# 13.5: Medicine and Health Care in the United States

Learning Objectives

• Summarize the major developments in the rise of scientific medicine.
• Discuss several problems with the U.S. health-care model involving direct fees and private health insurance.
• Describe any two issues in U.S. health care other than the lack of health insurance

As the health-care debate in 2009 and 2010 illustrates, the practice of medicine in the United States raises many important issues about its cost and quality. Before we discuss some of these issues, a brief discussion of the history of medicine will sketch how we have reached our present situation (Louden, 1997; Porter, 2006).Louden, I. (1997). Western medicine: An illustrated history. Oxford, England: Oxford University Press; Porter, R. (Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge University Press.

## The Rise of Scientific Medicine

The practice of medicine today in the United States and much of the rest of the globe follows a scientific approach. But scientific medicine is a relatively recent development in the history of the world. Prehistoric societies attributed illness to angry gods or to evil spirits that took over someone’s body. The development of scientific medicine since then illustrates one of the sociological insights discussed at the beginning of this chapter: the type of society influences its beliefs about health and ways of healing.

Figure 13.14: Modern medicine began during the 17th century with the discovery by English physician William Harvey of how blood circulates through the body. Source: http://commons.wikimedia.org/wiki/Fi...arvey-Foto.jpg.

The roots of today’s scientific medicine go back to the ancient civilizations in the Middle East, Asia, and Greece and Rome, which began to view health and illness somewhat more scientifically. In ancient Egypt, for example, physicians developed some medications, such as laxatives, that are still used, and they also made advances in the treating of wounds and other injuries. The ancient Chinese developed several drugs, including arsenic, sulfur, and opium, that are also still used. Ancient India developed anesthesia, antidotes for poisonous snakebites, and several surgical techniques including amputation and the draining of abscesses (Porter, 2006).Porter, R. (Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge University Press. Ancient Greece built medical schools in which dissection of animals was used to help understand human anatomy. Later, a Greek physician named Galen, who lived in Rome during the 100s A.D., wrote influential treatises on inflammation, infectious disease, and the muscular and spinal cord systems. Medical advances continued in the Middle Ages and the Renaissance, as various physicians wrote about smallpox, measles, and other diseases, and several medical schools and hospitals were established. Leonardo da Vinci and other scientists performed many dissections and produced hundreds of drawings of human anatomy. Other major advances, including the development of surgical techniques and the treatment of burns, were also made during this period.

What is now called modern medicine began in the 1600s, as scientists learned how blood circulates through the body and used microscopes to discover various germs, including bacteria. By the end of the 1800s, the germ theory of disease had become widely accepted, thanks largely to the work of Louis Pasteur and other scientists. Other key developments during this time included the discovery of ether gas as an effective anesthesia and the realization that surgery needed to be carried out under the strictest standards of cleanliness (Porter, 2006).Porter, R. (Ed.). (2006). The Cambridge history of medicine (Rev. ed.). New York, NY: Cambridge University Press. During the 1800s, the American Medical Association and other professional associations of physicians were founded to advance medical knowledge and standards and to help give physicians a monopoly over the practice of medicine (Starr, 1982).Starr, P. (1982). The social transformation of American medicine. New York, NY: Basic Books. In the early 1900s, scientists learned about the importance of vitamins, and penicillin was developed as the first antibiotic. Developments in immunology, physiology, and many other areas of medicine have obviously advanced far beyond what we knew a century ago and remain too numerous and complex to discuss here.

Scientific medicine has saved countless lives: life spans used to average no more than the age of 40 or so, as we have seen, but in industrial nations now average well into the 70s. Still, as we have also seen, huge disparities remain across the world today in life spans and the quality of health. Disparities also exist in the quality of health care across the world. In the United States, questions about the cost and effectiveness of health care have dominated the news. We now turn to some of these issues.

## Racial and Gender Bias in Health Care

Another problem in the U.S. medical practice is apparent racial and gender bias in health care. Racial bias seems fairly common; as Chapter 7 "Race and Ethnicity" discussed, African Americans are less likely than whites with the same health problems to receive various medical procedures (Smedley, Stith, & Nelson, 2003).Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Gender bias also appears to affect the quality of health care (Read & Gorman, 2010).Read, J. G., & Gorman, B. K. (2010, June). Gender and health inequality. Annual Review of Sociology, 36, 371–386. doi:10.1146/annurev.soc.012809.102535 Research that examines either actual cases or hypothetical cases posed to physicians finds that women are less likely than men with similar health problems to be recommended for various procedures, medications, and diagnostic tests, including cardiac catheterization, lipid-lowering medication, kidney dialysis or transplant, and knee replacement for osteoarthritis (Borkhoff et al., 2008).Borkhoff, C. M., Hawker, G. A., Kreder, H. J., Glazier, R. H., Mahomed, N. N., & Wright, J. G. (2008). The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. Canadian Medical Association Journal, 178(6), 681–687.

## Other Problems in the Quality of Care

Other problems in the quality of medical care also put patients unnecessarily at risk. These include:

• Sleep deprivation among health-care professionals. As you might know, many physicians get very little sleep. Studies have found that the performance of surgeons and medical residents who go without sleep is seriously impaired (Institute of Medicine, 2008).Institute of Medicine. (2008). Resident duty hours: Enhancing sleep, supervision, and safety. Washington, DC: National Academies Press. One study found that surgeons who go without sleep for 24 hours have their performance impaired as much as a drunk driver. Surgeons who stayed awake all night made 20% more errors in simulated surgery than those who slept normally and took 14% longer to complete the surgery (Wen, 1998).Wen, P. (1998, February 9). Tired surgeons perform as if drunk, study says. The Boston Globe, p. A9.
• Shortage of physicians and nurses. Another problem is a shortage of physicians and nurses (Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010; Fuhrmans, 2009).Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010). Understanding nurse manager stress and work complexity: Factors that make a difference. The Journal of Nursing Administration, 40(2), 82–91; Fuhrmans, V. (2009, January 13). Surgeon shortage pushes hospitals to hire temps. The Wall Street Journal, p. A1. This is a general problem around the country, but even more of a problem for two different settings. The first such setting is hospital emergency rooms, Because emergency room work is difficult and relatively low-paying, many specialist physicians do not volunteer for it. Many emergency rooms thus lack an adequate number of specialists, resulting in potentially inadequate emergency care for many patients.

Rural areas are the second setting in which a shortage of physicians and nurses is a severe problem. The National Rural Health Association (2010)National Rural Health Association. (2010). What’s different about rural health care? Retrieved from http://www.ruralhealthweb.org/go/lef...t-rural-health points out that although one-fourth of the U.S. population is rural, only one-tenth of physicians practice in rural areas. Compounding this shortage is the long distances that patients and emergency medical vehicles must travel and the general lack of high-quality care and equipment at small rural hospitals. Partly for these reasons, rural residents are more at risk than urban residents for health problems, including mortality. For example, only one-third of all motor vehicle accidents happen in rural areas, but two-thirds of all deaths from such accidents occur in rural areas. Rural areas are also much more likely than urban areas to lack mental health services.

• Mistakes by hospitals. Partly because of sleep deprivation and the shortage of health-care professionals, hundreds of thousands of hospital patients each year suffer from mistakes made by hospital personnel. They receive the wrong diagnosis, are given the wrong drug, have a procedure done on them that was really intended for someone else, or incur a bacterial infection. These and other mistakes are thought to kill almost 200,000 patients per year, or almost 2 million every decade (Crowley & Nalder, 2009).Crowley, C. F., & Nalder, E. (2009, August 9). Secrecy shields medical mishaps from public view. San Francisco Chronicle, p. A1.

## Complementary and Alternative Medicine (CAM)

As the medical establishment grew in the 19th and 20th centuries, it helped to formulate many standards for medical care and training, including licensing restrictions that prevent anyone without a degree from a recognized medical school from practicing medicine. As noted earlier, some of its effort stemmed from well-intentioned beliefs in the soundness of a scientific approach to medical care, but some of it also stemmed from physicians’ desire to “corner the market” on health care, and thus raise their profits, by keeping other health practitioners such as midwives out of the market.

There is increased recognition today that physical health depends at least partly on psychological well-being. As the old saying goes, your mind can play tricks on you, and a growing amount of evidence suggests the importance of a sound mind for a sound body. Many studies have found that stress reduction can improve many kinds of physical conditions and that high levels of stress can contribute to health problems (B. W. Smith et al., 2010).Smith, B. W., Papp, Z. Z., Tooley, E. M., Montague, E. Q., Robinson, A. E., & Cosper, C. J. (2010). Traumatic events, perceived stress and health in women with fibromyalgia and healthy controls. Stress & Health: Journal of the International Society for the Investigation of Stress, 26(1), 83–93.

Figure 13.19. Acupuncture is one of the many forms of alternative medicine. It is used by about 40% of Americans annually. © Thinkstock

Evidence of a mind-body connection has fueled the growing interest in complementary and alternative medicine (CAM) that takes into account a person’s emotional health and can often involve alternative treatments such as acupuncture and hypnosis. In the last two decades, several major medical centers at the nation’s top universities established alternative medicine clinics. Despite the growing popularity of alternative medicine, much of the medical establishment remains skeptical of its effectiveness. Even so, about 40% of Americans use an alternative medicine product or service each year, and they spend about $34 billion per year on the various kinds of products and services that constitute alternative medicine (Wilson, 2009)Wilson, P. (2009). Americans spend$33.9 billion a year on alternative medicine. Consumer Reports Health Blog. Retrieved from http://blogs.consumerreports.org/hea...e-alternative- treatments-vitamins.html (see Figure 13.20 "Use of Selected Forms of Complementary and Alternative Medicine (CAM), 2007 (Percentage of U.S. Adults Using Each Form During Past Year)").

Figure 13.20 Use of Selected Forms of Complementary and Alternative Medicine (CAM), 2007 (Percentage of U.S. Adults Using Each Form During Past Year). Source: Data from U.S. Census Bureau. (2010). Statistical abstract of the United States: 2010. Washington, DC: U.S. Government Printing Office. Retrieved from http://www.census.gov/compendia/statab.

## Medical Ethics and Medical Fraud

A final set of issues in U.S. medicine concerns questions of medical ethics and outright medical fraud. Many types of health-care providers, including physicians, dentists, medical equipment companies, and nursing homes, engage in many types of health-care fraud. In a common type of fraud, they sometimes bill Medicare, Medicaid, and private insurance companies for exams or tests that were never done and even make up “ghost patients” who never existed or bill for patients who were dead by the time they were allegedly treated. In just one example, a group of New York physicians billed their state’s Medicaid program for over $1.3 million for 50,000 psychotherapy sessions that never occurred. All types of health-care fraud combined are estimated to cost about$100 billion per year (Kavilanz, 2010).Kavilanz, P. (2010). Health care: A “goldmine” for fraudsters. CNNMoney. Retrieved from http://money.cnn.com/2010/01/13/news...ion=2010011315

Other practices are legal but ethically questionable. Sometimes physicians refer their patents for tests to a laboratory that they own or in which they have invested. They are more likely to refer patients for tests when they have a financial interest in the lab to which the patients are sent. This practice, called self-referral, is legal but does raise questions of whether the tests are in the patient’s best interests or instead in the physician’s best interests (Romano, 2009).Romano, D. H. (2009). Self-referral of imaging and increased utilization: Some practical perspectives on tackling the dilemma. Journal of the American College of Radiology, 6(11), 773–779.

In another practice, physicians are asking hundreds of thousands of their patients to take part in drug trials. The physicians may receive more than \$1,000 for each patient they sign up, but the patients are not told about these payments. Characterizing these trials, two reporters said that “patients have become commodities, bought and traded by testing companies and physicians” and said that it “injects the interests of a giant industry into the delicate physician-patient relationship, usually without the patient realizing it” (Galewitz, 2009; Eichenwald and Kolata, 1999).Galewitz, P. (2009, February 22). Cutting-edge option: Doctors paid by drugmakers, but say trials not about money. Palm Beach Post. Retrieved from http://www.palmbeachpost.com/busines...ials_0223.html; Eichenwald, K., & Kolata, G. (1999, May 16). Drug trials hide conflicts for doctors. The New York Times, p. A1. These trials raise obvious conflicts of interest for the physicians, who may recommend their patients do something that might not be good for them but would be good for the physicians’ finances.

## Conclusion

• Scientific medicine is a relatively recent development in the history of the world. For much of human history, religious and spiritual beliefs, not scientific ones, shaped the understanding of health and the practice of medicine
• The U.S. health-care model relies on a direct-fee system and private health insurance. This model has been criticized for contributing to high health-care costs, high rates of uninsured individuals, and high rates of health problems in comparison to the situation in other Western nations.
• Other problems in U.S. health care include the restrictive practices associated with managed care, racial/ethnic and gender bias in health-care delivery, and medical fraud.