Independence

Americans prize their independence.  Hollywood earns billions portraying characters that express their independence in an aggressive fashion.  Many Americans loath dependence and equate it with weakness.  Is dependence really equatable with weakness?

The author’s experience with nursing home and hospital patients over the last twenty years may shed some light.  The severely medically ill typically dread becoming a burden on their loved ones.  It is rare to find older adults who readily agree to live with their children.  Rarely does the avoidance stem from ill feelings, as from the aforementioned dread of becoming a burden.  The ailing older American is typically more resistive of living with their children than the children themselves.

Other cultures have less difficulty with dependence.  These patients typically experience less adjustment problems with illness and nursing home placement.  Forced dependence from medical illness is viewed as an unavoidable part of life, rather than stemming from a personal inadequacy.  Just as they may have taken care of ailing friends and relations, there is an expectation that it is a societal necessity to receive care in turn.  In such cultures, the resistance to unavoidable dependence would be taken as askew, and possibly indicative of mental illness.

These notions regarding dependence are focused on physical rather than mental illness.  Quite often long-term mental illness has a significant impact on parenting style and resources.  This impact may be resented by the children as they age; especially as they compare notes with peers whose parents did not suffer with mental illness.  Children of recurrent depressive and bipolar patients are often the least motivated to care for an incapacitated parent.  The very real physical responsibilities of providing care is even more difficult when the parent is uncooperative and apparently unappreciative.  It is nearly impossible for children to fathom the role of mental illness in parenting, as it requires a prospective obtained outside the confines of the family unit.
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In regards to mental illness, there was a disorder termed Dependent Personality Disorder.  This so-called disorder is no longer a part of the diagnostic nomenclature, but its very existence is significant.  Dependent Personality Disorder was confined to the American diagnostic manual of mental disorders, and has never been a part of the international classification of mental illness.  Too much dependence was viewed as a mental illness, and psychologists and psychiatrists were given the task of drawing the line.  Dependence was not only considered a weakness, but possibly a disease that required treatment.

Anthropologists and evolutionary psychologists now consider the the role of grandparents as an advantage unique to our species.  Grandparents living within the family unit were able to confer knowledge and skills to the children that the parents were too busy to provide.  This advantage may be the reason other forms of humanoids became extinct.  Prior to World War II, it was the norm for couples to live with their parents for many years.  Married couples initially depended upon their parents, and in turn, the parents came to depend upon their children.  It may be merely an artifact of simple economics, but the children and grandparents may have benefited in ways that were not reducible to mere income potential.

Dependence is a problem if either party perceives it as a problem.  Dependence is highly influenced by cultural norms.  Dependence stemming from mental illness is often less well received than physical incapacity.  Dependence may be an evolutionary adaptation that secured our species spot at the top of the food chain.  We depend upon others for their knowledge and experience, as well as physical support.  Others depend upon us for the very same reasons.  Perhaps dependence is often perceived as a weakness by those who are afraid of the responsibility.  The responsibility is to not hate those on whom we depend.  It’s very American.

Hospitalist Versus Primary Care-What Really Makes Us Well

A recent article in the Annals of Internal Medicine was very interesting.  It is research to determine the cost effectiveness of hospitalists versus primary care physicians.  A hospitalist is a physician that specializes exclusively in hospital care, and the primary care physician is the family doctor that is familiar to most people.  Family physicians may receive additional training to become a hospitalist, but most hospitalists are boarded in internal medicine-sometimes in combination with other specialties.  Historically, a primary care physician was allowed to visit and consult on their patients in the hospital.  About a decade ago, insurance companies discouraged hospital visits from the Primary Care Physician (PCP), in preference to physicians that were specifically trained to perform inpatient care-the hospitalist.  At first blush, this change in physician practice appeared to make good sense.  It provided an economic incentive for hospitalists to limit their practice to the hospital.  At the same time, it limited the economic incentive for primary care physicians to visit their hospitalized patients.  It seemed like a good method to avoid duplicate charges and overlapping skills.  It assumes the hospitalist provides similar or better care than the PCP.  The outcome research does not appear to support this conjecture.

The research by Kuo & Goodwin (2011) compared five percent of all enrollees to Medicare from 2001 to 2006.  The positive side of  hospitalist care resulted in a shorter hospital stay (about half a day), and a total savings of fifty Medicare dollars on every hospitalization.  This is in comparison to management by the patient’s community based PCP.  Unfortunately, examination of the elderly patient’s usage of the Medicare system after discharge told a different story.  Patients cared for by hospitalists resulted in significantly greater emergency room visits after discharge, more frequent use of nursing facilities, more frequently readmissions to the hospital, and patients were less likely to be returned to their home after discharge from the hospital.  The authors concluded that the “decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.”  There are several limitations to this study; for example the patient sample was largely elderly (selection bias), the period examined after discharge from the hospital was only thirty days (decreased power to extrapolate), and the statistical methods used may not be the most appropriate.  On the other hand, no other studies of this type, let alone size and scope, have been brought to this author’s attention.

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A primary care physician’s personal relationship with the patient is an important variable that separates the hospitalist from the PCP.  If all else is held equal, including skill and experience, this factor looms as a gigantic independent variable.  The dependent variable in this study is the patient’s health status after discharge from the hospital.  The independent variable of faulty communication between PCP and hospitalist cannot be ruled out or held as trivial, yet it is certainly less pervasive than then the personal relationship enjoyed by the PCP.  Sometimes this is referred to as “nonspecific factors” that are essential to health.  It is not that clinicians are unable to be specific in talking of these issues, it refers to the scientific difficulty of objectively measuring and comparing the features of a doctor-patient relationship.  Nonspecific factors in psychotherapy (patient’s perspective) include feeling accepted, being understood, being encouraged to overcome difficulties, being respected, and having someone interested in their welfare.  This research suggests that a preexisting personal relationship with a physician leads to increased patient wellness after a hospitalization.  Many of these nonspecific factors are crucial to a positive psychotherapeutic outcome.  It is a greater conceptual stretch to suggest that a personal relationship with one’s physician is crucial to a positive medical outcome.  Perhaps it is not crucial to physical health, but this study suggests that a medical doctor’s personal relationship with the patient is very important-regardless of diagnosis.