Brownlee, Shannon. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. 1st ed. Bloomsbury USA, 2007.
In my work guiding the development and maintenance of a Statewide electronic health record system, I used to say that a hospitalization is a devastating event for a patient and their family and should be prevented if at all possible. This book is a reminder that it truly can be.
I rented this book (more on that in another post) with the understanding that it would cover the issue of health care waste and relate to my intense interest in system accountability and transparency to patients. The first part of the book was horrifying to me because I have seen many of the examples cited with my own eyes (different patients, similar situations). The last part provided for a welcome reflection of myself as a physician, fortunate to be created and nurtured by one of the best-in-class health care systems mentioned in the book.
Scary excesses and waste in healthcare
The book begins discussing the work of Dr. Jack Wennberg, who discovered impressive differences in the way patients were treated in different regions, and the fact that the patients weren’t different, the health systems around them were. I was familiar with Dr. Wennberg’s work before, but I was not familiar with the fact that even today, his team is challenged at some level to achieve acceptance in a medical community that is rewarded for “doing more” rather than “doing right” by people. The examples of the distortion of care provision brought about by historical changes in financing are scary and realistic at the same time. I know them well and saw examples all the time; it was the environment I was trained in during medical school.
In my situation, I took a year off from medical school to attend the UC Berkeley School of Public Health. And then I began training at Group Health Cooperative, as a Family Physician. I marked Group Health as my #1 choice of residency because it seemed like a place where people were always working to do the right thing.
What a strange place it was, and in a good way – where specialists would consult with you and say, “This something that you can manage well, let me show you how,” or pharmacists would say, “You can actually prescribe this antibiotic and achieve the same result for your patient, with much lower cost.” Or when a surgeon once told me, not long ago, “I’m as interested in [informing] the 80% of patients [who are referred to me] who don’t need surgery as I am in the 20% that do.” Not a single piece of pharmaceutical paraphernalia in sight, and no discussion of drugs by their trade name, only the generic name. To this day I know very few trade names. I have never written a single prescription for rofecoxib or celecoxib.
A great read, but with some inaccuracies / cautions
The book ultimately promoted (with greater vigor) in me the feeling that we can and do things differently, that what we’ve all seen in the medical profession that seemed untoward, is untoward, and unfortunately it seems there are no stewards. I liked this quote:
…harm can only be seen in the aggregate, while the responsibility for it is diffuse
Referring to the idea that each individual actor is maximizing their own (self, and selfless) interest in a moral vacuum.
The chapter I had concern about was toward the end; throughout the book doctors seem to be alternately derided and praised, and toward the end, in the section on managed care, there was (in my mind) an unchallenged problem, which was that doctors didn’t/wouldn’t provide feedback or communicate about the best healthcare practices. The topic of medical education was also not discussed well, the idea that doctors are trained not to collaborate, to be islands unto themselves; very differently from their business administration colleagues. Finally, some of the characterization of Kaiser Permanente and (by extension) Group Health physicians as “a bunch of idealists” is a bit off the mark and superficial. If I have learned anything in my journey over the past 8 months, it is that all physicians and health care workers are idealists (my quote “everyone that goes into healthcare is exceptional; they have to be for a job this challenging), and crave a health care system that supports their energy and creativity.
The other key opportunity that I think Ms. Brownlee touched on but missed (and maybe will follow-up in another book?) is the value of patient and family involvement. The solutions she invoke include the concept of an “accountable” healthcare system, but they don’t touch on deep patient and family involvement, such as at centers like Medical College of Georgia. Health Information Technology and EHRs are referred to as physician tools only; patient access isn’t discussed. If anything, these are the true innovations of the systems that are praised throughout the book. A system that is willing to be transparent with its patients is probably more willing and able to improve itself over time.
A nice challenging look in the mirror
Despite some of the issues above, there’s a bit of courage in writing this story down, as well as in some other articles I have seen Ms. Brownlee pen online. I really believe that more we get involved in our own care, and promote that for every patient in every system, the more likely it is that the system will respond to the needs as they exist. My own heritage in one of the systems lauded throughout is affirming that doing the right thing by patients and not more of something is the right work and feels good to do. I think every physician (and patient) is capable of understanding the benefits of this, as well.