How Doctors and Patients Do Harm

Just how broken is the United States health care system? Dr. Otis Brawley, chief medical officer for the American Cancer Society, paints a grim picture in his new book “How We Do Harm: A Doctor Breaks Ranks About Being Sick In America’’(St. Martin’s Press).

If the title alone doesn’t clue you in, the reader quickly discovers that Dr. Brawley is determined to make everyone as uncomfortable as possible about the flaws, inconsistencies and inequities that are rampant in American medical care. The book, written with Paul Goldberg, a journalist, begins with a frightening tale of a poor woman who for so long went untreated for breast cancer that her whole breast literally falls off at home. She arrives at the hospital carrying it in a plastic bag, clinging to the naïve hope that it might be reattached. Dr. Brawley treated the woman at Grady Hospital in Atlanta, which happens to be the largest hospital in the United States, as well as the safety-net hospital for poor and uninsured patients in the area.

Dr. Brawley says it makes him furious when he hears “politicians and pundits” assert that American health care is the best in the world. The statement may be true for the rich, he says, but “it’s not a great place to be sick if you are poor and uninsured and want consistent, basic care.”

“I have seen enough to conclude that no incident of failure in American medicine should be dismissed as an aberration,” he writes. “Failure is the system.”

But as you nod your head in agreement, be warned that Dr. Brawley doesn’t place all the blame on insurance companies, hospitals and doctors. He also blames patients who have bought into the notion that more care — more treatment, more screening, more scans, more drugs — is better care. Many Americans, particularly wealthier ones, he says, are “gluttonous” in their consumption of health care resources and often use them unwisely.

I recently spoke with Dr. Brawley about the problems in American medicine, how both doctors and patients can be greedy and why he became such a “loudmouth.” Here’s our conversation.

Q.What prompted you to write this book?
A.I started looking at my career, listening to the discussions going on about health care reform and health care costs being exorbitant. A lot of people didn’t seem to realize that in a lot of the discussion, we’re talking about human beings who are suffering because of lack of health care, and sometimes we’re suffering because of overuse of health. People are so focused on fears about rationing of health care. The talk should not be about rationing health care but about rational health care. So much of what we do in health care is irrational.
Q.Can you describe an experience you’ve had with irrational health care?
A.There was a man with colon cancer who went to a wonderful hospital with a wonderful reputation. He got surgery and was referred to a medical oncologist who has a wonderful reputation as a doctor to the rich and famous in Atlanta. That medical oncologist started giving him chemotherapy and two other expensive drugs. When this man lost his insurance, the oncologist basically dropped him, and the guy ended up being seen by me at the county hospital. A doctor who is training with me to be an oncologist immediately realizes that this guy is getting a chemotherapy regimen for colon cancer that we stopped using about 15 years ago. His medical oncologist was practicing the best medicine of the late 1980s, but we were in 2006. The other drugs he was being prescribed were totally unnecessary. But the doctor could get a substantial markup and make a substantial amount of money by selling them. The oncologist had known just enough to be greedy and prescribe drugs he can make money off of, but he didn’t know enough to prescribe the chemotherapy that would have given the patient a much better chance of surviving his cancer.

I’ve seen that so many times, where doctors really have failed to evolve and failed to learn as the profession and the scientific evidence have changed over time.

Q.But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?
A.Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

Q.The story about the woman whose breast fell off was horrible. What were you trying to tell us with that example?
A.We so frequently talk about breast cancer almost as if it’s a boutique disease or trendy. I feel some people have forgotten how terrible this disease can be. This lady – I saw a lot of things in her background that were lessons for society about what we need to do if we want to defeat breast cancer. When she realized she had something growing in her breast, she had insurance, but logistics having to do with her job and child care and a little bit of denial kept her from going to the doctor and getting this thing diagnosed and treated when it was likely curable. Later on, when she wanted to see a doctor, she couldn’t because her insurance had gotten so expensive that she had to drop it. If she had come in when she first found this thing 9 or 10 years earlier, I probably could have cured it, and it would have cost about a tenth of what we spent when she was uninsured and receiving free care from the hospital. She lived for about two years after I met her. That’s a failure of medicine to educate people.
Q.In the book, you talk about a conversation with a hospital marketing executive who talks about drumming up business with free prostate cancer screenings at a mall health fair. How did that affect you?
A.That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does, and then I see a lady whose breast is falling off who couldn’t afford to see a doctor when she wanted to see one.
Q.Is there any hope that things might improve someday?
A.I am trying to get folks, through this book, to talk a little more about rational use of health care and realize that we are actually hurting people with overtreatment. Health care needs to be consumed in a wiser way that is much more concerned about allegiance to the science. We need to be more concerned about the welfare of our patients. There was a recent report, the 45 tests we do too much, that I was thrilled to see. People are starting to realize that we need to be a little wiser in our use of health care.
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