Book review: Overtreated – Why Too Much Medicine Is
Making Us Sicker and Poorer, Shannon Brownlee, Bloomsbury, 2007
Shannon Brownlee’s articles about medicine and health care have been published in the Atlantic Monthly, the New York Times Magazine, the New Republic, and Time.
Dust off the soapbox and check that it will hold me and not tip over, because I’m jumping up on it for a few minutes. Overtreated should be required reading for doctors, nurses, patients, politicians, and everyone else concerned about health care in America.
A bit of testimony from Dr. Marcia Angell, M.D., Harvard Medical School senior lecturer, former
editor of the New England Journal of Medicine, and author of The Truth About the Drug Companies, in a quote on the book cover: “This book could save your life. Shannon Brownlee explains how well-insured Americans get much more high-tech medical care – CT scans, angiograms, and the like – than they need, enriching the hospitals and doctors who provide it, but driving up the overall costs of health care and often endangering patients’ lives. Brownlee clearly shows in this important book that overtreatment, like undertreatment, is very bad medicine.”
There have been several attempts to fix our health care system, beginning almost a hundred years ago during World War I and on through the Great Depression, the Truman and Eisenhower administrations, the Medicare reform in the 1960s, the Clinton administration, and most recently the passage of health care reform in the Obama administration. As recently as 2006 we Americans spent more on health care than food and almost as much as the world market for petroleum. (Page 2)
Why is health care in America so much more expensive than in any other country? Several reasons:
1) Malpractice – physicians order more tests and prescribe more medication because they are afraid of being sued.
2) Medical insurance – because people who don’t pay out of pocket use more health care than they need.
3) Higher prices – fewer doctors per capita, doctors who earn up to 6.6 times what doctors in other countries earn, and hospitals that charge $1,666 per day, four times the average in the rest of the
4) The pay-for-service basis for health care – likely the fundamental reason health care is more expensive. Simply put, doctors make more money when they see more patients, hospitals make more money when they admit more patients, drug companies make more money when more patients buy their drugs, and so on.
Brownlee’s research showed that there is an enormous hole in the system: lack of scientific evidence
independent of drug companies, the lobby known as the American Medical Association, and a host of other “research” conducted by organizations that stand to make more money if the results of their research are marketed effectively. “In fact…stunningly little of what physicians do has ever been examined scientifically, and when many treatments and procedures have been put to the test, they have turned out to cause more harm than good. In the latter part of the twentieth century, dozens of common treatments, including the tonsillectomy, the hysterectomy, the frontal lobotomy, the radical mastectomy, arthroscopic knee surgery for arthritis, X-ray screening for lung cancer, proton pump inhibitors for ulcers, hormone replacement therapy for menopause, and high-dose chemotherapy for breast caner, to name just a few, have ultimately been shown to be unnecessary, ineffective, more dangerous than imagined, or sometimes more deadly than the diseases they were intended to treat.” (Page 27)
I have great respect and admiration for the doctors, nurses, and other medical professionals I have known and who have taken good care of me, but as I read about physicians ordering too many tests and too much medicine, surgeons performing operations that have still not been proven to be effective, hospitals that are forced by the nature of our system to focus too much on profit, I thought here is an area where an independent federal agency could perform the necessary scientific research. And then I turned the page and discovered such a federal agency already exists – it is called the Agency for Healthcare Research and Quality (AHRQ), which barely survives budget cuts from year to year due to the antigovernment sentiment prevalent in Congress when the Republicans are in charge and the lobbying efforts of the AMA and other groups more interested in profit and loss and preservation of the current dysfunctional system. (See Pages 293-4)
I’ll finish with one example of a wasteful and often unnecessary surgery: spinal fusion. When AHRQ’s predecessor agency appointed a commission of twenty-three experts who were to produce a clinical guideline for the treatment of acute lower back pain, and the commission recommended
nonsurgical treatments for most instances of lower back pain, the surgeons and manufacturers of devices used during spinal surgery bombarded Congress with accusations of bias among commission members, formed a lobbying group charged with opposing the recommendations of the commission and the agency itself, and sought a court injunction prevent the agency from publishing the recommendations. (Page 294)
“When the agency’s guidelines…were finally published, they had little impact on medical practice. The number of spinal fusions has continued to rise dramatically over the past decade, up 127 percent between 1997 and 2004. We spend more than $16 billion each year on spinal fusions, even though there still has never been a rigorous, government-funded clinical trial showing that the surgery is superior to other methods…. We spend an additional $2.5 billion on fusion hardware…which can add $16,000 to the price of a surgery. Yet there’s practically no evidence to show that all those screws and plates improve outcomes either.”
Take a few aspirin before you read this book; the details are going to startle you. If you don’t already support effort to reform health care in America, Overtreated might just change your mind.