Antidote Interview #3: Shannon Brownlee

I'm pleased to have the opportunity to interview Shannon Brownlee, a leading health and health care journalist, and a Senior Fellow at the New America Foundation. As you'll see, she has a lot to say about the direction of health care in the U.S., health care reform, how evidence-based medicine can help, and the role of journalism. Look for her forthcoming book on health care, to be released this fall.

I'd like to start with the topic of health and health care journalism, because I think you've been a particularly influential voice in this regard. What is your training, and how did you come to appreciate and learn about evidence-based medicine? Was there a defining moment?

I have a master's in marine sciences, and I trained as a behavioral biologist. I started writing about medicine in 1989, when I got a job with U.S. News & World Report. I was reporting on basic biomedical research, and had never heard of evidence based-medicine. Like most of Americans, I assumed the medicine was all scientifically based. Then I began researching the history of high-dose chemotherapy for breast cancer, a treatment that was used on some 40,000 breast cancer patients before it was shown to be no more effective than standard treatment. (High-dose chemo was also known as bone-marrow transplantation.) High-dose chemo killed thousands of women before the trials were completed in 1999, showing that it didn't work. I was shocked by the realization that a dangerous, experimental treatment was used so widely on the basis of so little evidence. That was the first time I really thought about the lack of evidence, and the tendency for U.S. medicine to plunge ahead into new therapies before doctors or patients really know whether the novel treatment was any good.

We now have a more recent, and far more costly, example in elective angioplasty and stents for heart disease. These two procedures, which are the tools of interventional cardiology, have been highly effective in the treatment patients in the midst of an acute MI. But the vast majority of angioplasties and stents are given not to the patient in the throes of a heart attack, but to patients who are suffering from the symptoms of heart disease. A few maverick cardiologists have been saying for years that there's no evidence that these procedures are any more effective than medical management in relieving the pain of angina or preventing heart attacks. Recent results from a randomized, controlled clinical trial, the gold standard of evidence based medicine, showed that the mavericks were right. That means we've been spending on the order of $40-$50 billion a year on invasive procedures that don't work any better than aspirin, beta blockers, and improved diet.

I was at a Cochrane Collaboration meeting with you a few years ago at Brown University where proponents of evidence-based medicine were reaching out to, well, evidence-based health journalists. The hope was that you and your journalist colleagues would "partner" with them in plugging systematic reviews, etc., in the mass media. This language raised some hackles about the appropriate role and function of journalists. What is that role? Is use of and reporting on best evidence a bias (to the extent that you're relying on groups like Cochrane and AHRQ), a tool, or something else? And what about editorial pressure to provide consumer-oriented health recommendations?

I don’t think it's my job to partner with the Cochrane Collaboration or AHRQ or anybody else, but I do think medical journalists should be more aware of resources like the Cochrane when they report on medical developments. Most medical journalism isn't very good, largely because most medical journalists are poorly trained when it comes to assessing the medical literature. (They're in good company. Doctors aren't trained to critically appraise the medical literature, either.) What journalists lack in critical skills could be made up for in more skeptical reporting, but that doesn't happen often enough. In any area of medicine, there's always a credible source who will offer an opposing view to the prevailing wisdom. But all too often, medical journalists don't seek out those critics, or they discount them as cranks.

The fact is, most of medicine is based not on evidence but on hunches and supposition, and on what's profitable. What I discovered in researching the history of high-dose chemotherapy was there were two driving forces pushing the therapy, even though the evidence for efficacy was based on historical controls, which is generally considered poor quality evidence. First, high dose chemo made much sense. If a little chemo could get rid of most breast tumor cells, a lot might offer a cure. This was part of the belief system in cancer treatment, and it proved to be a powerful motive. Two, transplanting breast cancer patients was hugely profitable, both for physicians and for hospitals. All too often, in American medicine, profitable procedures are done at the expense of effective medicine.

What would you like to see health journalists covering more? Are there gaps in coverage that you think could be filled usefully?

I'd like to see us following the money a little more assiduously. There are remarkably few investigative journalists in medicine, and there's so much to cover. I'd also like to see more skepticism. Where were the really critical journalists when researchers announced recently that CT-scanning for lung cancer could save lives? That research was full of holes, and any reporter who had the sense to go to one of several experts in screening epidemiology would have learned there was more to the story than met the eye. Yet most reports made CT-scanning out to be the greatest thing since sliced bread, and early detection the answer to fewer lung cancer deaths. I can understand why we make this mistake. I used to think all doctors understood how to analyze science, but many if not most of them aren't much better at it than a decent science journalist. So when journalists simply follow what the medical establishment is saying, they can fail to serve their readers.

Your forthcoming book is about the quality of health care. Have you learned anything about the topic that really surprised you? And without giving away the punchline - unless you want to! - is there a core message the book will convey?

I'm happy to give away the punchline, because it speaks directly to the questions you've been asking. The book will be out this fall, and the title is Overtreated; Why Too Much Medicine is Making Americans Sicker and Poorer. As the title suggests, the book focuses on the $700 billion worth of unnecessary care that's delivered annually in the U.S. There are many forces behind all this overtreatment, but they aren't the usual suspects that are trotted out, like malpractice, and patient demand. Yes, malpractice worries cause doctors to deliver unnecessary care. And yes, Americans do demand a great deal of treatment and drugs they don’t necessarily need. But there are two far more powerful effects at work. One is the over-supply of medical resources--beds, specialists, catheterization labs. Two, uncertainty and lack of evidence, the topic we're discussing here. Because so much of medicine has so little science to support it, much of what doctors do is based on supposition, on where they trained, what they believe, and how they're compensated for what they do.

Our health care system is also over capitalized. We have too many specialists in certain locations, too many hospital beds, too many devices like CT scanners. This overcapacity helps drive excess care, in part because medicine is so fragmented.

I just read in the Washington Post that each of the declared Democratic presidential candidates is in favor of universal health care, and the buzz around the topic is obviously huge. Senator Clinton has also sponsored legislation on health care quality and patient safety, but is anyone in Washington really thinking strategically about universal coverage and quality at the same time? Do you think universal health coverage - say, along the lines of Canada's system - will result in improvements in quality, or could it multiply the effects of a broken system with regard to delivery of high-quality care, or neither or both? (I hope this doesn't sound like a leading question; I'm honestly curious and am asking as many people as I can.)

I think Senator Clinton understands the need for improving quality and bringing down costs in conjunction with universal access, but it’s a lot easier politically to talk about covering everybody than it is to talk about how to rein in runaway costs and poor quality due to unnecessary care. Americans' perception of their health care is at odds with the idea that they are getting too much of the wrong kind of medicine (and too little of what could really improve their health). We try to get an appointment and we have to wait months. Once we get to the doctor's office, we cool our heels in the waiting room, and then we get all of seven minutes with the doctor before she rushes off to the next patient. We want the drugs we see advertised on television, and our doctor says we can't have them. The doctor recommends a surgery and the insurer turns it down. It's very hard for many Americans to wrap their minds around the idea that a lot of the care we're getting is not only unnecessary, but also harmful.

Medicare for everybody is not the solution. Universal coverage on its own will not solve our quality and cost problems; in fact, it will make them worse. Costs obviously won't go down when you cover more people. Extending coverage to everyone will simply provide hospitals and physicians with more paying patients to whom they can deliver more poor quality, expensive care.

Don't get me wrong. I'm all for universal coverage. It's a crime that we spend $2.1 trillion and can't seem to cover everyone. A little boy just died in Washington, DC, of a brain infection that developed from an abscessed tooth, all because his mother didn't have Medicaid or the $80 to pay for getting his tooth extracted. And it isn't just the poor who are going bare. I know a highly educated professional couple in their fifties who have been turned down by insurers on the individual market. They make enough to buy a nice house, but they've made the decision not to buy health insurance.

But the idea that covering everybody will magically solve our quality and cost problems is pure fantasy. Unfortunately, very few policy makers and lawmakers have grasped the enormity of overtreatment, and until they do, we won't be able to move forward on a coherent plan for improving quality and bringing down costs.

Because my readers would be shocked if I didn't ask you, what are your thoughts on rising health care costs? How do costs fit in with quality, who's responsible, and what can we do about it? OK, I know this is another book in itself, so is there anything in particular that stood out in your research regarding costs?

We have all sorts of misconceptions about what drives costs in health care. The silliest reason I've heard recently for our spiraling costs is illegal immigrants who get free care. Give me a break. We also imagine that malpractice is the problem, but malpractice amounts to about $20 billion a year, a mere 1 percent of the total. We think the problem is high priced drugs, and while it’s true, Americans do pay the highest prices in the world for pharmaceuticals, drugs amount to 11 percent of total costs. It's also important to remember that many of those drugs help us live longer, more comfortable lives. Then there's bureaucratic overhead. About 30 percent of our total costs go toward paper pushing. The Canadian system, by contrast, spends about 16 percent on overhead. Obviously we could cut down on overhead, but we can't eliminate it. Some economists blame the fact that American doctors make more money than their peers in Canada and Europe, particularly such specialties as interventional cardiology and orthopedics. Physician fees account for a quarter of the total costs. But we certainly can't eliminate doctors.

The one thing we can get rid of that adds absolutely nothing to our health is overtreatment. Finding ways to cut out $700 billion of unnecessary care would simultaneously improve the quality of care and cut costs.

But think, for a moment, about what cutting out $700 billion worth of care really means. For one thing, it means less money for doctors and hospitals, which often profit handsomely from unneeded procedures. Interventional cardiology and cardiothoracic surgery are two of the most profitable departments of any medical center. For some hospitals, interventional cardiology is the sole source of profit. If we could wave a magic wand and get rid of all of the several hundred thousand unnecessary cardiac interventions that are performed each year, it would be good for patients and it would save a lot of money. But think of all the downstream effects it would have. Some hospitals could go bankrupt. Device makers will lose sales. There will be fewer jobs for hospital workers because fewer patients will be hospitalized. Interventional cardiologists will see their incomes drop precipitously. The winners here, if we start treating heart disease patients medically? Patients, of course, payers (which is to say, you and me), and the drug industry.

Here's another example. French researchers recently released results from a study showing that a device called a vena cava filter does nothing to reduce mortality in patients who are already on a blood thinner. (Vena cava filters are meant to prevent blood clots from reaching the lungs and causing a pulmonary embolism.) If doctors stopped putting in unnecessary vena cava filters, we'd all save money, and patients wouldn't be subjected to unnecessary, invasive surgeries. But device makers would lose sales, and surgeons' incomes would drop.

You can see pretty quickly that improving quality and bringing down costs is not going to be painless. But we have to do it. There are some economists who are now claiming that we can afford to see health care eat up 20 percent of GDP. They argue that there's nothing wrong with that because health care provides jobs and profits as well as health. But this view fails to take into account the stunning inefficiency of our health care system. There's a huge opportunity cost to wasting a third of our health care dollars on care that not only does us no good, but also can cause harm. Elliott Fisher of Dartmouth estimates that 30,000 Americans die each year from unnecessary care. That's almost as many deaths as are caused by breast cancer.