The Corrosion of Medicine

The Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy?
Worried Sick: A Prescription for Health in an Overtreated America


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The Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy?
By John Geyman. 344 pp. Monroe, ME, Common Courage Press, 2008. $24.95. ISBN 978-1-56751-384-4.

Worried Sick: A Prescription for Health in an Overtreated America
By Nortin M. Hadler. 353 pp. Chapel Hill, University of North Carolina Press, 2008. $28. ISBN 978-0-8078-3187-8.

Health care reform is back ?- at least rhetorically. These two books suggest that both Democrats and Republicans are missing the boat, or perhaps rearranging deck chairs on a ship that is already listing. Both parties' presidential candidates trust private insurers and pay homage to the technical virtuosity of America's doctors and hospitals. But John Geyman blames insurers and their corporate brethren for the country's health care woes, whereas Nortin Hadler sees a medical establishment that has pushed interventionism to the brink of assault. The authors of both books analyze why our exorbitantly expensive medical efforts yield such mediocre results ?- but on very different levels.

Geyman focuses on financing policies and the corporate takeover of medicine. Longtime readers of the Journal will have encountered this theme, starting with Arnold Relman's classic 1980 editorial on the incipient threat posed by the "medical-industrial complex." Geyman marshals a quarter-century of meticulously referenced evidence to argue that market-driven care is driving inexorably toward dominance by large corporations whose priority is their bottom line. Investor-owned insurers, hospital chains, and drug companies have warped the priorities and practice of medicine. Too many doctors have gone along, seduced by drug company handouts, research funding with implicit strings attached, and insider profits from joint-venture specialty hospitals and the like. These lucrative liaisons have left the profession weakened and demoralized.

Geyman's literary voice arises from his unusual professional and political trajectories: from country doctor to academic department chair and prominent journal editor, and from longtime Republican to president of Physicians for a National Health Program, a group that advocates national health insurance. His book is packed with ideas, outrage, and data ?- for example, death rates at investor-owned hospitals are 6% higher than the rates at nonprofit hospitals, and yet treatment at investor-owned hospitals costs 3 to 13% more. Overhead for private insurers is four times that of Medicare. The number of medical administrators has grown 18 times faster than the number of physicians during the past quarter century. Every year, more than 18,000 American adults die because they lack health insurance. Geyman's book reads like a carefully prepared grand rounds ?- complete with charts and graphs ?- presented by a passionate advocate and scholar.

Geyman prescribes universal insurance that is set up like traditional Medicare, with funds collected through taxes and paid directly to doctors and to nonprofit hospitals, nursing homes, and other such institutions. By eliminating private insurers, simplifying reimbursement, and proscribing ownership of health care institutions by investors, such a program could save perhaps $300 billion annually on bureaucracy and profits ?- enough to cover the 47 million uninsured persons and to improve coverage for most other Americans.

Hadler, a rheumatologist and occupational medicine specialist, concentrates on medical decisions. He indicts doctors for peddling fake diseases and promising false cures, and he also indicts patients for refusing to accept the normal infirmities of age and the inevitability of death. Like many contrarians, he sometimes overstates his case, but the case is often a strong one.

Hadler offers a withering critique of the invasive treatment of chronic stable coronary artery disease, echoing the view that has long been advocated by noted cardiologist Bernard Lown. The single-minded focus on opening (or bypassing) narrowed arteries relies on an oversimplified model. Most acute occlusions do not occur at sites with previous high-grade stenoses; stenotic lesions often stimulate the development of collateral circulation that attenuates their danger; and modern medical management often stabilizes plaques. Moreover, randomized trials have shown that few patients with chronic stable angina benefit from mechanical intervention ?- apart from the 3% of patients with left main coronary artery disease.

Hadler also takes on screening for breast, colon, and prostate cancer, which has not been shown to decrease all-cause mortality but does increase radiation exposure, surgeries, and worry. He criticizes tight glucose control, prefiguring the unexpected results of a recent randomized trial. Unfortunately, he sometimes stretches his case ?- for example, minimizing the evidence that supports control of moderate hypertension.

Hadler mostly blames our cultural predilection for medicalizing discomfort for America's hyper-interventionist system of medical care. He mentions, almost in passing, the financial winners in the $88 billion industry that exists to care for patients with coronary artery disease, and the political and commercial pressures that members of that industry have exerted to invent, maintain, and publicly fund the interventionist paradigm. Although Hadler focuses on clinical decisions and Geyman focuses on financing policy, they concur that physicians, wittingly or not, have abetted the corruption of healing. Moreover, both sound a hopeful note ?- doctors have the knowledge, power, and moral obligation to reject the false coin of commerce and technological hype and to reassert the primacy of the patient.


Steffie Woolhandler, M.D., M.P.H.
David U. Himmelstein, M.D.
Cambridge Hospital
Cambridge, MA 02139

NEJM