Read an Excerpt
Prepare to Defend Yourself ... How to Navigate the Healthcare System & Escape with Your Life
By Matthew Minson Texas A&M University Press
Copyright © 2014 Matthew Minson
All rights reserved.
ISBN: 978-1-62349-162-8
CHAPTER 1
THE LANGUAGE OF MEDICINE
SIT, STAY, DIAGNOSE!
Before I get too far into the specifics of self-empowerment in the system, I think it's helpful to begin with a brief history of medicine. Now, I can already see your eyelids starting to get heavy, but indulge me here. Knowing how the system got like this helps a lot in understanding why and how those who surround you and do unspeakable things to you in your moment of need view you, assess you, process you, talk to you, and ultimately what you can and can't do about it to protect yourself. Or to put it in the more elegant words of H. G. Wells, "History is a race between education and catastrophe."
As far as historians have been able to tell, by 4000 BC many religions had identified certain of their deities with healing. Without any understanding of the process of disease or how drugs worked, most believed that a person became ill because he or she had earned disfavor with the gods. Therefore, culpability, shame, and ostracism were quickly associated with illness. Sadly, this mentality sometimes holds over even today, especially in the areas of addiction and mental illness.
In particular, the temples of Saturn, and later of Asclepius in Asia Minor, became recognized as healing centers. People would travel to these "centers of healing" and offer prayers and sacrifices. Dream interpretations played a significant role in the ancient healing process (sounds kind of Jungian, doesn't it?), and much like the modern equivalent of social services support, the effects of the patient's daily life were considered to be paramount for a good outcome. Beyond the metaphysical, however, the priests or ancient physicians who attended and supported such practices also stitched wounds, set broken bones, and used narcotics—specifically opium—for pain.
On the surface it might seem that there weren't many similarities between the ancients and what we see today, but consider the following. In order to curry favor with the temperamental gods, supplicants (patients) would place offerings (co-pays) of animal flesh—say, a haunch of beef or a game bird—on a fiery altar of the respective god. This barbecued tribute also supported the lifestyle of the priests, who ate the cooked flesh. And that is the story of how we arrived at professional fees. As you can see, there were a lot of similarities to our current system even then.
These spiritually oriented hospitals were also structurally similar to what we now see in modern clinics, care centers, and hospitals. Plans for a fifth-century BC temple in Athens dedicated to Asclepius showed large rooms, 24 by 108 feet, for multiple dreamer-patients. This is amazingly close in dimension to its modern equivalent, the post-anesthesia care unit (PACU), or "recovery room."
On a similar note a network of Brahmanic hospitals were established in Sri Lanka as early as 431 BC, and King Ashoka of Hindustan established a chain of hospitals about 230 BC. These might well be the first examples of an organized healthcare system. Around 100 BC the Romans established specialized hospitals, the valetudinaria, to treat their sick and injured soldiers. This was just the early analog to our Veterans Administration hospitals. This was less a benevolent act than pure pragmatism. The soldiers' care was important because the vigor of the legions increased the perceived power of the empire.
Literary sources occasionally mention ancient hospitals, but only documents from Egypt reveal how widespread and even secular they were. Testimonia from the temples of Dendera, Thebes, and Memphis in Egypt record a multitude of hospitals founded by private individuals and independent of ecclesiastical or religious influence. These early records show that the origin of the hospital as an independent institution dedicated to medical care and not just as an offshoot of worship can be dated to the third quarter of the fourth century.
Most historians agree that the earliest example of the modern concept of a hospital dates from AD 331, when Emperor Constantine, having been converted to Christianity, abolished all pagan hospitals and created the opportunity for a new approach to caring for the ill. Until then, disease had spiritually isolated the sufferer from the community. This new Christian tradition emphasized the close relationship of the sufferer to his fellow humans, upon whom rested the obligation for care. Care of the sick thus became a benevolent matter for the church.
In the year AD 370 Saint Basil of Caesarea established a religious foundation in Cappadocia that looked remarkably like a modern medical center in its layout. It included a hospital, an isolation unit for those suffering from leprosy (an early sanitarium), and buildings to house the poor (early homeless shelters) and the elderly (retirement communities), as well as the sick ("laying-in" facilities and rehabilitation units). Following this example, an explosion of hospitals expanded into the eastern part of the Roman Empire. Another notable accomplishment was that of Saint Benedict at Monte Cassino, founded early in the sixth century, where the care of the sick was placed above every other Christian duty, thus establishing a hierarchical obligation of care. It was from this beginning that one of the first medical schools in Europe was created at Salerno and was producing the finest medical practitioners in the world by the eleventh century. This example led to the establishment of similar monastic teaching infirmaries throughout the Western world.
Architecturally, the oldest evidence of a conventional hospital appears to be at Mihintale in Sri Lanka, which can be dated to the ninth century AD. The extensive ruins suggest there were patient rooms that measured 13 by 13 feet, which is surprisingly close to the dimensions of individual patient rooms today. The archeological dig of this site produced surgical instruments that would be recognizable to a modern surgeon. It also contained a stone "medicinal trough" approximately 7 feet long and 30 inches wide that may have been the first example of hydrotherapy using mineral water and medicinal oils.
In regard to the concepts of health care—co-pays, floor plans, and even our perceptions of illness—the more things change, the more they also seem to stay the same.
To fully understand the evolution of medical care, it is important to understand something about its politics and how it related to the crowned heads of the ancient world. I know what I am about to say next seems terribly absurd, but I think the best analogy can be found in taking a look at the Brady Bunch.
Prior to the Middle Ages, the system of primogeniture was set up to dictate the transfer of wealth and titles of nobility from generation to generation. This "law" stated that all wealth, property, and the endowment of power associated with title were to be passed on to a succession of children by order of birth, hence the term "heir apparent." The second son got nothing. Of course, if you think sibling rivalry is bad in the typical American family, then you can just imagine what it would be like if Jan Brady had just to kill off Marsha in order to become queen. Or if it works better, imagine Elizabeth I shrieking, "Marsha, Marsha, Marsha" right before she had Mary Queen of Scots beheaded.
Fortunately for the Bradys, the law of primogeniture generally applied mostly to males. In order to minimize the familial carnage and protect the throne, tradition dictated that the second son enter the military so the future king's top general had a strong family link. The third son went into the clergy so that all the powerful institutions of the developing world were covered for the royal family. With that in mind, Greg would be the heir apparent, Peter would go into the military, and Bobby would become a bishop or cardinal and therefore, the intellectual. I know what you are thinking, but you have to admit you won't ever forget the concept now.
Given what we have just learned about the progression of the temples of the healing gods to the religious custodianship of tending to the poor and the sick, the priestly evolution to physick or physician seemed only natural. The fact that the influential clergy/doctors were still tied to the royal family meant continued support and permanence for these new hospitals.
Fast-forward through the centuries: the church-based Hôtel-Dieu of Lyon was opened in AD 542, and the Hôtel-Dieu of Paris in AD 660. The monasteries had aninfirmitorium (hence the term "infirmary"), a place where their sick were taken for treatment. They also cultivated gardens of medicinal plants and even had a primitive pharmacy where the plants were turned into cures. In addition to caring for sick monks and local parishioners, the monasteries opened their doors to pilgrims and other travelers. Think of this as akin to a spiritual traveler's health maintenance organization (HMO).
Religion continued to be the dominant influence in the establishment of European hospitals during the Middle Ages, as the growth of hospitals and systems of hospitals exponentially multiplied during the Crusades. Pestilence and disease were more potent enemies than the Saracens in defeating the crusaders, and massive military hospitals came into being along the traveled routes. The Knights Hospitalers of the Order of St. John in 1099 established a hospital in the Holy Land that could care for some 2,000 patients. It is said to have been especially concerned with eye diseases and may have been the first of the specialized hospitals. Even today this order exists as the St. John's Ambulance Corps.
In the Moorish territories of Spain and North Africa and throughout the Middle East, the Muslims established hospitals in Baghdad, Damascus, and Córdoba. These hospitals were notable because they admitted patients regardless of religious belief, race, or social order. This was a socially remarkable advancement in the accessibility of health care regardless of religious inclination, a philosophy that was not adopted until several hundred years later in Europe.
Around the same time the Hospital of the Holy Ghost, founded in 1145 at Montpellier in France, established a factually based and reproducible clinical curriculum and later became one of the most important centers in Europe for the training of physicians. This scientific school of thought was remarkably distinct from 2,000 monastic institutions under the Benedictines and the beginning of our model of medical training.
The Middle Ages also saw the beginnings of support for hospital-like institutions by secular authorities. Toward the end of the fifteenth century, many cities and towns recognized the value and supported some kind of institutional health care. It has been said that in England there were no fewer than 200 such establishments that met a growing social need. This gradual transfer of responsibility for institutional health care from the church to civil authorities continued in Europe, especially after the dissolution of the monasteries in 1540 by Henry VIII. Unfortunately, it also put an end to hospital building in England for some 200 years.
The loss of these monastic hospitals in England suddenly required that secular authorities provide for those who were sick, injured, or disabled, thus laying the foundation for the benevolence society or "voluntary hospital" movement. The first voluntary hospital in England was established around 1718 by Huguenots from France (go figure) and was closely followed by the foundation of such London hospitals as the Westminster in 1719, Guy's Hospital in 1724, and the London Hospital in 1740. Between 1736 and 1787, hospitals were established outside London in at least 18 cities. The initiative spread to Scotland, where the first voluntary hospital, the Little Hospital, was opened in Edinburgh in 1729. Given that it was in Scotland, I've always wondered why it wasn't called the "Wee Hospital," but I suppose it was to prevent people from confusing it with a urology center.
The first hospital in North America was built in Mexico City in 1524 by Hernán Cortés, and the structure still stands. The French established a hospital in Canada in 1639 at Quebec City, the Hôtel-Dieu du Précieux Sang, which is also still in operation, although not at its original location. In 1644 Jeanne Mance, a French noblewoman, built a hospital of axhewn logs on the island of Montreal, which was the beginning of the Hôtel-Dieu de St. Joseph, out of which grew the order of the Sisters of St. Joseph, now considered to be the oldest nursing group organized in North America. The first hospital in the territory of the present-day United States is said to have been a hospital for soldiers on Manhattan Island, established in 1663. These early American hospitals were offshoot almshouses or charity centers, the first of which was established by William Penn in Philadelphia in 1713. The first incorporated hospital in America was the Pennsylvania Hospital, in Philadelphia, which obtained its charter from the Crown in 1751.
Now fast-forward to 1967—ignoring, of course, the development of X-rays, anesthesia, and penicillin—and medical history takes on a much more personal note. In Houston, Texas, a small boy sat in front of a television set watching the 1961 epic film El Cid, starring Charlton Heston and Sophia Loren. The small boy was me, and even at that age I had a real appreciation for Sophia Loren. There is a scene in the movie in which a group of people are cruel to a leper. I don't know if it really happened, but it is used in the film to illustrate the compassion of the Cid. For some reason the injustice of the leper's situation caused by his illness affected my six-year-old sensibility in a deep and disturbing way. I began crying sympathetically.
My mother came into the room from the kitchen with a look that said she would have believed me if I had claimed to have been stung by a scorpion or had eaten rat poison or been attacked by aliens. When she learned why I was carrying on so, the look on her face changed from alarm to one of matter-of-fact practicality, and, drying her hands on a dish towel, she offered a simple solution. "Maybe you can be a doctor someday, and you can help people like that."
She knew her son pretty well. I was a logic-driven creature even at the age of six, so with a plan I was able to cut off the waterworks and enjoy the rest of Sophia Loren. I owe a lot to that moment and to my mother ... in many ways!
With my course in life decided, I immediately started paying more critical—and I am sure discomfiting—attention to my own doctor, Dr. Spencer. On my next visit I told him confidently that someday I was going to take over for him. I remember him patiently and a little exhaustedly looking around before saying, "Well, honey, you better hurry up."
Dr. Spencer was, like most back then, a family doctor. He knew us and cared for us from cradle to grave and was, in turn, crusty, brave, selfless, and compassionate—alternating perfectly between admonishing and nurturing. We valued him because he was uniquely capable and diagnostically accurate and astute. He addressed the basic problems with us and was not distracted by the short goal of just alleviating our symptoms. When we were not at our best, he thought for us and was an objective mentality who saw us through to cure. He patiently bore our complaints, our uninformed self-determination and diagnosis, and at times our misguided attitudes. With his usual focus, objectivity, and calm, he even put up with the fact that we often had, by ill-advised behaviors, caused our own problems. He was uniquely heroic.
In those days medical technology was relatively primitive, and the clinician's inherent diagnostic abilities were, by necessity, arguably better than they are today. Doctors relied on the "history" taken from a patient. This included the chief complaint or why one was seeking care, the history of the present illness, any past medical history, and associated social elements, like smoking and drinking. It also included a secondary checklist called a review of systems and then, ultimately, a physical examination to narrow the "differentials" or possible diagnoses.
Already you can see that this takes some time and attention and is better served by a methodical thought process, not the hurried and time-pressured questionnaire we often experience today.
Unlike today, Dr. Spencer and his peers were predominantly generalists. Think family doctors and primary-care "specialists." They were the gatekeepers, the quarterbacks of our care, keeping an overarching eye on all of our medications and surgeries so that no negative interactions could occur. Medical specialists and subspecialists were in the minority. By the time I was starting medical school, an explosion in technological tools such as computerized tomography (CT scans), magnetic resonance imaging (MRI), and more had given doctors the ability to "look" rather than "ask." A natural but unfortunate development was a trend toward less attention to interaction with the patient and more "processing" of the data. On top of that, the new "business" element of health care put increased value on physician speed and expedited turnover. As a result the valuable time and interaction between caregiver and patient was even further reduced.
(Continues...)
Excerpted from Prepare to Defend Yourself ... How to Navigate the Healthcare System & Escape with Your Life by Matthew Minson. Copyright © 2014 Matthew Minson. Excerpted by permission of Texas A&M University Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
