I thought I knew what there was to know about the overuse of medical care. I work in a big city tertiary care subspecialist-driven hospital. I am a geriatrician and a palliative medicine physician. I spend much of my clinical time trying to help patients and families make decisions that best fit their needs and goals among the ever-increasing range of treatment options offered to them. So I was surprised to find myself staying up late to finish this book with a rising sense of despair at what has happened to our medical profession.
Rosemary Gibson and Janardan Prasad Singh tell the story of how our training, our payment system, the media, the culture of the teaching hospital, and the firm and unshakeable belief in America that more must always be better have hijacked the central tenet of medicine—to do right by our fellow human beings who trust us with their lives, our patients.
It was put best by Dr. Francis Peabody, lecturing at Harvard in 1912 after his own diagnosis of cancer: “The secret of the care of the patient is in caring for the patient.”
The Treatment Trap is beautifully written—clear and direct, filled with facts bookended by stories of people caught and harmed by the system and the doctors they had trusted completely.
The authors take us through the many forces conspiring to lead us to this place. They identify the fact that the system is perfectly designed to get the results that it gets. The public is bombarded with the latest research breakthroughs on the evening news. The for-profit manufacturers of these breakthroughs lobby congress and advertise direct to consumers.
Physicians are trained in teaching hospitals where the premium is on innovation, technical expertise, well-reimbursed procedures, NIH research dollars, and subspecialization. Students and residents observe and absorb the culture of these teaching hospitals—when in doubt do more tests, call more consultants; the terror of missing the diagnosis; the respect/space/staff accorded the high-volume and well-remunerated interventional cardiologists, oncologists, neurosurgeons.
Medical students graduate with hundreds of thousands of dollars in debt that must be repaid just as these young physicians are finally out of nine or more years of post-college training and trying to start a practice and a family. Physicians specializing in interventional or procedural specialties are paid many-fold higher than primary care internists or family practitioners.
Even doctors who want to practice primary care cannot afford to do so. Hence the intense competition for residency training in dermatology and plastic surgery and the unfilled fellowship slots in geriatrics just as the number and needs of the elderly in our nation explodes.
Not only do physicians believe firmly in what we have been trained to do, even when there is little to no scientific evidence supporting it, their patients, convinced by advertising and a breathless media, believe that there is no problem that American medical ingenuity cannot solve.
The audience for this book is the general public. But we physicians should read it and reflect on what we may be risking. The reward and privilege of the practice of medicine depends entirely on trust—the fundamental priceless trust of our patients in our intent to do all in our considerable power to help them.
Once the general public starts to believe that we could be using patients for purposes other than their own best interest—purposes such as increasing our volume to make money or to please hospital administrators; recommending treatments without a clear and honest explanation of the risks and the alternatives—we will lose the basis of our position and power to help.
New insurance reform laws just passed will not solve this problem of perverse financial incentives favoring quantity of care over its quality.
The authors acknowledge that most physicians in our country are honorable and continue to try to do the best for patients despite an increasingly difficult and bureaucratic practice environment—but the warning signs of erosion of trust of our patients are increasingly visible. Public trust and approval of Congress is at an all time low of 16%, because our elected representatives are perceived to be motivated by money and not by the public good.
The Treatment Trap is the canary in the mine for the medical profession.