Brawley is well aware of the need for evidence-based medicine and standardization. But he also points out the sometimes shaky science underlying the current standards for screening and treatment. To screen or not to screen? To treat or not to treat? These questions are not easy to answer; they go to the heart of arguments about rationality versus rationing, value versus cost, and population health versus individual health.
These profound issues are regularly in the news, but they are seldom examined in greater depth than headline teasers. Worse, they are often misrepresented, politicized, and trivialized by terms such as “death panels” (which do not exist) and “government rationing.”
Brawley frames several of them as issues of denominators versus numerators. Consider annual mammograms for breast cancer screening. For women between 40 and 49 years of age, only a few tumors per thousand screenings will be found, and the mortality rate will not be significantly affected by their early discovery (earlier, say, than those found through digital exams). The cost of the screenings, plus the cost (and anguish) of pursuing large numbers of false positives, dwarfs the benefits of affecting mortality in a small number of cases. If you make health policy or pay the bills for lots of plan members, the decision appears obvious: Cut the screenings. If, however, you are a woman who is not just in the denominator (population) of this analysis, but also in the numerator (i.e., you have a tumor), the decision is not easy at all. In fact, for too many patients, the only question may be, “Do you feel lucky?”
For gender balance, Brawley presents a similar example involving prostate cancer screening and treatment, which are actually somewhat more complex because of one simple fact: Far more men have prostate cancer when they die (28 percent) than die from prostate cancer (3 percent). Which cases merit intervention? Do screenings that result in treatment interventions actually cause more harm and expense than good? Research aimed at answering these questions is under way, but it is unlikely to remove the uncertainty anytime soon. Meanwhile, Brawley points out, the push for prostate cancer screening is not altogether altruistic: Depends and Viagra, both of which enjoy strong demand from those men suffering from the complications of often unjustified treatments, are among the sponsors of free (or deeply discounted) community screening programs.
Other than the dogged pursuit of rigorous research and honesty with the public and patients, Brawley doesn’t offer answers to these dilemmas. But he does take a strong stand on the need to personalize the issues as much as possible — a refreshing and attractive characteristic in a physician with academic and research interests. And he tells us what good research science is and what it is not (with compelling examples from his early-career work at the National Cancer Institute).
How We Do Harm is a profound and moving deep dive into the sociology and ethical challenges of healthcare and medicine. It is also a very accessible tale of caution and offers wisdom about the limitations of evidence-based medicine in a world with insufficient evidence.
Profiles in Excellence
Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs delivers just what the title promises. Its authors, Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, and Charles Kenney, an award-winning author and former journalist at the Boston Globe, take some of the big ideas discussed by Flower and Brawley and show how they have been put into action. Each chapter features a different case study, and the seven cases in the book illustrate how new approaches can powerfully change care, outcomes, and costs for the better.