All this masculine body-consciousness has some critics concerned. “There’s a lot of evidence that men are starting to be more strongly affected by the cultural discourse in terms of fatness being less tolerated even among men than it was quite recently,” says Paul Campos, a professor of law at the University of Colorado at Boulder and author of The Obesity Myth. “We’re just getting to see the internalization of the self-hatred and the pathologizing of variations of body size among men in ways we’ve always seen among women.” he says. “This culture is so completely f—ked up about it that it’s hard not to have a screwed-up attitude.”
About 90 percent of my animal patients are geriatric—and, as odd as this sounds, the veterinary world may hold lessons for the broader health-care system. While pet insurance exists, only roughly 3 percent of owners carry it; even then, clients pay a substantial portion of costs themselves. That means they usually want to know the rationale behind each test. I explain what I think is going on, what I want to look for, and which tests I need to perform to find it. I rank the diagnostics from most to least essential and lay out approximate costs. My clients then choose what they want done, with an understanding of the relative importance, risk, and cost of each option. This step-by-step approach may seem time-consuming, but it dramatically reduces the number of expensive, unnecessary tests. And the process is more gratifying.
We feel so righteous when we buy organic food or a compact fluorescent bulb or a Prius that our internal moral cup runneth over. According to this model, which is called compensatory ethics, people have an inner sense of how morally virtuous they need to feel to support their self-image. If a few actions (including espousing actions for other people) are enough to justify how we like to think of ourselves, then we do not need to perform any additional virtuous actions. It’s as if we accumulate moral points for ethical actions, and having accumulated “enough” we are free to act amorally, or even immorally. That’s why reminding people of what wonderful humanitarians they are causes them to give less to charity.
Consider the excitement over cocaine vaccines. Composed of a bacterial protein plus a molecule that is a coke look-alike, they train the immune system to produce antibodies against both. The antibodies also bind to cocaine, preventing it from entering the brain and causing a high. The good news is that the vaccine makes crack less pleasurable, notes Meg Haney of Columbia University, who led a 2010 vaccine study. That suggests the vaccine indeed kept the drug out of the brain. The bad news is that the level of antibodies in the volunteers (55 coke users in a 2009 study, 10 crack users in Haney’s) varied widely. Only 38 percent of the coke users produced enough antibodies to dull the effects of cocaine, and, of those, only half stayed clean more than half the time.
In contrast, a 2008 analysis of 34 studies of behavioral treatments for addiction to cocaine, marijuana, and other drugs showed impressive efficacy. “There is still no generally effective [medication]” for coke, pot, and meth addictions, notes psychiatry professor Kathleen Carroll of Yale University. “But the behavioral therapies we have are quite good,” bringing a 67 percent improvement. Yet that research gets the response of the proverbial tree falling in an empty forest.
Howard Brody, a family physician at the University of Texas Medical Branch, recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. “I’m pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones,” says Brody. It’s not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.
Medical groups have not exactly beaten a path to Brody’s door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from “we do no unnecessary care” (dermatology) to “only five?!” (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls “nth-line therapy”—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. “I don’t know what n should be,” he says. “But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity.”
The annual number of American medical students who go into primary care has dropped by more than half since 1997. It’s hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama’s reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that’s stalled the rest of health-care reform so far: politics.
The reason behind America’s doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it’s easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.
Scientists have been surprised at how deeply culture—the language we speak, the values we absorb—shapes the brain, and are rethinking findings derived from studies of Westerners. To take one recent example, a region behind the forehead called the medial prefrontal cortex supposedly represents the self: it is active when we (“we” being the Americans in the study) think of our own identity and traits. But with Chinese volunteers, the results were strikingly different. The “me” circuit hummed not only when they thought whether a particular adjective described themselves, but also when they considered whether it described their mother. The Westerners showed no such overlap between self and mom. Depending whether one lives in a culture that views the self as autonomous and unique or as connected to and part of a larger whole, this neural circuit takes on quite different functions.
Last month Britain’s General Medical Council completed a new two-and-a-half-year investigation into whether study lead author Andrew Wakefield & Co. followed proper research ethics in their study, and the answer was no. The 143-page decision (you can find a PDF of the report here) calls Wakefield’s conduct “dishonest” and “misleading” in numerous respects. But the bottom line is that he misled The Lancet about how children came to be studied (that is, through the attorneys), that the ethical statement in the paper (denying any conflict of interest) was false, and that the hospital where the research was conducted had not approved it. Most damning, the GMC found that Wakefield “showed a callous disregard for the distress and pain that [he] knew or ought to have known the children involved might suffer,” that he “abused [his] position of trust as a medical practitioner,” and that he brought “the medical profession into disrepute.”