TulsaAllergyNews

I don’t usually post articles about political subjects in medicine, but this one caught my eye.  Let me know what you think. 

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.

Doctors in the United States don’t see cancer patients like this every day. 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 this week (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.

On the other end, he writes, “wealth in America is no protection from getting lousy care.… Wealth can increase your risk of getting lousy care. If you have more money, doctors sell you more of what they sell, and they just might kill you.”

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.

There is always another opinion about every book published and here it is—>

“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 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.

But doctors may not question the system, either, says Thomas Smith, director of palliative care at Johns Hopkins Medical Institutions in Baltimore. “Most doctors are sleepwalkers, not evildoers,” Smith says.

“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 Smith.

Smith agrees with Brawley that changing the system will require educating patients and families. “This can’t come just from doctors and nurses. It will require some changes in society and people, to accept the medical facts,” Smith says.

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.”

Standing at the window of Grady’s tenth-floor cancer center, in his white doctor’s coat, Brawley points out Ebenezer Baptist Church, where Martin Luther King once preached, and the building where the Southern Christian Leadership Conference met. “This is the cradle of the civil rights movement,” Brawley says.

And like the civil rights movement, change will have to come from the bottom up, Brawley says, and from patients who have had enough.

“The health care system is dramatically broken,” Brawley says. “All of us need to radically change. I’m convinced that health care transformation is a civil rights issue.”

Brawley has broken ranks with his peers before, often by saying things on the record — clearly, and in colorful language — that others acknowledge only in private.

While his supervisors at the cancer society have always supported him — Brawley says he was a “known commodity” when hired in 2007 — his unvarnished assessments of cancer drugs and screening tests have often gotten him in hot water with patient advocates, and even cancer society members. While Brawley recommends mammograms, he says doctors should be honest with women about their limitations and risks: “There is this pervasive belief,” he says, “that mammography is better than it is.”

Prostate cancer advocate Tom Kirk is familiar with Brawley’s arguments, and his rhetorical flourishes. “There are a great number of us who have learned to engage with Otis, and it is rare that he says something about prostate cancer where there isn’t a chorus of us who respond,” says Kirk, president and chief executive officer of the group Us TOO. While Kirk says he appreciates Brawley’s efforts to get men to think carefully about health care decisions, he also fears that men could use Brawley’s words as an excuse to avoid doctors entirely. Men “have come too far in this country not to play an active role in our health care,” Kirk says.

Brawley praises other patient-led efforts, such as the National Breast Cancer Coalition’s Project LEAD. The free training program teaches patients and their supporters to understand medical evidence, and advocate for treatments and policies that reflect the best science.

Consumers typically misinterpret any attempt to limit care as a cost-saving scheme, Schwartz says. “Even if we had all the money in the world,” Schwartz says, “we would still want to make better decisions about how to make people feel better and live longer.”

Some of Brawley’s concerns are already being addressed, says John McDonough, a professor at the Harvard School of Public Health.

Beginning next year, Medicare will penalize facilities where patients get a lot of hospital-acquired infections, and where a lot of patients are readmitted shortly after being discharged, McDonough says.

The Affordable Care Act, the healthcare law championed by the Obama administration, also provided funding for a research center that compares existing treatments against each other, something that’s not ordinarily done when new drugs are approved, McDonough says.

The Affordable Care Act also creates community groups, called accountable care organizations, through which hospitals can work with local groups to improve community health, says Gerard Anderson, of the Johns Hopkins School of Public Health.

But McDonough also says it’s not possible to make the system work perfectly. “The notion that there is a pure, rational way to do something, on which everyone could agree, just doesn’t fit reality,” McDonough says.

And Anderson 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.”

Too much of a good thing? 

Here are some of my thoughts about procedures in allergy & asthma:

• Are too many allergy patients placed on immunotherapy (allergy shots)?
• Testing for lung function (PFTs) can be expensive, but this test is very helpful for the proper diagnosis.  Is the cost worth it for you?
• This article didn’t mention the legal aspect of NOT performing a test.  Doctors won’t get a break in court if they didn’t perform a test and say “I was trying to save the patient money.” 

Don’t think we’ll get this solved today but let’s have fun with it.