Medicine & Health
Different views around the world
Culture & Health
All ancient and modern cultures and societies had developed “health beliefs” to explain what causes illness, how it should be cured or treated, and who or what should be involved in the process. Although, “culture” is a term that appears frequently in the medical literature, it is typically used to denote “non-western” cultures. It is generally assumed, but not proved, that western industrialized societies, such as the USA, England, France etc., have principally the same view on diagnosis and treatment of illness, and at least similar rules for maintaining health, except maybe the “French Paradox”.
Medicine & Culture
Lynn Payer is the author of several books including her most important, Medicine & Culture. This book was first published in 1988, republished in 1995 and is still in print. Over the years we have shared copies of Medicine & Culture with many friends, family and clients. It is delightfully easy to read yet has many important things to say.
Medicine & Culture compares and contrasts the practice of medicine in the U.S.A., Britain, Germany and France. This is not a book about different health care systems, but rather a book about how doctors in the four countries diagnose and treat disease – and the evidence is that they do so very differently. To the layman at least, the differences are at worst scary and at best provide a dramatic illustration of how little medical care is really “evidence-based” and how much medical care depends upon fundamental assumptions about the body and disease which are not based on clinical research or outcomes data. What Lynn Payer made clear is that these assumptions differ dramatically from one country to another, that what is consensus-based medicine in one country would often be considered malpractice in another.
In his foreword to the 1988 edition of Medicine & Culture, Kerr White wrote that “only about 15% of all contemporary medical interventions are supported by objective clinical evidence that they do more good than harm.” In her preface to the 1995 edition, Payer wrote that this may have risen to 25%. Let’s be optimistic and hope that it is now up to 30%. Over the last two years Harris Interactive has conducted and published new surveys of physicians, large numbers of whom continue to practice medicine in ways which are neither evidence-based (where solid evidence exists) nor “consensus-based.”
Many people are surely unaware of how little diagnosis and treatment is evidence-based. They will find Medicine & Culture a true eye-opener – whether they live in the United States or anywhere else.
Therefore this article is devoted to reminding those who read Medicine & Culture of some of its contents and to encouraging those who have not read it to buy and read it.
Most of what follows are therefore quotations from Medicine & Culture, so that Lynn Payer can speak in her own words.
The big picture which emerges from Medicine & Culture is that doctors in the four countries practice medicine very differently because their national culture, history and medical training are fundamentally different.
Medicine & Culture
Varieties of Treatment in the USA, England, France & Germany
In the introduction to the 1995 edition Payer wrote:
“British, Canadian and American specialists in genitourinary oncology were asked how they personally would want to be treated if they had cancers. For locally advanced bladder cancer, 92% of American and Canadian specialists wanted radical surgery, compared to only 30% of British specialists. In the case of localized prostate cancer, 79% of the American specialists, 61% of the Canadian specialists, and only 4% of the British specialists wanted radical surgery.”
“Patients and doctors in England and America, while often taking opposite sides on the issue of whether it is better to do something or nothing, tend to see disease as something that comes from the outside. By contrast, Continental doctors and patients are more likely to emphasize weaknesses of particular organs or imbalances between various organs and/or systems.”
“French doctors will diagnose vague symptoms as spasmophilia or something to do with the liver; German doctors will explain it as due to the heart, low blood pressure, or vasovegetative dystonia; the British will see it as a mood disorder such as depression; and Americans are likely to search for a viral or allergic cause.”
“When psychiatrists from six countries tried to agree on who was dangerous, the overall level of agreement was under 50% for three-quarters of the cases considered, and the psychiatrists did not agree any more among themselves than did non-psychiatrists.”
“Not all French doctors are Cartesian, not all German doctors authoritarian romantics, not all English doctors kindly but paternalistic, not all American doctors aggressive. As with most caricatures, these pictures may be distorted, but they are based on truths found in the overall practices of each country.”
No doubt some of the many examples given by Lynn Payer are now out of date, but many differences surely remain. We are deeply indebted to Payer for making us aware of the different medical cultures, and we deeply regret that she will not be around to keep us informed.