BOOK REVIEW: The Black Count by Tom Reiss

This is a fabulous  non-fiction narrative that rivals many of the best novels ever written.  Even the fact that it made the New York Times bestseller list and also won the Pulitzer Prize hardly does it justice.  Tom Reiss obviously spent many months, even years, doing very original research on at least two continents and as many languages.  But let’s begin at the beginning

If you have ever read the novel The Count of Monte Cristo by Alexandre Dumas, and you liked it, or like me, loved it, Reiss’ book is a must-read for you.  Dumas also wrote The Three Musketeers and The Man in the Iron Mask, as well as dozens of other fiction and non-fiction books and articles.  The Count of Monte Cristo is a story of revenge; the story of a man imprisoned for life on unknown charges as the result of a conspiracy of three enemies he didn’t know he had.  He is condemned to a medieval prison, whose castle walls are several feet thick.  He makes a daring and miraculous escape aided by another prisoner, an aging abbe, who reveals to him the location of great treasure.  The hero becomes fabulously wealthy and the rest of the book is about how he wreaks revenge on those who had condemned and then forgotten him.  The Hollywood movie version in my opinion ruined the story by changing the ending.

What I didn’t know is that the author of these sagas, Alexandre Dumas, was a mulatto, and his father, Alex Dumas was a very dark black man from the island of Haiti who intermarried with a white French woman.  Through the real story of this man, Reiss takes us on a global panoramic tour of the institution of slavery itself, with many surprises along the way.

Slavery of course, has been around since the beginning of man’s recorded history, and obviously predated that history.  All acquisition of property and power throughout the ages was through conquest, and the victor took all, including the vanquished as slaves.  Slavery was not racially tinged until the 18th century.  Before then, anyone anywhere was at risk of becoming a slave if a predator group won the battle.  For example, when Alexander the Great conquered Egypt, he made slaves of the Egyptians, but he also imported lots of white slaves from what are now eastern European nations populated by ethnic Slavs, which is where we got the word slave.  Christians during this time period thought slavery was fine as long as the slaves weren’t other Christians.  So making slaves of non-Christians and especially the Moors, was acceptable.    In time these ethnic Slavs, who became known as Mamelukes,  revolted against their Egyptian masters, and the Egyptians became their slaves–until Napoleon came along and drove off the Mamelukes. Read more..

In the western hemisphere, there were large population centers located among the Mayans, the Aztecs, and the Incas.  One of the Incan cities had a larger population at the time than the European city of Lisbon, the capital of Portugal. Each of these south and central American civilizations had slave populations themselves.   When the Spanish conquistadors invaded they absorbed the existing slave populations and also made slaves of the former masters.   Those  who didn’t die of the white man’s diseases were turned into slaves and were sent to die in brutal, murderous silver and gold mines.  None of this was race related.

When other imperial explorers reached the islands of the Caribbean, they didn’t find precious metals as they had hoped, but instead found sugar cane, which they learned how to refine into sugar.  The sugar capital of the world became the island of Haiti, then known as Saint Domingue.  Growing sugar cane was labor intensive, and unlike in central and south America, there were no large concentrations of population that could easily be enslaved.  The African slave trade in the 18th century was largely concentrated around the sugar plantations of Saint Domingue.  There were few African women imported to Saint Domingue, and the men were treated so brutally they died quickly of starvation and beatings.  This rapid turnover further exacerbated the labor shortage, requiring more and more slaves.

Reiss traces how the imperial expansion into the western hemisphere took place concurrent with the philosophical movement of The Enlightenment with its special emphasis on liberty and individual rights.  The French were the first to attempt to come to grips with the contradictions between slavery and liberty.  The French were intrigued by the American experiment and the principles embodied in our Declaration of Independence and Constitution, and of course our revolution only came to a successful conclusion due to the assistance of the French navy.  As a matter of fact, the French involvement in our revolution drove their nation into bankruptcy, and precipitated food riots and their own Revolution.  The French Revolution championed the rights of man at the same time that it engaged in a Reign of Terror against its own citizens, sending thousands of innocent people to the guillotine.

The French resolved the slavery/liberty debate at first by declaring that any black man who made it to the shores of France proper was a free man, and the French sort of washed their hands, Pontius Pilate-like,  of what happened in the slave-holding colonies such as Saint Domingue.  Activists pressed the issue however, and within a short time freedom was being promised to slaves in the colonial territories, which of course enraged the plantation owners, who withdrew their support from the French Revolution.   This facilitated Napoleon’s rise to power, culminating in his naming himself emperor of France and ending the centuries-old monarchy.

Alex Dumas, the father of Alexandre, came to France as a young man and entered the military, and quickly distinguished himself.  For a while he actually outranked Napoleon, but in time came to report to him.  He was captured in what is today Italy, and spent several short years in a medieval prison, held without charges.  His prison experience broke his spirit and his health.  Napoleon meanwhile, in an effort to placate the very wealthy plantation owners of the French Caribbean colonies, rescinded many of the freedoms that the Revolution had instituted for blacks.

After many years of valiant service to the Revolution in which he devoutly believed, Alex Dumas found himself without a pension, without a home, and with no means of support.    Napoleon, who knew him well and personally, ignored his requests and his lieutenants ignored the requests and pleas of his widow after Alex died, still fairly young and impoverished.

This is broad brushing this delightful narrative, which holds many insights you’re not going to find in a history book.  Reiss approaches his topic without bias or political correctness, and what I came away with was that the lot of the common man of any race, color, or origin from time immemorial has been to serve as the cannon fodder of the ruling class of every nation, and that the golden rule prevailed:  he who had the gold ruled.

Reiss is quick to point out many of history’s ironies:

Napoleon and Alex Dumas fought against the Spanish in southern Italy.  This is the same Spain that was colonizing the central and southern Americas.  And that is how the South American tomato made it’s way to southern Italy, which of course made it famous. or was it the tomato that made Italian cuisine famous?

The French continued to refer to black and mixed race people in France as “Americans”, in America members of its Congress would not permit blacks into their presence except to serve refreshments or sweep up. Says Reiss: “But having enjoyed prestige as “Americans” during the[French] Revolution, black and mixed-race soldiers now found themselves denigrated as “Africans.”

The French helped us achieve the rights to life, liberty, and pursuit of happiness, and were also the first to give blacks freedom, at a time when  General George Washington said he didn’t think Virginians were ready for that step yet.   French  General Lafayette of Yorktown fame had to flee for his  life from his own Revolution.  He was captured by the Prussians and spent the next five years in prison.  His friend George Washington was powerless to help him because Prussia [parts of what is now Germany] and Austria at the time refused to recognize the new United States.

Miscegenation , or racial intermarriage, was common until it too was outlawed.  Haiti, the sugar capital of the world and probably the richest island on the planet, experienced the first successful major slave rebellion. The slaves fought 80,000 of Napoleon’s troops to a standstill; the French left, the plantations closed, and today Haiti is quite possibly the poorest island on the planet.  Today Haiti has experienced something of a brain drain as their best and brightest have abandoned her to seek their fortunes in the United States and elsewhere.

New post-revolutionary France decided to deflect attention away from their internal problems by invading most of their neighbors, which is how Napoleon and Alex Dumas came to know each other and fight almost literally side by side.  As always, the government attempted to finance their wars with debt, in the form of bonds backed by property–that had been seized from the Church.  These bonds were on pieces of paper called assignats, which were used as money,  and of course they printed more assignats than there was real estate collateral, which resulted in devaluing the assignats and creating massive inflation.  Eventually the floor under the assignats gave out–literally.  At the Paris printing house someone piled up too much of the worthless paper in one place and the floor of the building collapsed under the weight.  Their real-estate secured bonds were worthless.  Nothing familiar here, is there?

Reiss peppers his story with personal vignettes such as this description of one French revolutionary:  “. . . his main character flaw was that of so many French revolutionaries: a zeal for human rights so self-righteous that it translated into intolerance for the actual human beings around him.”  I’ve often thought the same of the purported champions of the war on poverty; their concerns are usually self-serving and they wouldn’t want to get too up close and personal with real poverty.  They preach humanity but don’t like poor people moving into their neighborhood.

Reiss weaves a wonderful and complex tapestry of events that spans the globe and leads to even more questions.  Life is never quite what it appears to be, and the more it seems to change the more it stays the same.  If you have strong opinions about modern race relations in the U.S., read Reiss’ book for a more global perspective.  Without our Constitution and limited government, there is nothing left but the governments guns, the moneyed powers behind the throne, and the ragtag mob.  Without individual freedom that cannot be voted away by any block of voters of any color for any reason, there is no freedom except by permission, and that is not freedom at all.

For author Alexandre Dumas, his novel The Count of Monte Cristo was the fantasy version of his father’s life.  Indeed part of the story begins in an obscure little village in Haiti (Saint Domingue) near the border with the Dominican Republic (Santo Domingo) called Monte Cristo.

Many parts of this biography of Alex Dumas, and his legendary fictional counterpart, the Count of Monte Cristo, read like a Kafkaesque novel.    Until we figure out a way to change human DNA, the possibility of a return to this world should never be dismissed lightly.  Liberty is and always will  be under siege.

BOOK REVIEW: The House of God by Samuel Shem

This book, originally published in 1978, became an almost instant cult classic.  The author Stephen Bergman (pen name Samuel Shem) was a Boomer  child of the fifties and sixties, and he wrote this, his first novel, when he was in residency at Oxford as a Rhodes scholar.  As far as I know he does not claim this, but it appears to me that the book is autobiographical to some degree.  The book is about a year as a medical intern in a Jewish hospital called The House of God.  It is funny, irreverent, occasionally salacious, and was frowned on by the medical establishment when it was first published.  

The book pulls the reader into the lives of the interns serving under intense, almost brutal conditions, and confronting what appears to be the very worst in life, its end and all the degrading things that happen to the human mind and body as they gradually shut down.  It is a revelation for the casual, non-medical reader to learn what  happens in the hospital to real people, the interns, members of the hospital hierarchy, and most of all the patients, most of whom are on the last part of the downhill slide. Read more..

The author doesn’t spare any of the gory details.  He discusses and describes in vivid technicolor many of the most unglamorous tasks undertaken by medical students and the attendant sights, sounds, and smells, work that may make you rethink your desire to go to medical school.  What was of the most interest to me however was what was happening to these young men and women as they struggled with the overwork, the authoritarianism of the hospital regime, and the realities of sickness, disease, and death.

The interns develop their own house rules and vocabulary, the first of which is that gomers don’t die.  A gomer (acronym for Get Out of My Emergency Room) applies to mostly elderly patients who have lost most or all of what makes them a human being.  They are existing and taking up space, but they have no awareness of what is going on around them.  As anyone who has spent time in a nursing home knows, their behavior can be humorous and tragic at the same time.  The patient load at The House of God was mostly gomers, and Rule #1 above means that gomers come in and out of hospitals like a revolving door, but they rarely die.  Their organs seem to function on auto-pilot.  It is mostly the younger patients who die in the hospital.  It’s hard to kill a gomer, and it’s impossible to cure or even save many of the young ones.

Even though this is fiction, there is a lot to be learned from this novel, and I am very glad I have read it.  I am amazed at how well known The House of God is, with over two million copies in print; I mentioned it to two middle-aged doctors just this week and they both immediately confessed to having read it many years ago, and they both broke into a grin when I mentioned the word gomer.

The hero among the interns was a fat black doctor who taught them that the goal of medical care was not to cure anyone, but to buff them and turf  them, which meant to make them look better, and then to transfer them out of the ward, either to another department (surgery, psychiatry, the morgue, or just back out onto the street).  When it came to treatment, they learned that less is better, and Rule # 13 was, heretically :  “The delivery of medical care is to do as much nothing as possible.”  It would appear this is a rule that modern medicine lost and is just now rediscovering–that there is a point of diminishing returns with continually prescribing more, and often unnecessary treatments.  Many of these do more harm than benefit.

The reader cringes at the descriptions of what the interns put the sick and dying through in the name of doing something, anything, even if it puts the patient through pointless, agonizing pain.  The concept of modern hospice, i.e. make the patient as comfortable as possible and let them ease into death, was incomprehensible and unacceptable.  You as the reader watch time and again the horrific prolonging of life out of “collective impotence and guilt” — of the interns and the families of the patients.  I cannot imagine anything being more graphic other than  being personally involved in such useless miscarriages of medicine.  I know that such things still happen, because I  remember the final weeks of my sister’s life when she was demented due to brain cancer and procedures for no known purpose were performed on her that obviously caused enormous stress and pain, because she shoved violently at the restraints that kept her bound to the bed.  She did not scream because apparently her brain was not able to transmit or translate the pain signals to other parts that controlled cognition and vocal ability.  It was modern medicine at its best and it was horrible to watch.  The author describes situations that make my sister’s situation pale in comparison, and the reader just prays for the damn interns to let this poor soul die.  And of course they can’t, because their code of ethics requires them to torment their subjects until there is nothing left of them.  That brings us to Rule #8  “”They can always hurt you more.”

I have to believe much of the medical information in the book is based on reality, and the novel is a fun way to explore how young men and women become doctors.  The reader also learns how normal, and sometimes even humble interns gradually evolve into the narcissistic god frame of mind that is partly responsible for the closed society that the medical fraternity has been.

The book is a good read and you will occasionally find yourself laughing out loud, and there will be times when you turn the pages in horrified anticipation of what is done next  in the name of medicine to the defenseless old or dying.

I will leave my readers with a very important question that remains unresolved in my mind:  How many patients have to die, on average, for one medical student to become a doctor?  Students, interns, and residents do practice on, and occasionally kill their patients, and very, very few of these become malpractice lawsuits.  What is the price in human lives and suffering for each apprentice to learn “to do no harm?”

Book Review: The Life You Save . . . Nine Steps to Finding the Best Medical Care—and Avoiding the Worst by Patrick Malone

As my regular subscribers know, I have been involved as a researcher and ghostwriter for a fabulous (of course!) book due to be released in the Spring of 2013 that for the moment we’ll just call Inside Medical Malpractice.  In that role, over the last eight months or so I have become something of an expert on the current literature on the state of American healthcare.  So for my busy readers, let me cut to the chase and simply say, get out your credit card and order The Life You Save . . . from Amazon or Barnes & Noble or your favorite bookseller, but do it now.  Get a copy for yourself, and get a copy for your grown children with a mandate to actually read it.  It will make a superb Christmas gift for anyone you care deeply about, including any who are healthcare practitioners themselves.  And no, I’m not connected to any of the beneficiaries of this enthusiastic endorsement, including the author. Read more..

So what’s this all about?  It is not my nature to gush or engage in hyperbole.  What’s up with my enthusiasm for  The Life You Save . . . ?  The shortest and straightest answer is in the title itself—this book is about saving your own life when it comes your time to enter the healthcare system for anything more serious than the common cold.

A few weeks ago I recommended How We Do Harm—A Doctor Breaks Ranks About Being Sick in America, by Dr. Otis Brawley, Executive Vice President of the American Cancer Society.  In my review of Dr. Brawley’s excellent book (you can read it here: I recommended this book as a wake-up call to naïve Americans who enter the healthcare system with an unwarranted confidence that they will be treated competently and with reasonable expectations of a happy outcome.  Dr. Brawley lays it all out with well-documented information about how broken, chaotic, and fragmented our system is, and how frequently patient safety is the last priority of the stakeholders in the system.

More recently I recommended Unaccountable—What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, by Dr. Marty Makary, a surgeon at Johns Hopkins Hospital.  You can read this review here: Dr. Makary’s book focuses on the culture of cover-up in the medical profession, and the intentional code of silence about mistakes, negligence, and incompetence.  He talks about how difficult it is for a patient to discover the safety track record of any institution or doctor, and Dr. Makary has excellent suggestions and comments about a ground swell of interest inside and outside the profession to clean it up and make it safer and more honest for the patient.  He makes the profound point that meaningful change will not happen unless we demand it, push for it, insist on it.

Then comes The Life You Save:  Nine Steps  to Finding the Best Care—and Avoiding the Worst.  The author, Patrick Malone, is a very successful medical malpractice attorney who has had clients all over the country.  His book, however, is not about medical malpractice, and his book is not some ill-disguised attempt to promote his legal practice.  This book is very simply a down-to-earth and comprehensive Survival Guide to coming out of the healthcare system unharmed and unscathed.  This book has valuable checklists for everything, from things to ask your family doctor; steps to take to find a competent doctor; checklists for safe surgery; the red flags that tell you to run like hell from someone you thought was a competent physician; how to become better informed about your prescription drugs; how to evaluate recommended treatments, procedures, and tests; how to avoid infection in hospitals; and how to evaluate hospitals, departments in hospitals, and the presence or absence of a patient-safety culture within the hospital or department you will be using.

Believe me, this guy knows what he is talking about.  For those who have a false sense of security by relying on federal and state regulatory agencies, Mr. Malone exposes the limitations and conflicts of interest that can cripple the effectiveness of these organizations.  He gets behind the statistics, and explains in simple street language what those horrifying prognoses really mean—and don’t mean, when the doctor tells you what your survival chances are, or how long you have to live.

Author Malone makes the point that we should not, as patients, have to go to such lengths to assure ourselves of being given competent, attentive care, but unfortunately when it comes to patient safety, American healthcare has only moved the space of a few inches on a journey of miles.  We have to become responsible for ourselves, which from my view on the bench, is not such a bad habit to cultivate anyway.  Because when you are sick it is often beyond your capabilities to be alert and assertive, it is essential that every one of us know someone who can go with us to our appointments, stay with us in the hospital, including overnight, and, oh, by the way, our friend needs to have big kahunas.  The healthcare system is not likely to pay much attention to someone without assertiveness, the ability to speak up and be firm.  The hospital is the last place to be intimidated, or in awe, of your healthcare providers.  These people are made of the same dirt as everyone else.  They have bad days, they suffer lapses of attention, they have other things on their mind, they have egos, they have wrong-headed financial incentives, they have attitudes, some of them are substance abusers, and some of them shouldn’t be practicing medicine at all.  With some of them, that is precisely the problem—they are practicing medicine.  As long as they are practicing, you had better be paying attention.  Caveat emptor.  Translation:  If you’re not being treated like a customer (instead of a patient), go somewhere else.

Malone cautions us that we also need to develop our relationship skills.  If we start acting like we know more than our physician, either we are now part of the problem or we need a new doctor (and maybe both).  Mutual respect is important.  And any good doctor will welcome an involved, educated client.  Yes, client.

A few days after I finished reading this book, I had an appointment with a new doctor.  I brought my checklist (borrowed from The Life You Save) with me.  My new doctor did not wash her hands after entering the examination room, and did not put on a clean pair of gloves.  She did not use antiseptic hand wipes, and she did not clean the head of her stethoscope in my presence before examining me with it.  She did have a bright cheerful smile as she shook my hand.  For the first time ever, I wondered, who else had she just treated, what sicknesses did they have, and did she shake their hands as well?

One more thing I loved about Malone’s book.  He lists dozens of websites where the reader can go for further information.  Unless you are a trained researcher, these websites are a fabulous resource.  Buy this book now, and keep it handy as your most valuable resource when the freight train of health issues is headed down your track.  Be prepared.  The Life You Save??  Let’s put it this way:  Like an ice-cold Budweiser, this book’s for you!

Book Review: Unaccountable–What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care by Dr. Marty Makary


Most Americans have been a hospital patient—probably more than once.  Very few have any awareness of the fact that entering a hospital is one of the most dangerous actions of a lifetime.  Not because there are a lot of bad people in there with the intent to harm us—quite the opposite is true.  The vast majority of those people are in their professions for the best of reasons.  But consider: Read more..


  • We are about to enter an environment where every single customer is sick; where pathogens and contagion abound.


  • Dozens of professionals will participate in our care, and the failure of any one of them to wash their hands before tending to us can contaminate us with infection other than what we brought into the building ourselves.


  • Dozens of professionals will participate in our care, and the means of communicating is often chaotic, fractured, and prone to error.


  • If we are there for surgery, someone is going to cut us open, and we most likely have no idea how many times s/he has done this particular operation before, nor do we know what his/her success/failure rate has been.


  • What facilities, staff, and equipment are available in the event something goes wrong with our procedure?


  • What if there is a better way to perform this procedure, but it is one that our surgeon is not very familiar with, and s/he doesn’t want to refer us to a colleague or institution more skilled in the better techniques?  Because of pride, ego, or compensation?


  • Do all these people participating in our care communicate openly with each other?  They are human like the rest of us:  what happens if someone is about to make a mistake, and everyone aware of it is afraid to speak up?


  • When someone comes in our hospital room and hands us medications, or hooks up an IV for us, how do we know they are giving us the right stuff?  Does anyone ever get killed in here because someone got the prescription wrong, the dosage wrong?  What happens to the patient when staff members can’t read the doctor’s handwriting?


  • Are any of our attending healthcare practitioners sloppy, incompetent, or under the influence of alcohol or other substances?  How would we know?  Were any of them C- students in med school?  Every profession has its underperformers.  Is the person beside my bed one of them?  Doctors have more access to controlled substances than anyone in our society.  How would we know if our doctor abuses drugs?


  • What happens when any one of these practitioners is overly tired, isn’t feeling well themselves but came into work anyway, are troubled with serious personal problems  at the moment, are forced by staffing shortages to care for a larger patient load than is safe?


  • What if the hospital we have been admitted to puts their doctors under pressure to recommend or prescribe procedures or therapies we don’t really need, subjecting us to unnecessary unpleasantness and possible complications in order to enhance billing?  Is my doctor a commissioned sales person?  Does s/he receive kickbacks/bonuses from pharmaceutical drug companies for prescribing, or worse, meeting sales quotas?


  • Obviously all hospitals are not equal, nor are all departments within any given hospital equal.  What if we are in the wrong hospital, or about to be operated on by the wrong surgeon?  How would we know?  Would the people who work here willingly choose our doctor, our surgeon, to make life or death decisions on their own behalf?


  • Who tells these people when to retire?  What happens when their memory starts to fail, or they begin experiencing tremors in their operating hand?


If you’ve never wondered about any of these things, it’s time for you to wake up to the realities of healthcare in America.  In his book, Dr. Makary,  a surgeon and researcher at John Hopkins University School of Medicine, exposes the inner workings of the system, identifying the various stakeholders, from the medical colleges to doctors, national doctor associations, hospitals, Medicare, the American Board of Medical Specialists, state medical boards, insurance companies, and most important of all, you, the patient.


His main point is that the medical culture for centuries has been a closed society and very resistant to reporting incompetence among its peers.  We as patients make huge assumptions about how the profession functions and are blissfully unaware of the perils that await us when it’s our turn to enter its doors.  The numbers are more than sobering.  Take for example his very conservative estimate that 2% of the physician population is impaired, either through substance abuse or burnout and psychological problems, which amounts to 20,000 doctors treating approximately 10 million patients on an annual basis.


Dr. Makary makes us aware that technology has made possible the accurate metrics for evaluating health care providers and institutions and particular procedures, but that participation so far is voluntary and sporadic.  Many hospitals have adopted the exit patient survey as a relatively meaningless metric, while the survey that really matters, which is the opinion of the individual staff members of the institution as to the safety culture they work in, either doesn’t get done or the results are locked up tighter than Fort Knox.  These are, after all, the only people who really know what goes on inside the walls of the palace.


The most sobering statistic of all, for me, is that according to Dr. Makary, virtually every doctor out there knows a doctor who for one reason or another, is unsafe or downright dangerous.  The only ones who know the identity of these unsafe practitioners are their colleagues, the doctors and nurses who work with them and who feel sorry for the malfeasants’  patients.  The professional code of silence doesn’t allow them to speak up, but published performance metrics, appropriately adjusted for the nature and severity of the patients’ pre-existing conditions,  would speak for themselves.


Until such metrics are made available to patients on a national basis, every one of us needs to become an amateur sleuth before making our healthcare choices.  To his credit, Dr. Makary does not demonize any of the stakeholders, nor does he lobby for any political viewpoint.  His solution is simple:  Insist on transparency, make information about hospital performance metrics  universally available to patients, and the free market will get the job done very efficiently, because informed patients will be free to choose.


Along the way, Dr. Makary gives us some delicious little bits of trivia.  For example:


  • Who is Dr. Hodad?  (Hint: S/he works in a hospital near you.)


  • What occurrence of medical malpractice, although never litigated, influenced U.S. foreign policy for over 30 years?


I highly recommend this book for anyone and everyone.  Besides opening a rare window into a profession known for its obscurantism, Dr. Makary presents detailed practical suggestions on what each of us, as a patient, can and should ask our healthcare providers before making choices.  I for one would never have thought of some of these.  And when it comes to saving our own lives, every one of us needs to become a passionate activist—at the very least about our next doctor visit or hospital stay.


Note:  Stay tuned for the release in the Spring of 2013 of a book demythologizing medical malpractice.  A rational, ethical, and non-polemic guided tour by a prominent insider to both the medical specialty practice of medicine and plaintiff law.  Read about it here first!

Book Review: How We Do Harm–A Doctor Breaks Ranks About Being Sick in America, by Otis Webb Brawley, M.D.

Otis Brawley says that the system of healthcare in this country is not broke.  He says it is “functioning as designed.  It’s designed to run up healthcare costs.  It’s about the greedy serving the gluttonous.”

Otis (he prefers to be called by his name rather than his title) should know.  He is an M.D.  He is a graduate of the Pritzker School of Medicine, University of Chicago, and he completed a residency in internal medicine at University Hospitals of Cleveland, Case-Western Reserve University as well as a fellowship in medical oncology at the National Cancer Institute.  Today he is the chief medical and scientific officer and executive vice president of the American Cancer Society, and he also serves as a professor of hematology, oncology, medicine, and epidemiology at Emory University in Atlanta.

And if I have the misfortune to contract a serious, life-threatening disease, I am going to call Otis and ask who I should go see.  I want him on my side.

But for right now, I am going to refer to him as Dr. Brawley.  Without having personally met him, it just seems more respectful, and this book he just published commands respect.  Dr. Brawley is a brawler.  He has had to be, just to survive, and certainly to achieve the level of professional distinction he now enjoys.  Growing up in the streets of Detroit, Dr. Brawley says that of a group of twelve from his childhood, only three got out.  Nine are dead or serving life sentences.  Dr. Brawley is black.

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Educated by nuns and priests, Dr. Brawley was helped and mentored by many who obviously gravitated to his sincerity and determination.  As a child he learned to duck bullets, and as a highly educated adult, he remains a keen observer of human nature and the nature of his profession at all levels.  He has overcome suspicions of a culture that would exclude him, but he remains empathetic to those who justifiably retain those suspicions.  Dr. Brawley is a skeptic.

As a practicing physician, a scientist and clinical researcher, an epidemiologist, and political activist, Dr. Brawley knows where the bodies are buried (sorry, couldn’t resist), and few are spared in his scathing criticisms of healthcare in America. And Dr. Brawley pulls this off still sounding humble, self-effacing, and passionately dedicated to his cause.  His book is part memoir, part jeremiad at callous and profiteering colleagues, and part exposition of what constitutes scientific clinical research and how findings are corrupted, repressed, or ignored by special interests. Consider:


  • America is #1 in dollars spent per capita on healthcare, but 50th among the world’s countries in life span, and 45th in infant mortality rates—behind even Cuba and Slovenia.  Shouldn’t that tell us there’s something wrong here?  Or should we just go to Cuba to have our babies?


  • “When you look at outcomes, our health-care system is closer to Communist states . . .


  • “Economic incentives can dictate that the patient be ground up as expensively as possible with the goal of maximizing the cut of every practitioner who gets involved.”


  • Of the 51 million Americans with no insurance, he says:  “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.”


  • Of the wealthy: “If you have more money, doctors sell you more of what they sell, and they just might kill you.”


  • “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.”


  • “Doctors who own labs have been shown to order more tests than doctors who don’t.”


  • Of free prostate cancer screening:  “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.”


  • “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. . . our professional societies tend to choose misguided collegiality over the well-being of our patients, the people who trust us with their lives.”


  • About patients:  “The majority is placid at best, confused at worst . . . [they] need to understand that more care is not better care, that doctors are not necessarily right, and that some doctors are not even truthful.”


  •  The importance of employer sick leave policies:  Some breast cancer patients with enough insurance will opt for a radical mastectomy, because the better option of a lumpectomy requires a regimen of radiation for weeks afterward and the patient can’t get the time off from work to make the appointments.


  • “Wallet biopsies”: You receive treatment in the emergency room of a private hospital until they learn you have no insurance.  You fail the wallet biopsy.


  • Insurance companies are sued by patients who want a certain treatment, and the insurance company has denied payment because the treatment is experimental or potentially unsafe.  Many patients have won their lawsuits only to discover (or their survivors) that the treatment was worthless and the side effects terrible, even lethal.  Be careful what you pray for . . .


  • Cancer treatments can easily reach $1,000,000 or more and surpass the lifetime maximum of a policy, leaving the patient without further recourse, uninsured and uninsurable.  Some, or many, of the treatments that ran up the bill may have been  spurious, ill-advised, or even harmful to the patient, but were cash cows to the providers.
  • Doctors’ pay is increasingly incentive-based, and they are under pressure to overprescribe.  Nurses in their practices are often trained to ask patients leading questions, such as asking a cancer patient if she experiences fatigue.  What cancer patient doesn’t?  This question predetermines an affirmative answer, which then segues into the sale of  a remedy for a novel medical condition ‘manufactured’ by the pharmaceutical company:  “cancer fatigue”.


The book contains about a dozen real-life case studies of catastrophic results from poor science and greedy practitioners.   Adjuvant therapy, which is additional therapy that is prescribed after the primary disease has theoretically been eradicated by other, earlier treatments, is singled out for special and extensive treatment in this book.  Adjuvant treatment is performed as insurance against the return of the disease.  Adjuvant therapy is sold as a no-brainer easy and lucrative source of revenue for physician practices and big pharma.  Adjuvant therapy is eagerly accepted by vulnerable, poorly informed,  and traumatized patients who will not be paying the bill out of their own pocket.  Unnecessary and overprescribed adjuvant therapies have inflicted excruciating harm and even killed patients, not to mention exploding  the cost of health care.  There is little or no malpractice risk for even a mediocre doctor as long as the treatment was within “evidence-based guidelines”, guidelines often written by the subspecialties of medicine whose members will profit handsomely from their application.

First of all, cancer survivors have been thoroughly traumatized by their disease and want to do anything to make sure they never have to relive this nightmare.  They are emotionally vulnerable and an easy sale for an unethical doctor who may (or may not) know the desired adjuvant treatment will most likely do nothing good for the patient,   and which  in some well-documented cases has actually done great harm by promoting the growth of new tumors where none existed after the primary treatment was successfully completed.  Many patients get very sick and even die from adjuvant therapies that physicians are all too happy to provide, but were not indicated by a now-symptom-less patient.  The cost of these therapies, for just one patient, can often run into five and six figures.  For a physician with a revenue quota to fill, this is easy money that is rarely passed up.  Ironically, the patients most at risk are the wealthy and the well-insured.  If you are uninsured or poor, you are not part of this particular target market.

In other cases, terminal patients are desperate and will grasp at any straws offered to them, including clinical trials of new drugs.  Very few of these patients are aware that Phase I of a clinical trial has only one purpose, and that purpose is NOT to cure them or even benefit them.  It’s only purpose is to determine the correct dosage of the new drug should it get approved.  Too little and it does no good; too much and it incurs catastrophic results.  Care to guess how the researchers determine what the magic dose is?  They start small and keep increasing it until something bad happens, then they back off from the cliff and hope they can rescue the patient.  In interviews very few patients in clinical studies really understood what was going on, and they were certain they were being cured.

Dr. Browley says the only ethical course for a physician is to “Tell the patient what I know, what I don’t know, and what I believe, and label all three correctly. Patients need to be informed about uncertainty in order to sit out the game or roll the dice.”

Everyone with a good mind and a ninth grade reading level should read this book.  The stories are compelling, even frightening.  The book is an educational tour of what really goes on in the hallways and offices of medicine.   Once we grasp the frightening concept that not  everyone we interact with as a patient is looking out for us but may instead be focused on their own self-interest, we will get off our duffs and take a close personal interest in what decisions we will need to make should we become sick, or what decisions others will make for us.  We also need to become less intimidated or awestruck by our health care providers.  They can be lethal.

Here’s a meaningless statistic of my own for you to ponder:  Fifty percent of all doctors graduated in the bottom half of their class.  When you are done laughing ask yourself,  was your doctor one of them?  Do you subconsciously judge your doctor by outward appearances?  Is the waiting room of your physician palatial? Is your doctor a prominent social pillar in your community?  Does your doctor belong to your country club?  Is your doctor the department head of  his specialty at the hospital?  Do you find particular comfort in his/her conspicuous affluence and projection of unquestionable almost god-like authority?  What do you really know about your doctor?  The practice of medicine changes by the hour.  Do your doctors stay up with the literature, or were they at their best only the first year they were out of their residency?  If you spent more time checking the references of your interior decorator than you did your physician, Dr. Brawley’s book may give you a few restless nights.  How We Do Harm  is a wake-up call for thoughtful readers.  The practice of medicine is this country is not a transparent profession.

Dr. Brawley’s book is predictably well documented and far more than a handful of mesmerizing, heart-wrenching case studies.  His book provides clinical detail for those who wish it, and if you are not a medical practitioner it is quite likely you will improve your vocabulary, which is always a worthwhile ancillary benefit to reading any good book.  If you are a physician, unless you are professionally engaged on the academic and research side, you don’t want to miss how Dr. Brawley connects the dots between academia,  scientific (usually) research, the pharmaceutical industry, clinical practice, hospital and institutional life, insurance, and, oh yes, let’s not forget the patient.  At every level of our system, ethical issues are constantly confronted, and unfortunately too often the financial incentives are  in all the wrong places.

The book is not an academic white paper; it is not boring.  Dr. Brawley is a good storyteller.  He is an original, and the kind of guy you would love to have as a neighbor or good friend.  The worst things I can say about his book is that in my opinion,  structurally,  it could have been pulled together a little tighter.  I wasn’t always sure where we were going, from one chapter to the next.  And of course, as a patient, at the end of the book, I wanted a prescription.  Where should I go next to find out more of what I don’t know? Perhaps that book isn’t written yet.

I admire Dr. Brawley, his attitude, his competence, his integrity and passion.  Dr. Brawley is an activist, and he believes the solutions lie in a massive grass roots movement to overhaul healthcare in America.  Perhaps I would agree with him if I had gone through what he has experienced.  But absent that, I have to content myself with appreciation for his having raised my awareness of how much we take for granted and how naive and ignorant we are, and I take his book as a call to action for me to educate and prepare myself and my loved ones for the day when  we may have to enter the healthcare system and hope to come out alive.  If each of us does that, we have reduced the problem by one.  Read this book.  Save yourself.  The world will be there (probably) when you get to it.


Book Review/Economics: Confessions of an Economic Hit Man by John Perkins

I am 63 years old and I need to live a very long time because my bucket list is extensive.  A significant item on that list is another sub-list–of the book titles that I still want to read or re-read.  At an average of two books per week, I can plan on reading about 100 books a year, or 1,000 in the next decade.  Included in this sublist of books-to-read are many of the classics of English and American literature.  These are the books that everyone knows you should read, but no one really wants to.  Or they would.  These are also some of the books that acquire more meaning and significance as you grow older.  They are best read, or re-read, later in life.  My choice of reading material depends a lot on serendipity and derives from suggestions from friends, browsing at Barnes & Noble, and what I stumble upon on the Internet.  The topics are mostly serious, only occasionally frivolous (and then usually because I feel a need to “lighten up”).  As I read I will post book reviews on this website.  I pretend at no special expertise other than an honest and inquiring mind.  My opinions are my own: the reader may follow or ignore my observations as you see fit, and at your own risk.  They may motivate you to read the book under review or save you time to move on with something more worthwhile.

Confessions of an Economic Hit Man by John Perkins was recommended by a CPA friend of mine.  303 pages including Notes and an Index.  The Preface to this book begins with this compelling paragraph:

“Economic hit men (EHM’s) are highly paid professionals who cheat countries around the globe out of trillions of dollars.  They funnel money from the World Bank, the U.S. Agency for International Development (USAID), and other foreign “aid” organizations into the coffers of huge corporations and the pockets of a few wealthy families who control the planet’s natural resources.  Their tools include

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fraudulent financial reports, rigged elections, payoffs, extortion, sex, and murder. They play a game as old as empire, but one that has taken on new and terrifying dimensions during this time of globalization.

I should know.  I was an EHM.”

Enough for me!  I was hooked!  I bought the book . . . and was disappointed.

The main story is about how the United States government through its various agencies seduced foreign governments during the seventies and eighties  into incurring debt they would never be able to repay.  Programs and financial instruments were sold under the auspices of altruistic intentions, but were in fact, thinly veiled efforts to advance the interests of empire, the American empire. Being the cynic that I am, I had to wonder well, why would our government treat foreign governments any better than their own citizens?  After all, in the last twenty years did we not compel our banking establishment to make residential home loans with little or no documentation of ability to pay to people who, well, had little or no ability to repay?  And then did we not cynically re-wrap these worthless financial instruments and pawn them off to foreign investors based on the fiction that the price of real estate can only continue to go up?  And when the bubble created by Federal Reserve-induced credit expansion popped, did our politicians not move in to prop up and save the elite moneyed interests?  A few straw men were sent to prison, but the masterminds and real benefactors became government appointees “to repair the system” and “make sure it never happens again.”

It seems an odd thing to say now in view of the current Euro crisis, but “beware Greeks bearing gifts” rings true today more than ever.  But I’m not talking about Greeks here.  Substitute “The Empire” for Greeks.    This reference to the Trojan Horse of antiquity well applies to any programs sponsored today by government promising something for almost nothing.  Something for little or nothing  always equals loss of control.  “Yes, of course, you can come home to live with us.  We still have the spare bedroom available for you” the aging parents say to their adult child suffering through a painful divorce or other financial setback.  Later, they will add “Of course, there are a few house rules you need to know about.”  Any foreign government or domestic citizen who accepts benefits from The Empire that make little or no  financial sense on their face can rest assured that somewhere in the fine print is a loss of freedom and a commensurate increase in the reach and control of The Empire. . .  ‘There are a few house rules you need to know about. . . ‘

My dissatisfactions with this book are not about the author’s premises and anecdotes, which are interesting enough. This much could have been accomplished in a book half this size.    At a deeper level, however:

1.  It offered nothing new.  No new perspectives and very little insider information.  Apart from sparse details of the author’s experiences in Indonesia, Saudi Arabia, Ecuador, and Panama, the author mainly resorted to repeating his fundamental premises ad nauseum without additional supporting material.  I even read his entire bibliography and all his footnotes to see if I had missed something.

2.  The author seemed to be guilt driven, and the sources of his guilt were unclear.  I couldn’t tell if he was agonizing over having gone too far in his career, or not having gone far enough.  Does he resent the privileges of his upbringing, or does he resent not having had enough privileges?  It seems that in spite of his modest successes, he is still struggling with some personal “impostor issues.”

3.  He offers no solutions to the dilemmas he presents, except the vaguest directives to personal activism.

Overall, I thought the author was boring with his endless self-flagellation, and the book was sophomoric in tone.  His argumentation in my opinion resembled the economic forecasts he submitted over the decades:  big on breathless rant and anecdotes, and weak on substance and documentation.  He still sounds like the second-hander he has always apparently feared being.  The shrillness of his exposition resembled the sententious moralizing of a new religious convert.

With all of his expertise, I would have expected much better of him.  Like the Wendy’s old commercial, I kept asking “where’s the beef?” The title of this book was the sizzle; unfortunately there was no steak.  I’m sure the author’s story plays well with the talking faces. I am disinclined to doubt his story, but mostly based on what I have learned from sources other than his book.

Coming up next for review:  How We Do Harm:  A Doctor Breaks Ranks About Being Sick in America by Otis Brawley, M.D. , Executive Vice President of The American Cancer Society.

Also:  Management and Machiavelli, by Antony Jay.