Sarah graduated college during the pandemic and landed a job with a Fortune 500 company in the IT sector, a competitive position. Like many others, she knew of the importance of landing a job, not just for a secure future with a good-paying salary, but in the United States as a way of securing access to health insurance.
This health insurance—being someone young and healthy—was something she got out of habit and best practice, following the dogma of always being risk averse. However, after the pandemic, Sarah continued to feel off with respect to her physical and mental health. The lethargy previously attributed to lockdown policies continued as lockdowns eased, and she struggled to clear the COVID cloud of cheerlessness we all appreciated during this time. Physically, her hair started thinning just in time for her to reintroduce herself to the world. She knew something was wrong.
In her annual physical checkup, she brought up these symptoms, and abnormal thyroid labs prompted her provider to start a discussion of her thyroid health. A woman deeply concerned with her ability to one day have kids, Sarah became distraught when her provider described the increased risk of miscarriage, preeclampsia, anemia, and stillbirth in those with hypothyroidism. Soon after realizing this, her provider’s words mixed together, and she left the clinic defeated.
However, she clung to hope: there was a positive. Hypothyroidism could be treated with diet changes and thyroid hormone supplementation. “Start taking levothyroxine and come back for a follow-up to monitor your levels,” her provider said in a bouncy manner. Motivated by a sense of agency, she followed her provider’s advice to a tee. She returned for her three-month follow-up, and there was a change in the opposite direction: she now had hyperthyroidism.
“All is well; many patients require meticulous alterations in dosing to find a sweet spot that fits the individual needs,” her provider reassured her. However, this was not the only change this time around. Unlike her annual physical checkup, Sarah was now charged for repeat lab tests and for a follow-up with her provider. She was confused; surely, this was a necessity, and surely, she had good health insurance that would make her pay less than 500 dollars for just a follow-up that was less than 15 minutes and one blood test.
Sarah’s optimism was defeated by the complexity of health care financing. Despite trying to disentangle such complexity by contacting her insurance company and the finance department of the clinic, she ultimately succumbed to the bill under the threat of a collections agency. While generally disheartened, Sarah tried to see the positive, “The way I see it, others less fortunate would have to decide between paying the bill or going on a vacation. I’m lucky in that sense.” However, her discomfort with the situation sprang back up as she had to see her provider once again due to out-of-normal thyroid levels, prompting another consultation where her dose was changed, a consultation that would charge her another 500 dollars.
She was appalled: “First of all, they don’t fix the problem and then charge me for it. If I don’t fix someone’s technical needs at work, I won’t get paid. And secondly, why am I paying this much for health insurance and then STILL having to pay this much for primary health care?”
In the United States, medicine and the role it should play in one’s life is a deeply polarized discussion: repeal Obamacare, Obamacare is not enough, Medicare for all, Medicare for some… The discussion has been thrown in with issues such as climate change, gun control, and immigration. Health care has become a litmus test of your political affiliation. However, a through-line Sarah and many millions of Americans share, irrespective of where they tilt on the political spectrum, is a rising distrust of the medical establishment. A lack of transparent pricing policies, rising health care costs, growing premiums and deductibles, and a rising sense of moral superiority and authority to dictate how society lives—as seen in the pandemic—have made patients deeply frustrated with our health care system, brewing deep distrust.
Plainly said, this is a big problem. Mutual trust is fundamental in a thriving physician-patient relationship, and as an incoming medical school student, such distrust, at times, feels undeserved. You feel empathy for the patient experience but inadvertently inherit a system of distrust you did not actively build. Resisting every aspect of this system is also a surefire way of the infamous “physician burnout.” So how does one with a passion to help others through medicine stay hopeful during such a time? History offers some insight.
In post-revolutionary France, medicine began to transition from the abstract knowledge of classical medicine to a more empirical art form built on the foundation of clinical observations, pathological anatomy, analysis of signs and symptoms, and technological advancement. Such a way of practicing medicine ran antithetical to the conventional approach; so much so that this time period has been long regarded by medical historians as “where medieval medicine becomes modern.” The rise in empirical medicine uncovered that classical medicine offered ineffective therapies, but empirical medicine itself offered no therapeutic options to replace the ones given traditionally. Lacking any practical solutions to the problems it objectively described, the public became disillusioned, “What is the purpose of medicine if it cannot offer healing?”
Ironically, a novel and sophisticated way of characterizing disease and health led the public to lose hope in medicine. Outside of France, especially in the U.S., society soon started to itch a skepticism of physicians due to their lack of therapies and complex, uninviting, and undemocratic knowledge, one society believed to be deliberately mystified by physician self-interest.
We, too, find ourselves in a similar situation as this 18th-century societal dilemma. Not only do we have better methods to understand disease empirically, but we also have orders of magnitude of better medical therapies to curtail disease. Yet, medical distrust festers once again, but now, it is due to a different issue: the way health care is fundamentally implemented.
Sarah, after two years of back and forth with her provider, finally stabilized her thyroid blood levels, but the damage had been done; in two years, her distrust had conceptualized and calcified. “Every time something is wrong with me, I hesitate to go see the doctor.” In her eyes, similar to the skeptic 18th-century statesmen, the whole system mystifies health in the name of self-interest, deceitfully obscuring costs and implementing undemocratic, uninviting knowledge in a way to maximize profits, not human health.
Fortunately, medicine was able to regain some of the lost trust because medicine started to provide tangible therapeutic benefits to patients. Pioneers—such as Fleming, Farber, and Salk—utilizing the empirical foundation set by those before them, started to transform the societal outlook of medicine. So why do I remain hopeful, even optimistic, about entering medicine during this time? It is precisely because of the times. Our generation is starving for sensible implementation of medicine. The onus is on us—future providers—to learn not only the biochemistry of our practice but also the societal implications of it. Ultimately, it is up to us to be our generation’s Farbers, Flemings, and Salks who provide more than therapeutic solutions but also implementation solutions, thereby restoring public trust and promoting the equitable health and well-being of those we serve.
Roshan Sapkota is a medical student.
