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.
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.