The Medical Model

Recently, I (Stephen Duclos) have had more contact with the medical establishment than one would want. My partner and I spent 19 hours in a Boston area hospital emergency room before being admitted. There were diagnostic problems related to severe right sided lung pain. I was seen primarily in the ER by nurses, and by a very good Physician’s Assistant, a young man of color. I mention this aspect of diversity because the hospital staff of technicians, nurses, and cleaners were culturally diverse and, from my perspective, competent and interested in my illness narrative.

Privilege

The problem was with the white male doctors who followed. (This blogpost is being written by an older white male.) In each case with the white male doctors, both my wife and I reacted adversely. In one case, a doctor, called a “hospitalist”, who we had not met, told our attending nurse to begin an IV drip of several antibiotics that our new pulmonologist, a Hispanic man who was very interested in our point of view, had said was unnecessary. The nurse, who was definitely “following orders”, was put in an awkward spot. My wife was quite insistent, and our adult daughter was taken aback by our assertions. We demanded at least an in person conversation before we might agree to this form of treatment.

The nurse called the hospitalist, who was on the floor where we were. He said he would stop by, which did not occur. Thus, no antibiotic drip. This problem occurred again upon discharge, when our pulmonologist discontinued an IV drip of a blood thinner, Heparin. Since our discharge was delayed by many hours, for unknown reasons, another attending nurse was told by another hospitalist to reattach the Heparin drip. Again, it had already been reported earlier that morning that the diagnosis had changed, and a blood thinner was no longer even marginally useful, and was in fact not therapeutic. I adamantly refused the reattachment, putting the female nurse again in an awkward position. Again we demanded to see the hospitalist for a conversation. He too was reported to be on the floor.

Four hours later on the this day of discharge, the white male hospitalist, who we had never met, came in to see us. He began by telling us what was wrong, never asked any questions, and made assumptions that were not accurate. Since he was standing over me and talking to me, I stood up, still dressed in practically nothing, and moved into a a more equal position, although I was still attached to a saline/potassium IV drip. This seemed to change the dialogue slightly, maybe because I was an older white man with an attitude.

Counseling

How might all of this relate to questions of mental health and psychotherapy?

Entitlement is a very subtle thing if not noticed or challenged in everyday situations. It also relates, I think, to systems problems in the medical and mental health model.

In the 19 hours in a busy emergency room, I had videophonic access to the comings and going around me. Our room looked out through a glass partition of a sliding door upon the “master control” operations, occupied almost exclusively by a series of nurses, technicians, EMT’s, and cleaning staff.

Doctors drifted in and out of our panopticon-like viewing space, the patient observing the controllers. I began timing the amount of time a doctor spent with an ER patient. It was uniformly less than five minutes. What I observed was an efficient system marred by not enough healing space or resources, even though this was in the medical mecca of Boston. Most patients were left in corridors, since there was no space in any of the “emergency” rooms. We were lucky enough to arrive during a 2 AM lull, in which a room was actually free. Since I am a therapist, I was also privy to the conversations of family members attending to their ill brethren. This was occurring directly outside my door, so there was no avoiding the interactions. In many cases, these conversations were medically useful, as one might expect, since family members were caring for these patients on a daily basis. Unfortunately, no doctor was listening.

The cleaning staff were cleaning up collections of vomit, feces, urine, and blood left over from helping citizens become less ill and more healthy and hopeful. Whenever I had to use a bathroom, which was often, I noticed their work. They went about their tasks quietly, efficiently, and productively. I was reminded once again that those of us who are ill paid in the health system often do difficult complicated jobs that are disregarded and disrespected by the white male patriarchy who never get a whiff of either the occupational tasks of the cleaners, or the illness narratives of patients.

I include in this occupational category not only the cleaners, nurses, technicians, and others in a hospital, but also psychotherapists, mental health personnel, nursing assistants in memory impairment units and other nursing home situations, and rehabilitation counselors, social workers, and staff of residential mental health and developmental disability facilities. This large contingent of mental health workers are ill paid by the medical/pharmaceutical establishment, and are included as substantially low paid personnel in several recent studies of workplace economics that focus on the economics of inequality.

Psychiatrists

For example, psychiatrists (mostly white heterosexual males in recent occupational studies) are paid by health insurers $325 for ten minutes of their time with a patient with mental health concerns. They then prescribe a psychotropic drug that many recent studies are questioning as being therapeutic or effective. What kind of illness narrative can one collect in ten minutes? By comparison, a family therapist, or any skilled and state licensed psychotherapist, receives $65 for 45 minutes (although most therapists must spend a full hour with couples and families) for listening to and treating the mental health problems of a family.

Economically this is untenable, given the costs of real estate and rent and overhead in any economic context. More than ninety percent of all therapists and other personnel in these low wage positions in hospitals, nursing homes, and mental health facilities are either women or persons of color.

Mental Health

Gun violence is an untreated mental health problem. Mental illness itself is marked by homophobia, racism, and a disrespect of persons with disabilities. The stories of treatment that I have heard over the past 40 years by the medical model of persons with schizophrenia, blindness, spinal cord difficulties, developmental disability, autism, and different sexual orientations are uniformly horrific. When these populations are treated and controlled by a dominant white male class that are uniquely ill-equipped to listen to one’s illness narrative, then we have systems problems that apply to everyone.

Problems of mental health and medical health will get better in the United States only when we as citizens wrest control of a medical model from a system dominated by the economic concerns of a pharmaceutical and health insurance system whose first concern is the profit of themselves and their shareholders. The medical model should not be for sale, or be a capitalist enterprise, as so many enlightened nations have learned.