Review of "Overdo$ed America", by John Abramson
Part I: Overview
Dr. John Abramson has written a lucid, insightful, strongly argued, polemic entitled "Overdo$ed America" (sic), with the subtitle "The Broken Promise of American Medicine" (HarperCollins publisher 2004). In summarizing the objective of the book the author asserts that his goal is that the book "will play a constructive role in helping to redirect American medicine back toward its highest ideals". (p. vi)
Dr. Abramson traces the "industrial colonization" of medicine and academia by the pharmaceutical industry. He expands on how the pharmaceutical industry is "masterfully" creating a marketing program that involves the synergy between the medical profession and the patient, but at the expense of the patient. His book is in line with past muckrakers, including Upton Sinclair, Ida Tarbull, Lincoln Steffens, Rachael Carson, I.F.Stone, Seymour Hirsch and many others.
The take home message from Overdo$ed America is that we need to be more critical consumers of scientific evidence "and the recommendations of 'thought leaders' on the payroll of the drug and other medical industries." (P. 259). He invariably cites evidence of "false" information on how "the sponsors (drug company) presentation of 6-month data are not statistically valid or supportable" (Note #30, p. 264). Pharmaceutical companies distort medical knowledge, mislead doctors and compromise patients health and reap the profits of this endeavor.
Dr. Abramson concludes with a challenge to his readers to "consider the responsibility of citizenship in this time of excessive medical profiteering and corporate influence, and to take up one of the most important challenges of our time: high-quality health care for all based on the translation of well-ordered science into accurate, unbiased medical information." (p. 260).
Part II: Substance
This is a well organized and easy to read book with references to "notes" in the back of the book that provides the source of his information. The notes are really his bibliography, and well worth reading. The inconvenience is that one has to flip pages back and forth from the body of the book to the notes.
The substance of the book is presented clearly, concisely and in a clinically pertinent way. However, the reader would like to read what the "other side" has to say about the same issues. The book will serve as a primer for anyone wanting to know more about the interaction between pharmaceutical companies, and medical care. The book strengthens the growing idea that the consumer take a more active role in health care and make a commitment to become more interactive with the treating physician, but not loosing sight how life-style also effects health. This could prove especially difficult for the frail elderly, a growing cohort group needing medical attention.
Part III: Structural analysis
Structurally, Overdo$ed America consists of three parts, totaling 260 pages, with 45 pages of notes and a bibliography of 4 pages. It has a retail listed price of $24.95.
Part I, A FAMILY DOCTORS JOURNEY OF DISCOVERY, lays out his personal journey to defining his biopsychosocial approach to medicine. The subtitles of the six chapters in part I clue the reader to the message he is trying to get across: "Medicine in Transition: Caring for Patients at the Crossroads"; "Spinning the Evidence: Even the Most Respected Medical Journals Are Not Immune"; "False and Misleading: The Misrepresentation of Celebrex and Vioxx"; "The Myth of Excellence"; "A Case in Point: The Saga of Hormone Replacement".
In these chapters, Dr. Abramson suggests instances of "unfortunate chapters in medical history" (p.52) and concludes, "that the commercialization of medicine wasn't just causing doctors to prescribe unnecessary drugs and procedures. It was actually subverting the quality of medical care. The only thing that appears to be certain about health care in our country is that we aren't getting the health care we're paying for." (p. 53)
Part II of Overdo$ed America is titled "The Commercialization of American Medicine" and has six chapters: "American Medicine's Perfect Storm": "A Brief History"; "The Commercial Takeover of Medical Knowledge"; "The Snake and the Staff: Duping the Doctors"; "A Smoking Gun: The 2001 Cholesterol Guidelines"; "Direct-to-Consumer: Advertising, Public Relations, and the Medical News"; "Follow the Money: Supply-Side Medical Care".
In these chapters, Dr. Abramson reviews the impact on medicine of the transition from traditional indemnity insurance to HMOs and managed care plans that now dominate the delivery of medicine in this country. Dr. Abramson corrects the impression that managed care companies do not serve patients well. "The data about the actual effect of managed care tell a very different story. The quality of care has neither improved nor deteriorated under managed care." (Italics added for emphasis) Yet, one could ask, why does the United States rank 37th in the world in healthcare, while we spend almost 15% of our GDP on care, a figure that is twice as high as countries that deliver better healthcare. Dr. Abramson places a lot of the blame on lack of primary care practitioners (his own field). He explains this dearth of primary care physicians as due to "less prestige among peers, intrudes more into one's personal life, and pays less than most other specialties." (p. 85) His facts may be right, but one wonders how his own bias may enter into these conclusions.
Part II shows how medical knowledge has been transformed from a public good, "measured by its potential to improve our health, into a commodity, measured by its commercial value." (p. 91) He traces medical research from an academic and scientific activity funded by public money to a commercial activity funded by private sources tied into the pharmaceutical and biotech industry. There is nothing intrinsically illegal about such arrangements, but Dr. Abramson questions whether it is possible to serve the public interest and commercial interests simultaneously. Are we paying an enormous amount of money for some mediocre medicines? Are we as patients demanding new medicines and techniques because we are ingrained with the idea that "new" is better?
Dr. Abramson at one point cites an editorial that appeared in the Journal of the American Medical Association (2003; 2128-2131): "Medical research, even if it is conducted by the pharmaceutical industry, is not solely a commercial enterprise designed to minimize personal gain or company profits. The responsible conduct of medical research involves a social duty and a moral responsibility that transcends quarterly business plans or the changing of chief executive officers." It is a simple organizational fact that the first priority of leaders of any company is survival of their company; they are for-profit companies. The companies highest priorities are their own goals of the survival, growth and financial well being of the company. The question is whether this is the best for the public or whether pharmaceutical companies have to integrate, along with their commercial interests, a social responsibility factor into their mission that is more reflective of the "public good"
Other interested players in the healthcare game will also have to reconsider their role. Dr. Abramson points out how the cost of care and health outcomes varies by regional, ethnic and socioeconomic levels in Medicare patients with a first diagnosis of heart attack, broken hip or cancer of the colon. The source of this data is a study from the Annuls of Internal Medicine, Principal Investigators Drs. John Weinberg and Elliot Fisher. (The reference in the Notes section fails to give the year the study was published.) He concludes: "The bottom line appears to be that once an adequate amount of care is being provided, as in the lowest-spending regions of the country for Medicare patients, more care is worse care. This seems to be particularly true for the kind of care that is pushed into service by supply side pressure." (P. 180-181). Citing four features shared by the medical services that are most vulnerable to overuse because of supply-side push, Dr. Abramson involves the patient, the medical technology service providers, the doctors and the hospitals in a process that disconnects costs from health care value.
Part III is titled "Taking Back Our Health" and has three chapters: "The Knee in Room 8: "Beyond the limits of Biomedicine"; From Osteoporosis to Heart Disease: What the Research Really Shows about Staying Healthy"; "Healing our Ailing Health Care system, or How to Save $500 Billion a Year While Improving Americans' Health". The headings of these chapters speak for themselves. If you do not have the time to read this book, the last chapter is a must read. It is a concise yet comprehensive guide for the reader to understand steps to provide quality healthcare to all Americans.
Part IV: Conclusions derived from Overdo$ed America
The public may have to rid itself of the notion that the answer to all health problems lies primarily in a pill or a fancy medical procedure. People need to take some responsibility for their health by staying mentally active, eating a well balanced diet, getting regular exercise, avoiding smoking and excess alcohol. These are all proactive, preventative steps that have a strong positive influence in the health of an individual.
At the same time, the government must maintain a level of
responsibility to eliminate potential environmental pollutants
that are a danger to health, as well as enforcing standards of
health care and drug surveillance such that they minimize the
risk of medication induced mortality or morbidity. This can only
come about if the government enforces its statutory clout to
penalize offenders without depriving them of their right to
defend themselves. At the same time, the penalty has to be severe
enough to get the offender to stop.
The FDA Division of Medication Errors and Technical Support (DMETS) is the place to start to achieve these goals. They will need additional financial and political support and stronger influence on other divisions within the FDA to which they report their findings. An alternative would be the establishment of, an independent panel, similar to the independent advisory panels that exist to give recommendations for drug approval. Those serving on such a panel would not have any connection to the pharmaceutical industry I.e. a consultant positions, no pharmaceutical grant money, no equity in pharmaceutical companies etc. The panel would act in an oversight role, monitoring research studies and follow-up when drugs and medical technologies are approved for clinical use.
Fixing blame with the pharmaceutical industry, or the FDA as a standard setting organization, or healthcare providers will not solve the problem; successful change requires a team effort. All key stakeholders must work together toward the lasting changes needed to providing much more information about the real benefits of the drugs in place as well as the various advanced medical technologies in use. At the same time, the consumer must take some responsibility for maintaining good health practices, as we must expect from drivers of cars to practice safety without excusing the drug manufacturer or car manufacturer from maintaining a high degree of public safety in their product.
Description of author
John Abramson, a family medicine physician who had spent time administering to the health needs of individuals in Appalachia, was a Robert Wood Johnson Fellow at Case Western University, and then worked for 20 years in a private family medicine practice in Massachusetts. His practice was integrated into the Lahey Clinic, and he is now on the faculty of Brandeis University School of Social Policy and teaches at Harvard School of Medicine.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "HOW TO SELECT A NURSING HOME"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
posted May 17, 2005
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