- The Washington Times - Wednesday, October 4, 2000

There is a crucial lesson repeated over and over again to medical students: make the diagnosis before starting to treat the illness. Physicians will adhere to this approach even while empathizing with the severe discomfort that their patients may be suffering. Do you have a terrible stomach pain? OK, but no painkiller until we know why.
Our nation could benefit from applying this "diagnosis first, treatment next" dictum to our health-care crisis. What is wrong with our health care? Is it the high cost? The lack of prescription benefits for senior citizens? The difficulty in trying to sue an HMO? Lack of access to specialist? And should we treat these symptoms with a few new laws to add to the plethora already on the books? Maybe such changes would move our country out of the 37th position shown in a recent WHO ranking of overall quality of healthcare systems. Maybe.
Unfortunately, what ails our health-care system is a malady or multiple maladies much more serious and much more systemic. The problems relate less to programs and policies, but rather to how health care professionals and the nation think and act. And, there's plenty of blame to go around.
The most serious flaw in our healthcare delivery is that patient and doctor have become emotionally disconnected from each other (a problem not unlike what we see more and more of in our society in general). To the "biz-med complex," which include practitioners, insurance companies, and drug manufacturers, the patient has become the "consumer" a profit center. To the patient, the medical community is a necessary evil: a curt purveyor of expensive and dangerous treatments that is not always to be trusted. The comfort and healing power to be found in the doctor-patient relationship is rapidly dissipating.
Almost as crucial is people's mistaken expectation of miracles even given their own lack of personal responsibility: Because I overeat and don't exercise, I have gotten fat please give me a pill. I have made a mess of my life please give me a pill to feel better about it. I got drunk and crashed please put me back together again like new. I'm still ill after not following your instructions so please give me something better.
To the above, add a sad litany: Physicians have replaced time to take important histories and do informative physical exams with expensive technology that may or may not be useful. Physicians and patients no longer control care, but have accepted their roles as bit players in the trillion-dollar-a-year health-care industry. Risks have markedly increase for patients as practitioners offer more and more potentially dangers medications and procedures often with questionable indications. We tolerate tens of millions of Americans remaining uninsured and those who are insured often lack adequate access to service. (Paradoxically, at times the fortunate ones are those who aren't subjected to care.)
These ills of our delivery system are treatable. They will require self-examination by both practitioner and patient as well as by government and industry. More careful selection of medical students and improvements in their education will help. A new infusion of ethics into the profession wouldn't hurt either. And there's that old devil of "personal responsibility." But mostly, we need a new philosophy of what health care is all about (try "caring" instead of marketing), what expectations are reasonable, and how patient and doctor can most productively relate to one another.
So, yes, you should still follow the political issues related to health care and vote wisely on them. And, yes, we can all try to put together a piece here and a piece there of better policies and regulations. Let's be sure those senior citizens have prescription benefits and that we can sue our HMO. But don't lose sight of the underlying diagnoses as the symptoms are treated at the ballot box. Meanwhile, it would certainly be refreshing to hear candidates talk about these truly basic issues instead of proposing to apply their patchwork Band-Aids.

Tom Minogue, M.D., is a board-certified psychiatrist on the medical faculty of the University of Illinois at Urbana-Champaign.

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