Book Review
Detached
Our reluctance to connect with each other affects the health and well-being of individuals and society.
By Carl Patow, M.D.
“Hoping to improve its image and boost sagging membership, the American Medical Association is launching a $60 million marketing campaign that includes heartstring-tugging ads that portray doctors as ’everyday heroes.’ … Convincing doctors that the AMA matters is also part of the campaign.”
—Las Vegas Sun, June 16, 2005
The Sun article goes on to report that in 2005 the American Medical Association (AMA) lost members for a fifth straight year and that only a fourth of the nation’s physicians belong to the association, which once represented two-thirds of doctors. The AMA is not the only established organization that’s losing members. Many historically strong civic, fraternal, and professional organizations have seen their numbers decline with every passing decade since their heyday in the 1950s and ’60s. Organizations such as 4-H, and the American Legion, National Grange, Jaycees, Kiwanis, Lions, NAACP, Masons, PTA, American Red Cross, and American Dental Association have all experienced membership losses. Given the pattern of decline, I am certain that author Robert Putnam would argue that it will take a lot more than television commercials to increase membership in the AMA.
In his book Bowling Alone, Putnam documents disturbing trends in declining civic engagement and community cohesion that are deeply affecting municipalities, organizations, and individuals. In fact, he argues, their decline is at the root of many intractable problems affecting society stemming from a lack of social consciousness, honesty, and mutual trust. Putnam says that involvement in groups builds what is called “social capital,” “connections among individuals—social networks and the norms of reciprocity and trustworthiness that arise from them.” The idea is that the work of individuals is more effective when it is embedded in a network of social relations. “A society of many virtuous but isolated individuals is not necessarily rich in social capital,” he observes.
Putnam describes how indicators of civic vitality have steadily eroded, for example, participation in political campaigns, church attendance, union membership, having friends over, and participation in league bowling. He points out that measures of community compassion, such as volunteerism and philanthropy, are waning. “Americans are a generous people,” he writes but then adds, “trends in American philanthropy relative to our resources are dismaying, for in the 1990s Americans donated a smaller share of our personal income than at any time since the 1940s.” He notes that although there are more volunteers today than in the past, more and more are older than 60 years of age. And the type of volunteer activity has changed. Where volunteering once meant raising a barn or refurbishing a park, participation today often means writing a check rather than actually doing the work. Thus, acts of charity are being transformed from events at which people interact with each other to individual acts separated from any social network.
The Health Connection
Putnam devotes a short chapter to the issue of health and social capital in which he concludes, “social connectedness is one of the most powerful determinants of our well-being. The more integrated we are with our community, the less likely we are to experience colds, heart attacks, strokes, cancer, depression, and premature death of all sorts.” Several theories are presented to explain why connected communities are healthier and happier. For example, tightly networked societies are more likely to provide citizens with assistance such as money, convalescent care, and transportation. Churches can provide a social safety net for parishioners, and political activism may result in better health care facilities.
On a standardized scale of social capital, Minnesota rates very high when compared with other states. Similarly, an index of state health status finds Minnesota to also be near the top. States with very little social capital have poor relative health indices. A disturbing trend is that as the degree of social capital declines over time, the proportion of Americans that state that they are in good physical condition is declining as well.
Changing Times, Changing Teams
It is interesting to speculate whether the generational change in social connectedness will be reflected in clinicians’ relationships with their patients and communities. One place where we might be seeing a sign of change is in residents’ connection to their patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted a rule limiting residents’ work to 80 hours per week. The ACGME recognized that excessive hours may lead to care that is unsafe. After institution of the rule, many physician educators have struggled with the fact that residents are required to leave the hospital at the end of their “shift,” regardless of the progress of their patients. To teaching physicians accustomed to the old system, this feels uncaring and unprofessional, as if a sense of connectedness to patients is slipping away. In fact, patients may be receiving safer, better care. But the definition of professionalism is shifting as new generations practice medicine within a different set of social values.
Thinking about Putnam’s premise, it is also interesting to speculate how declining social connectivity will affect teamwork. Hospitals and clinics are reorganizing staff into functional teams in order to improve service to patients and decrease costs. If social cohesiveness is a value that is disappearing from our culture, will the concept of teamwork be viable over time? Will younger clinicians feel that team interactions are important enough to invest the energy needed to develop relationships with team members? Perhaps the nature of teams will change. Young adults now play video games online as groups, if not teams. The social interaction is virtual, but it is still a form of interaction. How the definition of teamwork evolves will likely depend on the next generation’s commitment to developing social connectedness.
It is very tempting to look at the career choices of graduating medical students through the author’s “social capital” lens. The most difficult residency to fill is family medicine, a specialty that requires physicians to have close connection with a community. The most sought-after residency programs are radiology, anesthesia, emergency medicine, and pathology. It may be coincidental, but these four specialties encapsulate patient care into clearly defined hours and require relatively limited physician-patient interaction. It has been said that graduating medical students choose these specialties because they fit new lifestyle preferences or because they are financially more rewarding. This may be true, and the trends may be the result of natural cycles in career planning. But given Putnam’s thoughtful revelations, these choices might be viewed in a very different light, as a reflection of our society growing more socially disengaged generation after generation. MM
Carl Patow is executive director of Health-Partners’ Institute for Medical Education.