(Please welcome Shannon Brownlee, author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer in the comments — jh)
Pups, I’d like to let you in on a little medical secret – promise not to tell?
A whole lot of the "medical" books you find on sale in your local bookstore are a sad waste of trees. Among the worst are the "self-help" books…title after title of little jacketed tombstones defiling the memory of what once was a grove of living trees.
So when Bev emailed about this Book Salon, I cringed. I glanced at the title, imagined another jihad against "Western Medicine", and emailed her about possibly ducking out. We chatted and Bev sent me links to Shannon Brownlee’s work – and I was hooked.
And still am.
Shannon Brownlee’s long career as a science writer, her experience covering the medical "breakthrough" of the moment, her training in biology, and her keen observation were obviously an excellent foundation for this careful, readable, thorough look at one of the most basic problems with American medicine: when we doctors make choices about your care, why do we make the decisions we come to?
Divine voice? Nope, not so much.
Years of training supplemented by continual education? Well – that’s what you’d hope – but all to often, in vain.
Careful discussions with peers and colleagues about the latest proven results? Well, often…depending on how you describe "proven".
You see, the problem with the "self-help" books – almost all of them – is that the "treatment" they prescribe has almost never been studied and proven to be effective. Someone comes up with a treatment idea – maybe from their work patients, maybe to satisfy a publisher – and they’re off to the printer. Maybe the treatment works, maybe it doesn’t – who knows?
What does this have to do with medicine and Overtreated?
Well, rather a lot.
New surgical procedures are introduced because a surgeon does them – and tells other surgeons about what she does. And – years later – someone sits down to do a boring study to demonstrate precisely how well the once new procedure (now venerable) has helped thousands.
Only to find out the now widespread procedure didn’t help – or perhaps made things worse.
Same thing with new medications – or new ways of using old medications.
Same thing with new "systems" of health care – or new ways of using old systems.
You see, the dirty little secret of medicine is that – with some rare exceptions – we docs often do stuff because that’s what we know how to do – not because it has been shown to be effective.
The last five years of my life have taken me on a jaunt from academic medicine through three different settings in community medicine, where I treated very common psychiatric diagnoses (depression, bipolar disorder, schizophrenia, anxiety disorders) in three different settings.
Now – for all the psych diagnoses – a specific validated instrument allows one to make accurate diagnoses by asking specific questions from a flowchart. The instrument has a very high inter-rater reliability, and it is easy to use.
And – as near as I can tell – wholly unknown outside of a few training programs. Instead, I saw patient after patient diagnosed with "depression" or "anxiety" because that is the word they had used about their symptoms. Kinda like if you went to the cardiologist for that ripping pain in your chest and you went home with a diagnosis of "pain." Not too useful.
The common psych diagnoses above also have "flowcharts" allowing selection of the most effective known treatments – something called "evidence-based medicine".
Not much evidence-based medicine in community mental health that I can see.
My friends in academic medicine describe the same mismatch between optimal and what they actually find in practice – within our ivory towers, as well as in the community.
And you – the patients and taxpayers who pay for the whole mess – receive maddingly variable care, simply depending on where you live.
And – though too little care kills – too much care can be equally deadly.
In her clear and powerful work, Shannon Brownlee explains how the crazy fractured "system" of American health care came to such a dangerous place – and how to find a new and safer path.
Let’s give a big FDL welcome to Shannon Brownlee.