Dr. Otis Brawley, an oncologist and chief medical officer for the American Cancer Society, has long been an outspoken critic of unnecessary medical tests and procedures.
On this topic, he is perhaps best known for his opposition to the routine screening of men for prostate cancer, pointing out repeatedly that the scientific evidence does not support it — and stating that anybody who says otherwise is “not telling the truth.”
Earlier this week, Brawley spoke before a group of medical reporters at the annual conference of the Association of Health Care Journalists in Atlanta. Although I didn’t attend the event, I watched Brawley’s on-the-record speech on YouTube.
Once again, he didn’t mince words.
Unsustainable costs
Brawley began by pointing out that health-care costs are currently 18 percent of our gross domestic product (GDP), a cost that’s projected to climb to 25 percent in 2020. That’s just eight years away.
If we don’t start reining in those costs, Brawley said, “it’s going to cause our economy to collapse.”
Yet despite all the money we spend on health care in the United States, we still lag behind other countries in many important health indicators.
“When we had the conversation about health-care reform, I can remember some of the politicians talking about how great our health care system is,” Brawley said. “And I was thinking, ‘Gee, we’re 50th in life expectancy. We’re 47th in infant mortality rate. Countries such as Cuba do better than the United States in those measures.’”
In fact, said Brawley, we spend more than any other country on health-care costs — about $8,000 annually per man, woman and child. “The number two country, which is Switzerland, is a little less than $4,000 dollars,” Brawley noted. “Switzerland is fourth among [United Nation] countries in life expectancy, and we’re 50th. I don’t think we get what we pay for.”
Brawley also talked in his speech about how “the whole discussion about health care and health-care reform seemed to lack the fact that there were people out there who were suffering. There were people out there dying.”
He quoted a saying used by the Marines: “We are Americans. We leave no one behind.”
It’s a message, Brawley said, that appears to have eluded many of the politicians and others who are developing our health-care policies. “We are Americans, and we leave a lot of people behind in our health-care system,” he said.
‘Irrational form of medicine’
Brawley also pointed out that much of the spiraling health-care costs in the United States comes from waste and greed. Doctors need to be paid more for prevention than intervention, he said, and all treatments and procedures should have solid scientific evidence behind them to show that they’re both effective and safe.
We practice “an irrational form of medicine,” Brawley said. “When I hear politicians talking about death panels and rationing, we need to be talking about the rational use of medicine — not rationing, but rational. But unfortunately, that’s not happening in the United States.”
He peppered his speech with several examples of irrational medicine. Routine prostate cancer screening was one. But he also mentioned how pharmaceutical companies are able to make a minor change in a drug that is about to go off patent and then market it as a new — and, of course, much more expensive — drug, even though it’s essentially the same medication. His example was AstraZeneca’s transformation of the heartburn drug Prilosec into Nexium. The off-patent drug, Prilosec, now sells for about $1 a pill, while Nexium sells for about $6, according to Brawley. (A generic version of the drug sells for about 35 cents.)
Brawley also criticized the medical community for adopting medical treatments long before their benefits — or safety — have been proven. As an example, he cited autologous bone marrow transplantation for breast cancer, which was widely used in the late 1980s and 1990s. The theory behind the treatment seemed reasonable, Brawley said, so doctors and hospitals began providing it to their patients (and women began demanding it), despite the fact that nobody had done any studies to prove that it worked.
“The folks who wanted to make money said, ‘Why don’t we just do it?’” said Brawley.
Finally, in 1999, researchers published four clinical trials that showed that the treatment was more likely to kill women than to benefit them. But by then, said Brawley, “there were more than 220 bone marrow transplant breast-cancer centers in the United States” and thousands of women had received the treatment.
‘Subtle form of corruption’
Health care today is “a subtle form of corruption,” said Brawley.
Who’s at fault for this corruption? All of us. “Quite honestly, it’s the doctors, it’s the hospitals, it’s the hospital system, it’s the insurers, it’s the drug companies, it’s the lawyers, and it’s even the patients,” he said.
“What we desperately need to do is not reform health care,” said Brawley. “We need to transform how we view health care. We need to become more appreciative of health-care prevention efforts.”
We also need, he added, “to understand and appreciate science. We’re not going to have improvements in our health-care system until the mass population demands that doctors appreciate science [and] demands and asks doctors to justify their recommendations and justify their decisions. We need the skeptical, educated consumer. We need people who consume medicine to think about health care the same way they think about buying a television set at a Best Buy. We need people to stop just accepting things and start being skeptical.”
You can listen to Brawley’s speech — and the question-and-answer session that followed — on YouTube.
Follow the money
Why do we spend more and recieve SO much less? We must, as americans, assure a mega profit to those who have no direct connection to our healthcare. Hence the large incomes of CEO’s and CFO’s and the lowered incomes of real medical staff. And that cleaning crew that kept the hospital clean? Forget it, that costs too much.
Doctors need to learn to accept people being skeptical, too
I once had a doctor tell me I was an “adversarial patient” who didn’t trust doctors. When I asked him what he meant by that, he told me it was because I always asked questions rather than just accept what he told me needed to be done.
I know that in this – as in everything – the patient needs to be respectful of the doctors’ education and experience. But many doctors still have a long way to go in learning how to have a relationship based on dialogue rather than dictatorship.
This discussion mirrors
the larger issues of inequality in the United States. The system may be ruinously expensive, but at the high end it probably does offer some of the best care in the world. People with generous health insurance plans are getting state-of-the-art care. The trouble is that many Americans are either without insurance or have wholly inadequate coverage. For these people, the outcomes are not so rosy.
The largely unspoken fear about health care reform is that expanding coverage and achieving better outcomes for more people will diminish the quality of care at the top. It’s viewed as something of a zero-sum game in which health care goodies are “redistributed” from the top down. While overall outcomes will be improved, those who benefit from today’s highest-end medical care, whether they are providers or patients, fear a leveling effect that will harm their interests.
I am in complete agreement with Dr. Brawley about the need to stop paying for procedures that don’t work or, in some cases, are actually harmful. But good luck having a rational discussion about these issues. Look at the furor a few years ago over the US Preventive Services Task Force recommendations, suggesting less-frequent mammograms. Providers were quick to jump in and argue for preservation of the status quo and women were outraged that their health was supposedly being sacrificed on the altar of cost savings. For some reason, the public readily sees mercenary motives whenever it’s suggested that there’s “too much medicine” but seldom recognizes the huge financial interest in maintaining the current system.
Re: Pat Berg
And many patients are overly skeptical because of some garbage that they read on the internet. I know it is your health, but doctors are also trying to do more (for less pay) than they used to and know every other patient is a complete know-it-all. I find a doctor I can trust and then I trust him. I may be smarter than he is, but he knows way more about medicine than I do.
Way to throw the blame back at the patient
How about the doctor trusting the patient a little since it is – as you point out – that patient’s health that is on the line. And to the doctor, I am one of many. But I am the only “me” that I have got.
Setting even that aside for the moment, however – where does your suggestion leave the patient who is just starting with a new doctor? “Find a doctor I can trust” is a nice idea, but if I don’t know the doctor yet, and if you’re telling me I’m not allowed to ask reasonable questions, where does that leave me?
This shouldn’t be an adversarial relationship. Each one should give the other the benefit of the doubt – the patient being respectful of the doctor’s education and experience, and the doctor being respectful that their patient wants to be (and is capable of being) an informed member of the team looking out for that patient’s health.
That is actually the relationship I have with the veterinarian who cares for the health of my pets. Is it asking so much to want the same relationship with the person caring for MY health?
If you’re blindly trusting your doctor
You’re going to be in a world of hurt. They’re human beings and they make mistakes, and GP’s often have a spectacular lack of knowledge. My family has had a few close calls that were only averted because we made sure we didn’t just accept everything we were told.
My brother is a doctor and very critical of the way medicine is practiced in this country, especially tight scheduling of patients to get as many billable office visits in per day as possible, group practices where the emphasis is on profit for the partners rather than successful outcomes for the patients, over-medication, over-recommendation of surgery, treating the symptoms rather than looking for the causes, inattention to nutrition and lifestyle issues, insurance companies in general and the way in which they further distort the practice of medicine with their requirements for paperwork–forcing the hiring of additional personnel or an outsourced billing agency–and their “percentage of customary charges” reimbursements.
Problems with our health insurance system are well-documented, but has anyone ever looked closely at the malpractice insurance system? Yes, there have been some huge malpractice awards, but have there been enough to justify routine $200,000 malpractice premiums for some specialties? Or are the malpractice insurance providers price gouging, too?
“like buying a television set at best buy”?
Sorry, but no. If i have a serious condition, I do not have the knowledge or the time to “shop around.” The consumer-oriented medicine pitch ridiculous on its face. The cheapest doctor is not necessarily the best doctor because quality and price have nothing to do with each other in this system.
All those other countries he cites that get better outcomes for so much less all have one thing in common – some form of universal insurance coverage, and strong cost controls and approval of treatments based on science. None of those countries ask the patient to treat their chemotherapy or appendectomy like a TV at Best Buy. In almost every case (really, probably every case) the patient doesn’t do the shopping around in those countries. The government does, either directly or via proxies.
But Wait
The vast majority of health problems are lifestyle-induced. Lack of physical activity and poor diet are two factors outside of the healthcare system that are driving up costs. Ever hear someone say, “Why is America the only country where poor people are overweight?” The cheapest foods in the grocery store (and the foods at fast food joints) are are giving us health problems. We don’t subsidize fruits or vegetables but do subsidize corn and wheat. And yet despite this meddling in the free market, when Michelle Obama encourages (but does not require) the consumption of fresh vegetables and an active lifestyle,she gets criticized for “big government telling us what to do.” Like encouraging the production and consumption of corn and wheat isn’t
There has been a vast decrease in cigarette smoking not due to making it illegal but by the government saying “don’t do that”. We can do the same with being active and eating better. The least we can do is to stop encouraging the sale of food that is killing us.