For more than 20 years I practiced family medicine in a small town about 45 minutes north of Boston. During those years I often marveled at how lucky I was to have found my calling, balancing the science of medicine with the art of caring for people. I got enormous satisfaction out of watching children grow and families mature, assisting them through daily worries and occasional tragedies. I treasure the lessons I learned from my older patients as they met the challenges of their senior years with dignity and humor. I have had no greater sense of accomplishment than helping people preserve their health, recover from illness, and, when recovery was not possible, provide comfort.
Just before I left my practice to write this book, one of my longtime patients, Mrs. Francis, came in for a last visit. I always enjoyed seeing Mrs. Francis, a widow then in her in mid-eighties. Her greeting was warm and her presence made the exam room feel comfortable—an oasis in the midst of daily time pressures, multiple tasks, and complex patient challenges. During this visit, Mrs. Francis asked why I was leaving. This wasn’t just a casual question, nor did I feel that she was prying. Over the years, we had enjoyed many conversations, and I felt as if she genuinely wanted to understand what had gone into my decision. I did my best to explain.
I told her that over the last few years a profound shift had been taking place in the culture of American medicine. I explained that tests unlikely to improve patient care were being routinely ordered and expensive drugs that had not been shown to be any more effective or safer than the older drugs they were replacing were being routinely prescribed. I told her that the research I had been doing at night and on weekends was confirming my sense that much of the “scientific evidence” on which we doctors must rely to guide our clinical decisions was being commercially spun, or worse; and that many of the articles published in even the most respected medical journals seemed more like infomercials whose purpose was to promote their sponsors’ products rather than to search for the best ways to improve people’s health.
I told her that many of my patients were being drawn in by the growing number of drug ads and medical news stories; that patients were increasingly arriving for their visits with a firm (if not fixed) idea of the outcome they wanted instead of the expectation that the best medical care would emerge from open discussion of their symptoms, concerns, and exam, and then mutual consideration of the options. I told her that when I tried to refocus patients on interventions proved to be safe and effective, many were reacting as if I were purposely trying to withhold the best treatment, making me choose between providing the best care and yielding to their demands in order to maintain the healing potential of our relationship. Finally, I told her that I had come to the conclusion that the best way I could help people to achieve better health was to find out what the scientific evidence really shows and explain this to the public—in much the same way that she and I had talked over the years—and to other medical professionals.
That was the best answer I could give Mrs. Francis at the time. I wasn’t sure what I was going to find when I turned my full attention to these issues. But it was becoming clear that American medicine was like a runaway train picking up speed, fueled by the commercially generated belief that ever-increasing medical spending is necessary to achieve good health. It was also becoming clear that the train’s brakes were failing. It seemed to me that, despite a few clear and brave voices, there was no effective counterbalance to the influence of commercially sponsored research. Nor was there even a way to determine whether all this expensive new care actually led to better health. And it was also clear that this crisis would soon come to a head when the burden of relentlessly increasing medical costs became more than many Americans could bear.
What I found over the next two and a half years of “researching the research” is a scandal in medical science that is at least the equivalent of any of the recent corporate scandals that have shaken Americans’ confidence in the integrity of the corporate and financial worlds. Rigging medical studies, misrepresenting research results published in even the most influential medical journals, and withholding the findings of whole studies that don’t come out in a sponsor’s favor have all become the accepted norm in commercially sponsored medical research. To keep the lid sealed on this corruption of medical science—and to ensure its translation into medical practice—there is a complex web of corporate influence that includes disempowered regulatory agencies, commercially sponsored medical education, brilliant advertising, expensive public relations campaigns, and manipulation of free media coverage. And last, but not least, are the financial ties between many of the most trusted medical experts and the medical industry. These relationships bear a remarkable resemblance to the conflicts of interest the Securities and Exchange Commission recently brought to a halt after learning that securities analysts were receiving bonuses for writing reports that drove up stock prices with the intent of bringing in more investment banking business.
As a result of all this, the pharmaceutical industry is raking in unheard-of profits—more than three times the average of the other Fortune 500 industries, even after accounting for all its research and development costs. At the same time, the average yearly out-of-pocket health care costs for employees of large corporations (including payroll deductions for health insurance, co-pays, and non-covered drugs and services) increased by more than $1000 between 1998 and 2003. To put the magnitude of this growing “health tax” in perspective, the much ballyhooed middle-class tax cut amounts to $469 for the average American family. In 2004, out-of-pocket health care costs for that same family are projected to increase by another 22 percent, coincidentally costing exactly an additional $469 per year. While the drug and medical-device industries are enjoying their enormous profits, hardworking Americans are struggling to keep up with their health insurance premiums and medical bills, 44 million Americans are without any health insurance at all, and half of all personal bankruptcies in the United States are caused by medical expenses.
Worse, many of the mechanisms that Americans trust to protect their health and resources have been dismantled by political pressure from doctors and medical industry lobbyists, while others have become absurdly dominated by people with financial ties to the pharmaceutical companies—a situation that no impartial observer would ever conclude was designed to represent anything other than corporate interests. The shocking news is that this is now commonplace at even the most trusted of American health institutions, the National Institutes of Health and the Food and Drug Administration.
The bottom line is this: There has been a virtual takeover of medical knowledge in the United States, leaving doctors and patients little opportunity to know the truth about good medical care and no safe alternative but to pay up and go along. The ugliest truth of all is that these enormous costs do not come close to producing commensurate improvements in our health—the health of Americans is actually losing ground to that of the citizens of the other industrialized countries, which are spending far less and at the same time providing health care to all of their citizens.
Over the past 28 years as a physician I have had the privilege of observing the transformation of American medicine from a number of vantage points. My first experience as a primary care doctor was in Appalachia, with the National Health Service Corps (then a part of the U.S. Public Health Service). There I worked in a rural health clinic where I got an excellent introduction to the basics of clinical medicine—including working alongside an exceptional nurse practitioner, who showed me the importance of a team approach to patient care. Later, as a Robert Wood Johnson Fellow, I spent two years studying research design, statistics, epidemiology, and health policy and then researching the consequences of providing medical care to low-income inner-city residents through an innovative health maintenance organization (HMO). I was able to continue my academic interest in health policy at Brandeis University’s Heller School of Social Policy, participating in a project designed to tailor local health care expenditures to local health needs. I witnessed the evolution of HMO coverage from the inside during my seven years as a part-time associate medical director in an early HMO in Massachusetts. In the mid-1990s, I merged my practice into Lahey Clinic, a large, doctor-run multispecialty group practice. Lahey Clinic showed its commitment to primary care by setting up a department of family practice, in which I served as chair for seven years.
Teaching has also been an important lens through which I have observed the changes in medicine. I began teaching Harvard Medical School students in my office after I had been in practice for about 10 years and enjoyed supporting and supervising them as they progressed during these clerkships through the stages of becoming doctors. My first task was to help the students learn to apply the medical science they were learning to the patients they were seeing in my office. As they became comfortable with the nuts and bolts of disciplined primary care, I especially enjoyed helping them develop their skills in the art of medicine—understanding that the person-to-person connection they were making with their patients was not just a pleasant amenity but an integral part of medical care. I hoped to help them add this essential dimension of good doctoring to the technically oriented medicine they were learning while caring for very sick patients in university hospitals, where they spent most of their time.
As an outgrowth of this focus on the fundamental importance of healing relationships in good medical practice, I taught a course for several years at Harvard Medical School with Dr. Herbert Benson of the Mind/Body Medical Institute. My goal was to provide medical students with an intellectual framework to support (“protect” may be a better word) their humanistic ideals while they struggled to learn the scientific basis of medicine.
But by far the most important vantage point from which I observed the changes taking place in American medicine was caring for my patients. I enjoyed keeping up to date on the latest developments by reading the medical journals and occasionally using my research skills to check analyses and conclusions. I took great pleasure in working with specialist colleagues on patients who required more care than I could provide alone.
As I think back on my practice and patients over the years, I recall with particular clarity the moment before each visit when I would lift the patient’s chart out of the holder on the exam room door, pause for a moment to think about the person I was about to see, and refresh my memory with a quick look at the chart. As I entered the exam room, I would make a mental note of anything that might help me better tune in to my patient and then would begin the visit with either an open-ended question or a continuation of a conversation from the last visit (a recent change in medication, grandchildren, a job change, a sporting event, a marital problem, a school report, and so on). Visits of this kind gradually build the healing relationships that establish the foundation of good medical care. In the final analysis, it was both the loss of trust in medical science and the weakening of doctor-patient relationships that led me to write this book.
Mrs. Francis listened carefully to my explanation, but she had a hard time understanding what I was saying—not because she didn’t believe me but because the changes in American medicine that I was telling her about were so vastly different from the world of medicine and the values that she had grown up with and that had served her so well. Nonetheless, she sincerely wished me well, and we ended the visit making clear to each other that we would miss our relationship.
This book approaches the crisis in American medicine from the radical center—the simple ideal that unbiased medical science and strong doctor-patient relationships ought to define optimal medical care and serve as the basis of medical practice.
My research has shown me how easily this could be achieved simply by restoring the integrity of medical science and refocusing its mission on improving health. I have come to understand that the system we now have is far from the best way to advance medical knowledge and pay for health care, but is probably the best of all possible ways to transfer massive amounts of wealth from the American people to the drug industry and other medical industries.
Popular wisdom, even among health policy experts, is that there is no good solution to this crisis of rising health care costs. As long as the validity of our medical science and method of translating it into medical practice remain unquestioned, this is true. But our medical science has become deeply flawed, manipulated to serve corporate interests. What appears to be a crisis in the cost of medical care is really a crisis in the quality of American health care. Fixing the distortions in our medical knowledge will not only lead to far better health and health care, but at the same time save hundreds of billions of dollars a year.
Obviously, one person and one book cannot present an exhaustive discussion of all the issues that need to be considered to resolve this crisis. But by beginning to lift the veil of scientific authority, commercial spin, and outright deception, I hope I can improve public understanding about the contribution of commercial distortion to the crisis in American medicine.
This book is presented in three parts. The first, “A Family Doctor’s Journey of Discovery,” describes the changes that were taking place in my own practice and the commercial influence that was starting to appear in respected medical journals that made me want to delve deeper. Discovering the hidden truth about Celebrex and Vioxx and, later, understanding the debacle of hormone replacement therapy showed me how profoundly disordered American medical research and practice had become.
The second part, “The Commercialization of American Medicine,” presents a brief history of the commercial takeover of medical knowledge and the techniques used to manipulate doctors’ and the public’s understanding of new developments in medical science and health care. One example of the depth of the problem was presented in a 2002 article in the Journal of the American Medical Association, which showed that 59 percent of the experts who write the clinical guidelines that define good medical care (the standard to which doctors are often held in malpractice suits) have direct financial ties to the companies whose products are being evaluated. The exaggerations and distortions of the 2001 cholesterol guidelines that are responsible for millions of Americans’ being treated with cholesterol-lowering statin drugs (despite the lack of scientific evidence of benefit for such widespread use) is presented as a case in point.
The final part, “Taking Back Our Health,” proposes a broader paradigm of medical care than the one learned by doctors during their medical training and reinforced by the medical industry’s commercial interests. Part III examines what the research really shows about the most common chronic diseases—from osteoporosis to heart disease—explaining that much of what is called “scientific evidence” is really disease mongering designed to sell more drugs. The final chapter shows that restoring the integrity of medical science is the best way to finance universal health care and still save hundreds of billions of dollars a year.
This book tells the hidden story of American medicine. If you or your doctor ignore its findings, it could be hazardous to your health.