HealthCommentary

Exploring Human Potential

Planning for Evil vs. Planning for Goodness: Why Medicine Should Embrace the Social Sciences.

Posted on | January 30, 2015 | No Comments

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Mike Magee

An article by Daniel Jonah Goldhagen in last week’s New York Times Sunday Review, “How Auschwitz Is Misunderstood”, created a dramatic contrast to an address I delivered a few days earlier at a New York liberal arts college titled “Closing The Empathy Gap: Leveraging Healthcare Relationships”.

Goldhagan’s major point was that the widely held belief that German “death factories” were created for bureaucratic efficiency was inaccurate. Rather, he explains, it would have been far more “efficient” to murder their victims on site. Why then Auschwitz? In his fifth paragraph he answers the question. “The Nazi leadership created death factories not for expeditious reasons, but to distance the killers from their victims.”

The remaining eight paragraphs tie this historic horror to a distinctly non-empathic world view. As the article states, “It expressed the Nazis’ unparalleled vision that denied a common humanity everywhere, and global intent to eliminate or subjugate all nonmembers of the ‘master race.'” Putting a personal face on the German policy, he notes that “Heinrich Himmler, the head of the SS and the man most responsible for putting the Germans’ plans in action, proudly announced in an address in 1943: ‘Whether nations live in prosperity or starve to death interests me only insofar as we need them as slaves for our culture.’”

If creating a non-empathetic world requires planning and distance, then it follows that creating an empathetic world requires planning and intimacy marked by compassion, understanding and partnership.

This is the case I made a few weeks ago relying on work I presented in 2002 to the World Medical Association in Helsinki when serving as the WMA Resident Scholar. The study had shown that in six countries surveyed (U.S., U.K., German, South Africa, Japan and Canada), the most valued relationship in society, second only to family relationships, was the relationship with a physician.

In exploring why that was so consistently the case, simultaneous surveying of thousands of physicians and patients in those countries once again showed consensus in their definition of this relationship. Over 90% of doctors and patients agreed that its’ power derived from its ability to deliver compassion, understanding and partnership.

The study further revealed that, in 2000, the relationship, again consistently in all six countries, was evolving. It was moving from individual to team approaches, from paternalism to partnership, and from individual to mutual decision making.

As for the commonly held desire to evolve from an interventional to a preventive health delivery model, the study demonstrates that health information, flowing directly from the relationship, was far more likely to be followed and deliver desired behavioral change than information from all other sources including the Internet.

Was there room for improvement in this relationship. Yes, certainly. In a series of “gap analyses”, the study uncovered significantly different views when comparing doctors and patients, and reality to the ideal. Where were these gaps?

1. Information seeking: Patients sought out information, independent of their physicians, when faced with illness, far more frequently then their physicians realized. For example,in the U.S., 69% percent of patients said they had sought information independently, while only 35% of physicians believed that their patients had pursued information not provided by them. These gaps were even wider in other countries (Germany: 71%/11%; U.K.: 51%/15%; South Africa: 56%,9%; Japan: 35%/6%)

2. Empathetic Physician Behavior: On five measures of ideal behavior (compassion, trust, understanding, patience, listening), patients in all six countries saw average double digit room for improvement when comparing “ideal” to “reality”. Gaps: US – 19%, UK – 27%, Canada – 17%, Germany – 20%, SA – 12%, Japan – 31%.

3. Access to Physicians: On five measures of ideal access to physicians (attentiveness, time spent, ease of appointment, treatment choice, access to specialists), patients in all six countries saw double digit room for improvement when comparing “ideal” to “reality”. Gaps: US – 25%, UK – 40%, Canada – 29%, Germany – 22%, SA – 14%, Japan – 24%.

Finally, this social science, Harris Poll designed survey revealed that the positive impact of the patient-physician relationship in all countries studied was multifactorial. In addition to reactive care, the relationship contributed to preventive health planning, management of individual and societal fear levels, expansion of individual and societal confidence and optimism, reinforcement of family and community bonds, and maximizing productivity.

The final summary slide two weeks ago, at St. Thomas Aquinas College, said “Civil societies marked by empathy, compassion, and justice, are the result of stable, committed, trusting relationships by members of these societies. Family, educational, and health care relations are critical foundation blocks for any society committed to expanding human potential.”

As the Goldhagen article correctly suggests, preventing a “common humanity” takes work. But certainly then the reverse is true as well – creating a common humanity takes work as well. In retrospect, this study, utilizing social science tools, correctly forecasted the dynamic factors that would help shape the American health delivery system in the decade ahead. And yet it was rejected for publication by the New England Journal of Medicine, though one reviewer of three described it as “provocative”.

The challenge of creating a civil society must advantage existing relationships in a deliberate way. It is a “vision battle” as Eli Ginsberg suggested way back in 1937: “Social life implies control, control implies power, power implies conflict. The more dynamic a society, the more probable the conflict, for the great conservative institutions – the law, the church, the school – operate most efficiently in a static environment.  But the phenomenal vitality of modern technology leads ‘to ever new conquests.  The economic system is caught up in the advance… the political system follows in the rear… with strange twistings and tergiversations.’  Impotent is thought when in direct conflict with gold and the sword.”

More than ever, health has become a human endeavor with the potential to shape a society for the better. But to do so, medicine, and its educational institutions, must look beyond genomics and the wonders of biotechnology, to consider as well how the social sciences might advance human behavior.

As Eli noted, shortly before Himmler and Hitler broke out of their box, “Economic depression, political revolution, the transvaluations of legal systems, mass psychoses – these, the increasingly typical phenomena of Western civilization – underline the failure of the social sciences to control behavior…The test of genius is not so much the discovery of new facts, as the discovery of new relations between old facts.”

For Health Commentary, I’m Mike Magee

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