one. In this context then, thereL is some degree of truth in the above. It may also be said, on the other hand, that modern medical expertise truly shines in areas of management of life threatening infections and trauma. These are acute conditions. It is predominantly with the treatment of chronic degenerative diseases that our “health care” fails to provide the means for full recovery of the patient’s well-being. What we are doing with our treatment of chronic degenerative disease is more disease management – as opposed to health care. Disease management is long term symptomatic management, requiring equally long term follow-up with monitoring for the appropriateness of drug dosage to control disease symptoms, observe for side-effects, & etc. A recent study published in JAMA (April 15, 1998, Vol 279, No. 15) indicates that this type of disease management has, as o˘ne result, actually made the medical profession the sixth leading cause of death in America.
Clearly, things need to change here, and my medical opinion is that what must change first is our terminology. If the beginning of management indeed resides in calling things by their proper names, then what we must do is to begin by acknowledging that what doctors do is not health care, but disease management. Such changing of our terms of reference is not just our own task. The insurance companies, the drug industry, and other elements within the infrastructure of medicine are all unconsciously conspiring to not only maintain our status quo, but to define it themselves, and then to regulate it to a high degree. They refer to doctors as PCP’s – primary care physicians – a label I have always resented on account of another use of this particular acronym, this being for pneumocystis carinii pneumonia. The term PCP carries with it the implied uniformity and complete interchangeability between any individual physician and any other. Such uniformity greatly simplifies things for the captains of our medical industry, but it does little to allow for the individualized approach to patient management that is the hallmark of effective health care. Instead of PCP, the more appropriate acronym for such a physician would be DMT, for “disease management technician” – a personless being doing “health care” in support of the fastest growing failing business in the world.
These changes I am suggesting will most probably not be forthcoming from within the medical profession itself in any sort of proactive fashion. Nor will they come from the drug, insurance, or any of the other industries involved in the business of medicine. But come they most certainly will. As we begin the move into a post-industrial phase of our social and cultural development, the patient population is now in the process of voting with their feet, so to speak, in seeking out complementary and alternative forms of medical care from a wide variety of resources in this society. This populist phenomenon is now serving to force our hand. We must adapt or we will perish. And I believe we will not perish, because I believe there are far too many intelligent and good-hearted people in the medical profession to allow for such a calamity.
Instead of the term “adapt” used above, a far more fitting name for what we must do – in fact the underlying thrust behind much of what is now occurring almost ubiquitously within our society, including medical care in America – is to evolve. It helps to see that there is nothing reprehensibly wrong with the way things have evolved to date within our system of medical practice. What we see occurring has been – and still is – part of a natural evolution towards a new reality. The coming into being of this reality is analogous to a birthing process. Just as it is always darkest before the dawn, so too in the birthing process the actual birthing itself is – psychically – a traumatic, devastating, and totally annihilating phenomenon. However, it is also one immediately succeeded by a magnificent experience of reintegration, of fulfillment of the process, and of life. So there is a wonderful promise underlying the chaos we are living through at this stage in our present system.
I see a future characterized by our positive resurgence, out of the seeming dismal foundations of what now is, into the full power and manifestation of what we may have dreamed possible when first we decided to pursue a career in medicine. In the Bible, in Romans 5:3 it says,“We glory in tribulations also, knowing that tribulation worketh patience.” Tribulation we now have in great measure, and patience is what we need to bear the birthing of this evolutionary process: patience and understanding – along with learning to call things by their proper names. With relevant nomenclature all around, we may understand what this process is, who we are in the process, and what are the possibilities for us to actually manage things more effectively within an evolved and renewed practice of medicine.