Read March 2019
Recommended for health care providers, patients
★ ★ ★ ★
I don’t know that I’ve ever read anything that came so close to summing up my years in health care. That said, there’s one thing to get out of the way. The title is, as they routinely are, misleading. The appropriate title would be: Dr. Otis’ Thoughts on a Broken Health Care System and His Career in Medicine. Clearly, since Dr. Otis is African-American, male, from a prestigious family, trained as an epidemiologist as well as a medical doctor, and a national healthcare leader, we have different relationships to the system. But we’ve both spent years in oncology, done stints in the ER and have met many of the same types of patients and unfortunately, have noticed many of the same types of problems, so minus the Dr. Otis part, there’s a lot here that I will attest to as being absolutely, sadly, totally true.
It’s an extremely readable book, especially considering it is about health care and non-fiction. Granted, I’ve been in the field, but compared to I Contain Multitudes, which was excellent but idea-dense, this flew by. I was halfway through the book in a day. No doubt, Brawley’s co-writer, Goldberg, gets much of the credit. As a journalist, he’s probably comfortable conveying his ideas at a generalist level.
Brawley works for much of his career at Grady, an Atlanta hospital known for providing care to the poor, and particularly the African-American population once desegregated really took off (there’s an interesting aside about the ‘H’ shape of the building and the blacks literally being at the back). The ‘Chief Complaint’ chapter discusses a working-class woman, Edna, who comes in with a significant case of advanced breast cancer so severe that her breast has actually fallen off (okay, this I have never heard of, being in a relatively high-healthcare-using population). He discusses the ins and outs of late stages versus early stage and points out that “Had she come early in the course of her disease, it would have cost about $30k to cure her. She could have remained a taxpayer. Her kids could have had a mother. Now, a cure is not an option. Still we’ll fight… give chemotherapy that will cost more than $150k, even though chances are that she will still die in less than two years.“ Brawley talks about some of the specifics of breast cancer and relates them to risk. Right now, statistics tell us that African-American women tend to get the more lethal form of breast cancer and therefore die younger, but he explains how some of that may be screening bias over potential genetic disease risk. If you haven’t heard it by now, 25% of Medicare costs are for people in their last year of life. (source), so this concept of preventative versus “heroic” care is hardly unique.
‘Brawleyism’ is a short chapter on Otis Brawley, the author, and his family history as rebels. He then discusses the overall economics of the American health care system, and the fact that we’re 50th in life expectancy. Again, this isn’t new, but what is interesting is that he states “A rational system of health care has to have the ability to say no, and to have it stick.” Very powerful stuff… but he doesn’t quite take it to the next step and say the woman in chapter one shouldn’t have had chemotherapy. He does talk about about how financial incentives are built in for doctors who own/profit-share in labs, pharmacies, and imaging centers. At the very least, many have a professional and implicit bias where they believe their profession can help, although evidence may be slight.
‘Cadillac Care’ discusses how even people who have access to advanced care can be steered wrong. He contrasts Edna with Helen. While both are African-American, Helen is a highly educated, financially secure breast cancer survivor/advocate who is treated with a mastectomy and a bone marrow transplant, with the result of five months in a hospital and further time at a rehab center. Brawley spills the beans on how transplant programs were money-makers in the 1990s -20s for breast cancer. This treatment was based based on four randomized trials, with less than 1500 people, one of which was found later to be fraudulent. In this section, Otis also touches on his experience with black people being legitimately suspicious of the health-care system (particularly in the South!) and of black doctors.
People, this low-proof, expensive treatments are going on right now with CAR-T cell therapy, hailed as the next cure for ALL and B-cell lymphoma, only those studies are based on about 150 people. And roughly a third of the people died. But half of them were cured!
‘Red Juice’ talks about a drug called Procrit, another potential lifesaver on the cancer scene back in the 2000s. I started nursing when they were still pushing it as a way to recover blood counts that dropped as the result of chemotherapy, but it was only a couple of years later before they slapped the FDA’s strongest warning, a ‘Black Box warning’ on it. It turns out it led to a significant increase in strokes and heart attacks. Brawley shares a bit about a woman’s personal experience with it (I think she might have had 200 doses during her treatments) and how it was a money-maker, with $4.9 billion in sales in 2006 (so you can stop the bullshit about research costs, Amgen). He has insider info on how doctor practices that made ‘larger’ purchases could get back 21% in ‘rebates’ on their purchase, as well as discounts on their white blood cell stimulators.
Which are still on the market and making big, big dollars, as they’ve been proven to reduce length of neutropenic days (although I’m not sure if the data ever tied that into reduced death/infection rates).
So it feels a little like same snake oil, different decade. People wonder how I’m old and cynical. It’s because of this reading thing. I tell you, don’t do it.
A couple of chapters–and again, an unfortunately common refrain in my experience–was the story of Mr. Huzjak, a 78-year old who had stage 4 non-small-cell-cancer (with a 5 year survival rate of about 6% for distant mets). He was comatose when brought in, but his children wanted “everything” done. The family practice doctor couldn’t convince them. Otis couldn’t convince them. He finally died after enduring pain (the only thing he reacted to) of LPs, CTs, chest tubes, tube feedings, a MI and chest compressions. End result: same. Except it was traumatic for all concerned, particularly Mr. Huzjak. Oh, and expensive. I can’t even tell you how upset I get with Americans and their concepts about death (see Death Panel Discussions, Health Care Reform). Personal example: my own mom is 74 and won’t even talk about it like a reality, plan for it, whatever. Frigging baby boomers think they are going to live forever. Have you seen the obituaries where people say someone “unexpectedly” died at 80? Uh, no, people. That’s outliving our average lifespan right there; nothing unexpected about it.
Some of his story is more about himself, particularly towards Part III, and about population statistics, epidemiology and preventative medicine. He uses the example of poor Ralph, who stopped in for a “free PSA screening” at a local mall, had a high PSA, had surgery, then radiation, then medical complications. Screening for prostate cancer is even more complicated than screening for breast cancer, and what they’ve mostly found out is that it shouldn’t be done unless there is a reason to do it. Otis talks to a marketer who points out that the screening is good PR, brings people into the health care system (who are usually on Medicare), who might be candidates for drugs for incontinence and erectile dysfunction and implants. Otis also connects it to the rise of the DaVinci robotic surgery (which is an expensive device that came to my hospital shortly before I left) that has a $100k maintenance plan and requires 100 plus procedures for the practitioner to become proficient. It also tends to result in a small amount of biologically active prostate tissue being occasionally left behind, resulting in continued elevation in PSA.
TL; dr: The summation: use evidence-based medicine (not just from societies, who have a vested interest); don’t let your fears guide you into excessive treatment (as a patient or as a practitioner); preventative medicine costs less than curative; don’t be afraid of death. There’s many, many worse things than dying largely pain-free with people you love around you. Okay, I made that last part up. Otis didn’t explicitly say that. He calls his solutions “Rational Health Care.”
Overall, I’d highly recommend it for people in hospitals and clinics. It should make practitioners think about what we recommend and why, and what and who is behind our recommendations. Likewise, as a consumer, it might help us understand that asking questions is good. Not just “have you done this before,” or “what do other people do,” but, “what does the evidence say.” Yes, there’s an art to medicine, where careful assessment and questioning can get one far. A good practitioner should be able to couple that with cost-effectiveness and risk-analysis when it comes to exposure (if our cancer patients live, the odds of getting secondary cancers is quite high. We aren’t helping with all the radioactive scans to ‘reassure’ on progress).
Reasons against five stars: It really should have left out the beginning bits of Otis’ career, especially his training in epidemiology. I don’t know that it was germane. There’s a little tension in this story between the need to make it The Otis Story and the Breaks Ranks About Being Sick. I would have liked him to be bolder about calling the American Medical Association out for allowing bad doctors to practice, but we have to be realistic, I guess.
Part I: Three From the Gradys. Divided into five short pieces, ‘Chief Complaint,’ ‘Brawleyism,’ ‘Cadillac Care,’ ‘Skepticism,’ and ‘Wallet Biopsy.’
Part II: Failure Is the System. ‘Red Juice,’ ‘Tumor Promotion,’ ‘Defibrillation,’ ‘Palpitation,’ ‘Saving Mr. Huzjak,’ ‘God is Calling’
Part III: More Is Better. ‘Ole Boys’ Club,’ ‘Snuffy’s War,’ ‘How Much Protection?’ ‘The Guillain-Barré Syndrome,’ ‘Saving Representative Silvio Conte,’ ‘The Quintessential American,’ and ‘Faith-Based Medicine.’
Part IV: Evidence-Based Medicine. ‘The Denominator,’ ‘From the Health Fair,’ ‘Behind the Blue Curtain,’ ‘False Guidelines,’ ‘Algorithms for Judgment,’ ‘Saying ‘Enough!” ‘Project LEAD,’ and ‘Epilogue.’