The Psychology of Health Care

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Derek Lowe

There's something different, psychologically different, about health care. Debates about reforming the way we get medical treatment (and the ways we pay for it) can get a bit otherworldly (to my mind) if they try to pretend that this difference doesn't exist. Sheer economic and public policy reasoning just doesn't take some very important things into account.

Here's how I put it once: Imagine that if you wanted to buy a car, you were required to first visit a car consultant. This would be an expert who would eventually place your order with a car dealer, after first looking over your transportation needs, your financial status, and other factors. There would, of course, be a fee involved. But no one would be able to order a car on their own. Advertisements for cars would probably look similar to the ones we have today, except there would be a phrase at the end to "Ask your car consultant". Much more advertising and promotion, though, would be directed at the consultants themselves, as you'd figure. A steady stream of representatives from the various automakers would come by, extolling the virtues of the latest models and leaving stacks of glossy literature, DVDs, etc., along with offers of free trips to come by for some test-drives. Probably other incentives, too -- there would be scandals involving payoffs to car consultants for steering their clients to various makes.

A bit too science-fictional? Let's move the analogy over to, say, mortgages. Given the real estate meltdown over the last few years, it wouldn't surprise me much if someone, somewhere, has called for the creation of professional mortgage advisors. Anyone looking to borrow money for a real-estate transaction would be required to go through at least a cursory visit with one. The advisor would look over your finances, explain the different mortgage options out there, making sure that you understood what you were getting into. In fact, the advisor would do more than that - if you didn't meet certain criteria, their professional ethics would not allow them to put you in touch with a lender. Some advisors might be more lenient than others, but you'd have to see one, and have them sign off on your mortgage, before you could legally borrow money. There would, of course, be a fee involved.

Under this system, ads for low interest rates and creative refinances would still be around, but they'd always end with an urgent request to call your mortgage advisor immediately, before the great deal evaporates. And the bulk of the promotion money would, again, surely find its way to trying to influence the mortgage advisors themselves. Lenders would come in with figures showing how few people had defaulted with them, what percentage of the loans in a given market they underwrote, and so on. As gatekeepers in an important industry, the advisors would be much in demand. I'm sure that if a profession like this was created, you'd have to use high explosives to ever remove it from the process.

Enough with the thought experiments. In the world we live in, we trust adult consumers to be able to make decisions about which car to buy. The car companies lose no opportunity to try to make people think about the advantages (both emotional and tangible)  of a new car, and to suggest that it would be easy to purchase one. The car dealers themselves stress the same points, and add more details about how easy they are to deal with. People do get into bad leases or buy more car than they can really afford, but that's considered largely the customer's problem, unless the hard-sell tactics were truly egregious.

And (for now, anyway) we trust adult consumers to be able to decide for themselves if they're ready to buy a house, which houses they might be interested in purchasing, and how they might wish to round up the money to do so. This is a harder decision, since it involves a much greater commitment of time and money than purchasing a car, and there are many more options available. The existence of real estate agents and real estate attorneys show that more people feel the need for and are (more or less) willing to pay for outside assistance in finding, buying, or selling the property itself, but there are as yet no mandatory mortgage agents of the kind I describe above. The financing part is typically left up to the customer.

So we finally come to prescription drugs. Medical care is even more complicated than real estate. You can obtain licenses to sell properties or broker mortgages far more easily and with far less schooling than you need to obtain one to practice medicine, and that's a good thing. You also cannot obtain new medicines, or any drugs for major medical problems, without seeing a doctor first, both to make sure of the problem and to advise on its treatment. And I should make clear that I think that's a good thing, too - I believe that the benefits well outweigh the disadvantages. Consumers - in this area, we use the word "patients" - are free to follow or not follow that medical advice, however, or to shop around until they find a doctor whose opinions they like better (if any exist), but they are not free to purchase and dose themselves (or others) with prescription drugs.

One big difference is, of course, that medicine is a complicated subject. There's a lot to know, and not everyone -- to put it mildly -- is capable and/or willing to learn it. Society (rightly) sends such work to specialists who are ready to make that effort, and we pay them for doing so. But it's not like everyone is willing to leave it to the doctors and pharmacists. The huge number of internet sites giving medical details (real and imaginary) to the public is evidence enough of that.

And that takes us to what, in my mind, is the real issue. The complications of medical science are a difference in degree, but health, an intensely personal category unto itself, is a difference in kind. A person's health affects every aspect of their life, immediately and continuously, in a way that not even the roof over their heads can. Medical issues are unavoidably saturated with thoughts (and fears) of death or grave disability, and always have been. This has receded in places as medical science has reduced the incidence of some causes of death, but this emotional entanglement is very much with us, and will be for a very long time. Look closely, and you'll see it: as mentioned above, we have a whole special word for "customer of a physician", because we don't usually think of the relationship in business terms. "Patient" connotes someone who is in the care of someone else, whose fate rests partly or wholly in another's hands. There's no special word for "customer of a car dealer", or "customer of a real-estate agent".

The unusual quality of a medical transaction is understandable for another reason as well, since traditionally the course of a physical ailment has been uncertain, and the ability of medicine to do anything about it has been likewise in doubt. For most of human history, seeing a doctor has been very much like seeing a priest. It has not been looked at as a business deal, and in most cases it had no hope of ever being one in the usual sense. That's because there wasn't much, in the end, that doctors could do for people. See Lewis Thomas's The Youngest Science for more on that - he points out that almost everything his physician father prescribed in the early 1900s was a complicated placebo of one kind or another, and his father well knew it.

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Megan McArdle is a columnist at Bloomberg View and a former senior editor at The Atlantic. Her new book is The Up Side of Down.

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