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:
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)
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:
- Knows his cholesterol level within 10 milligrams percent.
- Has been biopsied in at least one non-palpable organ by age fifty.
- Has been biopsied in a palpable organ by age forty.
- Has had at least one major orifice endoscoped within the past twelve months.
- Is always waiting on a biopsy report or a repeat of a borderline or false positive lab result.
- 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