Chapter 9: Using Health Services

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Welcome to this deep dive, everyone.

If you are listening to this right now, consider us your your personal study buddies for the day.

Yeah, exactly.

We are fully taking the Last Minute Lecture approach for today's session.

Right.

So the mission here is pretty simple.

We are going to completely master chapter nine of health psychology,

biopsychosocial interactions, which is all about using health services.

Exactly.

And we're going to create this really supportive, just one on one tutoring session for you.

We're unpacking the whole journey from the second you feel a symptom to the, you know, the final decision of whether or not you actually take the medicine your doctor tells you to take.

And to really get this, we have to reframe how we think about health psychology for a second.

Up until now, a lot of the focus is usually on primary prevention, right?

Like stopping the illness before it even happens, eating well, exercising, that kind of thing.

Exactly.

But with this chapter, we are officially shifting into secondary and tertiary prevention.

Meaning the illness is already there.

Right.

It's arrived.

So now the whole biopsychosocial concept is about treating it to stop the progression or, you know, rehabilitating you to manage a chronic condition because medical care is, well, it's not just biological.

It is this incredibly complex dance between your physical symptoms, how your brain interprets them and the actual social systems you have to navigate.

Okay.

Let's unpack this.

I want to ground this in a real example from the chapters prologue.

Think about Joe.

Oh, right, Joe.

She just moved to a new town with her kids.

Yeah.

And she has hypertension.

So biologically, she has high blood pressure.

She has an illness.

Right.

And behaviorally, she takes her prescribed medication, but she also drinks this specific herbal tea that a clerk at a health food store told her would help.

Which is such a common behavioral response, by the way.

Totally.

So she needs a new doctor in this new town and a coworker recommends a physician named Dr.

Armstrong.

And Dr.

Armstrong is essentially the gold standard here.

He takes this really beautiful patient centered approach.

He actually chats with Joe.

He builds a relationship.

And when she brings up the herbal tea, he doesn't like roll his eyes or judge her.

No, not at all.

He actively listens to her.

He discusses it.

And then he provides actual evidence -based resources.

He's treating her as a whole person.

Which, as the chapter points out, is a huge contrast to her old doctor who used to just, you know, rush in, fire off a bunch of rigid questions and rush out.

Yeah, we've all had that doctor.

Seriously.

But Joe's story is the perfect roadmap for us because before you even get to sit in the room with a great doctor like Dr.

Armstrong, you have to actually navigate the medical system itself.

And that is a massive social structure.

It is incredibly intimidating,

especially in industrialized nations.

The whole system is built around this concept of specialization.

Right.

Where you have millions of practitioners, but they're all divided into highly specific fields.

Exactly.

You've got cardiologists for the heart, neurologists for the brain.

The pro here is obvious, right?

You have a rare heart valve issue.

You absolutely want a doctor who studies nothing but heart valves.

Yeah, of course.

But the con, well, it always reminds me of like a massive group project in college.

Oh, that's a great analogy.

Right.

You have all these brilliant people doing their specific parts of the project perfectly, but nobody's actually talking to the project manager.

That's exactly what happens.

The primary care physician is supposed to be the manager, but the communication between all these specialists is often terrible.

So the care just gets totally fragmented.

It does.

It becomes highly impersonal.

And then beyond the specialists, you have to look at the setting of the care.

Historically, for anything complex, you got inpatient care.

Meaning you were admitted to a hospital or a nursing home.

Right.

But now we are seeing this massive shift toward outpatient care because inpatient care is just astronomically expensive.

Right.

So there's a financial push to keep people at home.

Huge financial push.

Yeah.

And technology makes it possible.

Now we have pacemakers that remotely send your heart data to the clinic or, you know, insulin pumps that do the work automatically.

It's amazing, but it all kind of points back to the money, right?

The financial plumbing of the American healthcare system.

Oh yeah.

You really have to follow the money to understand it.

Because the US system is basically this giant patchwork.

You have Medicare for the elderly, Medicaid for low -income folks, but most working people have private insurance.

And private insurance has two totally different models.

First, you have the traditional fee -for -service model.

Where you pick your doctor, they do a service, and the insurance pays a chunk of the bill.

Right.

But inherent flaw there is the incentive structure.

The doctor makes more money by doing more things.

Every single blood test, every scan is a fee.

Which obviously makes the overall cost of healthcare just explode.

Exactly.

So to fight those costs, the system created managed care programs.

Things like HMOs and PPOs.

Which I feel like everyone listening has had to deal with at some point.

For sure.

Managed care flips the incentive.

The premiums are lower, but they heavily restrict the cost of healthcare.

That's what you can do.

You have to stay in network.

You need a pre -approval from your primary doctor just to see a specialist.

They're actively trying to prevent unnecessary procedures to keep costs down.

Right.

But then, you look at Table 9 .1 in the text, and you compare this whole US patchwork to universal healthcare systems.

Like in Canada or the UK, where coverage is just a given for citizens.

And the data is pretty shocking.

Despite the US spending way more money per person and having amazing technology, we actually rank 37th in overall health system performance, according to the World Health Organization.

37th.

Because the system is just too complex.

When it's tied to your job and there are all these competing financial incentives,

access is just a nightmare compared to countries where it's streamlined.

It really is.

So okay, we have this massive tangled system out there, but what actually makes you, the person listening right now, decide to enter it?

Like what prompts you to make that call?

Well, it all starts in your mind.

It starts with how we perceive our own physical symptoms.

Which is such a weird concept because we think of our bodies like cars, right?

Yeah.

Like the oil is low, the dashboard light comes on, and you just read it.

Yeah.

But human perception is nothing like reading a precise gauge.

We are actually incredibly bad at it.

For example, the chapter talks about people who are internally focused.

Meaning people who just naturally pay a lot of attention to their own bodies.

Right.

When researchers test them against a physiological monitor,

those internally focused people actually overestimate their own heart rates.

Wow.

And the environment plays a huge role here too, right?

A massive role.

If you have competing environmental stimuli, say you're at a really loud, exciting concert, you probably won't notice a minor ache.

But if you're in a boring environment, like sitting in a dull lecture, you are way more likely to notice a tiny tickle in your throat.

Your brain just has nothing else to focus on, so it turns the spotlight inward.

And here's where it's really interesting.

You have to talk about the Lorber study with the inert spray, figure 9 to 1.

Oh, this study is wild.

So researchers bring college students into a lab and have them inhale this spray.

And they warn the students, hey, this spray might cause some itchy skin, maybe some drowsiness, a headache.

But the spray is totally fake.

It's just an inert substance.

Zero biological effect.

Right.

But then they test the students in pairs, and one person in the pair is actually an actor working for the researchers.

A confederate, yeah.

So the real participant inhales the fake spray.

And a few minutes later, the actor starts violently scratching their arms and yawning.

And suddenly, the real participant starts feeling incredibly itchy and sleepy.

Yes.

Their brains literally manufactured a physical reality just from a social cue.

That is exactly how the placebo effect works, right, but just in reverse.

Exactly.

The placebo effect is expecting a positive outcome, so your body creates it.

What the Lorber study shows is the nocebo effect.

The nocebo effect, meaning you manufacture negative side effects just because you expect them.

Exactly.

And this scales up to a societal level, which is what we call mass psychogenic illness.

Like when one person in a workplace thinks they smell a toxic gas and feel sick, and suddenly 50 people are throwing up even though there's no gas.

Right.

The social panic triggers the nocebo effect.

And medical students are notorious for this, actually.

Oh, medical students' disease.

Yes.

Something like two -thirds of medical students will temporarily believe they have the exact rare diseases they happen to be studying that week.

Because they're stressed, they're hyper -focused on symptoms, and suddenly a normal stomach cramp feels like a rare ulcer.

Precisely.

So perceiving a symptom is completely subjective, but the next step is interpreting it.

Right.

Figuring out what the symptom actually means.

And the text gives this incredible case study of Mr.

Glover.

Mr.

Glover is the perfect example of how psychology overrides biology.

He's a 55 -year -old guy sitting in his office, and he suddenly gets this crushing chest pain and a sharp pain down his left arm.

And he had a heart attack six months prior.

So he knows exactly what this is.

The biological signal is screaming at him.

But instead of calling an ambulance, he gets up and starts pacing.

He tells himself he just needs to, quote, work it off.

He actually takes an Alka -Seltzer, claiming it's just bad gas.

It's pure psychological denial.

The fear of having a second heart attack was so overwhelming that his brain forced him to misinterpret the symptoms.

He only survived because his boss walked in and basically forced him to the hospital.

It's terrifying, but it shows how we're all just kind of acting as amateur detectives with our bodies.

The chapter calls it our common sense models of illness, right?

And there are four specific components we use to build those models.

When you feel sick, you try to figure out four things.

OK, what's the first one?

First is identity.

What is the name of this illness and what are the exact symptoms?

Makes sense.

Like, is this a cold or the flu?

Right.

Second is causes.

How do I get this?

Is it a virus or am I just super stressed out at work?

OK.

And the third?

The timeline.

How long is this going to last?

Right.

And then the fourth has to be how bad it is.

Exactly.

Consequences.

How serious is this going to be for my life?

And if your inner detective gets any of those four things wrong, you're going to make bad health decisions.

But we don't usually do this detective work alone, do we?

We talk to our friends.

Oh, constantly.

We consult our lay referral network.

The lay referral network, which is basically just your mom or your gym buddy giving you amateur medical advice.

Right.

You show your coworker a weird mole and they tell you what they think it is.

And sometimes they give good advice, like telling you to see a doctor.

But a lot of times I imagine they just validate your denial, right?

Like, oh, yeah, that just looks like a bug bite.

Don't worry.

Exactly.

Which causes huge delays.

And this brings us to the actual demographics of who uses health services.

Right.

The social aspect.

Demographically, it forms a U -shape across age.

Usage is really high in young children.

Because of vaccines and, you know, daycare germs.

Right.

And it's really high in the elderly who are managing chronic diseases.

It dips down in young adulthood.

Also,

women use medical services significantly more than men do.

Now, obviously, pregnancy and childbirth play a role there.

But the text points out that even beyond that, women report more symptoms and use more services.

And that has to tie into social conditioning, right?

Like, men are taught to just tough it out and ignore pain, which is so dangerous.

It is deeply dangerous.

And it heavily skews the data.

There's also a massive income gap.

Lower income individuals use health services way less for preventive care, simply because they don't have the access or the money.

So they wait until it's an absolute emergency.

Exactly.

But it's not just money that keeps people away.

A lot of people actively avoid the doctor out of fear.

Specifically, fear of iatrogenic conditions.

Right.

Iatrogenic conditions.

That's when the medical treatment itself actually causes a new illness or injury.

Exactly.

Like going in for a routine surgery and catching a deadly antibiotic -resistant bacteria from the hospital bed.

That is terrifying.

It is.

And beyond just fear of medical errors, there's a very real deep mistrust of the medical system, especially in minority communities.

Which is completely understandable when you look at history.

The textbook specifically brings up the Tuskegee Syphilis Study.

Yes.

For decades,

researchers literally withheld life -saving treatment from hundreds of black men who had syphilis just so they could observe the disease ravage their bodies.

They lied and told them they were treating them for bad blood.

It's completely horrific.

It is.

And when you know that history, avoiding the medical system, isn't just paranoia, it's a completely rational, protective instinct.

Absolutely.

So to map out how all these competing factors work, the fear, the money, the symptoms, psychologists use the health belief model.

Right.

It's essentially a scale in your mind.

On one side, you weigh the perceived threat.

Am I susceptible to this?

And is it serious?

And on the other side?

You weigh the benefits of getting treated against the barriers.

Okay.

So if the barrier, like a hundred dollar copay or having to take an unpaid day off work is heavier than the perceived threat of a weird cough, you don't go, you delay.

Exactly.

And that delay is broken down by safer and colleagues in their treatment delay model.

Figure nine to three, it happens in three distinct stages.

Okay.

I actually love using a car maintenance analogy for this.

Walk me through the stages.

Okay.

Stage one is appraisal delay.

This is the time it takes you to actually interpret your physical symptom as an illness.

Right.

So in car terms, that's like driving down the highway, hearing a weird rattling sound in your engine and taking three weeks to finally admit, okay, that's not just the wind.

My car is broken.

Perfect.

Though to be fair, if you are in severe physical pain, that appraisal delay shrinks down to zero pretty fast.

Makes sense.

Okay.

What's stage two?

Illness delay.

This is the time between realizing you're sick and actually deciding to seek professional help.

So, okay, my car is definitely broken, but do I really need a mechanic or can I just sort of ignore it for another month?

Exactly.

Then finally, stage three is utilization delay.

You've decided you need a doctor, but you still wait to actually pick up the phone and go in.

I know I need a mechanic, but it's raining today and I don't want to deal with the hassle of dropping the car off right now.

Yes.

And non -medical events cause huge utilization delays.

This is perfectly illustrated by that famous 2004 Boston Red Sox study.

I was hoping we'd get to this.

This is wild.

It really is.

So game seven of the American League Red Sox versus Yankees, a massive historic baseball game.

And during that specific game, emergency room visits across Boston dropped by 15%.

Which is crazy because biological emergencies didn't stop.

Appendicitis didn't pause for the ninth inning.

People were literally sitting on their couches suppressing severe acute medical symptoms just because they didn't want to miss the game.

Their utilization delay spiked simply because of a baseball game.

Wow.

But sometimes delay isn't just about waiting.

Sometimes it's about going somewhere else entirely, which brings us to CAMLIME, complementary and alternative medicine.

Right.

And the phrasing here matters.

Complementary means you use it alongside traditional medicine.

Alternative means you use it instead of traditional medicine.

And there are five main types the text outlines, right?

Yes.

There's manipulative practices like chiropractic, biologically based, like herbal supplements or special diets, mind -body interventions like yoga or deep meditation for pain,

energy therapies, and then whole alternative medical systems like traditional Chinese medicine.

And people usually turn to CAM because the traditional system just isn't giving them relief or they feel dismissed by their doctor.

Exactly.

But on the flip side of avoiding the doctor, we also have to talk about overusing the doctor,

like hypochondriasis.

Which is highly misunderstood, I think, because people with hypochondriasis aren't faking it, right?

No, they're absolutely not faking it.

They feel genuine benign bodily sensations,

but their psychological interpretation goes into overdrive.

So a normal muscle twitch makes them genuinely terrified they have a severe neurological disease.

Right.

It's heavily linked to neuroticism, the personality trait associated with anxiety and self -consciousness.

And the chapter is very careful to contrast that with chronic fatigue syndrome or CFS.

Yes.

CFS is a very real severely debilitating illness involving persistent fatigue for over six months, but it's medically unexplained right now.

You can't just take a blood test for it.

Doctors basically have to rule out every other disease first.

It sounds like an incredibly frustrating process for the patient.

It is.

Okay.

So let's say you've pushed past all this.

You didn't delay, you navigated the system, and you're finally sitting on the crinkly paper of the exam table.

Right.

The actual patient practitioner relationship.

This is where so much friction happens because everyone wants something different.

Some patients want to see their lab results and, you know, make collaborative decisions.

While others just want the doctor to be the absolute authority and just tell them what pill to swallow.

And when the doctor style doesn't match the patient's preference, it's a disaster.

Totally.

Traditionally, a lot of doctors use a doctor -centered style.

They have very brief yes or no questions.

And if you try to bring up like a side ache or how stressed you are, they just talk over you to get back to the main biological issue.

Which leaves patients feeling completely ignored.

That's why there's a huge push for a patient -centered style.

Like Dr.

Armstrong from earlier, asking open -ended questions, actually collaborating.

Exactly.

And avoiding medical jargon.

Okay, wait, I want to push back on this for a second.

If the whole medical community knows that patient -centered care and clear communication is better, why do doctors still use so much confusing medical jargon?

It's so alienating.

It is alienating.

And there's a fascinating study by McKinley that looked exactly at this.

Researchers observed doctors on a maternity ward interacting with lower -class women.

Okay.

And the doctors kept using terms like umbilicus instead of just saying belly button or protein.

Words they knew the patients wouldn't understand.

Wait, they knew the patients wouldn't understand, but they used the words anyway.

Why?

It comes down to power and habit.

Sometimes the doctors felt the patients just didn't need to know.

Which is incredibly patronizing.

Yeah.

Or it was just a way to subconsciously elevate their own status in the room.

But whatever the reason, it completely breaks the communication chain.

Though to be fair to the doctors, patients are pretty terrible communicators too.

We give incredibly vague descriptions of our pain.

Oh definitely.

A patient might say I can't read the paper anymore instead of just saying my vision is blurry when I look at things up close.

Which is why you have to advocate for yourself.

The chapter highlights a case about a guy named Maury who is facing a really serious illness.

Right.

Maury's case shows that you cannot be passive.

If you're facing a major diagnosis, you have to bring a friend to take notes.

You have to write your questions down before you go in.

Because if you don't, you're going to freeze up, leave the room totally confused, and that leads directly to the final and maybe most important piece of the puzzle.

Compliance.

Adhering to medical advice.

Think about it.

You've felt a symptom, you've gone through the psychological wringer, navigated the hospital, fought through the jargon, and the doctor hands you a prescription.

Do you actually take the pill?

And the statistics are brutal.

The average rate of non -adherence is about 40%.

40%.

Two out of five people just don't do the doctor says.

And finding that number is actually really hard.

Look at table 9 .2.

You can't just ask patients if they took their meds because they lie.

They want to please the doctor.

Right.

So researchers have to be sneaky.

Well, objective.

They use pill counting where they literally count what's left in your bottle.

Or medication recording dispensers that log the exact time you open the cap.

Or even chemical tests, checking your blood to see if the drug is actually in your system.

Exactly.

But so what does this all mean?

Like, are patients just lazy?

Because the text talks about rational non -adherence.

Are you saying patients sometimes make a completely illogical choice to intentionally disobey their doctor?

Yes, absolutely.

Imagine you're prescribed a blood pressure pill and it works, but the side effect is debilitating dizziness.

Okay.

To the doctor, the pill is a success.

To the patient, they can't even stand up to play with their kids, so they stop taking it.

Or maybe they simply can't afford the refill.

In their daily life, not taking the pill is a totally rational choice.

That makes a lot of sense.

And it also depends on what the doctor's asking you to do, right?

Taking one pill a day is easy.

But if they tell you to completely change your diet, quit smoking and exercise every day.

You're asking someone to undo decades of habits.

It's a huge cognitive burden.

And table 9 .3 shows that we simply forget a massive amount of what doctors tell us.

And honestly, we can't always blame the patients for forgetting.

Look at the Svartstad study.

Oh, the Svartstad study is wild.

They recorded doctors and patients and found that doctors spent on average less than two minutes actually explaining the medication.

Wait, less than two minutes?

Yes.

Patients were walking out literally not knowing how long they were

Well,

on an individual level, practitioners use behavioral methods.

They tailor the regimen, like telling you to put your pill bottle right next to your toothbrush so it links to an existing habit.

Right.

Or using text message prompts to remind you.

Exactly.

Or behavioral contracting, where you and the doctor literally sign a written contract outlining goals and rewards.

But systemically, the big fix they're trying is the chronic care model, right?

Yes.

It's a total redesign of how care is delivered.

It has six main features.

It shifts the organization of care back toward primary prevention.

It uses clinical info systems to track your progress, redesigns delivery so doctors have teams of health coaches,

provides decision support for providers, promotes self -management for the patient, and connects people with community resources.

It's trying to treat the whole person, not just the single symptom.

Wow.

We have covered an incredible amount of ground today.

To summarize this whole deep dive, using health services is the ultimate biopsychosocial event.

It starts with the biological reality of a symptom, then your psychology steps in to interpret it, manage the fear, and weigh the costs.

Then you navigate the social systems, push past the delays, and try to communicate.

And finally, it all comes down to a behavioral choice, adhering to the advice.

You really just cannot separate the biology from the psychology and the sociology.

They are all linked.

Totally.

And I want to leave you, our listener, with a final provocative thought to mull over on your own.

Society spends billions of dollars trying to invent the perfect miracle cure, right?

But no matter how amazing that technology gets,

it is completely useless if the psychological and social communication breaks down between the doctor prescribing it and the patient taking it.

Exactly.

If the patient is too confused or afraid to open the bottle, the science just doesn't matter.

The XR might show the broken bone, but it can't show the fear or the miscommunication that stops the healing.

Well, thank you so much for joining us for this one -on -one study session.

Yes, thank you on behalf of the whole last -minute lecture team.

You have got this material down cold.

Keep questioning, keep learning, and we will see you on the next deep dive.