Hope or Hype

The Obsession with Medical Advances
and the High Cost of False Promises

by
Drs. Richard A. Deyo and Donald L. Patrick
2005

reviewed by Mira de Vries

This is a highly legible book. The message is straightforward, well-argued, and devoid of the contradictions that mar so many other works. Throughout it is dotted with cartoons that are not only entertaining, but illustrate points the authors wish to make.

Briefly, the authors state:

People, physicians as well as patients, tend to think that new treatments are better, partly because that is how they are marketed. The opposite is true. The newer a treatment, the less experience there is with it, so the drawbacks aren’t known yet and health care professionals are inexperienced in applying it.

 In the past most treatments were for acute conditions like broken bones or appendicitis. You were treated and then you were better. Nowadays most of what doctors treat are chronic conditions, and treatment is indefinite. The trouble with these treatments is that you never know whether they’re helping you. You just assume they are, because you think your doctor’s decision is based on science, but science isn’t always what it seems. Often the research is biased, not to mention distorted by marketing, media hype, and wishful thinking.

High-tech medical services with marginal benefit come at the expense of other services, like better nursing staff ratios. Therefore patients are over-treated and under-cared for. Society could afford to pay for all effective treatments if we just stopped paying for the ineffective ones. Many patient advocates, even when they are truly patient advocates and not fronts for pharmaceutical or device manufacturers, get on the wrong bandwagon. Health insurers, though no paragons of virtue themselves, are justified in balking at payments for expensive treatments without proven value. These treatments drive up the cost of health insurance and make it unaffordable.

Drugs are among the high-tech treatments. Between 1997 and 2001 fourteen drugs were withdrawn from the market because of serious side effects. None of them was for a life-threatening condition. Nearly 20 million patients (almost 10 percent of the U.S. adult population) were exposed to five drugs that were recalled in 1997 and 1998 alone. Half the drugs approved by the FDA prove to have serious adverse effects that are unknown prior to approval. Many drugs are considered effective when they influence test results in a direction deemed favorable, even though they actually increase mortality. Demonstrating theoretical rather than proven benefits suffices for the FDA.

While commercial interests and regulatory practices heavily influence drug prescribing, tradition and authority perhaps more heavily influence surgery. A surgeon can perform any new procedure he wishes, assuming he can find a willing patient.

Physicians are expected to treat their patients according to standards of care. Such standards are not based only on science, but also on complex social, political, and economic processes. A treatment may be recommended because the doctor feels it ought to work, makes sense, is common practice, is what he learned to do in medical school, has always been done this way, is vouched for by an expert, or works in mice.

Medicine and the media share faith in experts and miracle drugs, and an attitude that biotechnology can solve all problems, that medical researchers are heroic, and that if we only spent enough money, we could find a cure for everything. Yet, as Richard Nixon’s ‘war on cancer’ showed, many cures aren’t just around the corner. The human genome project is also not going to unravel as many secrets as researchers predict.

The authors don’t touch on psychiatry, which amounts to around half of health care expenditures. Perhaps they figure that there’s no point in stirring up that hornets’ nest.

They do make some concrete suggestions:

• Insurers should invest in efficacy research. They should fund new treatments with as yet unproven value only if the patient agrees to enroll in trials that can shed light on the efficacy and safety of the treatment. An added bonus is that trial participants often receive better care than others. Patients who enroll in trials should demand basic information like who is sponsoring the trial.
• Patients should be better educated about medicine. They should have access to their own electronic records so that they can check the information and base health care decisions on it. Educated patients are less likely to be tempted by marketing ploys and other unsubstantiated promises.

Unlike most authors on this subject, such as Blech, Angell, and Medawar & Hardon, Deyo & Patrick have few illusions about the ability of government to control the health industry. They acknowledge that the FDA is useless, and point out that every effort of the US to set up a more effective regulatory agency alongside the FDA was politically doomed. Some agencies lasted longer than others, some were more generously funded than others, some had more powers than others, some were less corrupt than others, but in the end, they all succumbed to the interests of Big Business. Yet Deyo & Patrick can’t break the habit of hoping that someday government is going to protect the interests of individual consumers, perhaps the way physicians can’t break the habit of hoping that the new treatments they prescribe for their patients will be good for them.

I like this book so much, I think I'll purchase another copy, and send it to our minister of health.