NON-FICTION
Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer (2007)
By Shannon Brownlee
For many years, discussions about health care policy have revolved primarily around cost and access. There is little disagreement that the pattern of growth in costs is not sustainable and that costs are a barrier to extending even basic care to the 47 million Americans without the insurance needed to partake at the banquet that is American health care.
While these discussions have been going on, John Wennberg of Dartmouth and others have published mountains of studies documenting variation in health care services and outcomes, related primarily to geography and practice preference—not established medical evidence. Wennberg published his first paper on geographical variation in health care 35 years ago (Small area variations in health care delivery, Wennberg J, Gittelsohn, Science. 1973 Dec 14;182(117):1102-8, available at www.sciencemag.org) and went on to found the Dartmouth Atlas of Health Care (essential reading for all interested in improving our delivery system).
Shannon Brownlee has used the data in the Dartmouth Atlas and the principles of Wennberg's work, along with a number of individual stories, to describe overtreatment as a national problem. She makes essentially two points:
1. We spend between one fifth and one third of our health care dollars on care that does nothing to improve our health.
2. Overtreatment often causes harm, because medicine is inherently risky and even the safest procedure brings some risk.
Her points are no surprise to those of us who have functioned in any capacity in the delivery system in the last three-plus decades.
Why is this happening??
Again, no surprise. These results are the natural outgrowth of our fee-for-service health care system, which turns doctors from professionals into pieceworkers, "paid for how much they do, not how well they care for their patients." Hospitals, too, depend on volume of work for their income. Together, hospitals and doctors are the gatekeepers who decide what work needs to be done and when. Both also have to worry about being sued if they do too little, so they err on the side of overtreatment.
Brownlee quotes Wennberg as saying, "Nothing has changed since our Science paper." She goes on to say, "Nothing of course, except the fact that American medicine has swelled into a behemoth industry equal in size to the entire economy of Italy. Today, there are more technologies and drugs available to doctors and patients than ever before, and they are more expensive. For many patients, of course, the medical progress of the past several decades had meant the difference between life and a premature death or disability. But for others, it has simply meant more opportunities to receive more costly unnecessary care. For some, it has meant premature disability and death."
Brownlee is, I think, mostly evenhanded in her discussion of precipitating factors, which surely include aggressive physicians, litigious patients and hospitals anxious to add new capacity. Also contributing are direct advertising to consumers, control of clinical trials by Big Pharma, insufficient oversight by weak federal agencies charged with reviewing the evidence that treatments work, and patients with expectations that are unrealistic and over-entitled. There is plenty of blame to go around, and Brownlee meticulously details how everyone at the trough is vested in keeping it running.
Eventually (and if you get tired of the anecdotes, skip to the end rather than put this book down), Brownlee devotes some time to potential solutions. More academic and less suited to the more general audience at which the book is aimed, her discussion includes changing incentives for physicians to include patients more actively in decision making, liability reform, promotion of evidence-based medicine, and a very interesting review of some of the results of the "CARE" strategy (Coordination, Accountability, electronic medical Record and Evidence) at the Veterans Health Administration.
Some of the anecdotes are a little hard to believe or aren't typical of health care, but most of the concepts are familiar to those working in health care. We know that health care spending simply can't continue to rise at its current pace. At the same time, it is unpleasant and discouraging to acknowledge that the more technologically advanced and specialized our health care system becomes, the worse we all feel.
Changing demographics and medical technology pose a financial challenge to every nation's delivery system, but our system is clearly the outlier. The extraordinary failure of the U.S. to contain the costs of tests, procedures and drugs results primarily from our unique and pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, the recent wave of investor-owned specialty hospitals and outpatient treatment centers and the profit-maximizing behavior even by nonprofit hospitals and systems raise costs and distort resource allocation. How can it be that 35 years after Wennberg's gift we have not been able to significantly reduce practice variation?
"The resistance is structural," Dr. Wennberg told Brownlee. "It relates to the fact that doctors don't want to think they are not doing the right thing. You can understand why doctors feel that way; they've done it all their lives. But we don't need professionals who are trained to hunt with no requirements for accountability."
Therein lies the special challenge for physicians. We can be pieceworkers in a malfunctioning grid of dysfunctional incentives. Or we can recommit to our professional covenant that places the welfare of the patient at the center of our work, including those doomed to exclusion from the miracles of modern medicine because they don't have insurance. Toward that end, we will need to work together to embrace contemporary accountability, transparency and shared decision making, even in the face of fiscal realities that demand increasingly difficult trade-offs.
How Doctors Think
By Jerome Groopman, MD
Many readers are no doubt familiar with the work of Jerome Groopman, who has written extensively about complex medical conditions for the New Yorker and about health care policy for the New Republic. In this book, the Harvard Medical School professor describes the processes by which medical minds synthesize information and understand illness.
Groopman draws on a wealth of research, extensive interviews with smart, selfless and occasionally heroic doctors, and his own experience as a doctor and a patient to dissect the anatomy of correct diagnosis, appropriate treatment and humane care, along with diagnostic error, misguided therapy and thoughtless bedside manner.
Anchoring Groopman's book is the notion that while physicians recognize clinical patterns, a number of factors influence their perception and judgment. He writes, "Most errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don't realize." Cognition and emotions are, he says, inseparable.
He describes a number of cognitive mistakes, familiar to any of us. For instance, representative errors occur where thinking is guided by prototype bias, so that doctors fail to consider possibilities that contradict some existing prototype, such that symptoms are attributed to the wrong cause. One example is chest pain in an apparently robust younger person, felt unlikely to have coronary disease.
Attribution errors occur when findings are attributed to a negative stereotype such that alternatives are not considered, such as the cirrhotic who has another cause for liver disease other than alcohol. Affective errors can occur in the setting of genuine affection for a patient when we prefer what we hope will happen to less appealing alternatives.
Groopman is not, however, hypercritical and his book is not just a catalogue of physicians' mistakes. Instead, he seeks to inform the reader that skilled clinicians rely on pattern recognition to narrow an infinite number of possibilities, and often use seasoned reasoning and practiced communication skills. These clinicians are very far from making snap judgments to evaluate successfully very complex information to make life-saving diagnostic and therapeutic recommendations.
Groopman accurately and empathetically portrays the time-constrained environment in which medical decision making often occurs. In one chapter he compares the setting to spinning plates at the circus. He describes the medical uncertainty all physicians must deal with, noting that frequently decisions must be made despite uncomfortable uncertainty.
Whether a physician is defining a disease, making a diagnosis, selecting a procedure, observing outcomes, assessing possibilities, assigning preferences, or putting it all together, "a doctor is walking on slippery terrain," he writes. "It is difficult for non-physicians, and for many physicians, to appreciate how complex these tasks are, how poorly we understand them and how easy it is for honest people to come to different conclusions."
Near the end of the book, there is a clear, cogent and timely chapter on marketing, money and medical decisions. It is unlikely, Groopman notes, that in the near future personal financial gain will be extracted from certain clinical decisions.
Every thoughtful doctor will learn from this sensitive and refreshing book. The passion and honesty of the author generate an authenticity and eloquence that will resonate with anyone familiar with clinical medicine.
Deep Economy
By Bill McKibben
What is an economy for? Bill McKibben asks that question in his provocative new book, subtitled “The Wealth of Communities and the Durable Future.”
Up to the development of the steam engine in the early 1700s and the beginning of the Industrial Revolution, the standard of living of the average inhabitant of the planet varied little from year to year or even century to century.
Subsequently, we were able to exploit the earth’s storehouse of fossilized energy to perform work and make possible everything—including economic growth—which we consider normal and obvious about the world.
By 1776, Adam Smith in “The Wealth of Nations” was able to point out that “it is not the actual greatness of national wealth, but its continued increase” that raises wages and hence the standard of living.
Lawrence Summers, Secretary of the Treasury in the Clinton Administration, summed up the contemporary American economic gestalt regarding the economy when he said, “It is the task of economic policy to grow the economy as rapidly, sustainably and inclusively as possible.”
The central thesis of the book is that a single-minded focus on increasing wealth hides important costs, causes ecological havoc and fails to make us happier. Think of McKibben’s book as a response to The World is Flat, Tom Friedman’s largely positive take on the globalized economy. Sure we get stuff cheaper, McKibben says, but do we need more cheap stuff if it comes at the expense of the environment, the economy and the community?
After a brief review of the history of economic growth, McKibben describes the system of feeding Americans. It turns out that the average item on our dinner plate has traveled 1500 miles to get there and that the greatest single ingredient on that plate is the petroleum needed to plant, fertilize, process and transport that food. By concentrating food production, we have achieved tremendously cheap, widely available food of all sorts—but at an expense we rarely consider. (For more on this very interesting topic, see Barbara Ehrenreich’s recent Animal, Vegetable, Miracle.)
Throughout the book McKibben writes precisely targeted (and delightful) criticisms of Wal-Mart, Clear Channel and the other modern, consolidated and concentrated purveyors of cheap goods to individuals without regard to our larger communities. He also takes aim at the hyperindividualism of our times in a thoughtful chapter entitled “All for One or One for All.”
McKibben describes small local efforts, from farmers and farmer’s markets, local radio, small energy projects to local lumber projects. Not only can they be economically successful, he reports, they are akin to the social arrangements Adam Smith counted on to balance his new economics—sturdy communities where the baker and the butcher actually knew each other and where they had to show themselves as good citizens because they all had some level of dependence on one another.
Today, he says, we are essentially two nations: Wal-Mart Nation (gigantic, globalized, unsustainable in the face of climate change and coming exhaustion of fossil fuels and Farmer’s Market Nation (manageably small, localized, communitarian, neighborly and calibrated on a human scale). The latter can provide a different set and more satisfying set of rewards, he argues—not always cheaper but more closely tied to our daily reality, less wasteful of natural resources and more sustainable over the long run. McKibben anticipates and answers the objections to going back to a perhaps romanticized past. “Given the trend lines for phenomena like global warming and oil supply,” he writes, “what’s nostalgic and sentimental is to insist that we keep doing what we are doing simply because it’s familiar. The good life of the high-end American suburb is precisely what is doing us in.”
An intelligent, socially responsible localism—a readjustment downward of material expectations and in our own personal economies—“might better provide goods like time and security that we are short of,” he writes. He’s got a point. Perhaps life is more than another day at the mall.
The Post-American World
By Fareed Zakaria
To put Fareed Zakaria's latest book, The Post-American World, in context, I reached back to the novel The Camp of the Saints, written by Jean Raspail in 1973. Set 15 or 20 years in the future, Raspail imagined millions of starving citizens of India escaping their ghastly conditions by commandeering an armada of decrepit ships and setting off for the French Riviera.
In a scene on one of the fleeing ships, Raspail captured the specter of an India collapsing under the sheer weight of its fast-growing population:
"Now, stretching over that empty sea, aground some fifty yards out, [lay] the incredible fleet from the other side of the globe, the rusty, creaking fleet that the old professor had been eyeing since morning....He pressed his eye to the glass, and the first things he saw were arms....Then he started to count. Calm and unhurried. But it was like trying to count all the trees in the forest, those arms raised high in the air, waving and shaking together, all outstretched toward the nearby shore. Scraggy branches, brown and black, quickened by a breath of hope. All bare, those fleshless Gandhi-arms....Thirty thousand creatures on a single ship!"
The desperate voyagers had been inspired by a kind of liberation theologist exhorting them to advance upon the Western paradise. "The nations are rising from the four corners of the earth," the man cries out, "and their number is like the sand of the sea. They will march up over the broad earth and surround the camp of the saints and the beloved city...."
Raspail's real interest, however, was conjuring the varied responses of the French and the other privileged members of "the camp of the saints."
France, in fact, has not witnessed hordes of Indian boat people washing up on its shores. And India has not imploded in the face of population growth. Instead, it has seen major sectors of its economy grow as have many other emerging nations. Their economic growth has fueled political confidence, national pride and potentially challenging international problems. That is the world Fareed Zakaria takes as his starting point. In some not-too-distant future, Zakaria, asserts, we'll live on a planet where the United States no longer dominates the global economy, orchestrates geopolitics or overwhelms other cultures. Does this mean an increasingly dismal future for us? No, says Zakaria, setting the stage for a book not so much about the decline of America, but about the improving fortunes of everyone else.
After a brief introductory chapter, Zakaria reviews the globalization of the economy and growth in the last 20 years or so. In chapter three, he describes the relatively recent history of Western economic and political domination; he follows those with chapters devoted to the economic growth in China and India in the context of their unique political and cultural histories.
We are now, he says, in the midst of the third great tectonic power shift in the last 500 years. First was the rise of the West, which produced "modernity" as we know it: science and technology, commerce and capitalism, the agricultural and industrial revolutions. The second was the rise of the United States in the 20th century, and the third is what he calls "the rise of the rest," with India and China becoming bigger players in the world, Russia becoming more aggressive and Europe acting with increased strength and purpose on matters of trade and economics.
The final two chapters are the real strength of this fine book. Like Raspail, Zakaria's focus is not on "the rest" but on our own response to the changing dynamics. He describes the evolution of American power, including our recurrent anxiety about losing our edge. He then notes that our world-beating economic vibrancy and resilience has co-existed with a dysfunctional political system. He writes, "A 'can-do' country is saddled with a 'do-nothing' political process, designed for partisan battle rather than problem solving."
If we truly believe in the virtues of free markets, immigration, science and technological progress, competition and democracy, we cannot be suspicious of those virtues in the hands of others. Rather, we need to adopt new ways of relating to the rest of the world based on consultation, cooperation and even compromise, rather than go-it-alone unilateralism. Maybe that will begin to happen in the wake of the November election. Zakaria outlines some simple, but clear and lucid principles regarding the need to set priorities, build global rules and encourage flexibility.
This book is clear, well organized and insightful. My main criticism is that it is too short, and hence somewhat superficial. Nonetheless, it is an accessible, timely and valuable contribution to our national conversation at a time when we must begin a serious transformation of global strategy to share power, create coalitions, build legitimacy and retain our relevance in a post-American future.
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