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    Sunday, November 14, 2004

    We Have Met the Enemy, and They Are Us: Dr. John Abramson is somewhat of an anomaly. For starters, he's a family physician on the faculty of Harvard Medical School - an institution not known for its warm embrace of the family medicine concept. (In its place, they have something called the Department of Ambulatory Care and Prevention, staffed largely by internists and pediatricians and masters of public health, and oddly enough, funded by an HMO.) Which brings us to his other claim to anomalism - the publication of his book, Overdosed America : The Broken Promise of American Medicine. While other academics and health policy analysts point directly to the pharmaceutical industry as the root of all evil in our current healthcare system, Dr. Abramson correctly notes that the real roots of our problems lie in our culture - from the academic and health policy system to the professional and popular cultural mileau.

    Now, as healthcare systems go, ours isn't too shabby. We have the luxury of taking clean water and cheap, unspoiled food for granted. We live our lives free of the threat of death by bacteria. Most of us, no matter how poor, can find a doctor to take care of us in our hour of need. We don't wait for months for CAT scans or heart surgery, or to get an appointment with a doctor. We have a medical establishment that believes strongly in the importance of practicing medicine only with scientifically proven treatments - aka "evidence-based medicine." We have third party payers who monitor the quality of care by our physicians based on guidelines written by experts in their fields. However, as Dr. Abramson points out - an awful lot of the healthcare we get isn't the worth the money we pay. If our healthcare system were a car, it would be a Jaguar - fast, expensive, and beautiful on the surface, but little to offer for the long-haul.

    Part of the problem is the elusive nature of this thing called health. Like happiness, it's difficult to nail down. That's why our founding fathers claimed a right to the pursuit of happiness rather than the state of happiness. If only we were so wise when it came to defining our goals for health. Today, health and disease have much broader meanings than they did fifteen years ago. Fifteen years ago, disease meant illnesses caused by a malfunctioning of the body or outside invader, such as cancer or infections; today, disease includes the normal changes of aging, such as osteoporosis and thickening waist lines. Twenty years ago, to be healthy meant to be of sound mind and body; today it means a fine obsession with various biomedical measures of the body - from cholesterol level breakdowns to bone density values. What's more, we have a pill or a procedure to treat each of those biomedical measures of health. Is your LDL cholesterol a smidgen above the recommended guidelines? We can bring it down for just over a hundred dollars a month. Is your body mass index forever over 25? We can readjust your stomach to bring it down. Even better, we have insurance companies who are willing to pay for all of this. And if they don't, we'll pressure them until they do.

    Dr. Abramson doesn't spare the pharmaceutical companies any criticism. Our system of drug-financed medical reasearch and medical centers, corporate-sponsored professional organizations and medical education, and consumer advertising corrupts the decision making process of doctors, patients, and expert panels. The evidence central to evidence-based medicine can't be trusted because it's financed by drug companies. The practice guidelines that expert panels such as the American Heart Association publish which are supposed to guarantee we all practice high quality medicine can't be trusted because they're funded by drug companies. But that's only part of the problem. As Dr. Abramson says at one point in his book - "we have met the enemy and they are us."

    The problem can be traced back to the late 1980's and early 1990's when Medicare, Medicaid, and the baby boom population reached maturity. There was much hand-wringing at the time about the "crisis in American medicine," just as there is now. Then, as now, the crisis was the cost. The solution, which enjoyed wide support from all sectors of society - from the public, the medical profession, and politicians on both sides of the aisle - was the adoption of managed care, or HMO's. The public loved it because it meant they no longer had to pay for healthcare, at least not directly. For a minimum co-pay, and the price of their monthly insurance premiums, they would get unlimited access to their doctors and all the preventive care they needed - pap smears, mammograms, immunizations, and yearly physical exams, and drugs. The medical profession loved it because they believed passionately in the power of prevention and they also believed that by providing unlimited preventive care they could conquer disease. The insurance companies loved it because it shifted the inherent risk of their business to the medical profession. Politicians loved it because it meant that once Medicare and Medicaid beneficiaries were shifted to managed care programs, someone else would make the painful and unpopular decisions about rationing that are inevitably needed to rein in costs. It was win-win all around.

    Except it didn't quite turn out that way. The gatekeeping nature of HMO's turned out to be immensely unpopular - so much so that the insurance companies pretty much gave up on limiting benefits, lest they be accused of corporate malfeascence. Instead, they just raised premiums. The emphasis on prevention, and the willingness to pay for it, encouraged doctors and the public to accept expanded definitions of health and disease. Doctors could promote with impunity the necessity of having bone densitometry tests or fasting lipid panels done - and the necessity of treating values outside the defined norm - without giving much scrutiny to the actual benefit. And the public could accept it without much thought, since they didn't have to pay for it directly. Add to this mix the expansion of pharmaceutical advertising directly to the patient - who no longer had to worry about the cost of the product they were consuming, and you've got a recipe for unlimited demand, and unlimited spending. (The drug industry marketing departments knew a golden opportunity when they saw it. What other product has the luxury of advertising directly to a consumer who doesn't have to pay for it?)

    At the same time, the shift of Medicaid and Medicare patients to managed care plans meant less money for academic medical centers, who relied on these patients for their operating revenues. To remain competitive, they turned to private industry for funding, which in most cases meant the pharmaceutical industry. This relationship skewed the inherent bias in all research even further toward the positive, and meant that the emphasis would be placed on drug development rather than non-pharmacological management of disease and disease prevention. Those same researchers end up sitting on the expert panels that then write the guidelines that are supposed to guarantee quality care.

    It doesn't help that medical journal editors are by and large undiscriminating in the papers they publish. They, too, have their biases, and publishing papers that show positive results is one of them. So is publishing papers that suggest a revolution in treatment - such as reducing heart disease by treating cholesterol. They don't give the data much scrutiny in the process. And they never question the spin the authors give their data. Even worse, they press release that spin to the media for direct consumption by the consumer.

    And so we have our current system. A paper is published that suggests taking cholesterol lowering drugs cuts the risk of heart disease by 50%. In actuality, their data find that without the drug, 2 out of 100 people have a heart attack, while with the drug, only 1 out of 100 do. Their claim to a 50% reduction in risk is technically true, but misleading. The majority of people in both categories will do fine without the drug. But the authors have chosen to concentrate on the more impressive sounding relative risk reduction rather than the absolute risk reduction. It gets them more attention that way. The medical journal, and perhaps the author's institution as well, sends a press release to the media about these stunning findings. That week, the news is full of the amazing benefits of the drug. The company makes up television and print ads touting its benefits, too. Within the week, patients are asking their doctor about the cholesterol lowering drug that works saves so many lives. And the doctors? With any luck they'll read the abstract of the paper and conclude the drug must be beneficial, without ever noting the devil in the statistical details. And even if they did, they would have trouble convincing most people of the inadequacy of the drug given all the favorable publicity it's gotten. As a result, new drugs and treatments become accepted much more quickly than they otherwise would - and with much less scrutiny than they deserve.

    Dr. Abramson sees the solution to our cunundrum as more government oversight of the healthcare industry. He suggests we set up an impartial body, along the lines of the Federal Reserve Board, to monitor the quality of medical research and recommendations. In addition, he suggests that there be government funded universal healthcare coverage, which would pay only for those benefits deemed worthy by the oversight board. Dr. Abramson puts too much faith in the impartiality of government bodies. Even the Federal Reserve Board comes under criticism for being entirely a creature of the finance sector. The Institute of Medicine, which he also mentions as a model, is no less subject to bias. Their report on racism, for example, was written by people whose careers depend on the presence of racism. Their personal bias was to see racism even where it doesn't exist. Similarly, their report on errors in medicine was written by people who make their living selling safety systems and consulting on error reduction. Not surprisingly, the racism panel claimed racism was rampant (later debunked) and the error panel claimed more errors than statistically reasonable. Imagine what they would do with something like drugs and therapuetics which are much more subject to lobbying influence.

    History tells us that there's very little reason to expect our government to be immune to industry lobbying. As we've seen with Medicare spending and NIH research funding, all it takes is a celebrity or a Congressional relative with a disease to earmark money for its treatment. They're even more prone to influence from those advocacy groups and lobbyists who have the money for campaign donations.

    A better solution would be to move the decision making process, especially for preventive care, back where it belongs - between a patient and his physician. The only way to do this is for the patient to share at least some of the financial responsibility for their care. As long as someone else is paying the bill, the sky will be the limit. It's just human nature. A patient who has to pay for cholesterol lowering medication is going to be much more likely to question its benefits, and the doctor who has to justify the expense to his patient it is going to be much more willing to critique the evidence. This, of course, flies in the face of all that is politically correct in medicine. But, as Dr. Abramson so ably points out in his book, we aren't really getting very much in return for all of this very costly prevention. Isn't it about time that we all took responsibility for our share of the mess?

    ADDENDUM: For another take on the book, click here. Dr. Abramson's blog can be found here.

    (Cross-posted at Blog Critics.)

    UPDATE: Comments from another family physician:

    Bravo to you and Abramson both. Having been in family practice since it was called 'general practice' (I interned in a 'general practice' program; when I got out of the Navy two years later, I went back to the same hospital to do my 'family practice' residency), I'm amazed anyone's even listening to the guy.

    Every year I note the 'normal' weight/cholesterol/blood pressure/blood sugar, etc keeps getting defined lower and lower by the stroke of a pen, thus creating a whole new class of sick people. They now are trying to sell 'pre-hypertension'!

    My daughter was a detailer for the old Upjohn Corp in the early '90s and quit in disgust after a few years. The relationship between doctors and pharms is way out of line.

    posted by Sydney on 11/14/2004 06:32:00 PM 0 comments


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