Mindbend

AUTHOR’S NOTE

Since I graduated from medical school in 1966, I have heard the term “crisis in medicine” so often that it conjures up the allegory of the shepherd boy who cried wolf too many times. But until now the crises have all been voiced by particular interest groups and were often contradictory: too few hospital beds, too many hospital beds; not enough physicians, too many physicians. It was enough to make anyone confused and apathetic.

But now I have come to believe that “crisis in medicine” is applicable in a truly general sense. Unfortunately, because so many people have cried wolf in the past, the media have only just begun to take note of this very real crisis. What we are witnessing today is the gradual but quickening pace of the intrusion of business into medicine. It must be understood that the corporate mentality of the balance sheet is diametrically opposed to the traditional aspects of altruism that have formed the foundation of the practice of medicine, and this dichotomy augers disaster for the moral and ethical foundations of the profession. Big Business views the medical field as a high-cash-flow, high-profit, low-risk, and low-capital investment industry that is now particularly ripe for takeover.

Evidence of this shift toward business interests in the medical field is reflected in the newly interlocking ownership of proprietary (for profit) hospitals and nursing home chains, medical suppliers, and a deluge of other health-care organizations like dialysis centers, surgi-centers, etc. Even research has gone in the direction of business as evidenced by the new biotech companies.

Response to this activity has been surprisingly slight, despite the insidious effect it has on the practice of medicine. Professional journals have viewed the process with curious academic disinterest, doctors have either joined the entrepreneurial bandwagon or ignored it, the public has remained silent, and the media have only just begun to run articles sounding the alarm. It is my hope that Mindbend will help focus public attention. By couching the problem in an emotional framework, it brings the process into personal perspective and allows the reader to understand the implications of the situation through identification with the main character, which I believe is one of the key values of fiction.

For me, the realization of the intrusion of business into medicine came with a letter I received from a hospital, informing me that its census was low and that I should admit more patients for surgery, as if I had a group of people in the wings who were being denied appropriate operations. That letter, more than any other experience, made me realize that our medical system had inadvertently been constructed to depend upon and reward overutilization of facilities and services, thereby fostering its own rising costs. No wonder businessmen became interested.

For Mindbend I chose the drug industry as the focal point not because it has been any worse than any other group, but because it has been around longer than most businesses associated with medicine and it exerts a powerful and growing influence. The important point is that the drug firms are corporations which do not exist for the public weal, no matter how much they try to convince the public otherwise. Their goal is to provide a return on their investors’ capital.

The overriding commercial interest of the drug firms is underlined by the ungodly amount of money (billions of dollars per year) that they spend on promotion of their products, primarily attempting to influence the physician, who unfortunately is rather easy prey. There are very few doctors who have not accepted some gift or service from the drug industry. I still have the black bag given to me as a third-year medical student, and I have attended a number of symposia sponsored by a drug company. The drug industry currently spends more on promotion and advertising each year than it does on research! According to Pills, Profits, and Politics, the amount is also more than the total spent on all educational activities conducted by all the medical schools in the United States to train medical students.

It would be unfair to suggest that the pharmaceutical industry has not contributed to society. But this has been the by-product, not the goal. And there have been cases in which the public good has been ignored. One need only to mention the thalidomide disaster or the DES calamity to recognize that the record is variegated and that commercial interests can have unfortunate consequences. Drug companies have marketed products that they knew might be dangerous or ineffective or both merely to turn a profit.

Medical practice as it has been known in this country for the last thirty years or so is changing. The doctor-patient relationship used to be the fulcrum, but it is losing ground to economic and business interests. The American public has a right and an obligation to know what kind of system is evolving.

For those people interested in pursuing the issue, I recommend the following books:

Ainsworth, T. H., M.D., Live or Die (Macmillan, 1983). Written by a physician who looks at the problem from the vantage point of having been both a practitioner and a hospital medical director, this book is particularly poignant in its appeal for physicians to recognize what is happening to the profession and to reexert their leadership.

Silverman, Milton, et al., Pills, Profits, and Politics (University of California Press, 1974). This book gives an overall view of the pharmaceutical industry, and it makes for interesting reading. I’m confident it will arouse some unexpected emotions. Although it was written over ten years ago, it is still strikingly relevant.

Starr, Paul, The Social Transformation of American Medicine (Basic Books, 1982). This book provides an impressive overview of the history of medicine in America and gives one a realistic comprehension of how the current situation has developed.

Wohl, Stanley, M.D., The Medical Industrial Complex (Harmony Books, 1984). This readable, concise book discusses the issues with few embellishments.