the unseen crisis of our system

“21st Century Schizoid Man” is a 1969 antiwar song by the prog rock band King Crimson. It appeared as the lead cut on their debut album In the Court of the Crimson King. “Schizoid Man” is considered an epic, described by Rolling Stone as “a seven-and-a-half-minute statement of purpose: rock power, jazz spontaneity, and classical precision harnessed in the service of a common aim.”

Schizoid personality disorder is much less demonstrative but no less emblematic of the profound disconnection and emotional isolation that can characterize human experience. The disorder represents a stark contrast to the intense, expressive nature of “21st Century Schizoid Man,” highlighting how inner turmoil and detachment can be just as impactful, albeit in a more subdued and internalized manner.

Schizoid personality disorder typically begins in early adulthood. Individuals with this condition don’t desire or enjoy close relationships, even with family, and are often seen as loners. They may be emotionally cold and constricted. In theory, therapy and medications, such as antidepressants or mood stabilizers, can help. But in my experience, improvement is more of a wish than a reality; the prognosis for change is poor.

The same is true of the U.S. health care system. The hope that it can return to normal after decades of prog(ressive) dysfunction is also a wish – one that is not likely to come true. I’ve told my writer friends to stop complaining about how bad the system is. “Health care is beyond repair,” I tell them. “Don’t let unrealistic expectations cloud your writing vision. Instead, invest your prosaic energy in other topics and genres – memoir, fiction, poetry, and creative non-fiction.”

Yet, here I am, not heeding my own advice and dwelling on our broken health care system, thinking of it metaphorically as “schizoid” to illustrate its indifferent and often contradictory nature. Because schizoid personality disorder is characterized by a persistent pattern of detachment from social relationships and a restricted range of emotional expression, the diagnosis can be applied to our health care system to highlight several key issues.

Just as a schizoid individual might struggle with integrating different aspects of their personality, the U.S. health care system is fragmented with disjointed services. Patients often have to navigate a complex web of providers, insurers, and health care facilities, leading to gaps in care and communication breakdowns (think: Led Zeppelin). This fragmentation can result in patients receiving inconsistent information and care, complicating their course of treatment and potentially leading to poorer health outcomes.

The U.S. health care system lacks clear goals and suffers from inconsistent policies at federal, state, and local levels, much like the directionless thinking seen in individuals with schizoid personality disorder. This inconsistency can lead to confusion and inefficiency, with patients receiving different levels of care and coverage based on their location or insurance provider. These policy discrepancies create a landscape where accessing health care services is challenging, further exacerbating the system’s dysfunction.

Furthermore, there are significant disparities in accessing quality health care, similar to how a schizoid individual might struggle with forming consistent and meaningful connections. These disparities can be based on socioeconomic status, race, and geographic location, leading to unequal health outcomes. Such inequities highlight the system’s inability to provide uniform care across diverse populations, undermining public health efforts and social equity.

The economic aspects of the U.S. health care system can be seen as schizoid due to the disconnect between the cost of care and the value received. Patients often face exorbitant medical bills, while the system as a whole struggles with inefficiencies and waste. This economic dysfunction reflects a lack of coherence in how health care is financed and delivered, burdening individuals and families with financial strain and complicating the overall sustainability of health care provision.

Patients often experience the health care system as impersonal and bureaucratic, akin to the emotional detachment seen in schizoid personality disorder. This can lead to feelings of alienation and frustration, further complicating the patient-provider relationship and overall satisfaction with care. The lack of personalized, compassionate interactions can diminish trust in the system and deter individuals from seeking necessary medical attention.

Worse yet, there have been instances where patient dissatisfaction has escalated to violence. For example, health care workers in emergency departments, psychiatric units, and other high-stress areas are often at a higher risk of experiencing violence from patients or their families. This violence can range from verbal abuse and threats to physical assaults to outright homicide.

In fact, the profile that fits schizoid patients – aloof, solitary, and lacking friends – is also typical of white male shooters responsible for mass murders at schools and places of worship, not to mention the shooter who attempted to assassinate Donald Trump. However, schizoid personality disorder is not strongly associated with violence. Individuals are more likely to be withdrawn and emotionally unengaged, which typically results in a lower propensity for violent behavior.

Nevertheless, efforts to change the health care system often face significant challenges, much like the difficulty in treating patients with schizoid personality disorder. Political divisions, vested interests, and varying ideologies contribute to a lack of cohesive strategy for improving the system, resulting in piecemeal solutions that fail to address the root problems. This persistent inability to enact comprehensive reform underscores the systemic issues that hinder effective, equitable, and efficient health care delivery.

When King Crimson wrote “21st Century Schizoid Man,” they couldn’t possibly have foreshadowed the U.S. health care system as it exists today. However, the song’s vocals are heavily distorted, just as a patient’s perception of their health care journey has become distorted, making it difficult for them to feel that their care is being well-managed. Indeed, medical treatment does appear “schizoid” to most patients – and sooner or later, that means all of us.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Narrative Medicine: Harnessing the Power of Storytelling through Essays.