Because we refuse to acknowledge the power of money, that’s why. It’s no secret that our lack of a rational, single-payer health system has allowed market forces (read: middlemen) to trump health needs. What’s less obvious is that the misallocation of resources is rapidly turning doctors into nonscientists.
Granted, both Groopman and Gawande devote chapters to the influence of money and marketing on quality of care (making brief forays into the malpractice system, for instance, and doctors’ pay scales). Groopman mentions the spinal-fusion industry, in which surgeons “treat” low back pain by scraping out disks and screwing rods into lumbar vertebrae. Some 150,000 fusions are performed a year—at $20,000 each. No study has ever proved they help. (Here are two studies that are dubious about the benefits of spinal fusion.)
To suggest that doctors prefer chasing dollars over treating real disease might seem unfair, but the facts speak for themselves: In 2005, doctors performed over $12 billion worth of cosmetic surgery while, according to some experts, up to a third of our diabetics and hypertensives received inadequate care. Meanwhile, the proportion of U.S. internal medicine residents planning to enter primary care continued its slide from one-half (in 1998) to one-fifth. Why? Money rules. The average American medical school graduate takes on $130,000 in debt (European grads face much less). If some idealistic premed didn’t care about money when he started, he sure will when he graduates—as a radiologist or a dermatologist. At some point this siphoning of talent away from primary care has to undermine that field’s research and clinical skills.
Financial interest doesn’t just warp medicine by luring doctors to lucrative procedures: It corrupts the scientific data that underlie care. Take, for example, the recent news that hormone replacement therapy very likely causes breast cancer. As an intern 20 years ago, I memorized elaborate protocols on how to dose patients with estrogen and progesterone. It never occurred to me to question the underlying data, which it turns out rested on a few observational studies and slick marketing. It’s likely we doctors caused hundreds of thousands of cases of breast cancer—all the while scratching our heads over its rising incidence. How did that happen? Well, treating menopause with natural hormones seemed like a good idea.
Truly scientific medicine requires large-scale solutions. We need impartial research centers running clinical trials that ask the correct big-picture questions: Not “Does this drug lower cholesterol” but “Does it prevent heart attacks?” Not “Is this drug superior to placebo” but “Is it superior to existing drugs?” Instead, over the past 20 years we have ceded the asking of these crucial questions to industry.
Administrative overhead and the fear of malpractice suits also sap physician effectiveness. A staggering 31 percent of every health care dollar in the United States is wasted on overhead, while in Canada the tab is half that much. The financial squeeze not only forces clinicians into the 15-minutes-per-patient HMO vise but also leaves little time for teaching. Meanwhile, the malpractice industry—besides squandering money on lawyers, experts, and logistics—does its worst by stifling free inquiry into mistakes.
So how should doctors think? The answer lies less in how than in in what environment. While both authors hint at money’s nefarious influence, they ultimately back off, heading for the safe harbor of doc-on-doc exhortation. (Care more! Be self-aware! Measure!) In doing so, they miss an important chance to air larger issues. Universal health care is no panacea, but it is the obligatory first step toward building a scientific medical establishment that tests new drugs and devices rigorously, collects impartial long-term outcomes data, and cares for everyone in our society. By ducking the issue of how money now shapes everything about American medicine, Groopman and Gawande have, unfortunately, diverted attention from the questions we most urgently need to answer.
