“Foucault’s clinic is dead.” So starts Daniel Sulmasy’s book The Rebirth of the Clinic. My department chair will tell you that Sulmasy is referring to the clinic being spiritually dead. And that is clearly true (the entire book is on spirituality in medicine.) Yet Sulmasy goes through great effort to also portray the clinic as a dying form of medicine as well. “Managed care is simply it’s coffin,” he says.
I started reading this book last night during “Sunday reading night,” a practice my wife and I have recently started in an attempt to unplug a bit, and it caused two thoughts to pop into my head: 1) Oh shit, I promised CBD I’d post something at some point and 2) Is the clinic not just truly dead, but really most sincerely dead? And then a third thought: When did this book get published?
Resolving these thoughts in reverse: the book was published in 2006 (a eon ago for health care). At this point I think Sulmasy was right, the clinic was dead. At least it was mostly dead. It was certainly spiritually dead. But mostly dead is partially alive, and it seemed not quite dead from a practice standpoint. And there’s one group that seems to want to reanimate the rotting corpse of the clinic over and over again: politicians, usually leftist ones. And for that first thought: yay a post!
I started my interest in health care ethics as a pre-med in undergrad, right about the time Sulmasy would have been working on this book. My assessment was more or less the same as his: medicine had become technocratic, ignoring the person element of the patient. Indeed, I like to joke that one of my med school interviews went poorly when I answered a question posed to me by suggesting that two treatments being medically equal, the one that allows the patient more mobility and freedom and less time tethered to an IV infuser is the better treatment. It went poorly because the case posited to me was a real choice made by my interviewer. And while I choose the least inconvenient option, a twice a day infusion over a 4X/day infusion both at home, to allow the patient a minimal intrusion. In reality he had exercised a 3rd option which kept the patient on a 24 hour infusion in a hospital bed. My answer, based largely on a consideration of what I thought would make the patient most comfortable and thus happiest (i.e. being at home and only interrupted 2X/day) visibly upset him because it was the polar opposite of his actual choice.
The clinic is dead.
And I would have told you that slowly people were rebelling against the clinic. Alternative medicine is rising again. Patient satisfaction is falling, etc. etc.
It’s corpse is rotting.
But government, especially an over intrusive one, has a way of changing things. And Obamacare shot new life into the clinic, animating the corpse yet again. What we’ve seen as a result of the mess that is the ACA is a huge consolidation of providers, and a return to and amping up of “assembly line medicine.” Doctors have to see more patients to meet quotas, hospitals are cut out of networks, paper work is growing exponentially.
Like Frankenstein’s monster this reanimated corpse of the clinic is destroying everything in it’s path.
I’ll leave the intense analysis of the clinic to perhaps another post, but Sulmasy summarizes (and agrees with) Foucault’s assessment that his clinic is all about power. (It’s Foucault, did you really expect anything else?) This perhaps explains some of the draw of the politicians to constantly reanimating its dead corpse, first as HMOs, now as ACOs, soon as ‘universal health care.” Nothing provides power over a populace quite like controlling their health from the cradle to the grave. And if they have to destroy medicine to get that power, so be it.
I confess I’m only about 1/4 of the way though the book, so I don’t have any idea what Sulmasy’s specific suggestion is for adding spirituality (and thus care for the whole person) back into medicine is. But no matter what it is, I’m looking around for any organization that might be able to anything, but I’m not hopeful there is one.
I doubt we’d find a rebirth in the academic medical centers. Their very design, with it’s laser-like focus on science would be resistant to any such endeavors. Certainly I’m no fan of government, but even if I was, as I noted, government benefits from this dead form of medicine because it gives them more control.
In the past, I’d have turned to Catholic healthcare, figuring that perhaps their focus on “healing mission” would help to bring back what has been lost. But the longer I toil, the more cynical I become. It seems more and more that “mission” is mere lip service these days as even the Catholic institutions start behaving like “big medicine” with that focus on the bottom line.
I’ll close with an illustrating anecdote. Part of the consolidation here resulted in my former doctor’s practice being bought out by a large Catholic Hospital system in an ill conceived attempt to build an ACO out of “spare parts.” He’s my former doc, because he retired earlier about a year after the buyout (read: quit.) He had always been cynical about the state of medicine, Obamacare took that up a notch, but it wasn’t until the buyout he finally decided to leave. Just before that I was in for an appointment and he says “you know what really frustrates me? The focus on revenue. We have to send a bill 30 days late straight to collection. 25 years I’ve practiced, I’ve never seen any group so aggressive about getting collections. Usually you can work something out without resorting to threats. I just wish they wouldn’t be so hypocritical to us.”
Modern medicine’s clinic may be dead, but Obamacare has ensured it’s shambling corpse will keep moving for a while.