How We Do Harm (4 page)

When you look at outcomes, our health-care system—technology notwithstanding—is closer to Communist states, both former and current, than to other technologically advanced nations.

The CIA publishes a lot of information that is publically available.
The agency’s data notes that life expectancy for Americans is 78.37 years.
This makes us No.
50 among nations.
Taiwan is No.
51.
Monaco is on top, with the life expectancy of 89.73 years.
Canada is No.
12, with 81.3 years, the United Kingdom is No.
28, with 80.05 years.

Some argue that this comparison is inappropriate since the United States has high homicide and accident rates compared to other first-world countries.
I argue that this is the very point.
Homicide, accident prevention, and other preventive health measures are a part of the health-care system and are recognized as such by most outside this country.

Life expectancy is heavily driven by infant mortality rates.
This is not an area where we have much to be proud of.
Forty-four countries have better infant mortality rates than the United States, including Cuba and Slovenia.
This means that compared to a lot of other countries—many of them vastly poorer than us—we have a problem getting good care to pregnant women and babies.

And we pay a lot for mediocre results.
Per capita, our health-care spending is the highest in the world.
Here we are, indeed, No.
1.
The No.
2 slot belongs to Switzerland, but our spending exceeds theirs by 50 percent.
Americans spend two and a half times more on health care than on food.

Health care’s share of America’s gross domestic product is expanding.
It jumped to 17.3 percent in 2009 from 16.2 percent in 2008—the largest single-year increase since 1960.
At the current rate of growth, health-care costs are predicted to jump to $4.5 trillion in 2019.

At that point, health care will account for 19.3 percent—almost a fifth—of our gross domestic product.
Some estimate that these increases are on course to make health care account for 25 percent of our economy by 2025.

Conservative pundits and politicians are fond of maligning the Canadian health-care system.
Yet, Canadians spend half of what we do per capita.
Switzerland is ranked tenth in life expectancy, and Canada is seventh.
As No.
50 and the biggest spender by far, we aren’t getting what we pay for.

Efforts to slow the expansion of our health-care system predate my career in medicine.
Twenty-five years after I earned my white coat, from all my vantage points—as a doc on the ward, as an epidemiologist, and as a policy-maker—I see the same picture: our medical system fails to provide care when care is needed and fails to stop expensive, often unnecessary, and frequently harmful interventions even in situations when science proves these interventions are wrongheaded.

From my vantage points, I see that one painfully obvious approach to health-care reform has never been tried: No one has tried to make the entire system function rationally, based on science.

I devote a lot of time to studying the huge disparities in outcomes observed in the United States.
Disparities in outcome
is a euphemism for needless suffering and needless deaths.
And these disparities in health results are often linked to the ability to pay.

In the back rooms of American medicine, the analysis of the patient’s financial durability has a glib name:
a wallet biopsy.
If it returns positive, you stay in the hospital, you get more treatment, you can make a follow-up appointment.
If it returns negative, you have little hope of getting consistent care.

Off the top, the wallet biopsy denies quality health care to the almost 51 million Americans who have no insurance.
Often they get care of appalling quality or no care at all until they become sick enough or old enough for government benefits to kick in.
As soon as this happens, the system welcomes them as sources of revenue, because even at Medicare and Medicaid coverage rates, you can make money on uncontrolled diabetes, kidney failure, heart disease, and late-stage cancer.

Here’s a secret: wealth in America is no protection from getting lousy care.
Wealth can increase your risk of getting lousy care.
I spend a lot of time explaining to wealthy, insured patients that treatments they are convinced they need can’t be expected to make them live longer or better lives.
(In the following pages I will describe many such conversations.) When wealthy patients demand irrational care, it’s not hard to find a doctor willing to provide it.
If you have more money, doctors sell you more of what they sell, and they just might kill you.

It’s regrettable that the most recent round of debates over health-care reform focused on alleged threats to ration health care—that “death panels” would be formed to save money on caring for the rich and spend it on caring for the poor was an effective scare tactic.
People who scream about the rationing of health care fail to mention that rationing is already happening.
My colleagues and I, all good doctors, are always arguing with health insurance companies that want to reduce costs by telling us we cannot perform a particular test or use a particular treatment.

Opponents of health-care reform have misstated our national dilemma.
Health care is being rationed, while at the same time, irrational spending on unproven care is rampant.

I am not especially concerned about the rationing of health care.
I am more concerned about something else entirely: rational use of health care.
The problem is, we don’t use our expensive drugs and technologies appropriately.
Instead of using these interventions to benefit patients, we use them to maximize revenues, and often harm patients.
If we could learn to practice medicine rationally, the money we would save would help us provide the most basic care for those who are now shut out of the system.
Health care for the rich would benefit as well, because in medicine gluttony equals harm.

A rational system of health care has to have the ability to say no, and to have it stick.
This is the only way to protect patients from misguided, scientifically unproven interventions, to cut out waste, fraud, and abuse.
Those who pay—private insurers or the government—need to be able to protect the public from the miscarriage of medicine.

Denying useless treatment needn’t be motivated by saving money.
Let’s focus on not doing harm, refraining from peddling snake oil and false hope.
I empathize with a patient who views an unproven procedure as her only hope for living longer, but I have nothing but contempt for a medical practitioner who labels bullshit “hope” and profits handsomely from it.

It’s possible to provide better care at a lower price.
It’s possible to be justly proud of our scientific and technological achievements and provide quality and consistent primary care.

It’s possible to have innovation and quality and access and lower costs.

There is no need to choose.

*

I
am not worried about breaking ranks.
I look forward to it.

Some of my colleagues are willing to play the game, realizing that care—even useless and inappropriate care—makes cash registers emit pleasing sounds.
We doctors are paid for services we provide, a variant of “piecework” that guarantees that we will err on the side of selling more, sometimes believing that we are helping, sometimes knowing that we are not, and sometimes simply not giving a shit.

Would a doctor who sells radiation therapy tell you to go across the street to get chemotherapy, even in cases where studies show that it’s more appropriate?
Would either of these medical entrepreneurs advise you to wait for six months to see whether your disease is of the sort that would actually harm you?
All too often, the answers to these questions are no.

The financial incentives that drive the medical community have a devastating impact on patients and health-care costs, and we will not change unless we are forced to change.
Doctors who own labs have been shown to order more tests than doctors who don’t.
A doctor at a for-profit practice is more likely to prescribe the treatments that benefit him the most.
I’ve heard of community oncology practices that hold regular meetings to inform doctors about treatment techniques that maximize billing.

When money is to be made, the system can be proactive, again to the detriment of the patient.
Call it “disease mongering” or call it the marketing of disease, but as I write this, a fleet of aquamarine, white, and blue mobile homes is bringing prostate cancer screening to a shopping-mall parking lot near you.
These things are long, thirty-nine feet, plenty of room.
Come aboard!
The blood test is free, but the cascade of follow-up services will ring up considerable sales for treatments that leave guys impotent and incontinent.
Treatment that
may
have a minuscule chance of saving them from cancer, but have a much larger chance of treating a cancer that would never have harmed them, or may not even have been there in the first place.

Improvements in health come at a cost, but in the case of prostate cancer, no one has shown an improvement in mortality.
Despite concerted efforts, screening for prostate cancer has not been clearly proven to decrease men’s chances of dying of prostate cancer.
But that doesn’t mean there isn’t money to be made; recently, I noticed that Zero, an advocacy group that operates these screening vans, receives funding from the makers of Depend diapers.

I know doctors who are just plain bad.
Why do they continue to practice without impediment?
The answer is simple: because no one is looking over their shoulders, no one files a disciplinary complaint, no tribunal of peers punishes them unless they do something spectacularly awful.
No one is better suited to police the profession than the profession itself.
But our professional societies tend to choose misguided collegiality over the well-being of our patients, the people who trust us with their lives.

I will show how we academic physicians who practice in nonprofit institutions such as Emory are not pristine either.
If you don’t watch out, we’ll sell you on a clinical trial that will get our names on scientific papers, but not necessarily be appropriate for your disease.
Even as academics, we may be motivated to maximize billing to support our departments.
Or we may simply be enthusiastic about the procedures and therapies we are trained to deliver.

It’s not easy to challenge doctors to justify their decisions in the clinic.
As we’ll see, it’s harder still to challenge a wrongheaded consensus of a medical specialty as it marches in lockstep.
This is precisely what happens when professional societies of doctors who perform expensive medical procedures issue “evidence-based guidelines” that are anything but evidence-based guidelines.
Instead, the purpose of many of these documents is to protect the specialties’ financial stake in the system.

Why not just say no to the special-interest groups that peddle interventions that generate billions while doing harm?

Why not center the system on benefiting the patient, not the people who profit from lying to the patient?

Why not set realistic, scientifically based goals for treating our patients?

Why not teach doctors to start using the simple words
I don’t know
?

Why not teach doctors and insurers to say no to patients who are determined to get care that has no scientific basis?

Why not stop treatment when—scientifically, based on evidence—there is nothing left to do?

*

IF
the wreckage of health-care reforms attempted over the past twenty-five years is an indication, change from above will not get the job done.

Yet, high-quality health care for all is as much a civil rights issue as is one man, one vote.
In health care—as in voting rights—real change will have to come from below, not only from patients, but from all of us as citizens.

Sadly, patients who understand the system are a small, politically insignificant minority.
The majority is placid at best, confused at worst.
Many patient groups act as unquestioning advocates for pharmaceutical companies and medical specialties, failing to realize that the interests for which they advocate run counter to their own.

In the most recent round of reform, we saw special-interest groups of all sorts coming to the defense of their entitlements.
It was hard not to notice the opponents of change, but if there was even a trace of a public movement on the part of proponents of change, I missed it entirely.
Political moderates and progressives remained silent even as debates became dominated by Tea Party conservatives and fictional characters created by PR firms on behalf of business interests.

Proponents of science as a foundation for health care have not come together to form a grassroots movement, and until this happens, all of us will have to live with a system built on pseudoscience, greed, myths, lies, fraud, and looking the other way.

Patients need to understand that more care is not better care, that doctors are not necessarily right, and that some doctors are not even truthful.

Genuine health-care reform—like the right to vote—will not be granted magnanimously.
Like civil rights, the right to good health care will have to be won in public struggle.
To bring about real change, real people will have to say, “Enough!”

*

I
draw on the best source of information available to me as a physician: patients.
What role did the health-care system play in their disease?
Have my colleagues made treatment decisions based on the patients’ interests or based on self-interest?
Have I been able to mitigate harm, or have I caused it?
How have we doctors caused harm?
Through uninformed but billable trial and error?
By denying care?
By providing the wrong care, or too much care?

Although the stories in this book are true, names and identifying characteristics of patients have been changed to protect their privacy, except in cases where individual patients went public with their struggles.
The names and identifying characteristics of physicians have also been changed to protect their privacy, except where I discuss their scientific publications.
In clinical anecdotes, I note when doctors are identified by their real names.
The views expressed here are not those of the American Cancer Society or Emory University.