The health care system has an eating disorder.

The health care system is growing like a cancer, outstripping its own nutrient supply and robbing nutrients from other vital social organs. The defect may be a flaw in the immune system that should modulate and regulate cellular (component) growth necessary to maintain homeostasis. This model does not seem to lead to useful treatment strategies, however - at least the conventional, externally driven, high-tech therapies of modern oncology seem inappropriate. Infectious diseases, particularly viruses, have compatible and nonuseful features similar to those of neoplasms as a model. The health care system certainly does not have a degenerative disease.

Substance abuse as a disease model comes close. The current biomedical model of health care was initially dramatically successful in curing previously hopeless infectious and endocrinologic diseases. The social investment of money, power, and prestige had a potent effect, pleasing to the profession and the public. Only with time did it become apparent that the patient (the health care system) had become addicted to not only the money, power, and prestige, but also to the way of thinking about life (science). Any approach other than the biomedical approach was ridiculed and rejected, even when the biomedical approach failed to demonstrate effectiveness and began to hoard and consume resources beyond what could be considered to be necessary or even useful. This model (if we consider alcohol or drug abuse) also fails to lead to realistic interventions, because abstinence is not the answer. Any health care system will involve systems for dispensing money, power, and prestige, and the biomedical model should not be abandoned outright.

This led me to consider that our health care system has an eating disorder. Money, power, prestige, and biomedical constructs (all normal and useful "nutrients") are being voraciously consumed in increasing dysfunctional ways. This is certainly not anorexia nervosa, and there seems to be no purging to counter the binging characteristic of bulimia. But let us consider the cardinal features of eating disorders. In the face of massive and escalating consumption of resources, there is denial that a problem exists. The "patient" sees the consumption pattern as normal, logical, and desirable. If confronted with how different the pattern is from others, the patient will usually claim special characteristics that make exemption from the usual ("Supply and demand do not apply to health care. Health care is too important to be limited and controlled as education, housing, and even the military are.") Another level of defense is the claim that, if a problem exists, it is not the patient's problem. ("Everything was fine until my parents made an issue of my eating. They're the problem." "The only reason health care is a problem is because it is starting to cost the rich corporations some of their profits. There's enough money. People just don't want to pay for high-quality health care. It's not the health care system's fault.")

In eating disorders, there are usually dysfunctional family relationships and family denial of the problem until it is quite advanced. The patient may receive very mixed messages about roles in the family and the patient's image in the eyes of the family members. The health care system has been fawned over and idealized in its modern infancy and childhood; extremely high demands and expectations were placed on it. Doctors were revered and asked "to do everything possible." Perfectionism and obsessive behaviors were thought to be positive adaptations by patient and family. Then, as the patient began to discover its limitations (an adolescent task), the family (society at large) began to tell the patient it was too fat. It needed to go on a diet, not demand so much, but it was still expected to "do everything" and would be humiliated and punished (malpractice suits) when it failed to do so. It would also be retrospectively criticized when it tried to do too much without obtaining informed consent after full disclosure. The patient became very confused and developed a very distorted self-image. Interactions with the larger family became characterized by defensiveness, suspicion, and resentment.

In eating disorders, at this juncture the patient becomes afraid of further growth and development and holds to fixed beliefs about life and what his or her image ought to be. Similarly, the health care system has held to two major fixed beliefs:

* The reductionistic, biomedical model that relies on high-technology progress is the only path for high-quality medicine.

* Private, fee-for-service medicine is the preferred model in the ideal world.

The rationale for these beliefs is the same as the patient's: "These beliefs have worked for me in the past. They are what got me here so far. They are all I know." The unspoken corollary is: The alternatives are uncertain and very dangerous. But such is life.

The eating disorder analogy has many parallels with the health care system crisis in the diagnostic phase. Can it give guidelines for treating the patient? First, we must acknowledge how little we know about treatment of eating disorders. They are complex, demanding, frustrating disorders, so we can expect no simple or definitive answers. However, we can examine techniques or principles that have shown positive results, even if they are not universally or dramatically effective.

The initial step in treatment is to disengage the power struggle between the patient and family over control of the eating behavior. The patient is made responsible and accountable for the day-to-day behaviors. Clear and consistent consequences are established and enforced for failure to comply within certain parameters of healthful nutrient consumption. This has several implications for the health care system.

* First, physicians would have to accept some defined limits.

* Second, information systems would need to provide detailed, timely, appropriate feedback to physicians on their behaviors and results.

* Third, feedback would need to be reviewed and evaluated at reasonable, established intervals. The current practice of continuous micromanagement of physicians' decisions by administrators, the government, and hospital or insurance utilization reviewers is perpetuating a pathologic power struggle. Physicians' rage and indignation at this process is akin to adolescents' determination to eat what they damn well please because no one knows better what is right for them than they themselves. But the patients do not want to "be left alone." They seek appropriate autonomy but currently lack clear boundaries, so boundaries must be clarified.

* Fourth, consequences must be consistent with the behaviors required. Management and regulatory systems cannot impede utilization of necessary resources and then hold the physician solely responsible for adverse outcomes, as currently occurs in the malpractice tort system.

* Fifth, and overarching all the previous points, the issues that must be dealt with are not just about food. Attention must be given to the details of food and eating, but health is not achieved by focusing on food alone. If health analysts, economists, managers, politicians, and physicians only focus on food - money, power, hospital bed-to-population ratios, capitation rates, specialist-generalist quotas, etc. - they will only struggle to contain behavior and not work toward healing the illness. The statistics are the symptoms of the illness. The long-term work in treating eating disorders is to move beyond preoccupation with the symptoms and to grapple with the underlying issues of identity, growth, relationships, goals, and meaning.

Here is where a shift in thinking must occur for health care providers, managers, and planners. The shift entails a primary attention to the relationships of the parties in the system, not to the quantitative features of the components (number of visits, costs of services, etc.). Some of the key relationships that must be reviewed include (1) the medical-industrial complex and the community, (2) the medical education system and clinicians in community (private and public) practice, and (3) medical educators and their students.

In the United States in the past 40 years, the medical profession has attended to its own welfare before the welfare of the community. Self-interest has taken priority over service. This may seem offensive to many who have worked in underserved areas or donated abundantly of their time. The point is not to pass judgment on the behavior of individuals but to analyze the qualities of relationships. The "caring profession" has steadily increased in socioeconomic status while an increasing proportion of the community does not have access to its services. Voluntary charitable or pro bono services have been insufficient to meet society's needs, and the medical profession historically has not been an aggressive advocate for a plan for universal access to health care. Decisions to exclude or limit Medicare or Medicaid or no-pay patients are not based on the need "to make a living" but on a desire to support a life-style to which physicians have become accustomed and to which they feel entitled. This relationship is compatible with most social relationships in our capitalist society, but it grates with the healing traditions that predated the modern industrial era. There are several choices the profession can make that will influence the doctors-to-community relationship:

* Maintain the current value system within the free-enterprise market system. In that system, payers will increasingly negotiate and attempt to regulate providers in order to minimize costs and maximize their companies' or government's income.

* Graft a service ethic onto the selfinterest ethic through medical education and licensure. The relative weight of each ethic would be scrutinized in an ongoing manner by government agencies and public interest groups.

* Consider dramatic alternatives to the operating principles of capitalist society and study them scientifically, as modeled by R. Buckminster Fuller in his lifelong experiment to "comprehensively protect, support, and advantage all humanity instead of committing my efforts to the exclusive advantages of my dependents, myself, my country, my team."[2]

The next relationship to evaluate is the relationship between medical schools, the general public, and the community of practicing physicians. Will anyone deny that this relationship, with very few exceptions, has been characterized by an imbalance of aloofness, indifference, or elitism by the medical schools; ambivalence by the public; and frustration or outright hostility by community physicians? "Town-gown" hostility is a cliche surrounding most schools of medicine. Several states now have legislation under consideration attempting to mandate or motivate medical schools to shift the ratio of specialists/generalists that graduate, because the schools have been unresponsive or uninterested in the needs of the states. How did this relationship get in such a mess? One of the key factors may be an aspect of how reductionism is applied to the health care system. Health care is assumed to be composed of three components - clinical practice, teaching, and research. These three family members are separate and interact only through the interference of the unwelcome foreigner, administration. Family members have clearly defined roles - research is done by tenure-track faculty in the medical schools, teaching is done largely by clinical-track faculty in the clinical years, and clinical practice is done by the community physicians. But the family is outgrowing its prior interaction patterns. Medical schools are increasingly dependent on expanding their clinical base for economic survival; university researchers in the technological forefront are in competition with or jumping into the private corporate world; and community-based primary care networks are conducting more and more research. Computer networks will only increase the ability to gather, analyze, and disseminate new information and knowledge outside universities. Role separations are breaking down or becoming blurred, which usually occurs when a family achieves a certain stage of growth and maturity; this is a natural, healthy process. Dysfunction develops when members of the family resist this growth and attempt to hold to fixed definitions of their roles to the detriment of the growth of others. Dysfunction also occurs when no one wants to perform an essential task in the family life.

In the current health care system, that essential task seems to be teaching. As economic pressures tighten on medical schools, clinicians and researchers face the same dilemma as the community physicians - do they "have the time" or can they "afford" to teach? As with care to the underserved, the true issue is, "Would they will be willing to teach if it compromised the standard of living to which they have become accustomed?" From the societal perspective, the question is, "Who is willing to pay for teaching?" For society, payment would be not only the money for teachers and teaching resources, but also the willingness to interact with students. Does society and the medical profession maintain the tradition that students learn on poor people, but the wealthy would understandably prefer (and have a right) to avoid interactions with students or residents?

In the psyche of a patient with an eating disorder is a profound identity crisis. The teaching issue illuminates that crisis for the health care system. Are physicians "doctors" (from "docere", to teach) or medical service technicians? Is teaching inherent in the role of every physician, not just a subset within medical schools? Is the concept that every physician gives back his or her knowledge to the profession and to the next generation a quaint historical tradition, or is it an essential value of a healthy system? In the past 20 years, the medical profession and state governments have reaffirmed the ethic that all physicians must be lifelong learners if they wish to have their licenses and specialty certification renewed. Partial support for teaching functions has been given by granting some continuing medical educations credits for teaching of students or residents. A large industry has been spawned to provide CME. It could be a comparable process (with comparable controversies) to require that all physicians demonstrate an ongoing commitment to teaching to maintain their professional standing. It would then be incumbent on health care system executives to determine what means would be most effective in ensuring that physicians in their organizations remained good teachers, rather than penalizing them economically for teaching. It would also prompt more collaboration between community physicians and medical schools to design teaching programs that could best use the abundance of available teachers.

A more integrated approach to the health care system's needs for teaching, research, and clinical practice would have powerful repercussions on another key relationship, the relationship of teachers with students. With a few notable exceptions (McMasters, New Mexico, East Carolina, Harvard) and despite the recommendations of numerous distinguished authors and repeated national commissions from the Millis Commission in 1966 to the present,[3-13] this relationship continues to be characterized by paternalism. Medical school faculties claim to have the exclusive right to determine curricula and to have the best teachers, even in the absence of any consistent or required faculty development process for curriculum design or teaching methods. A physician becomes one of these "better teachers" simply by getting a job at a medical school. Why has there been so much resistance to recommendations to include more small-group, problem-based learning and less lecture-format didactics? The eating disorder analogy may give some more clues.

Without overworking stereotypes, it is fair to say that, in American culture, control-oriented, objective, logical, rational behaviors have masculine attributions, and emotional, intuitive, subjective, relationship-oriented, nurturing behaviors have feminine attributions. Modern medical discipline has been dominated by the former characteristics, as has much of American corporate and political life. In a feminist analysis of why so many more women than men seem to have eating disorders, Susan Orbach makes the following points: "The psychological requirements of successful femininity for the adult women today include three basic demands. The first is that she must defer to others; the second is that she must anticipate and meet the needs of others; and the third is that she must seek self-definition through connection with another." She goes on to discuss "how forcefully girls and women repress their needs for dependence and nurturance."[l4]

If we assume that some balance of masculine and feminine characteristics is necessary for a healthy, functioning, healing, and caring profession, it becomes more apparent just how limited the role of feminine qualities have been in the health care system. Physicians enjoy power and autonomy, not deference. Physicians largely define the health needs of others; they do not have an impressive record of anticipating or seeking clarification of others' needs. As discussed in the preceding paragraphs, the medical system has not devoted attention to the qualitative' aspects of its relationships with other sectors of society. The training process, as expressed by the old cliche, "students and residents have it so much easier than in my time," likens medical training to a male adolescent struggle-and-survive rite of passage, certainly not to a feminine process of nurturance. But the reeommended changes in the medical curriculum have a clearly feminine spirit. To successfully implement courses that foster individual and group problem-solving, patient or community orientation, and humanistic perspectives, faculty must accept, embrace, and learn to express these feminine qualities. This is a tall order for medical training institutions that have actively suppressed these qualities for decades. Perhaps pressures to open up the faculty to the broader community of practitioners will bring a sufficient volume of new voices who are actively dealing with the problems of the community to instigate some of the necessary changes. As in other sections of society, as the number of women who value these qualities increases in the profession, they may realize and exert their influence.

This clinical analogy of the health care system having an eating disorder is useful only if it stimulates perspectives that can be helpful in managing the redesign of the system. Eating disorders are chronic conditions that usually require long-term therapy. The same is true for our complex health care system. There is unlikely to be any "cure" - the patient will need ongoing attention, care, and modification. We are less likely to do harm, however, if we are clear in our understanding of the etiology of the illness and in our therapeutic goals. We must look beyond the symptoms of economics and appreciate that economics are simply the mathematics of our values. A more complete scientific and humanistic understanding requires an in-depth analysis of these values and of how they are expressed in the relationships within and outside the health care system. As with the eating-disordered patient, this analysis leads to a reflection on meaning and purpose. We must seek a wisdom beyond the male juvenile desire to "conquer disease" or "avoid death" and find a definition for health that applies to all people and includes a respect for the resources of our environment. As Dossey has written, "physicists such as Bohm believe that meaning must be recognized as a legitimate concept in physics. If it proves necessary to include meaning as a factor in order to understand simple systems such as atoms, it seems likely that meaning also will be crucial in understanding the behavior of much more complex entities such as human beings. And if this approach is applied to medicine, a great historical loop will have closed and meaning - once regarded as a vital factor in getting well - will again have a home in healing.[15]

References

[1] Prigogine, I., and Stengers, I. Order out of Chaos. New York, N.Y.: Bantam Books, 1984.

[2] Fuller, B. Critical Path. New York, N.Y.: St. Martin's Press, 1981, p. 124.

[3] Report of the Citizens Commission on Graduate Medical Education. The Graduate Education of Physicians. Chicago, Ill.: American Medical Association, 1966.

[4.] Barrows, H. How to Design a Problem-Based Curriculum for the Preclinical Years. New York, N.Y.: Springer Publishing, 1985.

[5.] Burstein, A. and Wogodsky, H. "The System Is Failing, but the Students Are Getting the Fs." Pharos 45(2):30-3, Spring 1982.

[6.] Eichna, L. "Medical School Education, 1975-1979: A Student's Perspective." New England Journal of Medicine 303(13):727-34, Sept. 25, 1980.

[7.] Glaser, P.J. "Has the Fun Gone out of Medical Education?" Pharos 45(2):36, Spring 1982.

[8.] Report of the Panel on the General Professional Education of the Physician. Physicians for the Twenty-First Century: The GPEP Report. Washing-ton, D.C.: Association of American Medical Colleges, 1984.

[9.] Rogers, D. Some Musings on Medical Education: Is It Going Astray?" Pharos 45(2):11-4, Spring 1982.

[10.] Tosteson, D. "Learning in Medicine." New England Journal of Medicine 301(13):690-4, Sept. 27, 1979.

[11.] Waugh, D. "Pedagogy, Self-Education, and the Information Explosion." Pharos 45(2):20-1, Spring 1982.

[12.] Odegaard, C. Dear Doctors: A Personal Letter to Physicians. Menlo Park, Calif.: Kaiser Foundation, 1986.

[13.] White, K. The Task of Medicine: Dialogue at Wickenburg. Menlo Park, Calif.: Kaiser Foundation, 1988.

[14.] Orbach, S. "Accepting the Symptom: A Feminist Psychoanalytic Treatment of Anorexia Nervosa." In: Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. Garner, D., and Garfinkel, E., Eds. New York, N.Y.: Guilford Press, 1985, p. 84.

[15.] Dossey, L. Meaning and Medicine. New York, N.Y: Bantam Books, 1991, pp. 103-4.