How We Do Harm (39 page)

The medical profession frequently allows bad doctors to continue to practice.
The profession doesn’t police itself.
Chalk it up to apathy.
Or ignorance.
Many physicians are ignorant of some aspects of the field of medicine in which they practice.
They tend to think the newer pill or newer treatment must be better because it’s new.
Ignorance is a failure to think deeply.
It is a failure to be inquisitive.
It is a failure to keep an open mind.

For some patients and their families, ignorance manifests itself as unrealistic expectations.
Sometimes we doctors do a lot to help patients have unrealistic expectations.
Americans suffer from a massive lack of appreciation for what’s realistic, given present science.

Ego, arrogance, and excessive self-confidence lead doctors to confuse what they know with what they believe.
This confluence of forces leads to a closed mind and has led to advocacy of many interventions that, after years of use, were ultimately found to be not useful or even harmful.

I have met my share of doctors who would have been great snake-oil salesmen.
I am amazed by the number of medical leaders who seek power and prestige through habitual lying.

Health-care providers, hospitals, drug and device manufacturers, and insurers all need to truly focus on the best interest of the patient.
Some try to do the right thing, but some hospitals become more consumed with competition than with providing good care.
Some drug companies seize control of medical education and advance their products through medical politics, perverse incentives, and thinly disguised (or blatant) bribery.

Take a quick inventory of everyone who benefited from the cascade of services that robbed Ralph DeAngelo of the golden years he was enjoying until that cursed health fair.
The list will be long.
It will begin with the manufacturers of the PSA test and go on for pages.
He paid the ultimate price for becoming a one-man multiplier effect.
Many health-care professionals have forgotten the definition of the word
professional.
It means a person who puts the interests of others above self-interest.
This requires that one care about the welfare of others.

I hear the pundits threaten that health care is going to be rationed.
I am troubled that I don’t hear concern for those who need good health care and don’t get it now.
As I look at this mess, I realize that we don’t need health-care reform.
We need a health-care transformation.
Americans need to change how we view health care.
We need to change how it is provided and how it is consumed.

Patients and their families can be their own best advocates.
They need to appreciate the scientific method and the medical literature.
They need to question the source of their information and recognize that a lot of advertisements masquerade as scientific papers.
They need to have skepticism and ask probing questions.

Rational health care has the potential to save millions of lives over the next several decades.
It must include preventive medicine and could actually have an amazingly positive effect on the economy.
To do it requires accepting that there is a significant problem, and resolving to address that problem.
Patients and health-care providers must work together, constantly asking these two questions:
“What is rational?”
followed by “What is reasonable?”

How do we protect ourselves, our loved ones, our neighbors?
There is only one way.
We do it by demanding a health-care system that can say “Prove it,” a system that can say “No” and make it stick.
For this to happen, real people—ideally, all 300 million of us—will have to say “Enough!”

Acknowledgments

I owe much to my mother and father, who did not just work to create opportunity for me and my sisters but made it known that they expected us to do well.
My father in particular had an inherent curiosity and an intolerance of wasted opportunity.
He imparted those traits in me, and the Jesuits even beyond Polo and the Reverend George R.
drove it home.

I also know that it takes a village as my aunts and uncles worked hard to support the vision.
I was fortunate as a number of people from the old neighborhood, from gang members to numbers runners, decided I was a good investment.

The lay teachers and sisters of the Immaculate Heart of Mary at St.
Cecilia and the lay teachers and Jesuits at University of Detroit High also molded me, infusing values and warning me about the world, its dangers and its challenges, but also enticing me with its beauty.
I have to mention good diocesan Basilian and Jesuit priests who befriended me and taught me.

For a time, for practical reasons of survival, I was what I will call an adjunct member of a gang in the inner city of Detroit, but I was also a member of a positive youth gang at U of D High.
At “the High,” as we called it, I had a group of friends with whom I debated, participated in Model United Nations, and discovered the world.
I owe a lot to Michael Montgomery, Mathew Wilbert, Mark Nagel, Mark Dreyer, Tony Vizzini, and Roger Barris.
They were a positive youth gang for me and are still dear friends.

I am fortunate that I have always found good influences.
At the University of Chicago I was encouraged by people to whom I will always be indebted, especially Elliot Kieff, Jonathan Fanton, and John Ultmann.
Later Vivian Pinn, Al Rabson, and Barry Kramer would fulfill this role.

It is fascinating, the rainbow coalition of blacks and whites and of Jews, Catholics, and Protestants.

I am of course grateful to my patients and their families and especially those who let me use their stories in this book.
Patients and their experiences have been the most important element of this doctor’s education.

—Otis Brawley

Notes

CHAPTER 1

A history of Grady Memorial Hospital can be found in Jerry Gentry,
Grady Baby: A Year in the Life of Atlanta’s Grady Hospital
(Jackson: University Press of Mississippi, 1999).

Discussion of the Grady mission with some historical perspective is found in A.
G.
Yancey Sr., “Medical Education in Atlanta and Health Care of Black, Minority and Low-Income People,”
Journal of the National Medical Association
80 (April 1988): 467–76.

The Tuskegee Syphilis Study and rumors about it are mentioned as reasons why African-Americans are often suspicious of medicine.
The facts of the trial are frequently inaccurately conveyed even in the news media.
Factual accounts have been written, such as S.
M.
Baker, O.
W.
Brawley, and L.
S.
Marks, “Effects of untreated syphilis in the Negro male, 1932 to 1972: A closure comes to the Tuskegee study, 2004,”
Urology
65 (2005).
James H.
Jones,
Bad Blood: The Tuskegee Syphilis Experiment
(1981; repr., New York: Free Press, 1993), is a history of “The Study of Untreated Syphilis in the Negro Male” (this is the official name of the Tuskegee Syphilis Study).
Jones’s book also mentions many of the atrocities that humans have perpetrated upon vulnerable humans and called research.

Medical Apartheid
by Harriet Washington is a superb history and ethical analysis.
She painstakingly researched and documented numerous medical abuses over the past two centuries, including abuses within the past decade.
Many of these abuses have long been talked about in the African American oral history tradition.
Washington was able to find proof of alarming truths.
These findings justify distrust of the American medical profession.

The literature on the fears that African-Americans have of the American medical system is portrayed in Rebecca Skloot,
The Immortal Life of Henrietta Lacks
(New York: Crown Publishers, 2010).

A number of patterns-of-care studies demonstrate that the poor as a group do not receive as high a quality of medical care as the middle class and have worse healthcare outcomes: S.
A.
Fedewa, S.
B.
Edge, A.
K.
Stewart, M.
T.
Halpern, N.
M.
Marlow, and E.
M.
Ward, “Race and ethnicity are associated with delays in breast cancer treatment (2003–2006),”
Journal of Health Care for the Poor and Underserved
22, no.
1 (2011): 128–41; A.
S.
Robbins, A.
L.
Pavluck, S.
A.
Fedewa, A.
Y.
Chen, and E.
M.
Ward, “Insurance status, comorbidity level, and survival among colorectal cancer patients age 18 to 64 years in the National Cancer Data Base from 2003 to 2005,”
Journal of Clinical Oncology
27, no.
22 (August 1, 2009): 3627–33 (epub, May 26, 2009); and E.
Ward, H.
Halpern, N.
Schrag, V.
Cokkinides, C.
DeSantis, P.
Bandi, R.
Siegel, A.
Stewart, and A.
Jemal, “Association of insurance with cancer care utilization and outcomes,”
CA: A Cancer Journal for Clinicians
58, no.
1 (January–February 2008): 9–31 (epub, December 20, 2007).

The NCI defines the medically underserved as “individuals who lack access to primary and specialty care either because they are socioeconomically disadvantaged and they may live in areas with high poverty rates or because they reside in rural areas”:
http://deais.nci.nih.gov/glossary/terms?alpha=M¤tPage=1
.

Trends in breast cancer by race and ethnicity: C.
Smigal, A.
Jemal, E.
Ward, V.
Cokkinides, R.
Smith, H.
L.
Howe, and M.
Thun, “Update 2006,”
CA: A Cancer Journal for Clinicians
56, no.
3 (May–June 2006): 168–83.

A higher proportion of the African-American breast cancer population has triple negative disease compared to the population of white women with breast cancer.
Triple negative breast cancer is the most serious type of breast cancer.
Other forms of the disease are more aggressive, but targeted therapies can slow the progression of the disease.
This is explained in L.
A.
Carey, E.
C.
Dees, L.
Sawyer, et al., “The triple negative paradox: Primary tumor chemosensitivity of breast cancer subtypes,” Clinical Cancer Research 13, no.
8 (April 15, 2007): 2329–34; and K.
M.
O’Brien, S.
R.
Cole, C.
K.
Tse, C .M.
Perou, L.
A.
Carey, W.
D.
Foulkes, L.
G.
Dressler, J.
Geradts, and R.
C.
Millikan, “Intrinsic breast tumor subtypes, race, and long-term survival in the Carolina Breast Cancer Study,”
Clinical Cancer Research
16, no.
24 (December 15, 2010): 6100–6110.

U.S.
breast cancer rates by race are provided by the National Cancer Institute Cancer Statistics Review at
https://seer.cancer.gov
.

The effect of postmenopausal hormone replacement therapy (HRT or HT) was studied in the Women’s Health Initiative, a study sponsored by the National Institutes of Health.

The decline in breast cancer incidence was documented in M.
Ravdin, K.
A.
Cronin, N.
Howlader, C.
D.
Berg, R.
T.
Chlebowski, E.
J.
Feuer, B.
K.
Edwards, and D.
A.
Berry, “The decrease in breast cancer incidence in 2003 in the United States,”
New England Journal of Medicine
356, no.
16 (April 19, 2007); and Million Women Study Collaborators, “Patterns of use of hormone replacement therapy in one million women in Britain, 1996–2000,”
BJOG
109, no.
12 (December 2002): 1319–30.

Public law 103-43, signed in 1993 by President William Clinton, mandated the Long Island Breast Cancer Study.
A good description of the study is found in M.
D.
Gammon, A.
I.
Neugut, R.
M.
Santella, et al., “The Long Island Breast Cancer Study Project: Description of a multi-institutional collaboration to identify environmental risk factors for breast cancer,”
Breast Cancer Research and Treatment
74, no.
3 (June 2002): 235–54.

The correlation between weight gain in childhood and earlier age of menarche is discussed in S.
E.
Anderson, G.
E.
Dallal, and A.
Must, “Relative weight and race influence average age at menarche: Results from two nationally representative surveys of US girls studied 25 years apart,”
Pediatrics
111, no.
4 (pt.
1) (April 2003): 844–50.

The relation between age at menarche and race and its relationship to disease in adulthood is discussed in D.
S.
Freedman, L.
K.
Khan, M.
K.
Serdula, W.
H.
Dietz, S.
R.
Srinivasan, and G.
S.
Berenson, “Relation of age at menarche to race, time period, and anthropometric dimensions: The Bogalusa Heart Study,”
Pediatrics
110, no.
4 (October 2002): e43.

Population trends in breast cancer in Scotland can tell us a lot about breast cancer in the United States: S.
B.
Brown, D.
J.
Hole, and T.
G.
Cooke, “Breast cancer incidence trends in deprived and affluent Scottish women,”
Breast Cancer Research and Treatment
103, no.
(June 2007): 233–38 (epub, October 11, 2006); U.
Macleod, S.
Ross, C.
Twelves, W.
D.
George, C.
Gillis, and G.
C.
Watt, “Primary and secondary care management of women with early breast cancer from affluent and deprived areas: Retrospective review of hospital and general practice records,”
BMJ
320, no.
7247 (May 27, 2000): 1442–45; C.
S.
Thomson, D.
J.
Hole, C.
J.
Twelves, D.
H.
Brewster, and R.
J.
Black, “Prognostic factors in women with breast cancer: Distribution by socioeconomic status and effect on differences in survival,”
Journal of Epidemiology and Community Health
55 (2001): 308–15; N.
H.
Gordon, “Socioeconomic factors and breast cancer in black and white Americans,”
Cancer and Metastasis Reviews
22 (2003): 55–65; B.
K.
Dunn, T.
Agurs-Collins, D.
Browne, R.
Lubet, and K.
A.
Johnson, “Health disparities in breast cancer: Biology meets socioeconomic status,”
American Journal of Public Health
100, no.
S1 (April 1, 2010): S132–39 (epub, February 10, 2010); and N.
Krieger, J.
T.
Chen, and P.
D.
Waterman, “Decline in US breast cancer rates after the Women’s Health Initiative: Socioeconomic and racial/ethnic differentials,”
American Journal of Public Health
100, no.
6 (June 2010): 972.