Jan Henderson, PhD, is a Harvard-trained mathematician and Yale-trained medical historian. She shares some of her thinking about healthcare in America in the second part of a three-part interview below.
Which medical journals do you read regularly?
I read the New England Journal of Medicine and the Journal of the American Medical Association.
NEJM has been admirably proactive about conflict of interest. I admire Marcia Angell, who was on the editorial staff for over 20 years. The editorials in NEJM on the health care debate were excellent.
JAMA is a bit more conservative in its commentary, but there are many things I appreciate about it.
They preserve the humanist side of the medical profession with regular features on art, poetry, and essays by doctors. They publish excerpts from JAMA 100 years ago, which is always fascinating.
And they have book reviews. I was disappointed that NEJM decided to discontinue book reviews earlier this year.
I read as much of the Lancet as is available without a subscription, which includes much of the editorial comment. They place a greater emphasis on health in the developing world, undoubtedly a remnant of British Empire days.
There’s a nice review of medical journals called Journal Watch. It’s written by a physician Richard Lehman with an understated British sense of humor.
What is your opinion of Atul Gawande’s public policy positions?
I’m a big fan of Dr. Gawande. The Lancet once said that by advocating safety checklists, he has probably saved more lives than any other physician in history.
The quality of life for patients near death is such an important issue. This is very difficult to discuss in our culture. We don’t want to be reminded of death. So I was pleased to see him open up this topic for discussion.
There was an online comment in response to the article that illustrates its impact. A reader wrote about her father, a smoker who was dying of lung cancer and struggling with a drug treatment that made him very sick.
She sent Gawande’s article to her parents. After reading it, they made plans to discuss treatment and end-of-life issues with their physician. They expressed their gratitude. Gawande’s writing makes a difference.
One of many things I liked about his health care article on McAllen, Texas was the physician’s perspective he provided at the end – something easily overlooked by those not directly involved with patients.
He said there would be dangers in changing health care too rapidly and too drastically. We’re talking about the health and lives of real people here, he said. With a radical change, some people would suffer from the transition.
Personally I’d love to see big changes in health care, but I really appreciated that point of view.
As a keen observer of medical culture, do you have a problem with the ethics of physicians blogging sometimes in great detail about their patients – oftentimes in unflattering ways? Do you feel that patients are being unfairly used?
Of course that’s an unwise and unethical thing to do. But I see a great deal of discussion, in blogs and in medical journals, that tries to educate the medical community about the issues. I hope this is just a period of transition we’re going through.
What are your thoughts on the culture change occurring in medicine regarding the elimination of physicians personally accepting patient care responsibility through the reduction of resident work hours and the forced imposition of duty hour restrictions. How do you feel about medical care rapidly becoming one of a shift-work?
This has been an interesting development in the history of medicine.
In 20th century America, business and industry became bureaucratized and were subjected to outside control. The medical profession held out against this change for a very long time.
It argued that the doctor/patient relationship was special and unique among professions and should be under the control of doctors and patients, not outside bureaucracies.
The medical profession may have also been concerned about loss of prestige and income, but the sanctity of the doctor/patient relationship was central to resisting external control. This more or less committed the practice of medicine to the model of the solo practitioner.
That model didn’t survive 20th century advances in medical knowledge and technology. The lone practitioner was overwhelmed with information.
I was just reading something from a 1910 JAMA on the plight of the physician: “For the overworked physician to steal an hour for the perusal of Carlyle or Coleridge when he ought to be ‘reading up’ an obscure case seems a sort of professional suicide.†And that was only 1910!
As medicine had increasingly more to offer, the demand for medical care increased. Ultimately the solo practitioner model was unable to meet the health care needs of the nation.
Bureaucratized shift-work is not good for doctors and it’s not good for patients. I don’t know what the solution will be.
Primary care doctors are asking to be paid by the hour, not for piece work. That might help. The wealthy can afford concierge doctors. Maybe something will come out of the medical home concept.
If doctors and patients get unhappy enough, perhaps a creative solution will evolve.
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