It's All in Her Head

PC, M.D.: How Political Correctness Is Corrupting Medicine, by Sally Satel, M.D. Basic Books, 256 pages, $27.00.

Are you concerned about the fact that 44 million Americans lack health
insurance and that millions of senior citizens are struggling to pay for medicine
prescribed by their doctors? Are you troubled by the denial of necessary care by
HMOs--or by other well-publicized abuses of "managed care?" Do hospital closings
in your community make you worry about how long it will take to reach an
emergency room if you ever have chest pains or an accident? Do you wonder what
kind of treatment you'll receive in the hospital or a nursing home amidst a
serious national nursing shortage?

Well, Sally Satel--a psychiatrist and fellow of the American Enterprise
Institute--has news for you: While these issues are "pressing," you're fretting
about the wrong things. What's really hazardous to our health in America is a
plague of "indoctrinologists." These are people who have "swooped in under the
radar" to unleash an epidemic of political correctness in the nation's hospitals,
clinics, nursing schools, doctor's offices, and public-health programs.

"Indoctrinologists" are not some new type of medical specialist. You can be one
with or without a medical degree. Among them are the psychotherapists who urge
patients to uncover repressed memories of childhood abuse and "multicultural
counselors" who "presume that nonwhite patients' personal difficulties largely
stem from their efforts to adjust to a racist society."

Also threatening us are public-health professors who, "in the course of expanding
the purview of public health to encompass the quest for social justice ... are
warping the indispensable mission of their profession: the practical,
here-and-now prevention of injury and disease." They are joined by those in the
mental health field who "revile medication and fight against public policies that
make sure psychotic patients take antipsychotic drugs" and by people who campaign
for the "freedom" of drug-addicted women to "use cocaine during pregnancy."

And let's not forget women's-health and minority activists--"especially black
Americans"--who, according to Satel, undermine the authority of physicians by
making unsubstantiated claims that racism and sexism affect how doctors treat
nonwhite and female patients. Or last but not least, the growing cabal of
feminist nurses who are fueled by "a fiery resentment of the medical
establishment, the so-called male medical elite" and whose "antipathy represents
a thoroughly postmodern rejection of the prevailing medical culture wherein
doctors direct the patient's treatment and nurses carry out many of those
directives."

If any of these health-care-system bogeymen (or bogeywomen) seem
unfamiliar--particularly in light of the real problems sick people face every
day--Satel's conservative muckraking technique is tediously familiar. Satel uses
the method perfected by Dartmouth grad Dinesh D'Souza, the scourge of political
correctness in higher education: Set up a straw man and knock it down. PC,
M.D.
thus greatly inflates the influence or role of fairly marginal players
and ideas within the health care system; it glosses over the factual record
(usually through a highly selective use of studies and sources); it minimizes the
impact that social and economic inequality has on health care; and it ignores the
power imbalance in doctor-patient and doctor-nurse relationships, a dynamic that
can indeed have an adverse impact on the quality of patient care.

The result is a book that is more of an exercise in witch-hunting than
whistle-blowing. Its description of alleged trends in public health and nursing
is typical of the author's approach. According to Satel, a group of left-wing
"social productionists" have attained enormous influence within the public-health
field. As she defines them, social productionists believe that "social
disenfranchisement can lead to infirmity and shorter life expectancy" through
"the stress of oppression ... and material disadvantage and inferior access to
health care."

In a brief nod to those who might accuse her of willfully ignoring widespread
social problems, the author does allow that "on average, people who are further
down on the socioeconomic ladder are less healthy and do not live as long as
those above them." But social productionists go too far because they refuse to
acknowledge the role of personal responsibility in maintaining health. They try
to advance their public-health agenda not by generating dry statistical reports
that gather dust on library shelves but rather through promoting critical public
debate. According to Satel, "documenting" the effects of social conditions on
health and "calling them to the attention of civic leaders is one thing."
Public-health "indoctrinologists" have a broader mission--"opposing the free
market system, supporting affirmative action and derailing welfare reform." By
pursuing these and other causes, they have, according to the author, actually
diverted resources from useful public-health endeavors like "discrete vaccination
programs and cancer screening campaigns."

While it is true that liberals and leftists are more active in public health than
in most other medical and nursing fields, the idea that there has been some sort
of Marxian takeover of public-health programs would come as a surprise to most of
the professionals under attack in PC, M.D. When I informed one
public-health professor that "social productionism" was, according to Satel, now
triumphant in the nation's public-health schools, he responded: "I had no idea.
What a relief!"

Left-of-center members of the American Public Health Association--or anyone who's
ever attended an APHA national conference--would similarly have trouble
recognizing the group in Satel's description of its activities. At the APHA's
annual gatherings, for every panel on social-justice topics, there are literally
hundreds more devoted to traditional professional concerns like epidemiology,
dental health, and maternal and child care. The same priorities are reflected in
state public-health budgets, which are not, in fact, skewed toward much-needed
campaigns to address poverty and inequality but instead support the very
nuts-and-bolts programs--dealing with substance abuse, smoking, communicable
diseases, AIDS, and so forth--that Satel supposedly favors.

If the growth and effectiveness of these programs has been hampered, it has not
been the result of left-wing faddism but rather because opponents of "big
government" have succeeded in cutting public-health funding, both in the United
States and abroad. As Laurie Garrett documents in her excellent new book
Betrayal of Trust: The Collapse of Global Public Health, the real scandal
in the field is the drastic curtailment of the public sector's role in disease
prevention, a shift that is exposing millions of people to the risk of
frightening new diseases and a recurrence of some previously contained old ones.

As someone who has spent much of the last decade writing about the nursing
profession, I was astounded by Satel's account of recent developments in the
field. Displaying little understanding of the profession's history or politics,
she depicts R.N.'s as succumbing to the siren call of women's studies programs
and the nostrums of radical feminism--despite the fact that nursing has long had
a tense and conflicted relationship with the women's movement.

In the chapter "Nursing Grudges," Satel's straw women are women's studies
programs and something called "therapeutic touch"--a healing therapy that uses
supposed exchanges of energy between patient and therapist to promote physical
healing. Satel insists that this is part of some dangerous feminist current
within nursing--one that has become so strong that it has already washed over the
profession in Great Britain.

"Thirty years ago British nurses were expected to observe rules of silence,
ritual and courtesy," Satel writes. "They were barred from getting married while
in training, personal jewelry was banned and hair could not be longer than
shoulder-length." As nurses struggled to overturn these strictures, they have,
Satel argues, abandoned the basics of bedside care. "By 1995," she claims, "all
the traditional nursing schools had closed. Nursing training was expanded to
include sociology, politics and race and gender awareness. Patient care
suffered."

Her first mistake is to attribute the growth of therapeutic touch to feminism.
Whatever one might think of this therapy's validity, it does not spring from
nursing's "grudges" against medicine but from some nurses' long-standing
interest in alternative therapies. While it is taught at a few nursing schools
and does have its devotees, it is by no means a staple of nursing education.
Even if it were, Satel wouldn't have much to worry about in most hospitals today,
since their main problem isn't too many nurses busily applying therapeutic touch
but the absence of enough nurses to provide basic traditional care.

Satel makes similarly overblown claims about the influence of women's studies on
nursing education and what she insists are resulting antidoctor campaigns within
the profession. Though understanding gender is crucial to a mainly female
profession, there hasn't been enough contact between women's studies and nursing
on university campuses. Moreover, Satel is utterly blind to the kind of
dysfunctional nurse-doctor relationships that prevail in most health care
institutions--relationships engendered by doctors' beliefs that nurses are their
handmaidens (or, as Satel puts it, mere extensions of the "doctor's directive").
If more nurses openly protested this definition of their profession, patients
would be better off.

Just as it wasn't feminists who closed hospital-run nursing schools in Britain
and the United States (the shutdowns occurred largely because hospitals and
insurers no longer wanted to bear the costs of nursing education), it is not
feminist nurses who are depriving patients of good nursing today: The problem is
created by hospital administrators--who continue to view nurses as a cheap,
disposable labor force--and by business and political leaders, who have failed to
provide adequate funding to support nursing research and university education as
the standard entry into practice for all registered nurses

And on it goes. Satel concedes that some doctors have mistreated mental
patients, women, and African Americans. But all that happened back in the Dark
Ages. Today's M.D.'s apparently are free of any taint of racism and sexism and
are unaffected by the corporatization of medicine. Driven by antifeminist zeal,
Satel assails women's-health advocates who have exposed the problem of
unnecessary hysterectomies. Confusing medically appropriate hysterectomies with
those performed for no compelling medical reason, she seems to suggest that even
the latter are good for women because they enhance sexual function and decrease
urinary incontinence.

Relying on only those studies that support her point, she insists that if
black Americans get fewer heart surgeries and angioplasties it's not because of
prejudice or poverty but because blacks have more serious physical problems that
increase the risk of such procedures. The idea that these risk factors might stem
from historical inequities does not seem to occur to her. And when Satel contends
that affirmative action programs designed to attract black candidates to medical
schools are unnecessary because many of the nation's hospitals serve minority
communities, she again ignores evidence to the contrary: An ongoing study being
conducted by Alan Sager of the Boston University School of Public Health that has
been tracking 1,200 hospitals in 52 U.S. cities since the mid-1930s has
documented that the race of neighborhood residents near a hospital is one of the
two or three strongest long-term predictors of whether the hospital will close.

Scattered throughout PC, M.D. are some good--albeit fairly obvious--points.
Some of the heroic medical procedures that advocates for women and minorities
seek may do more harm than good, and some of the therapies she targets are
indeed flaky. In criticizing feminist demands for more female role models at top
levels in health care, she points out that this absence has clearly not
discouraged women from entering the profession (although it may have discouraged
them from challenging the kind of hierarchical attitudes toward patients,
nurses, and other health care workers that Satel has so thoroughly absorbed). If
she had devoted more energy to a nuanced exploration of conflicts in contemporary
health care, she would have produced a more useful work--one like Anne Fadiman's
book The Spirit Catches You and You Fall Down, which she so admires; or
Of Two Minds: The Growing Disorder in American Psychiatry, by T.M.
Lurhmann.

But Satel's goal does not seem to be open inquiry and critical debate. Rather,
she stands rigidly opposed to creative or innovative ideas that might be
percolating on the margins of health care if such initiatives in any way
challenge physician hegemony and free market ideology. Consider, for example, her
thin-skinned response to a recent critical review in the New England Journal
of Medicine
(NEJM). As reported in The Boston Globe, Satel
initially chose not to write a letter to the editor defending her position--the
usual resort of authors whose books have been critiqued. Instead she had her
lawyer send the NEJM a "demand letter," often the prelude to a libel suit,
insisting on a formal apology and published correction. Talk about political
correctness.

Not to range too far afield, but as I was reading Satel's book, news reports were
coming in from Afghanistan about the Taliban's destruction of ancient religious
icons. You might think that leaders in such a place as Afghanistan would be
grappling with societal crises like the widespread hunger, unemployment, and
homelessness that afflict millions of their countrymen. Instead, they're busy
blowing up statutes of Buddha that few people paid attention to anyway. Satel
also has an odd choice of targets. Her Rx for our troubled health care system is
a purge of therapeutic-touch courses, the muzzling of "feminist and multicultural
practitioners," the elimination of funds for health care "survivor groups," and
so on. Even if one agreed that political correctness was a problem in American
medicine, after its few small monuments were reduced to rubble, would the rest of
us be any better off?

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