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Thursday, July 25, 2013

Culture, power and personal responsibility for health

Our culture, at least the movie-going part of it, seems to have embraced the adage: With great power comes great responsibility. Somehow, at the same time, it seems to have ignored the inevitable, underlying principle: Power and responsibility are conjoined. This, in turn, implies a corollary our culture also neglects routinely, if not universally: Before anyone can reasonably be expected to take responsibility, they must be suitably empowered.

After all, if great power brings great responsibility, then presumably modest power brings more modest responsibility. And, by extension, utter lack of power would bring, you guessed it, something very much like utter lack of responsibility.

There is something almost viscerally objectionable about the renunciation of responsibility. We just don't like it! But before you let your viscera coopt your view of this matter, let's consider how consistently we already do accept the notion that in the absence of power, there is no responsibility.

Newborns aren't responsible for anything, not even personal hygiene, because they have no power, no control, and none of the relevant skills. Newborn babies can't take care of themselves, and aren't expected to do so. As children grow, they are expected to take on responsibilities little by little, as they acquire the skills to do so. Let's be clear about the sequence: Power comes first, responsibility after. Only after potty-training do we expect our kids to take on responsibility for this most basic need, and even then, we anticipate accidents early on. There is the basic power associated with any given ability, but then only practice makes perfect.

We can't, and don't, ask someone to be responsible for acting on some set of instructions they don't have the literacy to read. We don't ask 3-year-olds to follow written guidelines. We don't ask the average literate American to take responsibility for instructions written in Armenian. In the absence of power, responsibility is a non-starter.

We can't, and don't, expect someone to ride a bike they haven't been taught to ride. And we can't, and don't, expect someone who knows how to ride a bike to ride a bike, unless they have a bike! There are many ways to be disempowered. Among them are a lack of aptitude, and a lack of relevant resources.

There is, as I have noted before in a series to which I return now after a pause of several months, a prevailing tendency in our society to associate obesity and the illnesses attached to it to some deficit of personal responsibility. This could be true, but only if the requisite empowerment prevailed, and were being squandered. If the actual problem is a lack of power, then invoking a lack of responsibility implicates the wrong suspect altogether. This matters, because one is unlikely to fix what is broken while focusing on what isn't.

There is, to my knowledge, no scientific evidence that the current cohort of Homo sapiens is less endowed with personal responsibility than all prior cohorts. I've looked. If the evidence is out there, I can't find it.

Perhaps, nonetheless, your convictions cause you to believe that we are now less personally responsible than our forebears, even in the absence of evidence. Perhaps you feel compelled to believe that obesity must be about personal responsibility. But obesity is now hyperendemic not only among adults, but also children under 10. Are we truly inclined to believe that the average 6-year-old today is less personally responsible than all 6-year-olds through history? If not, but today's 6-year-old is apt be fatter, then something else is going on.

I think we know what it is, and it's all about power, and culture. Culture is a powerful influence on us all. When personal responsibility involves defiance of the prevailing forces of one's culture, it becomes a very tall order indeed.

Unfortunately, that is just the order associated with personal responsibility for health. Obesity and chronic disease are not just prevalent in the modern world, they are so prevalent as to constitute the new normal. To remain free of them is to be ... abnormal. Abnormal, for good or for ill, is always hard.

In a commentary published in The Lancet in February of this year, a group of scholars made the very point that the power of culture, and profit, is all too often oriented in opposition to health rather than in support of it. We might ask people to take responsibility in spite of it all, but that's a bit like pitching someone off our boat and assigning them responsibility for keeping afloat, whether or not they've ever learned how to swim. Relevant power is prerequisite to responsibility.

If you know it's important to control your weight and attend to your health, but almost everything in your environment and your culture conspires against such efforts, how responsible are you, personally? If as a child you get brief, tepid messages about eating well in school, but are then bombarded with state-of-the-art advertisements on screen and online encouraging you to do otherwise, are you truly personally irresponsible if you go with the prevailing flow?

If there is logic and value in such musings, I believe they all distill down to this: How can the whole of our collective responsibility for health be so much less than the sum of what we expect from its parts? Do we truly expect every individual, adult and child alike, to compensate with personal responsibility for the collective abdications at the level of culture, and corporation?

In his famous song of that very name, John Mayer laments that we keep on "waitin' on the world to change." But since the world changes slowly, and health can fall apart a whole lot faster, none of us can afford just to wait. We can seek out the skills we need to become empowered, and then express our personal responsibility. We can, and for better or worse, we must.

But that's not a reason to accept the world as it is. The world can change, and since the modern world conspires against our health it should change. We can't change it alone, but we can change it together. And there is no reason to choose between defending the health of your own body, and being part of the body politic, working to make the world a healthier place for us all. Collectively, we can put health on a path of lesser resistance so no one of us needs to work quite so hard to get there from here.

Taking responsibility requires empowerment. But even when empowered, leaping tall buildings in a single bound is asking a bit much of the mortals among us. The power and responsibility for lowering that bar, reside with our culture. Power over culture, in turn, resides with us.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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