ST. MARTIN'S PRESS, HARDCOVER, PAPERBACK, KINDLE, 2012, ISBN 0312672977
In the interest of full disclosure, I have worked with both of these authors on various projects over many years and consider both to be valued colleagues and friends. For those of you who know these two guys, you would expect their book to be a “no holds bared, smash mouth, take no prisoners” treatise—and you will not be surprised or disappointed.
Through a series of skillfully presented and illuminating histories, Otis (he repeatedly states his desire to be called by his first name) documents the health care system's failure to deliver health care to the poor; illustrates the underuse, overuse, and misuse of our health care tools, and points out patients' frustrating demands for excessive, unwarranted, or even futile health care. While these are insightful, as the author himself points out, “The anecdote—the experience of a single patient—is least valuable still.”
Each case study explores these issues in revealing detail. However, the reader is left with a very critical—and in many ways, unbalanced—view of the problems. For example, when discussing the expanding share of America's GDP consumed by health care, the book fails to mention our growing and aging population and the expansion of truly effective and sometimes lifesaving health care in the past half–century. These demographics far outweigh the financial impact of the waste, fraud, and greed so well illustrated in the text.
When criticizing doctors' failure to police their own, the book fails to mention the “restraint of trade” realities of present-day law. Sometimes the authors are caught in their own criticisms. Frequently mentioned is the overuse of diagnostic imaging. However, when evaluating Helen, a patient with known metastatic disease, a PET/CT scan is ordered. Was it useful? Perhaps. Was it necessary? Absolutely not.
Otis, Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society, is a trained epidemiologist with a focus on prevention, and a large portion of the book is devoted to an analysis of various screening programs and their overall benefit. In these sections the book carefully spells out the data suggesting a more skeptical view of screening for prostate, breast, and lung cancers. But colon cancer, one of the most successful of all cancer screening efforts, is not covered. Again the authors are sometimes caught in their own criticisms. When discussing the complexity of breast and lung cancer screening trials, the book calls for strict statistical discipline for the breast trials but suggests that the 20% decrease in risk of lung cancer death with the use of spiral CT screening may be a “fluke” and points out that p=0.04 is just barely less than 0.05. This kind of selective interpretation seems difficult to justify.
For the lay reader, the book will be a difficult and indeed frightening read. It paints a picture of a medical care system driven primarily by greed, waste, ignorance, insensitivity, and duplicity. To be sure, all of that does exist, but committed, dedicated, informed, competent, and caring physicians like Otis also exist and in far greater numbers. It seems unlikely that the progress made in the last 50 years in medicine would have been possible with a system so callous and self-indulgent. In the absence of a clear strategy for improving the health care system and spelling it out for the lay reader, the book risks leaving the lay reader frightened and rudderless.
For the practicing oncologist, much of the text will be familiar. All of us have experienced the corrupt underbelly of cancer care. Unfortunately, those who most need to read this book will probably not do so, and even if they do, may fail to see themselves in the book's mirror.
The book's most refreshing and revealing story in my view is the evolution of Otis Brawley as a physician. He grew up in the Black Bottom section of Detroit, the son of a janitor and numbers runner. The transformational contributions of family, friends, and a stimulating and encouraging Catholic school system believed in him and pushed him to be critical and to succeed. This coupled with his personal drive took this African-American kid and catapulted him into the University of Chicago. From there he reached the highest echelons of medicine. Told in an understated and self-deprecating style, it's the most inspiring story in the book.
Also insightful for the oncologist reader and to readers in general is the matter–of-fact way that Otis illustrates the continuing ugly face of race in American medicine. Examples begin in the 1950s with the construction of Grady Hospital. Built in the form of an H to allow segregated populations to occupy the ends of the “Gradys,” it was supported by separate nursing training programs for the two races. One might have thought the date was 1850, not 1950.
Otis, with great sensitivity, illustrates through patient voices, the deep-seated mistrust of research harbored by African-American patients and the sometime distrust of black physicians by both races for different reasons. This theme of the book is one of its most engaging.
Although many of the flaws in our health care system are highlighted, the book is unfortunately light on solutions. There do not seem to be any straightforward resolutions of the obstacles presented by the country's demographic changes, which will continue to overload the health care system.
Likewise no strategy for addressing the personal weaknesses or the greed of some physicians is readily at hand. The book suggests no answers for the patients or families who desire unlimited health care even when futile. The reader is left with an aching view of our weaknesses but without a blueprint for improvement.