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Patients today expect their every last ache and pain to be immediately cataloged and cured. They want the pill they just saw advertised, or the latest, greatest procedure. Many doctors, reluctant to tell patients that waiting or doing nothing is often better, are all too willing to accommodate. As a result, we are becoming a nation of over-diagnosed and over-treated people. But how can we know how much medicine is good medicine? And how do we know which treatments might actually work? In More Harm Than Good, Michael Bellomo and Dr. Alan Zelicoff offer a compelling look at medical care today and explore how common conditions like prostate cancer, heart disease, and diabetes are being over-treated, wasting billions of healthcare dollars and producing less than ideal, if not detrimental results. The authors arm readers with the facts and questions they need to better discuss options with their doctors, and examine the way doctors select treatments in the first place.
Based on solid scientific and medical research as well as interviews with surgeons, internists, and general practitioners, More Harm Than Good will empower readers to make better health decisions. Revealing and impeccably researched, this is a revolutionary book that will change how we look at being sick.
|Product dimensions:||6.10(w) x 9.10(h) x 1.30(d)|
|Age Range:||17 Years|
About the Author
Alan Zelicoff, M. D. (Albuquerque, NM) is a physician and physicist. He has testified before Congress on public health issues and published op-eds in The Washington Post and The Wall Street Journal.
Michael Bellomo (Burlingame, CA) is the author of The Stem Cell Divide (978-0-8144-0881-0). Together, they are the authors of Microbe (978-0-8144-0865-0).
Read an Excerpt
I N T R O D U C T I O N
I T ’ S HARD TO PI C K UP a newspaper or popular periodical and not read about an exciting new medical breakthrough. Usually the breathlessly worded article recounts the results of a small group of patients with an incurable disease who seem to have been successfully treated—or if not cured, at least helped—by a new medication or surgical procedure.
Or perhaps there are remarkable pictures of the inside of the body or images of the brain that show its function changing while people carry on normal tasks. The medical author may go on to quote the researcher studying a new scanner’s pictures who speculates that there’s little doubt that within a few years the cause of Alzheimer’s disease will be revealed due to new tests like the one described in the fourhundred-word article.
But what one almost never sees is the follow-up to those stories.
Perhaps the effects of the new treatment were either temporary or had down-the-line side effects that led to what appeared to be a fruitful line of research being abandoned. Maybe the new scanning machine revealed so many apparent abnormalities or gave so much inexplicable information that either no one knew what to do with the data, or worse, acted on it (usually in the hope of helping the patient), but ended up doing little more than proving that the information wasn’t worth having in the first place. Meanwhile, many of these scanners might have been bought and installed by people—including physicians—
hoping to make a profit. Of course, because the costs are high a even absent any evidence of benefit, they get used—and often paid for by patients directly if insurance companies refuse to do so (and insurance companies are not always wrong in this judgment). Billions of dollars are wasted every year, and, more times than we like to admit a people are harmed.
As we will show in this book, scientifically and economically proven treatments—which save both lives and money—are being underused.
At the same time, expensive or invasive procedures and treatments (or those that are both expensive and invasive) are clearly overutilized. In at least the elderly population—where the most suffering occurs—it is now clear that we have gone beyond the law of diminishing returns to the law of negative returns. Put another way, from community hospitals to academic medical centers, in both private and public hospitals large and small, there is a better than even chance that the next dollar being spent for medical care is, in fact, lessening either the quality of life or longevity. It is highly likely that the same result obtains in doctor’s offices and physician-owned hospitals and diagnostic centers.
There is no doubt that many people have been helped by hightech modern medical advances. The engineering research into new materials has led to long-lasting joint replacements for worn-out hips and knees that otherwise would have been so painful as to render many people with degenerative arthritis immobile, leading in turn to the loss of quality and enjoyment of life and further complications from muscle atrophy and bone thinning due to lack of use. Who among us now expects to give up walking for enjoyment or for countless activities of daily living as we age? Similar work in physics and engineering have led to lens replacements for cataracts, once an almost inevitable result of aging and a certain decline into blindness. With a 20-minute procedure a sight is now restored, and the implantation of artificial lenses gives many people in their seventies and eighties better sight than they enjoyed when they were 40. Few of us will ever suffer for long from cataracts when we live into old age.
And, for a small number of people, the miracles of organ transplantation—
first of kidneys, then hearts, and now livers and lungs—
have completely reversed various chronic, otherwise irreparable damage to these organs and eliminated the attendant suffering and inevitable decline until death supervenes. This is a tiny percentage of the population, to be sure, but we have no doubt that the individuals and those who care about them would say that the benefits were worth the cost (and sometimes the long recovery periods).
At the same time, ask most Americans if they are satisfied with their health care and you’ll find that the answer is mostly no. As with any polling, the answer depends very much on the way the question is asked and also who is asked. In 2003, among the fewer and fewer
Americans with employer-provided health insurance, more than 80%
rated their health care plan or coverage positively,1 but more than half are worried that coverage either will be unaffordable or vastly different (and unsatisfactory) in the future. By 2007, just four years later, in a
Zogby poll only about 58% of Americans—most still covered by either employer-paid insurance or, if elderly, by Medicare—expressed satisfaction.
About as many (10%) say it is ‘‘the worst possible imaginable system’’ as say it is the ‘‘best possible imaginable system (16%).’’2 Differences were clear along income lines: about two-thirds of people living in households with more than $100,000 of income were happy with U.S. health care, and more than half with incomes hovering near the poverty range ($25,000 to $35,000) were dissatisfied. Many additional studies and surveys—which are designed to assess individual satisfaction with American health care—reach identical conclusions.
On the more personal level, a Harris poll in 2000 concluded that many—and perhaps most—people were deeply unhappy with the interaction they had with own doctors, frustrated that they had to wait for hours for a 5- or 10-minute visit and wondering why they had to take time from their own work just to ask a question or get a referral.
Most patients preferred being able to communicate about gardenvariety problems or needs via email, and, perhaps unsurprisingly, doc-tors were often stunned that patients would prefer electronic rather than face-to-face contact.
Taken in the context of a system that is gobbling up an ever greater share of the economy as it grows at a inflation rate three percentage points greater than overall inflation, these large-scale results overwhelm the few—though tangible—successes of modern medicine.
Other books address the failings of the health care ‘‘system’’ and provide varying (often mutually contradictory) prescriptions for success.
Some advocate greater government oversight,3 even though most physicians would point to regulations books that are thousands of pages long from Medicare and argue that, despite more rules and restrictions a costs have continued to skyrocket.4 Market-driven care, they would claim, pushes doctors to chase lucrative insurance contracts with extensive high-tech approaches (almost always paid for by someone other than the actual patients) and beggar much more cost-effective but poorly reimbursed preventative care. Others argue that, as long as employers or government provide health care, there is little incentive for consumers to make choices and force competitive change5 and that much more in the way of market forces is necessary to bring down the accelerating costs that now tally more than 15% of GDP but leave
American’s wellness and sense of well-being at best in the middle of the pack among our chief economic competitors in Europe in Asia.
We believe that the current raft of books that examine the American way of doing medicine leave the most important decision makers—people who will one day all be patients—out in the cold.
Therefore, in this book, we adopt a very different approach. We focus on providing insights into the management of common chronic diseases of adults, which cause the greatest amount of suffering and which utilize the vast majority of the healthcare budget. There is no question that chronic diseases have the greatest impact on the lives of individuals and the population at large as any with diabetes, heart disease, or cancers of various types knows well.
Our basic philosophy is that, to effect rational change, individuals must—and certainly can—understand the basic medical facts and biology behind the common diseases that account for the vast majority of long-term suffering and the lion’s share of health care costs. We
endeavor to explain them.
Second, we are convinced that there is overwhelming proof that most—yes, literally most—physicians do not practice medicine based on the scientific evidence readily presented in medical school, required continuing medical education, and medical journals, nor do they pay much attention to the easily available reviews published for free that address dozens of the most common clinical questions physicians face. Thus, well-educated consumers may need to encourage their physicians to gather the latest recommendations or guidelines; it is as we shall show, a bit much to expect physicians to do such analyses themselves both because they are very busy though often with valueless tasks and because they are not trained to do even the simplest statistical analysis of data. We realize that the latter piece of news may be surprising to most readers. We should explain how this unfortunate fact has come about.
Third, many of the common practices in modern medicine, let alone the new and novel, have very few carefully done studies to back them up. It is impossible to cover every medical condition and look for so-called ‘‘outcome studies’’ by treatment for all of them. So we discuss the most common problems—the ones each of us is most likely to face—and give the reader enough background and information to ask the right questions, including the hardest one of all: ‘‘What happens if I do nothing for a certain condition?’’ We hope the results will enlighten rather than startle the reader.
Finally, we move beyond concerns for individual health to broader health care policy: how much money are we going to spend? Do we finance health care via taxation? Is universal coverage as desirable a goal as it seems? What is the return on investment? Who pays for research and new treatment trials? Are there more effective and much less costly ways to deliver care for the vast majority of medical needs in the United States? We have constructed the chapters in this book to assist the thoughtful reader in pondering these difficult questions a which will certainly always be debated to some extent and which for the foreseeable future will be a prominent part of the campaigns of each election cycle. While there are no final answers, we believe that the fundamental direction is clear: medical practices should be based in science, and thus any serious policy debate must go beyond how to finance medical care (which is by far the dominant theme and focus in political discourse) to how we make science part of daily medical practice.
As this book attempts to demonstrate, we have a long way to go to realize that goal.
1. Available at : http://abcnews.go.com/sections/living/US/healthcare031020_poll
.html. Last accessed Nov 9, 2007.
2. Available at: http://health.msn.com/general/zogby_sicko.aspx.
3. Daniel Callhan and Angela A. Wasunna. Medicine and the Market: Equity vs.
Choice (Baltimore, MD: Johns Hopkins University Press, 2006).
4. James C. Capretta, ‘‘What’s ailing health care?’’ The New Atlantis, Spring 2007; 16:
5. David Gratzer, The Cure: How Capitalism Can Save American Health Care (New
York: Encounter Press, 2006).
Table of Contents
C O N T E N T S
F O R E W O R D i x
I N T R O D U C T I O N
1 The Medical Prognosis—Why More Is Not Necessarily
Taking the Data to Heart 2
The Modern Doctor’s Dilemma 5
A Deadly Intersection: Soft Medicine and Hard
Understanding the Odds Can Even Them 7
The Evolution of Medical Knowledge 8
The Difference Between Trends and Individuals 10
2 Dissecting the Practice of Medicine 13
The No-Sum Game 16
The Value You’re Getting 25
Painting by Numbers 29
Flipping a Coin on a Heart Attack 30
A Stroke in the Eye 32
Under Pressure 34
Beyond Medicare 35
Is It as Bad Among Younger Populations? 36
3 Nothing Exceeds Like Excess 41
More Room at the Inn Means More Treatment 47
The Dollar Cost of Variability in the Latter Years of Life 51
Many Captains, One Ship 51
Following the Money 53
What Is to Be Done? 55
. . . And the Patient’s Preferences 58
. . . And the Doctor’s Preferences 59
4 Are You Past Your Expiration Date? 63
The Price of Living Past Your Expiration Date 64
The Body’s Expiration Date 65
Deadly Turnover 70
5 Screening Out Common Sense 75
How Doctors Make Decisions During Checkups 76
What ‘‘Sensitive’’ and ‘‘Specific’’ Mean 79
The Gold Standard in Strep 80
Good Test, Bad Test: Same Test 82
The Popularity of Screening—Uncle Ivan and the CT
Terrorized by Technology 86
Screening Gone Awry 88
Pitfalls and Promises in Cancer Screening Tests 91
Length- and Lead-Time Bias 91
Testing For Prostate Cancer 96
What Makes Sense? 104
6 News from the Front: The War on Prostate and Other
How Cancers Cause Problems 112
A Closer Look at Cancer: Incidence and Impact 113
The Rise in the Rates of Prostate Cancer 115
What About Other Cancer’s Incidence Rates and
Some Hopeful News from the Front on the War on Cancer:
What Might Be Around the Corner 121
7 Diabetes: Things You May Not Know 125
What Is Diabetes? 126
The Use and Abuse of Glucose 127
Two Types of Diabetes 129
Glucose: The Small Molecule That’s a Big Deal 132
Should High Glucose Levels Be Fixed? 134
So What Makes Sense for Patients with Type II
8 Why Some Think Threading the Artery Is Easier Than
Threading the Needle in Cardiovascular Disease 143
Putting a Price on Quality of Life 144
What Interventions Are Available to Prevent CVD? 147
9 Degenerative, Infectious, and Autoimmune Diseases 155
The First Line of Defense 157
Recent Breakthroughs in Understanding the Immune
The Autoimmune Diseases 161
Do We Really Knee-d This? 165
Making a Pain in the Neck Even Worse 169
More on Degenerative Diseases 175
10 Making the Best Medical Decisions for You 179
The ‘‘All You Should Eat’’ Special 180
Oils from the Sea and the Tree 181
All That Is Sweet Isn’t Good 184
A Hard Look at Supplements 186
An Aspirin a Day . . . 187
The Wages of Sweat 188
Additional Benefits of Exercise 191
But Doctor, Why Is My Attempt at Weight Loss Taking So
Watch Your Mouth, Young Man (and Woman) 193
Examining the Physical Exam 196
A Pocket Summary 198
11 How to Do More Good than Harm 203
Turning Things Around: The Payers and Players 000
Revamping Medical Education: Undergraduate and Post-
Graduate Studies 216
Providing Medical Care Based on Scientific Evidence 219
The Need for Universal Coverage 222
Electronic Medical Records and the Internet 224
Bringing It All Together: A Comprehensive Unified System of Payment (‘‘CUSP’’) 225
I N D E X