the-lancet---culture-and-health.pdf

40 different theories about illness become more

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40 Different theories about illness become more familiar as their merits are investigated. This fact explains why many medical anthropologists are clinically trained and why many clinicians take up medical anthropology. When illness is at stake, the appreciation of these factors by caregivers and their ability to communicate with those they care for becomes important. These are not the only reasons why clinical competence should include cultural competence. By the 1970s, the value of clinical communication and, particularly, caregivers’ understanding of patients’ individual back- grounds, were not only understood, but also quantified. In 1975, the importance of communication for clinical competence was shown by the results of a study 41 that compared effectiveness of face-to-face interviews with both physical examinations and laboratory tests for achievement of clinical accuracy. In 66 of 80 patients (83%) “the medical history provided enough information to make an initial diagnosis of a specific disease entity which agreed with the one finally accepted”. If 83% of all correct diagnoses can be made by taking of a complete medical history from the patient, why are clinicians so often held to brief and often routine clinical encounters? 42 And why has this fact not been taken into account during assessment of the costs and health benefits of what happens in the clinic? Some say testing has increased for entirely non-clinical, but quite cultural, reasons. Scientific American com- mentator John Horgan puts it bluntly: “Over-testing undoubtedly stems in part from greed. Most American physicians are paid for the quantity of their care, a model called ‘fee for service.’ Doctors have an economic incentive to prescribe tests and treatments even when they may not be needed. Physicians also over- prescribe tests and treatments to protect themselves from malpractice suits.” 43 According to Ezekiel Emanuel, the yearly cost of health-care provision in the USA was almost US$8000 per person. 44 Emanuel invites us to compare this
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The Lancet Commissions www.thelancet.com Vol 384 November 1, 2014 1613 expense with the entire GDP of China, the world’s second-largest economy: “China’s G.D.P. is $5·9 trillion (compared to America’s $14·6 trillion). So the United States, with a population a quarter of the size of China’s, spends just on health care slightly less than half of what China spends on everything…If we continue at this rate of growth, health care will be roughly one-third of the entire economy by 2035—one of every three dollars will go to health care—and nearly half by 2080.” 43,44 But if laboratory investigations are not cost eff ective, why are they used instead of reallocating resources so that clinicians can spend more time with patients? Is it because health care has become an increasingly predatory business endeavour? Is it because biomedical cultures have become overly devoted to testing practices? In what way, for example, might health-care cultures in the USA be called caring
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