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Summer 2006

   Hope or Hype
    The Obsession With Medical Advances and the High Cost of False Promises
    By Richard A. Deyo, M.D. and Donald L. Patrick, Ph.D
    Amacom Books, New York, 2005: 335 pp. (with notes and index), $24.95.

   This book is by two University of Washington professors, one an expert in medical ethics (RAD)
   and the other in health policy (DLP). The combination is uniquely qualified to discuss the subjects
   of the book: drugs, medical and surgical treatments, devices, insurance and health policy matters in the
   United States. Is newer always better? Is the cost/benefit ratio too high for a given drug or device or  
   course of treatment. Are common conditions of lifestyle and ageing being redefined as illnesses
   demanding treatment. Are medical entitlement and grandiose expectations driving the enormous costs
   of medical care in the U.S., the most expensive in the world? Is prolonging life a few weeks or months
   with extraordinary and hugely expensive care worth short-changing preventive measures and insuring
   the young? All are pertinent questions and are thoughtfully addressed in this volume.

   An example of medical progress gone amok: both financially and medically is the artificial heart to
   which the authors devote a detailed history. An expensive flop in the eyes of most. The ghost of
   Barney Clark still lingers over the topic. High technology treatment isn't the answer to all diseases all
   the time. Often cleaning the air and water or reducing the speed limit does more to save and extend
   lives than all the complex gadgets and high powered drugs in the medical arsenal. As the authors
   point out, one has to think in terms of populations instead of individuals to appreciate this. That is
   often a hard concept for physicians trained to do the most for their patient. And of course, the
   more they do, the more they make. The commercial interests are expected to keep an eye on the
   bottom line but they often do so by inventing diseases, making "me too" or ineffective drugs that
   are priced outrageously and by ignoring troublesome and occasionally lethal side effects.

   Sometimes in healthcare, more is actually less, both in terms of cost/benefit and possible complications.
   Physicians will often subject patients to unnecessary diagnostic tests and then treat them without
   clear indications. This may be for financial gain or to avoid malpractice suits but the results are often
   inferior to doing less or occasionally, nothing at all. Every doctor has had the experience of an
   abnormal test result that leads further investigation at increased cost and sometimes higher risk. There
   is a tendency toward, in the authors' words, "prescriptive promiscuity" such as prescribing antibiotics
   for viral infections or antidepressants for a variety of ailments that might be due to depression. The
   availability of high tech machines and treatments often leads to excessive use of these instruments,
   especially in ICUs and at the end of life. Competition is sometimes responsible as in cases where every
   hospital and clinic in a town needs an MRI scanner, often the latest model at the highest price. Then
   it must be used to justify its cost and make a profit.

   So who's at fault for the sad state of American medicine? Why doctors, hospitals, insurance companies,
   drug companies, the FDA and other government agencies, the media...and oh yes, patients. All play
   some role in the deteriorating situation. Of course the pharmaceutical industry is the current favorite
   whipping boy due to the high cost of prescription drugs, many of which, as the authors point out
   repeatedly, are me-too drugs without much additional benefit for the cost or worse, are harmful.
   FDA approval of a drug is no guarantee of safety for all. Often the drug must be taken by thousands or
   even millions of people before unexpected toxicity shows up. Consider the antibiotic Ketex that was
   found to cause severe liver damage after it was marketed. Unfortunately this drug was marketed
   heavily despite the fact that it added little to other anti-bacterials already on the market. The authors
   also cite Vioxx and Baycol, two very popular, very expensive drugs that were recalled due to
   unexpected toxicity. The pharmaceutical companies should thank big oil for taking some of the heat
   off them due to the high price of gasoline.

   Pretty much all the excesses and medical hyperbole are covered: the media's phony advertising and
   "gee whiz" over-reporting of medical breakthroughs that aren't;  ineffective or dangerous new drugs
   and medical devices that disappoint; unnecessary, unproved and potential dangerous surgery; the
   weight loss racket; the latest cancer cures and other fraudulent claims, etc., etc. While the book
   doesn't exactly have the literary merit of a New Yorker article, it does have a few cartoons scattered
   through the text to mix a little laughter into the general indictment of nearly all the health care
   players.

   The authors conclude with a section of advice and suggestions for all the powers influencing today's
   healthcare, some of which may actually have a chance of becoming reality. Until then, for the medical
   consumer, caveat emptor.
   
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