Where Does It Hurt?

When it comes to medical treatment, more may not be better.

OVERTREATED

Why Too Much Medicine is Making Us Sicker and Poorer

By Shannon Brownlee

Bloomsbury. 343 pp. $25.95

Is the problem with American health care too little treatment or too much? Most people would probably say the former, pointing to the millions who lack health insurance or to those who don't have enough. From Michael Moore's "Sicko" to the presidential campaign trail, heartrending images of medical care denied have gotten the lion's share of attention.

But in her persuasive Overtreated, Shannon Brownlee, a medical journalist and senior fellow at the New America Foundation, argues that too much medicine -- for many patients, much of the time -- is doing serious damage to the nation's health, while also costing us an arm and a leg. "We spend between one fifth and one third of our health care dollars . . . on care that does nothing to improve our health," she points out. Many treatments that have become widely accepted in recent years -- including proton pump inhibitors for ulcers, arthroscopic knee surgery for arthritis, hormone replacement therapy for menopause and high-dose chemotherapy for breast cancer -- "have ultimately been shown to be unnecessary, ineffective, more dangerous than imagined, or sometimes more deadly than the diseases they were intended to treat." In addition, Brownlee argues, doctors and hospitals routinely overuse high-tech tools like MRIs and CT scans, which can confuse the diagnostic process. And they are too quick to perform invasive procedures like coronary angioplasty and stenting, which carry risks of their own and may be unnecessary for many patients. (These procedures have not been shown to " prevent heart attacks in patients with symptoms of serious heart disease," she notes.)

Why so much aggressive, ultimately unhelpful care? Brownlee touches on a range of explanations, from perverse incentives to corporate perfidy to biases embedded in the culture of medicine. Doctors and hospitals may favor high-tech tests and procedures in part because they are reimbursed more lavishly for these than for medical management or preventive care. Indeed, Brownlee highlights examples in which doctors or hospitals who wanted to offer, say, nutritional advice to diabetics or intensive follow-up for heart patients lost their shirts. The amount of specialty procedures performed in a given region aligns surprisingly well with the number of specialists in the area, suggesting that medical supply can drive demand. Heavy marketing by drug and device manufacturers places an additional thumb on the scales. And doctors' and patients' own tendency to believe in breakthroughs can cause them to embrace the new before its value or safety has been fully established.

Brownlee's skepticism toward novel treatments can be too sweeping. She points out, for instance, that high-dose chemotherapy for breast cancer was a bad idea -- a brutal approach that ultimately proved ineffective, despite some promising preliminary evidence. But it's easy to say that in hindsight. New treatments are always accompanied by uncertainty, and desperate patients aren't necessarily wrong to take a chance. In retrospect, the AIDS patients and clinicians who demanded faster access to AZT in the late 1980s do not seem so misguided.

Still, Brownlee's larger point that we should try to cut back on unnecessary care is well taken, as are her suggestions for change, including: better coordination among doctors, a restructuring of incentives to favor preventive care, and better information for patients. The good news is that by reducing dangerous care for the overtreated, and its ruinous costs, we might have more resources to help the undertreated and uninsured as well. *

Amanda Schaffer is a science and medical columnist for Slate.