Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line

Critical Global Health: Evidence, Efficacy, Ethnography

by Sharon R. Kaufman

Most of us want and expect medicine’s miracles to extend our lives. In today’s aging society, however, the line between life-giving therapies and too much treatment is hard to see—it’s being obscured by a perfect storm created by the pharmaceutical and biomedical industries, along with insurance companies. In Ordinary Medicine Sharon R. Kaufman investigates what drives that storm’s “more is better” approach to medicine: a nearly invisible chain of social, economic, and bureaucratic forces that has made once-extraordinary treatments seem ordinary, necessary, and desirable. Since 2002 Kaufman has listened to hundreds of older patients, their physicians and family members express their hopes, fears, and reasoning as they faced the line between enough and too much intervention. Their stories anchor Ordinary Medicine. Today’s medicine, Kaufman contends, shapes nearly every American’s experience of growing older, and ultimately medicine is undermining its own ability to function as a social good. Kaufman’s careful mapping of the sources of our health care dilemmas should make it far easier to rethink and renew medicine’s goals.

Genres: Medicine, Medical, Nonfiction, Anthropology

336 pages, Paperback

First published May 4, 2015

About the author

Sharon R. Kaufman is Chair of the Department of Anthropology, History and Social Medicine at the University of California, San Francisco. She is the author of …And a Time to Die: How American Hospitals Shape the End of Life.

Reviews

[Traci · Rating 3 out of 5]

*Thanks to NetGalley and Duke University Press for the opportunity to read and review an advance reader's copy of Ordinary Medicine.

In Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line, Sharon R. Kaufman, a medical anthropologist, poses the question of “when, where, and how to draw the line” when it comes to medical care for the aging, particularly toward the end of life. Kaufman states that “a nearly invisible chain of social economic, and bureaucratic forces has made once-extraordinary treatments seem ordinary, necessary and desirable." She provides a well-researched portrayal of the operations of the U.S. health care system and examines the fine line between providing “enough” treatment to older adults vs. over-treatment, or “too much,” thereby increasing quantity of life without necessarily increasing quality.

Kaufman refers to this as “a perfect storm created by the pharmaceutical and biomedical industries, along with insurance companies.” She details how research and clinical trials contribute to new treatments, what treatments are subsequently funded by Medicare (and thus all private insurers as well), how treatments come to be considered standard and necessary, and concerns of fairness and ethics with a variety of medical issues.

Kaufman mentions several changes in the field of medicine that have been the focus of widespread concern (and that I have noticed as well during a career in the health care field) including:
• Too much life-sustaining but death-prolonging technology is being used at the end of life
• Drug companies are increasingly paying physicians to promote their products
• Expensive tests, devices, and procedures are overused
• Drug costs have skyrocketed, yet the new drugs don’t necessarily offer better results than existing treatments

Kaufman further affirms that “In the United States today most deaths, regardless of a person’s age, have come to be considered premature.” She says that “the particularly American ethos of ‘more is always better’ underlies the high-tech and aggressive approaches to treatment." She then delves into what she considers the four primary drivers, and provides patient vignettes to illustrate each: 1) The biomedical research industry and mushrooming clinical trials engine, 2) Medicare and private insurance determination of whether specific therapies, devices, or procedures should be reimbursable, 3) The ensuing standards of care that arise once a therapy is reimbursable by insurance, and 4) The resulting ethical difficulty, or even impossibility, for physicians, patients, and families to refuse a specific therapy once it is deemed standard.

Ordinary Medicine is definitely not a light, quick read. It is more along the lines of a dissertation or (very long) journal article about the issues involved in end of life care, with many notations and references along the way. For this reason, I think the book may appeal more so to those with some health care background, or at least those with a strong interest in learning more about the influence of social, economic, political, ethical, and cultural forces on U.S. health care.

[Jane · Rating 5 out of 5]

I was asked to review this book by the Nursing Times Journal.


Description:
This is an interesting and thought provoking book. this focuses on the older patient. In this day and age and the ever increasing advances in medicine do we as clinicians and healthcare practitioners do too much? When is enough? This book gives the reader a little breathing space to re-evaluate and review our practices.


Highlights:
The chapter concerning chemotherapy and giving a patient perhaps longer to live was really thought provoking. the author explores this with the other side of the coin, and the dilemmas concerning at what cost, will this be to the detriment of the patients quality of life and at the same time being bombarded with life expectancy figures. There is at times perhaps misunderstanding that having very invasive treatment for incurable cancers will not cure them. The author explores the more is better, which can be right up to death and could the patient have had quality of life in a shorter time. it shows as we know medicine cannot be an exact science.

The older patient becomes a dilemma, we are living longer but with that comes complex medical problems. The clock ticks but yet clinicians are striving to keep people alive irrespective of patient’s medical conditions.

It begs the question do we need a rethink at times and do we need to ensure we are treating patients as individuals and not conditions.

The author has spent time listening to patients, clinicians and family members to gain their perspective and unique experiences.


Strengths and weaknesses:
Written for the healthcare settings in the States, but that need not deter UK readers as the information is just as relevant in the UK.

Potential Readers:
This is book for all healthcare practitioners and medical staff making decisions and caring for patients. Examples could be used for case studies in mortality and MDT meetings. This is a book to be on junior doctor and nursing reading lists and just as apt for the senior medical team also.


https://webmail.talktalk.co.uk/cp/ps/...

[Judy · Rating 5 out of 5]

I found this book fascinating. As a physician I deeply appreciate the perspective, history and ethical evaluations this book provides to understand the forces that currently shape medicine in the US. I read the book with increasing interest. The author writes as a scholar, but the book is quite readable. She explains that "Ordinary Medicine" is beneath the radar and has been formed by the forces of funding/reimbursement--focusing on Medicare, an aging society and the shift from patriarchal medicine to "shared decision making" which often foists a huge burden upon patients. Until I read this book, I had no idea that implantable defibrillators had become so ubiquitous in elderly patients and she describes a situation--a perfect storm--of unlimited Medicare funding for hospital based medicine, technological advances and clinical guidelines that encourage intervention. She evaluates the ethics and practice of transplant medicine where organs are allocated by time on the list and quite elderly patients receive organs from much younger donors. The system is in desperate need of change, and yet as she quoted a physician daughter of a terminally ill patient harshly responding "more is more" to a physician's attempt to palliate. Americans are terrified of rationing and lack of access to treatment in healthcare, but this book shows how so much of the "evidence based" decisions are often based on reimbursement, market forces and unexamined ethical quandaries. And conflicts of interest abound. Most of us in medicine need perspective and we're often in the trenches and unable to take this long view. This book provides much needed clarification and exploration of the unseen forces behind "Ordinary Medicine".

[Tomo · Rating 4 out of 5]

Although published by an academic press, this book is written in easy prose and many non-academic readers would find this book relevant and interesting. Kaufman tackles the fundamental question facing medicine in the US today: while it is possible to extend human life longer and longer with new technologies, how much is too much? She points out that the "medical-industrial complex" as well as Medicare force doctors to provide new technologies for old patients. But should decisions on what options patients have be influenced by the interests of the industry? Should we prioritize patients over 65 in medical care just because they have Medicare when so many younger Americans don't even have access to basic healthcare?
While a lot of what the author says specifically applies to the US (especially about the politics of insurance do not apply to many other contexts that have universal health care), I think the questions she discuses are prominent in many other societies as well. My mother's friend's husband in his late 50s recently had severe brain damage in Japan and he is brain dead, but he is being kept alive by latest medical technologies. Doctors cannot stop this treatment because doing so would be equal to "murder" - but is this really the best option for him and his family, when his wife does not have a job and keeping him alive for an unextended period of time costs tons of money? Ultimately, as Kaufman argues, there should be a nation-wide and global discussion about what is ethically agreeable care, especially for the old, the brain dead, and the chronically-ill.

[Alyssa · Rating 1 out of 5]

Unfortunately this author felt the need to present work, in the spirit of "just asking questions," that bring forth arguments commonly used to support eugenics. The theme of the books is largely "do elderly people deserve care?" Using terms such as "selfish" and "entitled", Kaufman repeatedly drives home her obvious opinion that care is wasted on the elderly and should be saved for the younger, rather than asking why our care is so limited that we would have to make that choice in the first place. Lacking any kind of material analysis, this work seeks to lead the reader to ask 'which among us is deserving of care?' Disappointing that so many in academia praise this author.

[em]

the first of many medical sociology books i’ll be consuming this semester 🕺

[Josephine Ensign · Rating 4 out of 5]

Ordinary Medicine is one of those books that is simultaneously deeply disturbing and enlightening. Having lived through the reality of both of my elderly parents being offered--and accepting and demanding--extraordinary medical treatments that extended (but at a huge cost in all ways) their lives by perhaps a few years--reading this book was validation of the ethical complexities of it all. Where to draw the line?--indeed--is the multi-billion dollar question we all need to ask ourselves.

[Sharon · Rating 3 out of 5]

Ordinary Medicine looks at the advances in medical science from the perspective of geriatric and/or end of life medicine. It provides insights into decision making for feeding tubes, liver transplants, dialysis, pacemakers, IEDs, bypass surgery etc. It is very helpful for making end of life decions for parents or self.

[Ann · Rating 4 out of 5]

Interesting and thought-provoking.