How We Do Harm exposes the underbelly of healthcare today—the overtreatment of the rich, the under treatment of the poor, the financial conflicts of interest that determine the care that physicians' provide, insurance companies that don't demand the best (or even the least expensive) care, and pharmaceutical companies concerned with selling drugs, regardless of whether they improve health or do harm.
Dr. Otis Brawley is the chief medical and scientific officer of The American Cancer Society, an oncologist with a dazzling clinical, research, and policy career. How We Do Harm pulls back the curtain on how medicine is really practiced in America. Brawley tells of doctors who select treatment based on payment they will receive, rather than on demonstrated scientific results; hospitals and pharmaceutical companies that seek out patients to treat even if they are not actually ill (but as long as their insurance will pay); a public primed to swallow the latest pill, no matter the cost; and rising healthcare costs for unnecessary—and often unproven—treatments that we all pay for. Brawley calls for rational healthcare, healthcare drawn from results-based, scientifically justifiable treatments, and not just the peddling of hot new drugs.
Brawley's personal history – from a childhood in the gang-ridden streets of black Detroit, to the green hallways of Grady Memorial Hospital, the largest public hospital in the U.S., to the boardrooms of The American Cancer Society—results in a passionate view of medicine and the politics of illness in America - and a deep understanding of healthcare today. How We Do Harm is his well-reasoned manifesto for change. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America
Dr. Brawley has written a powerful indictment of the current state of health care in the United States. He asks the questions that need to be asked in an age where advertisement trumps evidence and he challenges those who know better to do better. Be warned: once you truly internalize the reality of the wallet biopsy, you will never be able to see medicine the same way again. And that's a good thing. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America Depressing all around. A sharp criticism of our health care system, filled with hopeless tidbits, such as America has the forty-fifth worst infant mortality rate on the planet, yet per capita our healthcare spending is the highest in the world. Well great, way to be, America! Expect horrific stories such as the woman with a tumor in her breast that was so big, her breast fell off or the man who had prostate cancer & begged for possibly unnecessary radiation after his surgery, which ended up giving him a rectal fistula into his bladder (this is just as appalling as it sounds); this one's a real downer. Most unfortuantely, Brawley is extremely unlikable & comes across as the one man who can do no wrong; even mistakes made early in his career seem glossed over. He portrays most doctors as either buffoons who are bumblingly in it for the money or cold-blooded charlatans who don't care who they hurt with their faulty science. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America In which I learned that breasts can fall off. It makes sense, given the context--very advanced breast cancer--but my reaction was nevertheless, Holy shit, they can do that?
I am a skeptic and rationalist, Scully to the world's Mulder. Science is the best explanation for how everything works.
And yet, every encounter I've had with conventional medicine has reinforced my belief that the science and practice of medicine is horribly corrupted by the unrelenting power of money.
(This of course, has the nasty side affect of putting me in the same company as loony anti-vaxers and nutters who believe you can cure cancer with the right application of crystals and apricot seeds. Sigh.)
How We Do Harm: A Doctor Break Ranks About Being Sick in America is a well-researched call for rational health care in the U.S. Citing examples primarily from his own practice, Dr. Brawley explores how little effort (read: money) is put into true prevention and cures, and how the emphasis for the greatest health care system in the world is on extracting as much money as possible from patients. He also explores how the pharmaceutical industry exploits the public's scientific ignorance and our false belief that new is better to push expensive drugs with mediocre to poor efficacy. In one of the most wrenching narratives, he shows how one family's unwillingness to accept death resulted in the medical torture of a dying, catatonic, elderly man.
It's pretty much an indictment of the whole system, from the highest corporate levels down to the patient. While Dr. Brawley tries to remain hopeful that change will come, my inner cynic only sees the situation getting worst, especially given the current political climate.
As frustrated as it left me, this book was worth reading, if only for providing concrete reasons for my extreme aversion of the U.S. medical system. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America This is an excellent discourse on the economics of medicine, using the economics of cancer and the history of bad science on treating cancer as a rubric.
This book is really required reading for e-patient advocates because it dispels some of the core myths inherent in the pursuit of better medicine.
Most notably, it really skewers the basic notion that more testing is a good thing. It shows how testing can be more dangerous than not testing, especially for poorly understood diseases.
It also shows how different professional organizations recommendations differ from what is actually best care. This was probably the most disturbing part of the book, because it shows how easily influenced doctors can be when their wallets are on the line.
How We Do Harm: A Doctor Breaks Ranks About Being Sick in America Dr. Otis Webb is brutally honest.....if we could all stand up to the health care system that we have like Dr. Otis, it would only change for the better. Would highly recommend. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America
I don't know that I've ever read anything that came so close to summing up my years in health care. That said, there's one thing to get out of the way. The title is misleading (shocker). The appropriate title would be: Dr. Otis' Thoughts on a Broken Health Care System and His Career in Medicine. Back to reality. Since Dr. Otis is African-American, male, from a prestigious family, trained as an epidemiologist as well as a medical doctor, and a national healthcare leader, we clearly have different relationships to the health system. But we've both spent years in oncology, done stints in the ER and have met many of the same types of patients and unfortunately, have noticed many of the same types of problems, so minus the Dr. Otis part, there's a lot here that I will attest to as being absolutely, sadly, totally true.
It's an extremely readable book, particularly considering the health-care focus and non-fiction aspect. Granted, I've been in the field, but compared to I Contain Multitudes, which was excellent but idea-dense, this flew by. I was halfway through the book in a day. No doubt, Otis' co-writer, Goldberg, gets much of the credit. As a journalist, he's probably comfortable conveying his ideas at a generalist level.
Otis has worked for much of his career at Grady, an Atlanta hospital known for providing care to the poor. The chapter 'Chief Complaint' discusses a working-class woman, Edna, who comes in with a case of breast cancer so severe that her breast has actually fallen off (okay, this I have never heard of, being in a relatively high-healthcare-using population). He discusses the ins and outs of late stages versus early stage and points out that Had she come early in the course of her disease, it would have cost about $30k to cure her. She could have remained a taxpayer. Her kids could have had a mother. Now, a cure is not an option. Still we’ll fight... give chemotherapy that will cost more than $150k, even though chances are that she will still die in less than two years. Otis talks about some of the specifics of breast cancer (see blog), but if you haven't heard it by now, 25% of Medicare costs are for people in their last year of life, so this concept of preventative versus heroic care is hardly unique.
'Brawleyism' is a short chapter on Otis Brawley, the author, and his family history as rebels. He then discusses the overall economics of the American health care system, and the fact that we're 50th in life expectancy world-wide. Again, this isn't new, but what is interesting is that he states A rational system of health care has to have the ability to say no, and to have it stick. Very powerful stuff, and he shows how people that wanted more got it, basically from unscrupulous or less-caring doctors (If I didn't do it, someone with less expertise would have). He does talk about about how financial incentives are (were? The ACA did give incentives for these small practices to become part of big systems) built in for doctors who own/profit-share in labs, pharmacies, and imaging centers. At the very least, many have a professional and implicit bias where they believe their profession can help, although evidence may be slight.
'Cadillac Care' discusses how even people who have access to advanced care can be steered wrong. Brawley spills the beans on how bone marrow transplant programs for breast cancer were money-makers in the 1990s -20s until they were proved useless. This treatment was based based on four randomized trials, with less than 1500 people, one of which was found later to be fraudulent.
There are some similarities going on right now with CAR-T cell therapy, hailed as the next cure for cancer, only current studies are based on about 150 people. Though roughly a third of the people died. But half of them were cured (and half of those with complications), so full speed ahead.
'Red Juice' talks about a drug called Procrit, another potential lifesaver on the cancer scene back in the 2000s that turned out to be deadly (more on blog) Otis shares a bit about a woman's personal experience with it (I think she might have had 200 doses during her treatments) and how it was a money-maker, with $4.9 billion in sales in 2006 (so you can stop the bullshit about research costs, Amgen).
So it feels a little like same snake oil, different decade. People wonder how I'm old and cynical. It's because of this reading thing. I tell you, don't do it.
A couple of chapters--and again, an unfortunately common refrain in my experience--was the story of Mr. Huzjak, a 78-year old who had stage 4 non-small-cell-lung cancer (with a 5 year survival rate of about 6% for distant mets). He was comatose when brought in, but his children wanted everything done. The family practice doctor couldn't convince them. Otis couldn't convince them. He finally died after enduring pain (the only thing he reacted to) of LPs, CTs, chest tubes, tube feedings, a MI and chest compressions. End result: same. He passed on. Except it was traumatic for all concerned, particularly Mr. Huzjak. Oh, and expensive as well. I can't even tell you how upset I get with Americans and their concepts about death (see Death Panel Discussions, Health Care Reform). Personal example: my own mom is 74 and won't even talk about it like a reality, plan for it, whatever. Frigging baby boomers think they are going to live forever.
Some of his story is more about himself, particularly towards Part III, and about population statistics, epidemiology and preventative medicine. He uses the example of poor Ralph, who stopped in for a free PSA screening at a local mall, had a high PSA, had surgery, then radiation, then medical complications. (continued at blog)
TL; dr: The summation: use science-based medicine (not just evidence-based guidelines from societies, who have a vested interest); don't let your fears guide you into excessive treatment (as a patient or as a practitioner); preventative medicine costs less than curative; don't be afraid of death. There's many, many worse things than dying largely pain-free with people you love around you. Okay, I made that last part up. Otis didn't explicitly say that. He calls it Rational Health Care.
Overall, I'd highly recommend it for people in hospitals and clinics. It should make practitioners think about what we recommend and why, and what and who is behind our recommendations. Likewise, as a consumer, it might help us understand that asking questions is good. Not just have you done this before, or what do other people do, but, what does the evidence say? Yes, there's an art to medicine, where careful assessment and questioning can get a good doctor far. A good practitioner should be able to couple that with cost-effectiveness and risk-analysis when it comes to exposure (if our cancer patients live, the odds of getting secondary cancers is quite high. We aren't helping with all the radioactive scans to 'reassure' on progress).
Reasons against five stars: It really should have left out the beginning bits of Otis' career, especially his training in epidemiology. I don't know that it was germane. There's a little tension in this story between the need to make it The Otis Story and the Breaks Ranks About Being Sick.
My blog has longer paragraphs with detail if you like, and links to stats. https://clsiewert.wordpress.com/2019/... How We Do Harm: A Doctor Breaks Ranks About Being Sick in America The author of How We Do Harm, Otis Webb Brawley, is chief medical officer and executive Vice President of the American Cancer Society. A medical oncologist with an interest in epidemiology and biostatistics, Brawley works at one of the largest hospitals in the United States, the Brady Memorial, in downtown Atlanta. This is the facility where the indigent, the insurance-less, the unconscious accident or trauma victims come (if they were alert, they’d likely direct the attendants elsewhere), but is also the place that police and firefighters choose because of the optimal trauma care it provides. Brawley can tell you which cancer screening tests are useful, whether certain cancer drugs actually work, and the ways in which cancer strikes white and black Americans differently. In short, he is eminently qualified to provide “a guided tour of the back rooms of American medicine.” (p.20)
Quoting a friend, Brawley says the American health care system would be better named the sick care system. It is a system that combines famine (for poor Americans who receive too little health care, especially of the preventative sort) and gluttony (for the rich, who unwisely consume too much health care that is sometimes of spurious value, and even frankly detrimental). Brawley writes with some bluntness that because doctors are paid piecemeal for their services, most succumb to recommending procedures that will line their own pockets, even when these procedures are of questionable value. “Dismal outcomes on both ends of the spectrum [rich and poor]” could be improved, he says, “if we were simply faithful to science, if we provided and practiced care that we know to be effective.” (p. 12) He provides a number of quite compelling case studies of patients he has known who have faced life-altering, often terminal, cancer diagnoses to illustrate his points. Although he occasionally sounds a tad full of himself, his book is generally a worthwhile and interesting text of considerable educative value.
How We Do Harm: A Doctor Breaks Ranks About Being Sick in America I rarely give contemporary books a 5-star rating.
This is one of those books that will help you think straight about what may be happening to you and maybe the guy next to you the next time you visit a doctor's office or clinic.
The main author, Otis Brawley, was formerly director of the National Cancer Institute. He is well-credentialed, yet he advises patients not to be swayed by titles like chair of the department but rather to challenge the luminaries to justify their treatment decisions.
Brawley encourages patients to become as knowledgeable as possible about their condition, to scan the credible medical literature (as opposed to only the pharmaceutical company ads), to ask probing questions, to be skeptical. If you find yourself a candidate for a complicated procedure, compel your doc to make these distinctions 'say what you know, what you don't know, and what you believe'. Don't let the doc confuse what he believes with what he knows for sure.
Not surprisingly, if you're a patient with good insurance, then it's much more likely you'll undergo an unnecessary and potentially harmful procedure.
Filled with patient stories, this book does not read like a dry textbook. But it is a timely indictment of the avarice and politics endemic in the healthcare arena. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America A great read. From the opening story about a woman whose.breast falls off from cancer to the resulting advocacy of a man who lost his wife to the disease, this book sheds light on the multiple systemic ills of our health care system. Brawley is a doctor, but more importantly a great storyteller. This book is.frightening, infuriating, and amazing to read. How We Do Harm: A Doctor Breaks Ranks About Being Sick in America Sometimes books line up in unpredictable ways. I just finished Kahneman's Thinking Fast and Slow, which discusses how our native thinking is heavily emotional and resists the hard work of rationality, and along comes this book--as if to use my own thinking to verify Kahneman's thesis.
Take screening for health problems. As an oncologist, Brawley primarily discusses cancer screening--but the epiphenomena surrounding identification and treatment of cancer may be taken as illustrative of the general issue.
My own reflections-while-reading went something along the lines of: what could be wrong with screening? It seemed to me an entirely well-meaning and innocent activity. But as Brawley puts it: With screening, you are redistributing risks and benefits across a population. You have to perform a screening test on a certain number of people to detect a certain number of cancers in order to save a life. You may be saving lives, but you accept the notion that you are also hurting people--possibly even killing some with interventions. My thinking about screening suffered from the halo effect--it was all good. I did not even begin to suspect a downside.
Brawley, the chief medical officer of the American Cancer Society, shows a significant downside of medical care that caused snowballing, bad outcomes for insufficiently good reason. He talks about a family that can't bring itself to allow their terminally ill father to be eased into death, but insists instead on heroic measures whose only result is to exacerbate the man's agony. He discusses our tendency to see cancer and the possibilities for treatment in all-or-nothing terms--cure or die--when often it would be better to understand that it's more about weighing the quality of life against the quantity of time actually available.
The result, in Brawley's damning terms, is a health care system that works exactly as designed. It's designed to run up health-care costs. It's about the greedy serving the gluttonous. ... Much of the money currently spent on health care is money wasted on unnecessary and harmful, sick care. Even for the sick, a lot of necessary care is not given at the appropriate time. The result is more expensive care given later.
Why isn't that necessary care not given? Money. 51 million American adults who have no insurance live desperate lives. They don't get the necessary, appropriately-timed preventive and educational care. And meanwhile, those with access? Some of them insist on paying 12 times more for name-brand medicines because their insurance covers it, a practice that earns Brawley's scorn: As a scientist, I can assure you that we are being laughed at.
This book is a scathing indictment of the current system of healthcare in the US: As I look at this mess, I realize that we don't need health-care reform. We need health-care transformation. Americans need to change how we view health care. We need to change how it is provided and how it is consumed.
How We Do Harm: A Doctor Breaks Ranks About Being Sick in America
Otis Webb Brawley Ñ 4 review
