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Recently I fractured a tooth. I was going to book an appointment with my usual dentist when a friend recommended his own dentist, promising me I would get outstanding treatment. I thought it worth a try, and made a booking. Before my appointment I had to fill in a long questionnaire about my medical and dental history. When I arrived I found splendid premises and magnificent equipment. The dentist gave me the longest and most thorough examination of my dental and oral health I have ever had, followed by x-rays and ultrasound images. He sat me down and explained his findings, which included not only the broken tooth but a lot of cavities and fillings in need of replacement or investigation, as well as some gum disease and discolouration. I was very impressed. He fed this data into a computer and printed out his recommendations: 10 appointments with himself and five with his dental hygienist, at a predicted cost to me of £5300 (minus whatever my dental insurance would cover).
I asked him if he could possibly just sort out the broken tooth for the time being. He looked at me sternly and warned me about the possible consequences of living with so much disease and decay in my mouth. I went back to see my old dentist—who has kindly fixed the fractured tooth in three appointments at a 10th of the cost. I don't feel at all critical of the expensive dentist. From what I understand he is providing the nearest to dental perfection that is currently available—it's just that I wasn't particularly seeking that for myself. And I probably would have thought no more of the encounter, if a colleague hadn't sent me a paper the following week that shed some interesting light on what had happened. The paper wasn't about dentistry at all, but about healthcare utilisation generally. The writer is a psychiatrist called Thomas Maier, from Lausanne in Switzerland.1
Maier has taken ideas from both systems theory and psychoanalysis to look at the way people use health services. He argues that everyone in modern industrial societies—both patients and health professionals—has become caught up in a dichotomy between seeing things as either ‘healthy’ or ‘ill’ and increasingly defining everyone and everything as falling on the ‘ill’ side of the line. He points out that: “The intensified, obsessive effort of modern healthcare to discriminate the healthy from the ill can be demonstrated in various tendencies and developments of contemporary medicine (many of them enhanced by corresponding changes in public opinion and the legal system).”
Among the examples Maier offers for this are:
Increasing efforts to define exact diagnostic criteria for all kinds of diseases in order to separate the healthy from the ill
New, sophisticated diagnostic instruments aimed to clarify the status of unclear symptoms or asymptomatic findings
Insurance payments that entirely depend on the approval of illness in terms of official diagnostic categories
Medical research based on precisely defined diagnoses
Doubtful findings and unclear symptoms that must be clarified regardless of costs.
The way Maier draws attention to the medicalisation of people's lives is not in itself new—although a surprising amount of what he says in this respect applied to my dental encounter. Iona Heath in the UK has described ‘the medicalisation of distress’, where states of normal human unhappiness are increasingly reframed as psychiatric conditions.2 Others have criticised the insidious way that elderly people in particular are put on large numbers of drugs in circumstances where it is very unclear if they have any clinically meaningful benefits.3 What is new about Maier's approach is that, to the best of my knowledge, he is the first person to ask the questions: should we be making a distinction between illness and health at all, and is the concept of pursuing ‘health’ now doing more harm than good?
These are questions well worth asking. As mortal beings, we are all in a continuous trajectory towards decay and death. How satisfied we are with the state of our bodies and minds (not to mention teeth) is determined to a large degree by our economic and cultural circumstances, and our own dispositions or preferences. It may well be worth redefining our notions of ‘well-ness’ and ‘ill-ness’ in terms of our social contexts and expectations as much as on objective standards. However, Maier's argument goes further than that. He points out that seeing everything in terms of illness draws us professionals into collusion with very large numbers of people who actually depend on being seen as not healthy.
Maier isn't talking here about those who get obvious material benefits from a diagnosis, such as welfare payments or insurance payouts. He is referring more to people who are psychologically dependent on identifying themselves as not healthy, and who find an important source of emotional support in their interactions with the health services. He refers to the mechanisation and automation of modern civilisation (internet, cashless money transfer, mail order business, and so on) and how this allows many people “to live in the midst of society without ever getting in touch with any real person”. He describes how chronic and relapsing diseases and complaints guarantee continuous and repeated contacts with medical staff, sometimes closer than they have with any other person.
Since doctors and other health professionals are trained in a tradition of caring, Maier suggests, it is only too easy for us to buy into parental roles, and either offer motherly care or exert abusive power in response to the emotional needs that patients bring into the system. He pulls no punches in describing what he calls the ‘collusive entanglement of healthcare’. In his words: “Doctors and nurses also have emotional needs to be satisfied; they may also be prone to collude in sado-masochistic interactions and to compete for narcissistic grandiosity”. In other words, our patients are acting out some fairly primitive emotional needs in their contacts with the health services, and we fall in with this by doing the same.
Maier's prescription for this state of affairs is partly political. He argues that politicians should move away from a consumerist view of healthcare that sees patients as customers acting solely in accordance with reason rather than having emotional needs as well. In his view, doctors and other health professionals should acquire a frame of mind that is not strictly focused on the ‘health–illness difference’. What I find most refreshing about his approach is that he is inviting us to engage in a new kind of conversation with patients, one that involves honesty on both sides about the human condition and the bodily faults and frailties we are all heir to. Such conversations will require more situational awareness among doctors about the social and political systems in which we find ourselves, as well as self awareness regarding the temptation either to martyr ourselves or punish our patients in response.
If we accept Maier's argument, we need to recognise that many conversations with patients about their so-called ‘health’ or so-called ‘illnesses’ aren't really about the subjects they seem to address at all. They are about the human condition, the extent and limits of what can be done in the real world, and about the choices that both parties to the conversation—the professional and the patient—want to make about this.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.