Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

by Shannon Brownlee

Though touted as perhaps the best in the world, the American medical system is filled with hypocrisies. Our health care is staggeringly expensive, yet one in six Americans has no health insurance. We have some of the most skilled physicians in the world, yet one hundred thousand patients die each year from medical errors. In this gripping, eye-opening book, award-winning journalist Shannon Brownlee takes readers inside the hospital to dismantle some of our most venerated myths about American medicine. Using vivid examples of real patients and physicians, Overtreated debunks the idea that most of medicine is based in sound science, and shows how our health care system delivers huge amounts of unnecessary care that is not only expensive and wasteful but can actually imperil the health of patients.

The interests of politicians and the medical-industrial complex continually trump those of patients, seducing the wealthy with unnecessary procedures and leaving the poor with haphazard access to treatment. Backward economic incentives allow patients with chronic conditions to receive ineffective care, and roll after roll of red tape undermines even the best-intentioned doctors. Tens of thousands of patients die each year from overtreatment. American medicine is in desperate need of fixing.

Nevertheless, Overtreated ultimately conveys a message of hope by reframing the debate over health care reform. Americans worry about rationing―that any effort to rein in the high cost of health care will result in limited access to life-saving treatments. Covering the uninsured seems like an insurmountable problem because it will drive up costs even more. Overtreated offers a way to control costs and cover the uninsured, while simultaneously improving the quality of American medicine. Shannon Brownlee's humane, intelligent, and penetrating analysis empowers readers to avoid the perils of overtreatment, as well as pointing the way to better health care for everyone.

Genres: Nonfiction, Medicine, Health, Medical, Science, Health Care, Economics

352 pages, Hardcover

First published September 18, 2007

Reviews

[La Crosse County Library · Rating 4 out of 5]

Review originally published October 2008

Calling Dr. Kildare!

Rarely do I recommend a book as a “must read.” My personal reading tastes are quite unique (whose aren’t?), and I realize that not everyone shares my unbridled enthusiasm for the two Daves (Barry and Sedaris). Nevertheless, here it is: a book I solidly suggest as one you should not miss.

But first, a little background…

In the years prior to my membership in the exclusive over-60 club, I operated under the Doctors Welby and Kildare system of health care. Any hitch-in-my-git-along that required a doctor’s attention would be fixed by a kindly older male physician who would probe around, frown thoughtfully, maybe take an x-ray or blood sample, tell me what to take to feel better, send a bill and that was that. You’d either get better or you wouldn’t. The only “odds” they gave you were “good” or “bad.”

Well, those days are gone, gone, gone. Now a doctor will tell you what percentage of people with your health problem, having X surgery or taking Y prescription, have Z likelihood of surviving XY number of years. You’ll hear about clinical trials and statistics. LOTS of statistics. And you’ll be expected to be part of the “team” determining your own treatment.

And that’s only the beginning. Modern medicine is more complex, expensive, and convoluted than Doctors Welby and Kildare could have imagined. And unless you’ve been vacationing on the planet Zork for the past few years, you know that there is a crisis in modern American healthcare.

Which leads to that all-important book I mentioned: OVERTREATED: WHY TOO MUCH MEDICINE IS MAKING US SICKER AND POORER by Shannon Brownlee. Overtreated is as fascinating as a who-done-it novel.

With the precision of a skilled surgeon and the readability of John Grisham, Brownlee dissects issues such as the scarcity of primary care physicians, medical errors and why they happen, why you have to cool your heels for hours waiting to be seen by a doctor, the role of medical device manufacturers and drug reps (who are invariably good-looking) in determining your treatment, why some surgeries seem to be more prevalent in certain geographic areas, and numerous other quirks of our current method of healthcare.

One of my favorite parts is her analysis of direct-to-consumer television advertising of drugs, some of which simply show healthy, sexy people romping on a beach with a suggestion that you ask your doctor if this drug is right for you. (If there’s really a drug which would make me look like that, I’d certainly want it. In mass quantities!)

Patient demand for advertised drugs and for tests which may or may not be beneficial are crucial elements of the problem. But there is plenty of blame to go around: fear of malpractice suits, insurance companies, hospital fiscal mismanagement, overscheduled physicians, and, most emphatically, a system that rewards doctors and hospitals for how MUCH care they deliver rather than how effective it is.

We in the La Crosse County area are fortunate to have excellent physicians, clinics and hospitals, but no one is immune from the dangers Brownlee so vividly presents. So take a break from worrying about global warming, potential nuclear war, the instability of the dollar, “what’s the matter-with-kids-today,” and other mundane life uncertainties.

Instead, think about your health. Be prepared. Come to the library. We can help you sort through the myriad of books and electronic resources on diseases and illnesses both rare and common. Learn about any suspected or already-started illness and read Overtreated.

Do it NOW because you probably won’t feel like it when you personally are in the throes of your own particular medical malady, lying covered in only a thin cotton gown on an examining table, and wondering how the HECK you wound up in such a predicament.

There’s a 90% chance that Overtreated or materials on your disease-of-choice will be available immediately, a 15% chance that you’ll have to wait a few days for any specific title, a .001% chance that you already know what’s written in all of them, and a 100% chance that I’m making up all those statistics!

Like my favorite local towing company (Don’s) which claims to be open 23 ½ hours per day, we at the library are ALMOST always able to assist you in finding what you want. The odds are definitely better than average!

Find this book and other titles within our catalog.

[Books Ring Mah Bell · Rating 4 out of 5]

Excellent book on the many failings of our health care system. Why do we have 47 million American without insurance? Why are there over 100,000 patient deaths a year due to medical errors? And why the hell is care so expensive?

Brownlee gets into the various factors of why our system is totally jacked up. Doctors order unnecessary testing/procedures to cover their behinds in case of lawsuits. Doctors cannot treat the way they want due to guidelines set by insurance companies. Sometimes, there are so many doctors involved in treating one patient, they have no clue what tests or meds have been given. Pharmaceutical reps and the media work together to create "disease" that sends people flocking to their doctors for meds. Medications that may be dangerous (Vioxx, anyone?) or not needed are prescribed to patients.

As for offering solutions to the problem, Brownlee offers the example of the "new and improved" VA as well as the Mayo Clinic as standards to strive for. Is pay for performance the answer? Are there ways to restructure HMO's to be efficient?

Whatever the case, something's gotta give. This book clearly lists our weaknesses. Let's do something about it. Our system is sick and needs help.
STAT.

[Andy Oram · Rating 4 out of 5]

This book was written before the passage of the Affordable Care Act and was five years old as I read it, but it remains relevant and damning, showing just how difficult reform is. I liked the book because it covered a lot of ground and explained the common bugaboos of treatment--doctors' propensity for prescribing too much care, pharmaceutical companies' hegemony over drug testing, patients' inflated expectations of medicine--with a good journalist's strong style that combines anecdote with statistics. True, Brownless does not delve into details, which would have included explaining the weaknesses of current electronic health records, explaining that pharma companies are having trouble finding new drugs, and exploring patient-centered medicine. But what she covers is explained in a depth that is sufficient for entering the debate. The failures of several earlier attempts to reform health care should make us cautious about celebrating the current wave of innovation, lovely as its goals are.

[Craig · Rating 4 out of 5]

This book will make you angry. Very angry. Angry at doctors. Angry at hospitals. Angry at governments. Angry at insurers. And yes, angry at yourself. It will do this because it will show you what a total mess our health care system is in, and it shows us how all of these groups are responsible for this mess.
We all suffer from the delusion that our health care system is the best in the world. The author does a fabulous job of showing that, while we may have the most expensive health care in the world, and almost certainly the most impressive technology, our delivery of care is so mis-allocated and overdone that we do not get the right care at the right time in the right way. Ultimately, thousands of us die every year because of this.
It is fashionable to blame insurers for the mess we are in. We blame them for denying us coverage when we think we need it. We blame them for the overhead and profit and paperwork that they add to the system. And these are valid criticisms. But these pale in comparison to the inherent flaws in the health care delivery system and its patients. The author provides illustrative real case studies and descriptions of systemic flaws to illustrate her point, including examples such as:
- Cataract surgery being offered to a patient dying of cancer with just months to live
- Surgeries such as back fusion being routinely done when there is no medical evidence to support their use
- Medicines (think Vioxx) marketed with knowledge that their side effects are worse than the near-zero marginal improvement in their effectiveness over far cheaper and safer medicines.
- Big Pharma reps basically buying their way into doctors’ toolkits.
- Big Pharma “buying” the studies they need to support approval and marketing of their drugs
- Direct to consumer advertising to “create” diseases out of normal variation in human physiology and psychology
- Self dealing by doctors to enrich themselves at the expense of their patients
- Bullying by insurers and government payors that basically force doctors to take on more patients than they can handle effectively.
- Marginalization of the primary care doctor in favor of specialists
Fortunately, she offers some solutions as well. I hope the powers that be listen.
Read this. It matters.

[Suzanne · Rating 4 out of 5]

Author Shannon Brownlee, MSc, is a prolific healthcare writer and speaker who holds a masters degree in biotechnology. She is also a former Senior Vice President of the nonprofit Lown Institute (www.lowninstitute.org, @lowninstitute), a nonpartisan think tank that addresses the “industrialization of healthcare [that] has disrupted the healing relationship between patients and clinicians.”

Overtreated was named “Best Economics Book of 2007” by the New York Times and is another good explainer about the problems with the American healthcare system, the factors that drive it toward dysfunction and away from providing good and equitable care, and what people / patients should be aware of to navigate it safely.

This book is a bit outdated, having been published in 2007, even before the Affordable Care Act, but is still very relevant in most respects. Topics include how and why hospitals deliver unnecessary care and the dangers that can create (even if doctors are well-meaning), how many common but potentially risky procedures aren’t as evidence-based as you’d think, how referrals to “profit centers” often trump the actual needs of individual patients, the undue influence of pharmaceutical firms on studies and journal articles that appear to endorse their products, the rampant overuse of imaging and the diagnostic problems that can arise from this, the prevalence of “condition branding” by pharmaceutical company marketing department to create demand for their products, and what insurance companies and HMOs have done to drive physicians, especially primary care doctors, out of the profession, when we need them the most.

The message here is, more is not always better. But given the many areas of the medical-pharmaceutical industrial complex that stand to benefit from the status quo, it’s no wonder it’s such a challenge to accomplish any sort of true comprehensive reform.

[Austin Larson · Rating 5 out of 5]

This is the best explanation I've ever read for the cost of healthcare in America. Brownlee covers the problems with fee-for-service payments for doctors, fragmented delivery of care and direct-to-consumer advertising. She starts the book as a profile of the doctor who developed the Dartmouth Atlas and explains his 30 years of research on that vast differences in the amount of healthcare consumed by americans in different areas. There is basically no correlation between the amount spent on healthcare in a city and the health of its population. The book is written for the lay audience and doctors will find some points to quibble with and/or be offended by. I feel like I've had this conversation 100 times and I'm really happy to have found a book that conveys these ideas so well.

[BethK · Rating 4 out of 5]

Although this book is now 11 years old, many of the issues it discusses as to why US medical care is so expensive, chaotic, inefficient, and uncoordinated are as true today as they were in 2007. The landscape of the medical industry, including advertising reps calling on physicians, direct-to-consumer marketing, journal articles ghost-written leading to problems of anyone - including physicians and patients not knowing what the real scientific evidence says. Much unneeded medical care is done - because there really is not a "market" in the true sense for medicine, but rather a big dissociation between payers and patients, and who the customer is remains unclear. Reimbersement systems of Medicare and insurance have created an upside-down system of "if you build it, they will come", and areas with large amounts of capacity in some area overuse that capacity, while at the same time not really addressing patient's actual conditions - leading to overtreatment and undertreatment at the same time! This does not have good outcomes.

There is a solution, which no scheme to reign-in medical costs had in 2007, nor has it by 2018 addressed - except in a few systems in a few locations where it has worked very well.

[Rajesh Kurup · Rating 5 out of 5]

Must read for consumers that want/should know more about the health care system, even if ignorance is bliss. After reading this book, I feel that we have a responsibility to become involved in our care. There are too many third party influences that are pushing doctors to prescribe particular drugs or treatments for us not to question them. Since the fee per patient has come down, doctors are under high pressure to churn patients and push us on to specialists. As a result, per Brownlee, we become the most attune to what all care we receive, especially if in the hospital.

One of the chapters I really appreciated was the second to last which lays out the recent history of medicine. From the 1970s to the advent of HMO's, managed care, PPO's. Brownlee tries to explain the intent of the evolution and this missteps that lead to the next step. This book was written before the ACA was passed but does help me get some background on the new law.

The book can make you very angry. There is way too much money being spend unwisely on healthcare for us not to be a little angry.

[Julie · Rating 3 out of 5]

Interesting points, and important to know, but it can't seem to get around the sense of "scare tactic" that permeates the chapters. There is also quite a bit of repeated material, over and over, to make extremely nuanced points that sometimes don't further the conversation. Instead, it tends to make you feel a bit overwhelmed and frustrated.

The last chapter is hopeful, proposing some interesting ideas to solve the problems she addresses. Still, the solutions depend on massive overhauls of existing systems that may take years to fix.

Overall, the book left me feeling cranky about the state of our medical system with little hope and without the tools to assist me, the patient, with all of the cracks I see in the foundation thanks to this book.

[Chris Demer · Rating 4 out of 5]

This is a well-written and thoroughly researched book about medicine in this country. Clearly, we are seriously lagging behind the rest of the developed world in terms of cost, outcomes, delivery and access. There are numerous reasons, some of which are political, economic or ideological. What Brownlee is not in doubt about is that we have the power and money to fix it, but apparently not the political will.

This is not a new book, having been published in 2007, however, the problems she points out have barely been addressed, except perhaps with the Affordable Care act in terms of access. So much more needs to be done.

So what are some of the systemic problems she discusses?

---"If you build it they will come" We are not talking about a baseball diamond here but high tech diagnostic equipment, hospital beds, "state of the art" specialty units, etc. Wherever these exist, they are utilized to the max. Interestingly enough, however, the outcomes for patients utilizing them are not particularly improved. What is improved is the bottom line of the hospital or facility with these accouterments.
Multiple studies have shown that in areas where there are top notch cardiac cathetrization labs available, many more caths-and stents and even surgeries are performed that in areas where they are not available--and the outcome of this is that many of these procedures were never necessary. Availability drives use, not patient need. "Supply is inducing demand."

--- Hospitals are some of the most dangerous places to be. Medication errors and infections are not uncommon. thousands of patients are injured or killed every year because of these adverse events.

---Many treatments including dramatic, new ones with terrible side effects, have never been studied for effectiveness. One example is the use of high dose chemotherapy and rescue with bone marrow transplant-for advanced breast cancer. This treatment has been shown to be ineffective in producing a cure. (And this is on top of the prolonged use of radical mastectomy when lumpectomy and radiation have been shown to be just as, if not more effective for breast cancer treatment.)
These treatments provided lots of money for doctors and hospitals however.
There are other common treatments that are either of questionable use or have been proven to be useless in most cases-spinal fusion being one.

---Over reliance on expensive diagnostic tools. Some of these expose patients to large doses of radiation and are not even needed. Some are done at the request of patients, of course, because they know they are available and will not cost them anything due to their insurance. Of course advanced diagnostic equipment is useful and often of critical importance. But doctors need to hone their diagnostic and physical examination skills, develop intuition, listen to patients and not just order tests because they can. They drive up the costs for all of us.
Preventive scans and diagnostic imaging falls into this "usually unnecessary" category. Two problems here: the feeling that you are fine because the scan did not show any problem and the scan shows some irregularities (which would probably never result in a health crisis) that result in unnecessary and costly interventions.

---Direct to consumer advertising- usually of medications, but also devices and procedures. This is just plain disgraceful. The only other developed country that allows this is New Zealand, which is one reason drugs are so much cheaper in other countries. Drug companies: (don't even get me started) are spending more on advertising than on research and development. They invent diseases and disorders that few have ever heard of, then advertise just the right (expensive) medication for it.
They control congress and the FDA. Patents were extended to 20 years from 17 and many new drugs are very similar to older, cheaper ones, but hyped to make them seem much better. (Example: Celebrex and Naproxen). Drugs are often poorly tested: small sample, specific samples (i.e. tested on patients who are not the likely population to use the drug), tested only against placebos, not other drugs known to be useful for the disease or disorder, etc. Then foisted onto the unsuspecting public, only to be withdrawn from the market a few years later due to disastrous side effects. (example: Vioxx causing pulmonary hypertension).
They literally "Foster a condition then align it with a product," (in the words of medical marketing and media).
Even articles in respected medical journals are often written by drug company marketers, and come complete with the names of qualified physicians as authors: ghostwritten! And most physicians rely on information in these journals.

---The decrease in the family physician, the generalist, is another big problem. Many patients see several specialists depending on what particular system is bothering them at any given time. The result is that none of the doctors see the whole picture and often work at odds with one another --and the patient. This is all very costly of course, and can result in over medication and over treatment in general. It results in less access and self diagnosis as well.

The author has a lot of good things to say about how managed care should be. She has investigated some of the positive changes made by the VA system and suggests that they be made in other areas of health care access.
She seems upbeat and hopeful that our care "system" can be improved, but I am not convinced, based on the political power of the players in this country. This is 2018. Access is still a problem and costs have continued to climb, while the actual life expectancy in the US has decreased. Most Americans still think more treatment is always better than less and are insulated from the costs by insurance. We have a very long way to go!

I recommend this book to any interested in the health care dilemmas we need to fix.

[Graeme · Rating 5 out of 5]

Perhaps out-of-date in some areas by now (it was published in 2007) Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer gives a definitive and essential portrayal of American health care, its history, its astonishing complexity, and worst of all, its deep corruption. It made the author Shannon Brownlee a national treasure. She writes beautifully and with great power, and is still very active in improving our health, the systems that support it, and the people within the systems.

[Laura Walsh · Rating 5 out of 5]

Excellent, important, disturbing, but should be required reading for all at the mercy of the health care system in this country. My theories of just how 'business' is done in the industry were sadly confirmed while reading this book. It was first written in 2007, with an update to the ebook version in 2010. From where I sit, none of the suggestions on how we *can* improve the care we receive, have eben addressed.

[Monica Willyard Moen · Rating 4 out of 5]

This book’s message is as important and valid as the day the book was written. It describes the many ways over treatment and over prescribing affect our healthcare system, making our healthcare outlook worse for rich and poor people alike.

[L L · Rating 4 out of 5]

Though not nearly as deliciously funny or narratively delightful as Michael Pollan’s The Omnivore’s Dilemma, Shannon Brownlee’s book was very informative on a subject that I didn’t know much about previously (though apparently is common knowledge across medical schools in the nation). Primarily through concrete examples of hospitals and individual cases, and an accessible, easy-to-understand overview of plenty of academic studies, Brownlee demonstrates how doctors overtreat patients with drugs, scans, and procedures that do not necessarily make them any healthier. Brownlee delves into hospital management, the latest body scanning technology, cultural beliefs concerning medical care, the incentive structures of the current health care system, insurance policies, pharmaceuticals and advertising—exploring the various (generally economic) reasons why we are so “overtreated”.

At times, she can get repetitive, drilling home the same point again and again, but she manages to explore enough facets of her thesis that it does not actually get boring—her book is replete with examples, references and other information to support her thesis, instead of just endless abstract ruminations.

She also manages to present some hope in the situation, by examining a few health care systems that do work—Mayo Clinic, Kaiser Permanente and surprisingly enough, the Veterans Health Administration, which recent turnaround in 1992, runs an incredibly successful health care system. By properly aligning financial incentives, implementing better record-keeping and technology, the care received by patients in these health care systems is far better and far cheaper. Brownlee also envisions small steps of reforms that could lead to the replication of these medical groups.

In any case, whether or not you actually do support universal health care, this book is a wonderful introduction to the economics and injustices and inefficiencies of the health care system, that have resulted in some (usually the rich) getting far too much care, and others (the poor) not receiving enough. (It’s that irony—that while in third world countries, people still die of starvation, people die from too much food in America).

[Clara · Rating 2 out of 5]

Overtreated was a decent primer, but I thought it was a bit too simplistic to be of real value.

Brownlee takes an extremely complex, multifaceted issue and boils it down to one or two "problems" which I think can be misleading for readers who are not familiar with health economics, or the history of healthcare in the US. For example, Brownlee discusses skyrocketing medical costs, and associates these with increased FFS Medicare payments. She pretty much concludes that Medicare is responsible for driving medical costs up. While Medicare did contribute to healthcare costs inflation there are tons of other factors also contributed to increasing costs, none of which she touched on -- this could lead readers to think that Medicare was the only (or majority) cost driver, which is not the case. I would say that a greater contributor than Medicare were employment laws capping wages while allowing fringe benefits (such as health insurance) to go untaxed; this fueled the growth in medical spending by shifting payment to third parties on a massive level.

After systematically presenting everything that she thinks is wrong with the system, Brownlee does present some solutions. However, her solutions are again quite limited. She holds electronic medical records as one of the major solutions to the healthcare crisis. While I do think HIT is an important component to a high-functioning, efficient system, it's again only one piece. I think many people are expecting HIT to revolutionize health; absent evidence-based guidelines and practice recommendations, HIT cannot be used to its full potential.

Bottom line: a good primer, but don't expect that you're getting the whole story here. The book had a viewpoint, but felt a bit biased.

[Josh · Rating 5 out of 5]

Before I would have any type of operation today, I would research the heck out of it. Shannon Brownlee’s book is one of the reasons for this. Everything we know, or more precisely, everything we think we know, about medicine is not necessarily true. More to the point, medicine is a façade; it is a man behind a curtain. Be sure to check what you are getting!

Page 6 Today, Americans believe devoutly the power of medicine not only to heal but the cure. In surveys conducted by a group of Harvard researchers, 34 percent of respondents said they believed that modern medicine" can cure almost any illness for people who have access to the most advanced technologies and treatments." "We are the new priesthood," says Stephen Baker, one of the doctors you'll meet in this book. " the myth we are peddling is not everlasting life in heaven, but everlasting life here on earth. "

Page 7 Home Depot does a better job of tracking a box of nails then your local hospital does and tracking you, the patient.

Page 27 Then head wrapped itself in the mantle of Science, yet much of what doctors were doing was based more on hunches then good research. In fact, as research would show over the coming decades, stunningly little of what positions do has ever been examined scientifically, and when many treatments and procedures have been put to the test, they have turned out to cause more harm than good. In the latter part of the 20th century, dozens of common treatments, including the tonsillectomy, the hysterectomy, the frontal lobotomy, the radical mastectomy, arthroscopic knee surgery for arthritis, x-ray screening for lung cancer, proton pump inhibitors for ulcers, hormone replacement therapy for menopause, and high-dose chemotherapy for breast cancer, to name just a few, have alternate Lee been shown to be unnecessary, ineffective, more dangerous than imagined, or sometimes more deadly than the diseases they were intended to treat. By the 1990s, progressive doctors were talking about a new movement called "evidence based medicine " but well into the 21st century, much of what doctors do remains evidence free.

Page 40 I asked Jack Wennberg why doctors deliver so much medical care that is useless and even harmful." Most doctors don't know they are doing it, the general attitude is more medicine is better. " when there is incomplete or conflicting evidence about whether a procedure is effective, some doctors will be more aggressive about using it than others, especially if money is a motivation

Page 47 For the most part, patients are cared for by people who are competent and dedicated- who want nothing more than to do their very best to heal. Yet in a hospital, the most innocent of mistakes can, and with astonishing frequency does, result in dire peril.

Page 50 Fisher and his colleagues discover that patients who went to hospitals that spent the most- and did the most- were to 2 to 6 percent more likely to die than patients who went to hospitals that spent the least.

Page 101 "We know we can prevent heart attacks with aspirin, and with drugs called beta blockers. We know that for certain," says Lange. "But it has turned out to be a little more mushy when it comes to the advanced technologies. Angioplasty and stenting have never been shown to improve survival. You can stent until the cows come home and not prevent a heart attack." and while the elective uses an angioplasty and stents has skyrocketed over the past 15 years, there has been no change in the rate of heart attacks.

Page 135 Today, doctors routinely prescribed drugs, perform procedures, and use medical devices and tests on the basis of evidence that sometimes has only a little more science to support it then the contagion theory.

Page 172 When Cordis, they manufacture of cardiovascular stents, introduced the first drug coded stint in June 2003, interventional cardiologist begin using them without evidence that they represented an improvement over bare metal stents. They just seemed like a good idea. Uptake was so widespread and so rapid that by 2006 over 90 percent of all stents placed in patients were coated. Clinical trials are now showing that the drug coded stents increase the risk of a clot, which can cause a stroke, unless the patient takes drugs to prevent one.

Page 180 In 2002, doctors wrote nearly 11 million prescriptions for psychotropic drugs for kids between the ages of 1 and 17. Rate of pediatric prescriptions have been going up dramatically, along with the rate of pediatric physicians for anti-psychotics, powerful drugs that were developed to treat such serious psychiatric conditions as schizophrenia, mania, and bipolar disorder. Psychiatric visits the included treatment of a child with an antipsychotic went from a little over 200,000 in 1993 2 1.2 million in 2002. More than 90 percent of those prescriptions ( all of them off label) we're for the atypical antipsychotics, newer versions of the drugs that may cause serious side effects. Among boys ages 6 to 12, more than half of the antidepressant prescriptions written are intended to treat so cold conduct disorders, like hyperactivity and attention deficit,

Page 182 Pharmaceutical industry has pushed new diagnostic categories and other medical arenas, and it has helped broaden the definitions of risk factors that can be treated with drugs. For instance, the criteria for who needs to be on a statin, or cholesterol lowering drugs, were redefined in 2001, more than doubling the number of Americans who could be put on drugs like lipitor and zocore from about 13 million to 36 million. Many experts argue that these new guidelines are based on a faulty interpretation of the medical evidence and could actually prove harmful to many people who wind up taking the drugs. Critics also note that 8 of the nine authors who crafted the revised guidelines we're being paid by the companies that make statins.

Page 183 The drug industries role in persuading both patients and doctors that we are sicker than we really are, and that the path to wellness lies with medical intervention: with a pill, an operation, or a test.

Page 186 "Disease oriented" ads often list symptoms of an ailment, give a disease a new name, or make the disorder sound as serious as possible in an effort to scare consumers into going to the doctor for a test. Pfizer ran an ad in a popular magazine for its anti-cholesterol drug Lipitor that showed the tagged toe of a corpse above a headline urging women in their 50's to get there cholesterol checked. Of course, the ads glossed over the possibility that Lipitor itself might kill them.

Page 194 Marketing shouldn't be confused with education, and letting drug companies defined who needs to take their products is like letting your local Lexus salesperson decide what kind of car you should buy, and how often you need a new one.

Page 195 here drug manufacturing was once all about searching for cures, condition: branding is all about "the creation of medical disorders and this dysfunctions " marketing executive Vince Perry.

Page 200 Taking everybody's blood pressure is a good idea, because treating those with hypertension lowers the risk of a heart attack or stroke. But many other tests, which have their place if a patient has symptoms, have had the perverse effect of benefiting only a small minority when they are given routinely too apparently healthy people in the name of prevention- while exposing the majority too invasive, often dangerous treatment they don't necessarily need. This is especially true for the PSA test - a simple blood test that most Americans believe implicitly will help them off Lloyd and untimely death.

Page 208 There are children who are impaired by ADHD, to be sure, and adolescence who suffer from debilitating and even suicidal depression. But by redefining " the boundaries that separate the healthy from the well, " as Ray Moynihan and Alan Cassels put it, and by exaggerating the dangers of mild problems and the prevalence of rare conditions, drug marketing has helped persuade both physicians and patients that they must worry about the littlest sign of incipient illness, that getting treated as early as possible for disease will lead to a longer and healthier life.

Page 209 (Regarding his son being prescribed sleeping pills and depression medication) Was the risk of agitation and suicide worth taking for a teenager who may have been suffering from nothing more serious than a few sleepless nights in college? Justin's grieving family doesn't think so. In early 2007, 6 years after Justin's death, his father Gary was able to say, "the real tragedy and this is doctors don't let patients know what the odds are. If you read a list of side effects on this stuff, you would have to sit down and say, how damn bad do I have to feel to risk all that? "

Page 216 At least 16 studies have found that drugs that are most heavily marketed to physicians are the ones most likely to be prescribed. The more time doctors spend with drug reps, and the more free gifts, drug samples, and food they accept, the more likely they are to prescribe the brand name drugs that the reps are pushing. Physicians who have the most contact with reps prescribe the most "irrationally," which means they give patients expensive, brand name drugs when there are cheaper and often better, safer alternatives- or when no drug at all would have been the best choice.

Page 227 Discrepancies routinely afflict the medical journals: complex findings, which are reported by academics with conflicts of interest, who portray the results in a way that obscures risks and plays up benefits.

Page 228 In the view of Richard Horton, hey British physician and editor of the prestigious Medical Journal The Lancet, "journals have devolved into information laundering operations for the pharmaceutical industry. "

Page 234 Info poems is an online subscription service that's if through more than 2000 articles published each month in a hundred medical journals, looking for the few articles that could make a real difference inpatient care. The research team, all of whom are experts and dissecting clinical trials, pick apart each article to make sure the results are credible. Only about one in 40 studies make the cut. Qualifying articles are then summarized and posted on info poems website and sent two doctors who subscribe to daily email alerts. For example, one recent alert informed subscribers of the results of a large study looking at vitamin E supplements, which showed that contrary to widespread belief, they don't help patients with heart disease. They do, however, slightly increase the risk of death.

Page 294 The number of spinal fusions has continued to rise dramatically over the past decade, going up 127 percent between 1997 in 2004. We spend more than 16 billion dollars each year on spinal fusions, even though they're still has never been a rigorous, government funded clinical trial showing that the surgery is superior to other methods of relieving back pain. We spend an additional 2.5 billion dollars on fusion hardware like pedicle screws, which can add $16,000 to the price of the surgery. Yet there's practically no evidence to show that all those screws and plates improve outcomes either.

Page 303 On the one hand, we want to believe that medicine can cure every disease, if only we could afford the right doctors. We hold on to the fantasy that medicine has become all powerful, that we don't need to exercise any discipline in our lives, because there's a pill to fix the results of smoking and eating to excess. We think we shouldn't have to suffer pain for any reason, or put up with the infirmities of old age.

www.veggierunner.com

[Ashley · Rating 4 out of 5]

Brownlee takes the conventional view of medicine and treatment - more is better - and turns it on its head in this accessible, engrossing, and fact-filled book. Arguing such a contrarian POV is never easy, especially in such a charged topic as healthcare. Brownlee handles the topic deftly and persuasively, though, and I was left feeling like I learned a LOT. The gist of her argument is this: more treatment leads to more people being involved in your care, each of whom is likely to make a mistake. This, coupled with the fact that more intervention makes you more likely to have an adverse reaction, actually results in the fact that the more care you receive, the higher the mortality rate is. Study after study has borne this out and I had never even heard the first inkling of it.

Each page had some fact or figure to back up her arguments and they were just too fascinating not share. Here are a few of my faves:
- In 2006, the US spent ~$1.2T on healthcare. That's as much as the worldwide market for petroleum and more than the US spends on food. It's more on healthcare per capita than China spends, per capita, on EVERYthing.
- At the peak of federal funding (1973), $2B a year was going toward subsidizing medical school education. This led to a dramatic increase in the number of specialists. Sutdy after study has shown that the more specialists to GPs an area has, the more overtreatment there is and the higher the mortality rate is.
- Between 1960 and 1980, the number of med school grads doubled from 16k/year and over the following two decades, the number of physicians increased 4 times.
- Contrarty to the AMA's fears (they spent $50M campaigning against the implementation of Medicare), Medicare drove the steep and unprecendented escalation in the income of both hospitals and doctors that had already begun a decade earlier.
- In the mid-1960s, doctors were among the highest paid professionals earning ~$141k in today's dollars.
- In the year after Medicare was enacted, average physician income grew by 11% thanks to usual customary reimbursements and physician rate spirals (docs began inching up their fees to the top end of the range they would be reimbursed for).
- Between 1950 and 1978 physician fees rose 43% faster than other wages
- Within a decade of Medicare's enactment, total spending on healthcare exceeded 10% of GNP
- The avg American specialist earns $274k a year and the avg American GP earns $173k a year (though 15% of GPs earn less than $100k/year). These salaries are 6.6 and 4.2 times the average patient's salary, respectively, and are 4 and 3.2 times times other countries. Meanwhile some specialists earn over $600k/year (20% of invasive cardiologists, 25% of neurosurgeons, and 14% of orthopedists).
- In 1949, 59% of doctors were GPs; by 1995 it had fallen to 37%. Med school grads choosing primary care is down - in 2000 14% of grads were primary care but in 2005 only 8% were.
- Per a 1999 report, overtreatment leads to ~98k errors per year and 400k incorrect uses of a drug each year. Even if you use the lowest estimate out there - 30k deaths a year due to overtreatment, that's the equivalent of a fully loaded 747 crashing every week with no survivors.
- By 1995 (30 years of Medicare), its bills totaled $181B a year, a 6000% increase. On a per person basis, Medicare spent $500pp in 1965. By 1995 it was $5000pp, an increase at more than double the rate of inflation.
- A 1996 study showed that the average Medicare recipient cost $8414 in Miami but only $3341 in Minneapolis. The discrepancy is not due to charges/costs, incidence of disease, etc. - it's due solely to overtreatment.
- In a 2000 study, it was estimated that 30k elderly Americans are killed each year by too much medicine (newsflash - getting old is not a disease; it's normal). That's 4x the death rate from skin cancer; 2x the death rate from brain cancerl and 2x the murders committed in the US each year. The study also concluded that 30% of Medicare and private insurance spending is useless and adds no benefit to the patient, a treatment plan, or wellness. That means that in 2006 when the US spent $2T on healthcare, that $700B was wasted and uneccesary.
- When your only tool is a hammer, everything looks like a nail (referring to specialists who see their fix as the best/only way)
- American medicine is an industry the size of Italy's entire economy
- Regions with fewer specialists and more GPs in relation to the population have better overall health as proved in numerous studies.
- Healthcare is the only industry where supply drives demand. I.e. cath labs and invasive procedures are used more often once expensive equipment is purchased rather than using more medical mgmt techniques like counseling on diet, exercise, or prescribing aspirin.
- Autopsy results dating back to 1938 have consistently found high rates of diagnostic errors. 25 - 40% of patients died from an undiagnosed cause (i.e. were being treated for cancer but died of heart disease). This rate has remained virtually unchanged today.
- The first drug advertisements didn't name the drug to get around having to state all the side effects. Drug companies and doctors initially found advertising for drugs distasteful and worried it would lead to patients diagnosing themselves. In 1995, drug companies spent $595M on advertising; by 2005 it was $3B. No wonder, since every dollar in advertising results in $4.20 in sales.
- In 1999, researchers estimated that the avg American sees 9 drug ads on TV a day. Drug companies are selling a disease; marketing is not education.
- In 1993, the avg American had 7 rx's per year. In 2004 it was 12.
- By 2002, the top 10 drug companies had profits equal to the other 490 Fortune 500 companies COMBINED.
- The US spends as much on drugs as we do buying retail goods online ($200B). The US takes 25 - 50% more rx drugs per capita than citizens of Canada and European countries.
- About 15% of people who undergo an appendectomy (one of the easiest conditions to diagnose) don't have appendicitis. In women of reproductive age it's 25%. In those 80+ years old it's 35%. Despite CT scans being widely used to confirm a diagnosis of appendicitis, these figures haven't changed since CT scans became widely used.
- Managed care and capitation (flat fee per patient) turns GPs into mini-insurance companies forcing them to assume the risk associated with the possibility that some of their patients could get quite sick and result in high costs to treat. Unlike real HMOs (i.e. Kaiser Permanente), individual doctors can't risk adjust, or set their fees according to how sick they expect patients to be over the course of a year.
- Vicious cycle between managed care, lower reimbursments, having to see more patients to make up the fees, less time to educate patients, more uneccesary treatment to satisfy the patient and CYA, leading to higher costs.
- Most HMOs/managed care plans failed b/c insurance companies selectively chose which pieces to implement from successful HMOs (i.e. Kaiser). Such as discharging new moms and babies 24 hours after delivery; Kaiser does this but they have amazing prenatal care and extensive follow-up care performed in-home by nurses and other health care professionals. Commercial insurance companies didn't adopt the pre- and post-natal care part though, just the 24-hour hospital stay.

[शिखा · Rating 5 out of 5]

Thanks to Shannon Brownlee for such a wonderful insight into the medical world. The author has to be appreciated for her painstaking research which involved meeting so many doctors, patients, administrative authorities, insurance companies and other stakeholders. Each interview is so well documented in the book that it doesn’t disturb the flow of reading at all. What I particularly liked in the book was the way she has classified the information into chapters depending on areas of specialization. The real-life examples of patients were heart-wrenching. As I finished each chapter I was compelled to complete the next one even faster. She has given a very good picture of the old pay-by-service system in comparison with today’s managed care system. The role of insurance companies and pharmaceutical companies in influencing a doctor’s decision has left me in a state of shock. In the last two chapters, she has given a very positive picture of the working of Veterans Health Administration and also suggested some changes to the current medical system.

The book has completely changed the way I would look at healthcare henceforth. If one is serious about long healthy life there is no way but adapt a healthy lifestyle and keep doctors and hospitals at bay as far as possible!

-Shikha
www.shikhawrites.wordpress.com

[Chrisanne · Rating 4 out of 5]

Conglomeration of thoughts:

Perhaps socialized medicine, not "Medicare for all," but medicine, care, insurance strictly regulated might be the answer. Her arguments for the VA system seem to be solid. But they, the VA, do seem to have some drawbacks.

This book was published before Obamacare/ACA was created, put into being, etc. I wonder what, if anything, the writer would change with that law in place.

If the problems with American Healthcare were visualized, it would be as follows:
Physicians, Insurance, Patients, Hospitals, Laws & Lawyers, Pharmaceutical Companies... all pointing fingers at each other but, in reality, all responsible for a portion of the issue (and some of them very well-meaning).

Intermountain Healthcare was touted as one of the better companies/hospitals. If that is true either a) something has changed in the last eight or so years or b) other hospitals are pretty terrible.

[Margaret · Rating 3 out of 5]

A discussion, if rather dated at this point-of how we spend too much on unnecessary care in the US and don’t do a good job of getting people the care they need. She has some good set pieces and some amazing anecdotes and characters, but...she doesn’t really get into how medical decisions are made. And the solutions she presents are problems she discusses in earlier sections of the book. And she only glances over what to me are obvious fixes: about a quarter of Medicare is spent on people in their last 6 months of life. This is almost all wasted care, and much of which the patient doesn’t want but is done because we can. Doctors need to learn how t-and get paid to-talk to patients and their families about end of life care.

[Miranda · Rating 5 out of 5]

A brilliant, terrifying, and maddening look at the economics of the health care industry. A must read for anyone interested in learning more about how messed up the healthcare business is. Despite being drenched in pessimism after reading this book, it helped me to realize the importance of being your own health advocate.

[Taylor · Rating 3 out of 5]

In this book there are a lot of stories about people getting too much treatment from the US healthcare system. There are a lot of good examples of inefficiencies. I think a good amount of them are out dated examples because we’ve gotten better, and I also don’t think inefficiencies are the problem. I think the problem is with the structure of the system.

[Julian D'achille · Rating 4 out of 5]

Still relevant even post implementation of the Affordable Care Act as well as some of the remedies that Brownlee mentions in the book (like electronic medical records). Many of the challenges remain as the cost of healthcare continues to increase.

[Daniel Weiner · Rating 5 out of 5]

Excellent discussion about issues with how health care is provided and paid! There were a few things that were slightly out-of-date (pre-ACA), but the concepts are still relevant.

[Lauren Birmingham]

This was one of the books that got me interested in health economics and public health... which is what I ultimately got my PhD in years later! Very informative read, but likely outdated now.

[Leah · Rating 4 out of 5]

Very good book, just wish it were updated to today. I was left wondering how things have gotten better or worse in the years since this was written

[Rob Jandl · Rating 5 out of 5]

Excellent review of the the issues around over testing and over treatment. Highly recommended.

[Liz Nelson · Rating 4 out of 5]

Fascinating read!

[Andrea · Rating 4 out of 5]

This book was delightful. Brownlee captured much of what is ailing with the US Healthcare System, and she clearly did her research. She presented some ideas for improvement in the last chapter- none of which are being considered in Congress for healthcare reform. Maybe part of our problem is we don't listen to the ideas of people who actually know something, so our "reforms" end up making the system worse. Gotta cover these ideas in my podcast now!

[Anthony · Rating 4 out of 5]

This is a must read for any modern American. Brownlee’s thoughtful research provides a very poignant diagnosis for the pathological misgivings of the US health care system. Through several detailed examples she exposes many of the myths that we have the best health care in the world and demonstrates how the the spiraling costs are a symptomatic result of our belief in the newest technologies, diagnostic equipment, and out of control malpractice system. The premise of the book is best summarized in Brownlee’s own words in the following passage:

“Our relentless search for wellness through medicine has created a kind of therapeutic imperative, the urge to treat every complaint, every deviation from the norm, as a medical condition. We’ve come to believe that if a test can be performed, it should be performed; if a treatment can be used to lengthen life, no matter how incrementally, is should be used, regardless of whether the intervention will improve the patient’s sense of well-being, or is what the patient really wants. Families often tell doctors to “do everything possible” for their elderly and dying loved ones, often without realizing that “doing everything” won’t necessarily stave off death for long but could make the patient’s last few days or weeks more miserable that they might have been.” (206)

There are stories of cardiologists that unnecessarily perform cardiac surgery on patients that would be better off medicated, children diagnosed with depression and ADHD for simply going through the normal difficulties of their teenage years to become placed on medications that cause them to commit suicide, cancer patients who refuse chemotherapy because they desire a dignified passage to death to later be placed on life support against their will. Brownlee also provides a scoping overview of the political changes of the past 30 years that have affected the health care system, driving primary care into oblivion by promoting high paying specialization while managed care insurance plans place limitations on what primary care physicians are permitted to do.

More than once this book caused me to feel a sense of dread and doom because I am afraid that the problems we all know are inherent in our health care system won’t get better until they get progressively worse. As we all know from the past two years of health care debate and the enactment of the Health Care Affordability and Patient Protection Action “Obamacare,” more that 50% of our nation public is vehemently opposed to reform despite the skyrocketing cost of insurance premiums and ballooning cost of diagnostic tests and medications. The truth is that our highly individualize society is unwilling to forgo the most expensive treatment because our culture inherently believes that more is better.

This book caused me personal conflict since my career has been bound to the health care industry. The last ten years I have been working in the pharmaceutical industry and I’ve witnessed countless investments to polish up the manufacture of drugs that have not chemically changed in 15 years, and these high cost investments occur because the FDA expects the most current and practices to be employed at all times, even if it has no affect on the drug itself. All of this cost is pushed to the consumer. Also, as a recent nursing graduate soon entering into a hospital based profession I have been witness to the high cost of care required to have multiple doctors, nurses, physical therapists, dietitians, and social workers all provide overlapping care at high cost to the patient’s insurance plan. It is an interesting industry that I have benefited from, one that may bankrupt our nation.