Vitalism Signs

By Rebecca Koch
At my first visit with her for my initial “physical,” my newest insurance-mandated physician gave me the most superficial and peremptory exam I could have imagined. I’m sure she was shocked when the lab results didn’t reveal any conditions to treat. What a disappointment I must have been! (After all, at 5’7”, I’m quite short for my weight; I should at least have had high blood pressure or pre-diabetes.) However, I did get an order shortly thereafter for a mammogram.

Mind you, my young doc and I had no conversation about this at all—just the order in the mail.

I’m not convinced that mammograms do what they claim. I’ve had them in the past and they’ve seemed to result more in unnecessary anxiety and potential for over-diagnosis than anything else. On a larger epidemiological level, it doesn’t appear that the mammogram experiment has been successful. If mammograms do result in early detection and saved lives, it stands to reason we’d have seen a certain pattern emerge: An initial increase in the detection of early breast cancers followed by a decrease in the number of late stage breast cancers following their widespread introduction. That hasn’t happened. For this and other reasons, I didn’t follow my MD’s orders to have a mammogram.

I also recently received a call from the MD’s office to say my insurance company had ordered a bone density test. Oh, great! Now my insurance company is ordering me around (the insurance company that is part of an industry that claims to only cover healthcare, not dictate it). Apparently, 1984 also called and wants its allegory back.

Needless to say, I didn’t have the bone density test, either. And, as you might imagine, the conversation that ensued at my most recent “physical” took on a different character than my physician, in all probability, is used to experiencing. More of what follows is truer than you’d likely believe.

MD: I see that you didn’t have the mammogram.
Me: No, I know they’re the best tool we have, but I’ve concluded they aren’t that effective.
MD: Do you do self exams?
Me: Occasionally, even though they’re no longer being recommended as effective. I do enjoy the occasional effort at detection through the Man-O-Gram, though. My husband takes care of those.
MD: Stony silence
Me: Sorry.
MD: Have you scheduled your bone density test?
Me: Well, no…I wanted to ask you about that first. What would be the outcome if the test showed that I had low bone density?
MD: We have several medications for that. We’d get you on one of them.
Me: OK. That’s what I thought and, since I wouldn’t take any of the medications for that, I don’t see any reason to have the test.
MD: (In her first use of scare tactics.) So, you’d rather go around breaking bones?
Me: You mean, more than if I get on the medication now and take it for the rest of my life? Which I hope is more than the five years it takes for those drugs to make my bones so brittle, my femurs break if I decide to jump rope with my grandkids—like that lady that made the news. No, I’ll take my chances with osteoporosis.
MD: Then why are we doing a physical?
Me: Well, I’m not sure. I was counting on you to know. We don’t have to. It’s certainly OK with me if we don’t. Should I get dressed?
MD: There’s no reason to do a physical if you’re not going to do the tests.
Me: I’m sorry, I don’t understand. Is a bone density test part of the physical?
MD: No, I have to order that; I can’t do those here.
Me: OK, then. I’m sorry, I still don’t understand. Let me try again. How does my decision not to have tests that aren’t part of the physical affect what you do during the physical?

You may be wondering what this rant has to do with Vitalism. Well, not much, really. My experience during this physical was pretty mechanistic. I was reduced to a collection of parts and lab results. It’s clear that honing the ability to make observations about patients is no longer a valued part of the physical exam. My MD didn’t attempt to know anything at all about me and made no meaningful observations about my demeanor or carriage. She didn’t attempt to gain any information using her inherent or acquired skills. She didn’t make keen use of her powers of observation or empathy or use any method other than instrumentation and testing. Even though she was operating mechanistically, she didn’t employ any mechanism that would allow her to know me in order to help determine the state of my health (or sickness). We did seem to see eye to eye on how frustrating we each found the experience, however, and applying my own keen insightfulness, my guess is I’ll be looking for yet another new doctor this year. Wish me luck.