The Patient Was…

Among the many descriptors and distinctions defining and explaining health care, perhaps none are more important and contrasting than the concepts of public health and personal health care.

In the simplest terms, public health is concerned with populations or groups of people, while personal health care concerns individual patients. It seems that there should be considerable common ground between the two but, in reality, they stand in great distinction from one another.

It is the responsibility of a practicing doctor, one who treats patients, to focus on and advocate solely for those individual patients. The physician should not compromise medical decisions because of concerns over their societal impact. The welfare of the patient before them should be their sole motivation.

The person involved with public health, on the other hand, must think in terms of the greater good of a group or population. Compromises can be made that benefit some at the expense of others. Trade-offs are necessary and permissible that reward one segment of society and deprive another.

An individual physician may be engaged in both personal medical care and public health, but that individual must separate the two activities. One may be an advocate for public health measures and policies and be a treating physician, but not at the same time, not with a specific individual patient before them.

The Hippocratic Oath, originally written in Greek and attributed (perhaps incorrectly) to the Greek physician Hippocrates, is essentially an oath of ethics; notably, it outlines ethical duties to individuals, not to society. And more modern versions, developed by medical societies and institutions, still focus on duties and responsibilities to individual patients.

To understand how public and private or personal focuses can come into conflict, let us consider a few examples.

Imagine you are in your doctor’s office. You have a fever, you’ve been coughing for a few days, you have no appetite, and you just feel “lousy.” (Hey, we’ve all been there.) You’ve been resting at home, taking aspirin and trying to drink more fluids, but you’re not getting better; in fact, maybe you’re getting a little worse. Your doctor examines you, finds nothing specific but some coarse breath sounds in your lungs. The doctor thinks you probably have a virus infection of some sort.

Now, there is no specific treatment for a viral infection, but there are two other considerations: first, the doctor can’t rule out the possibility of a bacterial component to your illness; second, in your weakened condition, you might get a “secondary” bacterial infection on top of your current supposed viral illness. So, the doctor suggests you take a “broad-spectrum” antibiotic, one that is effective against a wide range of bacteria.

From a personal point of view, the decision seems sensible. If your illness is only viral, the antibiotic will neither help nor hurt. But if there is some bacterial infection present, or the possibility of developing one in your weakened state, the antibiotic is a good choice.

But from a societal viewpoint, your doctor is prescribing an unnecessary medication, an antibiotic where there is no clear-cut evidence of a need for one. And indiscriminate prescribing of antibiotics contributes to bacterial resistance to the drugs, which is a true societal issue. (The development of new and effective antibiotics to overcome the problem of bacterial resistance is a real pharmaceutical challenge.)

Should your doctor withhold your prescription for an antibiotic which is in your best interests, for the sake of a societal benefit? Your practicing physician prescribes the drug; a public health official would likely counsel otherwise.

Another example of the potential conflict between personal and public health interests, one where life and death concerns come up against financial resource constraints, deals with screening of young athletes for hidden health risks. We all have heard of terrible instances where apparently healthy young athletes, in high school or college, suddenly collapse and die on the playing field. Some of these young people have heart conditions, usually congenital, that predispose them to sudden cardiac death during physical exertion. At least two of the more common conditions responsible for these tragedies are often detectable with simple, painless, noninvasive testing.

Why aren’t all young athletes then screened for these conditions. Usually, it’s because the resources, generally financial, aren’t available because they are allocated to other things. One analysis by a university concluded that just to screen the members of their football team for heart conditions of consequence to the players’ health would require more funds than the entire university athletic budget.

In public health, where effects on groups of people are the focus, trade-offs are always necessary. Funds allocated to one area mean that another area is denied. In private medical care, there is no denial or deferral of action based on the needs of someone else. In public health, there is essentially competition for resources. In private care, there should not be.

At one time in my career, I was entrepreneurially involved in a new technology to detect coronary heart disease. The testing was done with the patient at rest and required nothing but special EKG (electrocardiogram) recordings of the heart’s electrical activity. Completely safe, completely painless, the test was as accurate as stress-testing, then a gold standard, in detecting sub-clinical or latent coronary heart disease.

One of the potential markets we envisioned was corporate medicine, that is, large companies that self-insured their employees and had a vested interest in keeping them healthy and working. Wouldn’t it be beneficial to detect early heart disease and address it proactively, rather than wait until active disease struck, employees were unable to work for long periods, and care became extremely expensive?

We secured a meeting with the Medical Director of one of the major corporations in the United States that self-insured all of its employees. He was extremely interested in the technology and recognized the benefits to both individuals and the corporation. But he said, regretfully, that he couldn’t move forward with it. When questioned, he explained that he had a limited budget for corporate medical expenses and he had just been “forced by worker activism” to cover annual mammograms for female employees. He acknowledged that was a good thing, but actually expressed concern that male employees would soon demand coverage of tests for prostate cancer; and he didn’t know how he would accommodate that within his budgetary constraints.

Another form of “corporate medicine” plays a relatively large role in personal medical care. It is the insistence of insurance companies that they must authorize certain diagnostic procedures and treatments before they are offered to patients. The treating physician may prescribe, but the insurer will not pay for the patient to receive what the doctor ordered. This process, called “prior authorization” is a major source of tension and contention within the current healthcare system.

In earlier times, the personal versus public health quandary was much less evident. There were fewer medical tests and diagnostic procedures available. Treatments and therapies were also fewer, less sophisticated, and less complex. And everything, of course, was less expensive.

Rarely was there a question of denial or limitation of personal care because of broader, societal concerns. The impact of personal health decisions on public health resources was not a major issue. Conversely, the requirements of public health policies had little impact on personal health decisions made by physicians and their patients.

Health care expenses can be calculated in different ways: percentage of GDP (Gross Domestic Product); federal government spending; per capita costs; etc. A few relevant 2024 figures include: 18.0% of GDP; $1.9 trillion of federal spending or 27% of federal outlays; $15,474 per person.

The figures are dramatic, and they continue to grow. Many people say they are unsustainable. As of now, no universally acceptable solution has been proposed. And I have no answer to the problem.

But I know that when I am engaged with an individual patient, my sole concern is with his or her welfare. I don’t think about the societal impact of what I propose as diagnostic and therapeutic procedures. I don’t entertain considerations of alternate resource allocation. I offer what I believe is best for that patient in their current state.

I hope your physician does the same for you.