“Clinical Man”–by Clifton Meador (Why Do So Many Of Us Need Medical Tests to Tell Us That We Are Well?)

Editor’s Note–

Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories.  (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)

In the post below, Meador refers to one of his best-known stories, a tale set in the not too distant future titled The Last Well Person.”  The fiction, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)

This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:

–“The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?

–“Unheard Hearts–a Metaphor”

— “How Medicine Became a Growth Business;

Today, Meador is a professor  of clinical medicine at Vanderbilt. The essay  below originally appeared on The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB) 

 M. M

                                         Clinical Man

by Clifton Meador

In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth.  I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging:  homo clinicus.

An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.

Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.

There has been a progression of terms for this new species. First, there was the “early sick” then “the worried well.” That was followed by “the worried sick.” We now have arrived at a definable new species that differs from pre-clinical man.

Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, “An apple a day keeps the doctor away.” That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That’s the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough.”

Clinical man is neither sick nor well. He is simply in clinical limbo. As you will see in the definitions of this new species below, he is always under medical surveillance. Clinical man requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something that needs to be rechecked.

Medicine and man have evolved in a symbiotic manner ­­– like the whale with those little fish that swim in and out of the whale’s mouth. The fish need the whale for food particles and the whale needs the fish for dental hygiene –something like that. There is nothing strange about this symbiosis of medicine and man.  Big medicine needs clinical man and clinical man needs big medicine. That’s just the way it is. Where would all the endoscopists be without clinical man? And what about all those proceduralists who do interventions and biopsies? What would we do with all the CAT scans and MRIs and PET scans without clinical man? How would all the surgi-centers and imaging centers and stand-alone diagnostic centers survive without a long line of clinical men? Don’t forget the insatiable needs of big pharma and the relentless mongering of created, pseudo diseases on television.

Clinical man goes to the doctor when not sick. That’s part of the definition of the new species. No longer able to decide by themselves, they come in increasing numbers to find out if they are sick or well. Some even demand to know what disease might loom in the future for them.

Here are a few of the characteristics of clinical man:

  1. Knows his cholesterol level within 10 milligrams percent.
  2. Has been biopsied in at least one non-palpable organ by age fifty.
  3. Has been biopsied in a palpable organ by age forty.
  4. Has had at least one major orifice endoscoped within the past twelve months.
  5. Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
  6. Never goes more than twelve months without medical contact.

How did this evolution from an avoidance of medicine to medicine becoming a necessity occur?  It is actually quite simple; medicine has been assigned successes by television and the public that are not attributable to medical care. Nearly all of the increases in health and life expectancy from birth are traceable to public health measures, clean water and milk, vaccinations, and a myriad of positive effects of the age of modernization.

It is a strange irony that at a time of maximum health, more people than ever are coming to see doctors. Preclinical man will soon be extinct



4 thoughts on ““Clinical Man”–by Clifton Meador (Why Do So Many Of Us Need Medical Tests to Tell Us That We Are Well?)

  1. Maggie:

    Ever try to get your meds without seeing a doctor at a one year time period?

    Ever have two doctors (GP and Cardiologist) in the same clinic, see only one, and try to get your meds from the other when the tests and checks are almost the same?

    Ever go to the VA to have them process your meds (far cheaper), the doctor you see there is on staff at the same clinic/hospital as the other two are, and they want you to get the records from them rather than read the clinic system?

    Even for the simplest of meds, they want the appointment for you to come into the office and spend $180 paid out – of – pocket or eventually covered. If you get it coded preventative, it can be covered by insurance of some sorts. The cost is still picked up by someone through your premiums or the pool.

    I like my doctors and they have served me well; but, it is their business I have come to disdain as they do not care. It is a business. You know my history and up to a certain point in my life, I was pre-clinical man and it was only because I was healthy I survived what ran me over twice. I am healthy today and just a bit slower.

    Here is a thought for you. When I started rehab, I had to be checked out. In Ohio and part of a heart clinic , I just saw some techs who ran the stress test and had it read by the doctor. At U of M when I came back to my home state, an NP did the exam. No big deal for me except the supervisor was a Doctor and the charge came back at $180 to which the insurance company balked.

    • run75411

      This is why, in other countries, doctors’ charges are regulated.

      Here, we let doctors make up their own rules.

      It makes sense to ask you to see your doctor once a year in order to have meds renewed.
      Someone should be checking to see if they are working, to make sure that you’re not overmedicated, and
      to review all of the meds you are taking to avoid redundancies and bad combinations.

      That said, there is absolutely no reason why that doctor can’t be a VA doctor. And you are right because the VA negotiates prices with drug companies (and refuses to
      pay for over-priced drugs that are no better) having your drugs renewed through your VA doctor is much cheaper.

      I take it from what you say your other two docs want you to go through them?

      Now that you are back home, can’t you go to a VA hospital for meds?

      Charging you $180 when a NP runs a stress test and renews a prescription could make sense. If she is doing the same work a doctor does, and the reading the tests
      requires the same knowledge, there is an argument that she should be paid the same amount. (Equal pay for equal work). On the other hand, the cost of becoming a NP
      is significantly less than the cost of a medical education to become a cardiologist, and she probably did not emerge from school with as much debt.
      That probably should be factored in when deciding how much she can charge.

      But in this case, it seems that they are charging you more because she is “supervised by a doctor”. It’s not likely that the doctor spends much time
      supervising her. Running a stress test and reading it is a pretty straightforward procedure. Requiring that she be supervised by a doctor is simply a scam.

      Having techs run the stress test makes sense. (It sounds as if the system in Ohio is more rational than in your home state. Or maybe the problem is the U. of M.

      Bottom line: fees should be regulated by the government. All doctors and hospitals and NPs in a given place should charge the same amount for a given procedure.
      This is the case in Maryland–which had an “all payer” system. Academic medical centers can charge more, to adjust for the higher cost of running a teaching center. And hospitals that see higher-risk patients can charge more. That’s it. But it should not be up to the individual hospital to decide what it charges based on
      how much it thinks the market will bear.

      Finally, drug prices should be regulated by the government. If they were, having a prescription renewed would cost significantly less.

      Letting health care providers set their own prices (so they are the “price makers” and we are the “price takers”) is unfair because medicine is a
      necessity–like electricity. You don’t have any choice–you have to buy the product. We don’t let utilities simply set prices–they are regulated. WE should treat medicine the same way.

      I do think that we will begin regulating drug prices in the near future (maybe before 2016–almost certainly after 2016). And regulations of hospital and doctors’ prices will become easier as more of them become part of accountable care organizations who are paid for value, rather than fee for service.

      But we also need to address the huge variations in how much different providers charge for exactly the same procedure. This is why I like Maryland’s system.
      Some years ago, a fair number of states had an all-payer system. But then Republicans took over those states and one by one, they did away with the all-payer system.

      Finally, health care inflation has been lower in Maryland than in comparable East-Coast states with a mixed population of rich and poor and similar cost-of living (which determines how much hospitals and doctors must pay for labor).

      I know the Obama administration has been interested in Maryland’s all-payer system. Perhaps the next Democratic administration will be able to expand “all payer” as
      part of “Health Reform 2.0) — improving and refining Obamacare beginning in 2016.

      Good luck with getting your meds–I’d urge you to go to the VA even if it means traveling . . .

  2. If you are having trouble commenting on this post, please let me know. Maggie Mahar

  3. Maggie:
    For metoprolol (succinate is a tier 2 {which does not make sense]. I could use the simpler version and take twice a day for less money) I go to the VA as it is half the cost of going through Part D. The other drugs I go through Part D as there is no copay. If it was all Tier 2 or higher and I was subject to the doughnut hole, I would go to the VA for all of my needs.

    I keep the Plan N and Part D around because at any time Congress could exclude me from VA coverage (I have deductibles) since I came out of the service in one piece suffering only a loss of hearing. If you are disabled, you have coverage for that issue. If I suffer effects from the polluting of water at Camp Lejeune during my station there, I am 100% covered with no deductibles.

    The VA doctor (who is on staff at U of M) suggested I keep my doctors at U of M and bring any needs for certain Meds to them. The VA is crowded although they now gave me a card to go through private healthcare if I can not get in to see them after an attempt to make an appointment. For me, I have trouble doing such even though it takes 2-3 months to see either a GP or Cardiologist at U of M.

    I could tell you the difference in have a walk-about in my heart at Med Central Ohio and U of M Michigan. It is pretty big. Yet both hospitals have good reps for by pass operations.