WHAT’S THE HARM IN HEALTH CARE?
A DOCTOR’S EXPOSÉ,
ATLANTA — The woman walked quietly into the busy emergency room at Grady Memorial Hospital, Atlanta’s safety net hospital for the poor and uninsured. She waited four or five hours to be seen, sitting patiently on a gurney and clutching a plastic bag.
Inside the bag was a moist, light blue towel that held one of her breasts. She was hoping it could be reattached.
A mixture of fear, poverty and lack of paid sick leave had led her to delay cancer treatment for years. Eventually, the tumor grew so large that it cut off the blood supply, causing her right breast to die and fall off, says Otis Brawley, chief medical officer at the American Cancer Society, who saw the woman in the ER that morning in 2003.
In his new book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America, Brawley presents the woman’s suffering as a metaphor for a rotting health system that is run, he says, “by the greedy serving the gluttonous.”
A nation of extremes
Brawley uses the book, on sale today (St. Martin’s Press, $25.99) and co-written with journalist Paul Goldberg, to show that ours is a nation of extremes, with the poor or uninsured frequently denied even the most basic care while the well-insured often are “overtreated,” receiving unproven drugs and procedures that can cause real harm.
Too many patients, Brawley writes, get a “wallet biopsy” that decides whether they’ll get care.
Brawley says he doesn’t want to ration care or dash the hopes of desperate patients who are willing to gamble on experimental therapies. But he says he’s tired of those hopes being exploited by a medical system that’s too lazy to insist that care be based on science rather than profit or best guesses.
Patient advocates such as Fran Visco, a breast cancer survivor, welcome Brawley’s call to action. “We pour so much money into overtreatment,” says Visco, president of the National Breast Cancer Coalition. “All of that could be channeled into getting more people care.”
Brawley’s message may resonate with policymakers because of his high rank within the cancer society, says Dartmouth Medical School professor Lisa Schwartz, who co-wrote a book last year called Overdiagnosed: Making People Sick in the Pursuit of Health. Brawley’s folksy style and sense of humor — his take on medicine is often darkly funny — makes complex issues easy for the public to understand, says Barry Kramer, director of cancer prevention at the National Cancer Institute.
Brawley fills the book with the stories of patients no longer here to speak for themselves.
Consider the woman who died after being given massive doses of an unnecessary but highly profitable anemia-fighting drug that could, studies later showed, sometimes “act like Miracle-gro for cancer,” Brawley says.
“I’m quite sure Otis remembers the patients who didn’t do well, more than the patients who did, because that’s the kind of caring individual he is,” says Michael Friedman, director of City of Hope Comprehensive Cancer Center in Duarte, Calif. “It’s not that Otis has all the answers, but he’s asking all the right questions.”
Some point out that doctors aren’t deliberately trying to harm their patients.
“A lot of people are trying to do their best in a broken system,” Schwartz says, adding that it’s too simple to say it’s all about greed. “It’s about how hard it is to come up with a system that gives people what they need.”
Making the best decision about care — such as when to provide hospice care, for example, rather than more invasive procedures — can be complicated and doesn’t necessarily reflect a doctor’s desire to make money, says Thomas Smith, director of palliative care at Johns Hopkins Medical Institutions in Baltimore.
Patients affect care, too
Brawley notes that patients themselves often ask for unproven treatments, even demanding that insurers pay for them. In many cases, however, those extra tests and treatments aren’t in patients’ best interests. “Prostate-cancer screening and aggressive treatment may save lives,” Brawley writes, “but it definitely sells adult diapers.”
And Gerard Anderson of the Johns Hopkins School of Public Health says that even the most educated and empowered patients may still have trouble challenging their doctors.
“When your doctor says, ‘You need this procedure,’ it’s really hard to say, ‘Really? I don’t think I need that,’ ” Anderson says.
“We just don’t have enough information as consumers.”