Let’s talk about the American medical system – the system that takes care of us, tells us if something is wrong, and informs us on how to manage medical diagnoses.
There are many stakeholders in that system, but I’m going focus on two: the doctor, and the female patient.
But before I do, I will go on a tangent about other stakeholders that are in relation to the doctor and are also worth mentioning:
Educational institutions
Insurance companies, provider (hospitals, clinics, etc.) administrations
Pharmaceutical companies
These additional stakeholders are inextricable from the “doctor,” for they each play an integral role in shaping how our doctors think, act and behave. Some context on each:
1. Educational Institutions
Med school, where doctors are groomed for success. As we all are aware, getting into med school is no cake walk. It requires tons of pre-requisite courses obtained in an undergraduate degree, robust past experience, excellent test (MCAT) scores, and an expressed devotion to the medical field. Differentiation that gets candidates in the doors of the most competitive institutions is often based on brilliance and unique extracurriculars. To top off the difficulty, hundreds of thousands of dollars in student debt before and after med school burden its students. And not to mention, if you don’t get into a top 20 institute – don’t bother going (because only competitive institutes – ranging from having 1-3% acceptance rates – are the places that will connect you to legitimate residencies and thus jobs to pay off your hundreds of thousands of dollars in debt).
Med students put a lot of faith into their institutes, because, well, they’ve worked their asses off to get into them. It is critical to keep in mind that with the degree of hard work and diligence required for entry to these schools, students are susceptible to develop a self-justified perception that they are exceptional. Rightfully so, these schools make admission nearly impossible. So, to be admitted, is to have accomplished the (near) impossible. Pretty impressive stuff, with a caveat: this is where the MD ego is borne.
But let’s get back to the often unconditional faith these students put into their institutions. When at a prestigious school to learn about concepts and ideas that are utterly new to you, and proposed as unarguable on the basis of science, you are going to believe what you’re taught. The training programs at these schools have deep historical roots that, when looked at through a critical lens, have likewise deep cultural inequities embedded within them.
Who has historically led science? Men. Who has historically led medical school programs? Men. This is important for the sake of our conversations on this blog. If white men have traditionally led the charge for medical science and its discoveries, what medical issues do you think have been deemed as top priority? Ovaries? Female sex hormones? Menstrual cycles? Male-targeted birth control? Think again.
The point I’m trying to make here is that for good reason, medical students believe in their schooling. They religiously follow their curriculum. They are trained to think in a particular way, and told that their way of thinking is the best in class. These facts are problematic for two primary reasons:
When one solution is determined the only, curiosity for what else might work better is squashed and thus the system of accountability that gauges the efficacy of that solution is dismantled. There is little to no room for new thought, or challenging old thought.
The leadership of medical schools historically and currently shape the narrative thousands of graduating, new doctors venture out into the medical world, on a yearly basis, to reinforce.
2. Insurance Companies and Provider (hospitals, clinics, etc.) Administrations
Insurance companies impact doctor behavior in that they will “cover” (pay for) all or a portion of particular services the doctor performs. Since healthcare is tremendously expensive (it is one of the industries with the least amount of cost transparency), insurance companies try to mold doctor behavior by covering less of the costly services they render. For example, a simple blood panel done at an onsite laboratory can cost approximately $1000. Unwilling to pay all $1000, an insurance company will say that blood panels are only 50% covered, and leave $500 for the doctor’s office to pay*. Where does that money come from? The office administrative team. $500 versus $0 adds up quick. And for small medical practices (one or two doctor-led offices), those are hefty fees to pay at scale. Thus, the doctor in many cases will not order blood panels when sometimes that is the best thing to do for the patient. This payment structure lets on to what we call a perverse incentive. The same goes for large hospital systems with fancy Chief Financial Officers heading their management. These hospital systems don’t like high, theoretically “avoidable” fees either, and will train their doctors to not make an order for a test that, again, might be best to conduct.
*I’m not here to talk for or against insurance actuarial science. However, it is important to note that due to minimal transparency for costs in the healthcare industry overall, we must ask why it costs a whomping $1000 dollars to conduct a laboratory test. Insurance companies do not set that price. Does that $1000 include payment to the nurse drawing blood? Do the laboratory equipment makers set the price? How big is the cut the laboratory itself is taking from that paid service? Nobody knows. Insurance companies just know it’s a lot of money, they can’t target why, and they aren’t willing to pay exorbitant fees that arguably sit unjustified. When we look at the high cost of healthcare, considering that it is set up in a capitalist, for-profit system that lacks cost transparency is critical to understanding why our national debt on healthcare racks up to trillions of dollars.
The last point on insurers that I’ll make is that they time providers. Insurance companies will agree to pay patient cost of the visit if it falls within a 15-minute increment. Increments change according to specialty, but the variance is minimal. This rushes the doctor consultation with the patient. Why would the doctor want to stay past 15 minutes if they know doing so would incur a cost to the patient and/or their office administration? I can’t think of a compelling answer other than morality. But morality gets tough to stick to when your job is on the line, and you have administrators possibly threatening your employment and ridiculing your inability to get the patient out the door before the insurance clock runs out.
3. Pharmaceutical Companies
Talk about incentives. Some basic facts on the pharmaceutical industry are that the United States has its own, separate governing body—The Food and Drug Administration (FDA)—that dictates which pharmaceutical drugs are approved for the public. The FDA is notoriously riddled with controversial methodology and practice, if you Google “FDA issues” you will be met with a laundry list of plausible offenses. But what is important to know is that the primary error in the FDA structure is that it is the only accountable organization for drug approval in the entire country. Thus, there is no other organization to keep the FDA in check. This is problematic when you throw the pharmaceutical lobby into the mix.
The pharmaceutical lobby is the largest of all lobbying efforts in the United States, leading ahead of electronics and equipment, oil and gas, and business associations lobbies, to name a few. In 2019 alone, some $295 million were expended for pharmaceuticals alone; oil and gas, the second largest lobby in the US, came in at considerably lower $156 million.
Why does this matter? The important take away is that pharmaceuticals have sway, a lot of it. They are constantly swaying opinion and interest towards their products. And how do they sway? They monetarily incentivize. Pharmaceutical lobbying efforts are no different in Washington than they are in the doctor’s office. Doctor’s and provider administrations are given payments by the pharma companies when they promote particular drugs to their patients. In a 2016 study, ProPublica found that there was a 58% likelihood that a doctor would prescribe a drug they were being paid to prescribe. Duh.
What does all of this mean?
The point is this: American doctors think what they think because they’ve been trained by and large by a single dogma, one that is heavily influence by a predominantly white, male body of work and systematic structure. Those doctors are incentivized by insurance companies and pharmaceutical companies. These incentives limit the methodological processes that might be more beneficial for doctors to use. They limit time spent with the patient, and adequate next steps that should occur post patient visit. And, finally, pharmaceutical sway in the doctor’s office jeopardizes the doctor’s mindset for solutioning, it focuses on medicine for the problem, not the root cause of the problem. The patient has iron deficiency? Give them iron supplementation! Why focus on the bodily malfunction that is causing the deficiency (i.e. abnormal, heavy menstruation)? Because the doctor will get paid to prescribe iron and the patient will be on it for the foreseeable future (paying for monthly prescriptions) because the root cause is not being rectified.
These are all critical issues to understanding the context for which we as patients are, often, fighting with when it comes to advocating for our own health. And as women, I want to make it clear that pharmaceutical products are not just iron supplements, or blood pressure pills for our grandparents. Pharmaceutical products, too, are birth control pills. Birth control pills are, in my opinion, one of the biggest fallacies for female empowerment.* It is my hope that in having you understand the male-dominant, industry-pushing forces that have created an exceptional marketing campaign for female empowerment, you come away from this with an understanding that “the pill” is not that; the pill is another way to succumb to discriminatory healthcare delivery, and it is another way of submitting your personal health to the profit of an industry that does not care for it.
*A post on the possible health risks associated to pharmaceutical birth control (there are many) is to come. Don’t fret, we will be diving deep into that abyss – if only to re-emerge better informed and more empowered to make conscientious decisions on what we subject our bodies to in the short and long term.