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How We Do Harm exposes the underbelly of healthcare today—the overtreatment of the rich, the under treatment of the poor, the financial conflicts of interest that determine the care that physicians' provide, insurance companies that don't demand the best (or even the least expensive) care, and pharmaceutical companies concerned with selling drugs, regardless of whether they improve health or do harm.
Dr. Otis Brawley is the chief medical and scientific officer of The American Cancer Society, an oncologist with a dazzling clinical, research, and policy career. How We Do Harm pulls back the curtain on how medicine is really practiced in America. Brawley tells of doctors who select treatment based on payment they will receive, rather than on demonstrated scientific results; hospitals and pharmaceutical companies that seek out patients to treat even if they are not actually ill (but as long as their insurance will pay); a public primed to swallow the latest pill, no matter the cost; and rising healthcare costs for unnecessary—and often unproven—treatments that we all pay for. Brawley calls for rational healthcare, healthcare drawn from results-based, scientifically justifiable treatments, and not just the peddling of hot new drugs.
Brawley's personal history – from a childhood in the gang-ridden streets of black Detroit, to the green hallways of Grady Memorial Hospital, the largest public hospital in the U.S., to the boardrooms of The American Cancer Society—results in a passionate view of medicine and the politics of illness in America - and a deep understanding of healthcare today. How We Do Harm is his well-reasoned manifesto for change.
- Sales Rank: #181276 in eBooks
- Published on: 2012-01-31
- Released on: 2012-01-31
- Format: Kindle eBook
Review
“Otis Brawley is one of America’s truly outstanding physician scientists. In How We Do Harm, he challenges all of us-- physicians, patients, and communities-- to recommit ourselves to the pledge to 'do no harm.'”-David Satcher,Former Surgeon General of the United States, Director, Satcher Health Leadership Institute, Morehouse School of Medicine
“Sweeping, honest and brave . . . How We Do Harm dazzles with a wealth of scientific insight, but its genius lies in the author’s recounting of individual patient stories that illuminate the dark underbelly of medicine’s missteps. Brawley does not shrink from revealing medicine’s warts, butthis book offers much more. It is a triumph of humanity and clarity in which oncology becomes a Rorschach for the practice of American medicine. You will finish this arresting book reluctantly, with a new appreciation of what American medicine could be.”-Harriet A .Washington, author of Deadly Monopolies: The Shocking Corporate Takeover of Life Itself and the Consequences for Your Health and Our Medical Future and Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present
“Dr. Brawley is a premier academic oncologist and a minority doctor in the nation's largest inner city hospital. How We Do Harm places in stark contrast the health care resources available to the rich and the poor, the insured and the uninsured, the white community and the community of color . He makes the cogent point that more testing, screening, and interventions available to the rich does not always mean better medical care .”-Bruce Chabner, MD, Director of Clinical Research, Massachusetts General Hospital Cancer Center
“Otis Brawley shares in equal measure his compelling personal story, the development of modern medical oncology, and the wide range of his strong opinions. Whether you agree with him or not, the reader is given access to Dr. Brawley’s unambiguous scientific and ethical framework. He provides an anvil for shaping your own perspectives and biases.”-Michael A. Friedman, MD, President and Chief Executive Officer, Director Comprehensive Cancer Center, City of Hope
“A tough-minded, solidly argued indictment of health care. . . Brawley’s sense of outrage is palpable.” -The Boston Globe
"A powerful contribution to the ongoing discussion on health-care reform.”-Kirkus
This book is shockingly detailed and it should serve as a wake-up call to fix the dismal mess and rethink the politics of illness in America. Dr. Brawley provides a well-reasoned manifesto for change.”-Tucson Citizen
“Any who want to know how behind-the scenes healthcare works will find this a key title." –Midwest Book Review
About the Author
DR. OTIS BRAWLEY is the chief medical and scientific officer and executive vice president of the American Cancer Society. Dr. Brawley currently serves as professor of hematology, oncology, medicine and epidemiology at Emory University. He is also a CNN medical consultant. He is a graduate of the University of Chicago, Pritzker School of Medicine, and completed a residency in internal medicine at University Hospitals of Cleveland, Case-Western Reserve University, and a fellowship in medical oncology at the National Cancer Institute.
PAUL GOLDBERG is an award-winning investigative reporter who covers oncology for The Cancer Letter, a weekly publication focused on drug development and the politics of cancer. His articles have appeared in The New York Times, The Wall Street Journal, The Washington Post, The Washington Monthly and he has been featured on 60 Minutes, 20/20, CNN and NPR. Goldberg is also the author of two books on the Soviet human rights movement.
Excerpt. © Reprinted by permission. All rights reserved.
Chapter 1
Chief Complaint
SHE WALKS THROUGH the emergency-room doors sometime in the early morning. In a plastic bag, she carries an object wrapped in a moist towel.
She is not bleeding. She is not in shock. Her vital signs are okay. There is no reason to think that she will collapse on the spot. Since she is not truly an emergency patient, she is triaged to the back of the line, and other folks, those in immediate distress, get in for treatment ahead of her. She waits on a gurney in a cavernous, green hallway.
The “chief complaint” on her chart at Grady Memorial Hospital, in downtown Atlanta, might have set off a wave of nausea at a hospital in a white suburb or almost any place in the civilized world. It reads, “My breast has fallen off. Can you reattach it?”
She waits for at least four hours—likely, five or six. The triage nurse doesn’t seek to determine the whereabouts of the breast.
Obviously, the breast is in the bag.
* * *
I am making rounds on the tenth floor when I get a page from Tammie Quest in the Emergency Department.
At Grady, we take care of patients who can’t pay, patients no one wants. They come to us with their bleeding wounds, their run-amok diabetes, their end-stage tumors, their drama. You deal with this wreckage for a while and you develop a coping mechanism. You detach. That’s why many doctors, nurses, and social workers here come off as if they have departed for a less turbulent planet.
Tammie is not like that. She emotes, and I like having her as the queen of ER—an experienced black woman who gives a shit. When Dr. Quest pages me, I know it isn’t because she needs a social interaction. It has to be something serious.
“We are wanted in the ER,” I tell my team.
The cancer team today consists of a fellow, a resident, two medical students, and yours truly, in a flowing white coat, as the attending physician. I lead the way down the hall. Having grown up Catholic, I can’t help thinking of the med students and young doctors as altar boys following a priest.
I am a medical oncologist, the kind of doctor who gives chemotherapy. My other interests are epidemiology and biostatistics. I am someone you might ask whether a drug works, whether you should get a cancer screening test, and whether a white man’s cancer differs from a black man’s cancer. You can also ask me if we are winning the “war” on the cluster of diseases we call cancer. As chief medical officer of the American Cancer Society—a position I have held since 2007—I often end up quoted in the newspapers, and I am on television a lot. In addition to my academic, journalistic, and public-policy roles, I have been taking care of cancer patients at Grady for nearly a decade, first as the founding director of the cancer center, and now as chief doctor at the ACS.
My retinue behind me, I keep up a fast pace, this side of a jog. Bill Bernstein, the fellow, is the most senior of the group. Bill is a Newton, Massachusetts, suburbanite, still boyish. He is having trouble adjusting to the South, to Atlanta, to its inner city. He is trying, but it’s hard to miss that black people and poor people perplex him. Contact with so much despair makes him awkward. But he has a good heart, a surfeit of common sense—and he is smart. Whatever we teach him at Grady will make him a better doctor wherever he ends up.
Grady suffers from what the administration here calls a “vertical transportation problem.” Our elevators are slow at best, broken at worst. We head for the stairs, rushing down to the first floor, then through long, green hallways into the ER.
Grady is a monument to racism. Racism is built into it, as is poverty, as is despair. Shaped like a capital letter H, Grady is essentially two hospitals with a hallway—a crossover—in the middle to keep things separate but equal for sixteen stories.
In the 1950s and ’60s, white patients were wheeled into the front section, which faces the city. Blacks went to the back of the H. This structure—built in 1953—was actually an improvement over the previous incarnation. The Big H—the current Grady—replaced two separate buildings—the whites got a brick building, the blacks a run-down wood-frame structure. Older Atlantans continue to refer to the place in a chilling plural, the Gradys.
You end up at Grady for four main reasons. It could happen because you have no insurance and are denied care at a private hospital, or because you are unconscious when you arrive by ambulance. When your lights are out, you are in no position to ask to be taken to a cleaner, better-lit, suburban palace of medicine. A third, small contingent are older black folks with insurance, who could go anywhere but have retained a dim memory of Grady as the only Atlanta hospital that accepted us. The fourth category, injured cops and firemen, know that we see a lot of shock and trauma and are good at it. We are their ER of choice.
Today, our 950-bed behemoth stands for another form of segregation: poor versus rich, separate but with no pretense of equality. Grady is Atlanta’s safety-net hospital. It is also the largest hospital in the United States.
The ER, arguably the principal entry point to Grady, was built in the center of the hospital, filling in some of the H on the first floor. To build it, Grady administrators got some federal funds in time for the 1996 Summer Olympics. This fueled financial machinations, which led to criminal charges, which led to prison terms. (In retrospect, the bulk of the money was put to good use. Many of the victims of the Olympic Park bombing came through our ER.)
The hallways here are incredibly crowded, even by the standards of inner-city hospitals. Patients are triaged into three color-coded lines—surgery, internal medicine, obstetrics—and placed on gurneys two-deep, leaving almost no room for staff to squeeze through.
You might see a homeless woman drifting in and out of consciousness next to a Georgia Tech student bloodied from being pistol-whipped in an armed robbery, next to a fifty-seven-year-old suburban secretary terrified by a sudden loss of vision, next to a twenty-eight-year-old hooker writhing in pain that shoots up from her lower abdomen, next to a conventioneer who blacked out briefly in a cylindrical tower of a downtown hotel, next to a fourteen-year-old slum dweller who struggles for breath as his asthma attack subsides.
When I first arrived in Atlanta and all of this was new to me, I took my wife, Yolanda, through the Grady ER on a Friday night.
“Oh, the humanity,” she said.
Yolanda, a lawyer with the U.S. Securities and Exchange Commission, feels happier above the Mason-Dixon Line.
* * *
TAMMIE Quest—I use her real name—is cute, has a broad, infectious smile, and comes from privilege. She grew up in Southern California and frequently refers to herself as a “black Valley girl.”
Though she identifies with the West Coast, a lot of Atlanta has rubbed off on her in the Grady ER.
No two ERs are alike. Ours tells the story of Atlanta more clearly, more poignantly than its skyline. Patients everywhere are scared of their wounds or diseases that rage inside them. Here, in the middle of this big, hot, loud, violent city, they have an added fear: they are terrified of each other, often with good cause.
Elsewhere, patients might trust us doctors, admire us, even bow to our robes, our honorifics, and the all-caps abbreviations that follow our names. Here, not so much.
A place called Tuskegee is about two hours away from here. It’s where government doctors staged a medical experiment in the thirties: they watched black men die of syphilis, withholding treatment even after effective drugs were invented.
Tuskegee is not an abstraction in these parts. It’s a physical place, as palpable as a big, deep wound, and eighty-plus years don’t mean a thing. Tuskegee is a huge, flashing CAUTION sign in the consciousness of Southern black folks. It explains why they don’t trust doctors much and why good docs such as Tammie have to fight so hard to earn their elementary trust.
Like me, Tammie is a member of the medical-school faculty at Emory University, and, like me, she has several academic interests. One of these interests is end-of-life care for cancer patients: controlling the symptoms when someone with advanced cancer shows up in your ER.
Seeing us approach, she walks toward us and hands me a wooden clipboard with the Grady forms. I look at her face, gauging the mixture of sadness, moral outrage, and fatigue.
She says something like “This patient needs someone who cares,” and disappears.
I glance at the chief complaint.
“Holy shit,” I say to Bill Bernstein and, more so, to myself.
I introduce myself to a trim, middle-aged, black woman, not unattractive, wearing a blue examination gown conspicuously stamped GRADY. (At Grady, things such as gowns, infusion pumps, and money tend to vanish.)
From the moment Tammie paged me, I knew that the situation had to be more than a run-of-the-mill emergency. This patient clearly is not about to die on the examination table. She doesn’t need emergency treatment. Before anything, she needs somebody to talk to. She needs attention, both medical and human.
The patient, Edna Riggs, is fifty-three. She works for the phone company and lives on the southeast side of Atlanta.
Sitting on an exam table, she looks placid. When she extends her hand, it feels limp. She makes fleeting eye contact. This is depression, maybe. Shame does the same thing, as does a sense of doom. Fatalism is the word doctors have repurposed to describe this last form of alienation.
In medicine, we speak a language of our own, and Edna’s physical problem has a name in doctorese: automastectomy. It’s a fan...
Most helpful customer reviews
164 of 172 people found the following review helpful.
The Unfortunate Reality of American Medicine
By Loyd Eskildson
First, a few words on Dr. Otis Brawley and my bias - he's the Chief Medical Officer for the American Cancer Society, Professor of Medicine at Emory University, and a CNN medical consultant. As for my bias, after reading his book and bio, I would trust him to give me the best medical recommendations. I wish I lived closer so he could be my physician - I'm really impressed!
'First, do no harm' is the first precept of medical ethics taught in medical school 'How We Do Harm' is Dr. Brawley's description of the real world, of how medical practice deviates from that basic ethic. The bulk of the book consists of anecdotal examples that he has become aware of.
Dr. Brawley begins by comparing how much America spends on health care vs. other nations. We're now at 18% of GDP, and Switzerland is #2 - at 12%, obviously much lower. We spend 3.5X as much on health care as on food. Canadians spend half what we do, and are ranked #7 in life expectancy. We're #50. More is not better - in fact, American health care is making our nation sick, in an economic sense.
Many health care providers allege that they're financially short-changed by Medicare and Medicaid; others contend that the relatively low reimbursement rates of those programs is a form of 'cost-shifting' that raises rates for others. Dr. Brawley, however, states that providers can still make money at those reduced rates treating complex cases involving uncontrolled diabetes, kidney failure, heart disease, and late-stage cancer.
As for Tea Party allegations of ObamaCare medical rationing, per 'Death Panels', Dr. Brawley says this is already happening - via insurance companies. Yet, irrational spending is still rampant. We need to return to a focus on not doing harm, peddling snake-oil and false hope - that will lower costs and improve quality. The current financial incentives driving medical practice have a bad impact on patient health and costs. Doctors who own labs order more tests than those who don't. Some community oncology practices hold regular meetings to inform physicians about treatment techniques that maximize billing. 'Disease Mongering' is overly prevalent - the proactive marketing of disease with free initial tests followed by lots of expensive for-pay follow-up. Another example - 'Zero,' an advocacy group that sponsors prostate screening vans, receives funding from the makers of Depend diapers. (Prostate removal, usually not required or recommended, subsequent to these screenings creates incontinence.)
Professional medical societies have chosen collegiality over patient well-being. Professional doctor societies issue 'evidence-based' guidelines for performing expensive procedures that are anything but evidence-based. Many patient advocacy groups act as unquestioning advocates for drug companies and medical specialists, not realizing that the interests they advocate run counter to their own. Debates between Tea Partiers and fictional characters created by PR firms further mislead.
Pseudoscience, greed, myths, lies, fraud, and looking the other way have far too often taken the place of science in directing health care. Good health care will have to be won in a public struggle, just as civil rights were. We need more stress on prevention, starting with health education.
Bottom-Line: Dr. Brawley is to be commended for shattering the 'good-old boy' image of medicine. Reality is that, like Wall Street, the profession is driven by outrageous greed. Days of family practitioners making house calls, accepting payment in eggs and chickens (if paid at all), are long gone. My most recent health care experiences (dental and medical) both follow Dr. Brawley's observations. Also amazing is the disparity between providers' 'list prices' and the prices paid by insurance firms - if list prices matched even the highest insurance payment, far fewer uninsured patients would be bankrupted by health care, and expenditures wasted on health care overheads (advertising, patient 'selection,'care review) would drop.
"How We Do Harm" is an invaluable contribution to those wanting to improve health care.
86 of 88 people found the following review helpful.
Horror stories about health care, Breast Cancer, PSA Test
By jwt99
I could not put this book down. I would say this is a must read for anyone that might get or who has cancer. Also anyone who has a chronic health problem should put this book in their library.
I think Dr. Brawley gives compelling examples that illustrate how our health care systen is broken.
Read this book!
This is an excellent book unless you are a quack, a greed driven doctor or drug rep. Dr.Brawley points out that we should not waste valiable tax money or even insurance money on unproven cures or on drugs that cost 10-20 times as much as a proven drug. All medical care should be research based, rational and above all "do no harm".
I hate to tell you this, but we as a country cannot afford to waste massive amounts of money anymore. If we don't get serious about health care it will break the country. We cannot afford to transfer wealth to quack doctors or for procedures that don't work. A spinal fusion costs about $80,000 yet 80% of the research says it does no good and it does a lot of harm. Is this any way to run a health care system?
If you don't believe Dr. Brawley read the research for yourself.
Use a little of your time to dig and see if he is telling the truth.
A lot of the raw research is locked up tight and hard to access and not easy for a lay person to understand. We must rely on honest doctors like Dr. Brawley to tell us the truth about our healthcare system
The chapters on the "PSA" test for prostate cancer were shocking to say the least.
All the examples about the breast cancer problems are on point. My wife went through this several years ago and thank goodness we had a doctor whose first words were us was " I don't give any treatment that has not been through a double blind study."
We feel like my wife received excellent treatment without receiving too much treatment. Too much can be as bad as too litttle as Dr. Brawley states.
Dr. Brawley points out through his examples that "raw greed" on the part of hospitals, doctors and drug companies has layed waste to our health care system.
The economic incentives are all on the side of more care not appropriate care. There is a vast difference between the two.
Thank you Dr. Brawley.
72 of 74 people found the following review helpful.
Terrible and true
By Kara Smigel
Dr. Brawley (excuse me, Otis) has written a book about the kind of things doctors say to each other, but not out loud and certainly not for publication. The contrast of healthcare for the overprivileged to the lack of care for the underserved (and the sea of confusion for those in-between) should not exist in the United States, and yet it does. That so much of this happens in the care of people with cancer is really unforgivable. Many will be unhappy with the author, but many more will have to agree that he is indeed telling the truth -- and doing so in a way that is compulsively readable. Otis knows how to get your attention and weave a tale that points out the things you should be seeing. He does not claim to have the answers and is free with admitting his own missteps along the way. I already sent a copy to my niece who is a 2nd year resident at an inner-city hospital and told her to be sure to pass it around once she has read it.
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