The renowned cancer expert shares why he wrote the provocative new book How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.
Cancer expert Dr. Otis Webb Brawley
Tavis: Dr. Otis Brawley is executive vice president and chief medical officer at the American Cancer Society and a professor of medicine at Emory University in Atlanta, of course.
He’s also the author of the provocative, and I do mean provocative, new text. It’s called “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.”
Talk about big shoes to fill – his own family history his great uncle was the first dean of Morehouse College, who later became the chair of the English department at Howard. Dr. Brawley, big shoes to fill, but you’re doing it. Good to have you on the program.
Dr. Otis Webb Brawley: Thank you for having me.
Tavis: Good to have you on. We all know that credo that you all take is to do no harm, and yet you write a book called “How We Do Harm.” That’s the kind of thing that could get you in some trouble.
Brawley: Yeah. The reason I did it, because during the healthcare reform debate there was lots of talk about how we had the best healthcare system in the world, and that’s actually true if you actually can afford it and actually know how to get through it.
But actually, as I look back over a number of my patients, and the book’s about stories of my patients and how the healthcare system actually hurt them. There’s over-treatment, people getting too much treatment; there’s under-treatment, people who need to get treatment and can’t get it.
Unfortunately, medicine is frequently a big business, so the default is to try to sell things. So you hear a lot of things that are under the guise of health information that are actually advertisements with all of the things you get with advertisements, including a corruption of the truth.
Tavis: How did healthcare become – and I’m not naïve in asking this question; that’s why I’m asking you how as opposed to why. But how did healthcare become such a big business?
When you think about our health, one ostensibly would think that you all go into this business to treat people and to make them healthier and to help people live healthy lives, and somehow, money has corrupted the whole process. How did that happen?
Brawley: Well, it’s not just doctors. Actually, once one reads the book you’ll come to the conclusion, I believe, that the fault lies with doctors, with patients, with hospitals, with drug companies, with device manufacturers, the insurers, the lawyers, the politicians – everybody has fault for this system going awry, and everybody seems to make money off of it as it’s going awry.
We have the most expensive healthcare system in the world. It costs nearly $8,000 per man, woman and child in the United States for healthcare every year. That’s the per capita cost. The average for most other countries is about $4,000 – half that.
Tavis: What do we get for that eight grand per person? Where does that rank us around the world?
Brawley: Well, we do not have the best outcomes. We’re 50th in life expectancy; we’re 47th in infant mortality. We do not get what we pay for. We have the most expensive healthcare system in the world and we’re 50th in life expectancy. We criticize countries like Canada – Canada’s 10th in life expectancy.
Tavis: When you ran that list a moment ago of all the persons who share blame for the money that’s corrupted the system, you threw me off when you said “patients.” I get everybody else in that process, because they’re making money, but how are patients to blame for this?
Brawley: Well, there are some people who are patients who are just gluttonous, they get too much healthcare. Actually, several chapters in the book are about how too much healthcare can actually be harmful to your health.
There are people who have decided that they want this drug or that drug. For example, let’s name names. There’s a drug called Nexium on the market, which is $6 per pill. Take one pill a day. It is equivalent to generic omeprazole, which is available for about 35 to 40 cents per pill. It is FDA approved because it’s equivalent to the 40 cent pill, yet many patients insist on getting the big purple pill.
They tell their doctors, “I don’t want the generic; I want the more expensive pill.” That’s adding to our costs of our healthcare system. Many patients go to their doctors and insist on getting screening tests that they don’t need. Nonsmoking women in their forties insisting on getting spiral CT screening for lung cancer, a test that actually ultimately might cause them to have cancer and is unlikely to save their life.
So patients are at fault as well. Patients can also be a solution. If patients start being more skeptical, start asking questions of their doctor, do I need this test, why do I need this medicine, how does this medicine work, if patients start getting interested in their health and being a little bit more skeptical, we can actually start changing the system.
Tavis: I want to get to some specific stories, because you do tell some arresting, alarming stories about patients in the book. You mentioned the healthcare debate a moment ago, which really, as we all know, isn’t over as yet.
Brawley: That’s right.
Tavis: Because if certain Republicans have their way, they’re going to turn this over and some parts of this law are still being challenged in the court system, as we know, now. But what most troubles you about that debate?
Brawley: The debate was all numbers, and it was devoid of the fact that there are human beings, there are people who are hurting because they don’t get enough healthcare. There are people who are dying in this country because of the unavailability of healthcare.
I really partly wrote the book because I wanted to put a human face on this and get away from these broad concepts and make people actually realize that this healthcare debate is about people hurting and people dying because they’re not getting the care that they need.
Tavis: To your point now, there’s a story in the book about a woman who walks into Grady Memorial – I know it well – in Atlanta, and she has something wrapped in a soft paper, and I’ll let you tell the story of who she was and what she had wrapped in there.
Brawley: Yeah, this was a lady who actually had a job and she walked into the emergency room and her chief complaint was that, “My breast fell off,” and she wanted to know could we reattach it.
Tavis: Say that again – what fell off?
Brawley: Her breast.
Tavis: Her breast fell off.
Brawley: Yes, yeah.
Tavis: She had wrapped it up and brought it into the hospital.
Brawley: She had wrapped it up and put it in a moist terrycloth and put it in a plastic bag and wanted to know if we could reattach it. What she had was called an auto-mastectomy. This is a woman who had had breast cancer and had known that there was something growing in her breast for well over 10 years. She could date it from when her son was in second grade and he had graduated from high school.
And she ignored the fact that this thing was growing in her breast, was at times afraid to go get healthcare, at times could not afford it because of work and lack of insurance.
She finally came to us after the tumor grew so large it literally severed the blood supply to the front part of the breast, and her breast literally fell off.
Brawley: It’s called an auto-mastectomy. We see that at Grady probably twice a year. Only once in my 25-year career has anyone ever walked in with it and said, “Can you reattach it,” but yes, we do see this sort of thing. In the United States, in 2012, that sort of thing happens in big public hospitals.
Tavis: In the story you just told, I heard two or three different things. One – in no particular order – I heard fear on the part of the patient, over 10 years, just really didn’t take care of her health.
Number two, I heard inability to pay over the course of that 10-year period. Which raises the question for me about responsibility. You mentioned earlier that patients can be responsibility for the cost of the system.
Tavis: But how much of what ails and troubles our system has to do with individuals not being proactive, not taking care of themselves?
Brawley: I think a large part of the system is individuals not being proactive and not taking care of themselves, but a large part also is people who simply don’t have access. They can’t afford it; the bills will be too overwhelming.
In this lady’s case she had a job, but she had family responsibilities to keep a roof over her kids’ head, keep them fed, and that came first as opposed to paying for doctor bills.
Tavis: Mm. Let’s get down to the nitty-gritty here about physicians themselves, and the hunger, the greed that some of them – I don’t want to indict the entire field.
Tavis: But the greed that some of them have to make more money by recommending product X, Y, or Z.
Tavis: By connecting themselves to study X, Y, or Z. I’ll let you tell the story, but tell me about the harm that some – again, some – physicians do.
Brawley: Yeah, and I appreciate you saying some, but unfortunately, it’s a larger group than one would think. Doctors tend to prescribe things that are of benefit for them. A surgeon is much more likely to suggest operating when radiation therapy also might be an option, for example.
We really do have to question our doctors and actually ask them why do you suggest this versus that. We also need to go get second opinions. Patients have to actually get interested in their healthcare, do some reading about how things are treated and by the way, even among doctors like myself, I think of myself as someone who’s very interested in patients and very interested in patients’ best interest.
I think I give better service when people actually interact and ask questions with me. But yeah, in medical oncology, the field that I practice, and there’s several stories in that book there where doctors actually gave chemotherapy and they would choose to give drugs where the markup, the amount of money they got paid, was higher than other drugs that are equally as useful that they don’t make as much money off of.
You’ll see this happening a lot, even in dentistry. You will see cavities that get filled that perhaps ought to be watched.
Tavis: What’s a patient to do about that? If I ask my physician why he’s doing X instead of Y or what the alternative is to Y and he or she gives me an answer, given that I didn’t spend 15 years going to med school and residency and all of that, how do I know that what I’m hearing – what do I do about that?
Brawley: I think most people – gut feeling actually goes a long way, and if you have a doc who’s willing to interact with you, willing to discuss these sorts of things, I think that’s a good doctor. If you have a doc who’s not willing to talk about those things, I think maybe you ought to get a different doctor.
Tavis: You don’t go really, really deep into this, but I know you touch on it in your work and you have some thoughts about it, so I want to ask, and that is how much of the harm that’s done by physicians has to do, Dr. Brawley, with a lack of culturally competent care?
I ask that because it was the first African American president who pushed through, whatever one thinks of the healthcare bill, and I’ve got my issues with it, to be sure, it was the first African American president, while seven others tried, to actually get this through, and he did it at a moment in American history where we have the most multicultural, multiracial, multiethnic nation ever.
That is not reflected, as you well know, in the color of the physicians who provide the care. So how much of the harm that’s done has to do with a lack of cultural competence?
Brawley: There is some harm due to lack of cultural competence, but it can actually go in ways that people don’t normally think. A Black physician taking care of a Black patient may actually think of him or herself as being better than that patient.
There can be a sort of socioeconomic discrimination amongst Black people. My uncle actually used to say that he preferred Jewish physicians because it was his experience that Jewish physicians actually understood where he was coming from and were interested in him.
So I am very interested in the doctor-patient relationship, but I can see problems in terms of cultural competence in Blacks taking care of Blacks, Hispanics taking care of Hispanics, and even whites taking care of whites, and socioeconomic discrimination is one of the things I worry about, or people who are just not very sophisticated being thought of in a way that is very negative by the physician and getting not as good care because they’re not sophisticated. I see that happening a lot.
Tavis: Having nothing to do with race, what about the notion of bedside manner? I’m asking this question because these are conversations I have with my friends all the time who feel like harm is being done to them, sometimes in significant ways, sometimes in maybe not as significant a way. But bedside manner is a terribly important thing.
Brawley: It is incredibly important and it’s something that many of us fall down on, and unfortunately many of the systems that doctors work in now in outpatient medicine, you have to see four to five patients per hour. So we’re talking about how is the doctor going to establish a rapport, understand what the patient’s needs are, make a diagnosis and make a suggestion for treatment, and do all this explaining all in what basically is 12 to 15 minutes.
It can be very difficult, and that’s one of the ways that the insurance companies and those who reimburse, it’s very unfortunate. Doctors get paid to operate on people and to do interventions on people. We do not get paid very well to talk to patients and the counsel, and that’s one of the problems in the system now.
Tavis: Tell me about the intersection, and you touched on this in a variety of ways in the book “How We Do Harm.” Tell me about the intersection increasingly, to my read, at least, the increasing intersection between medicine and politics. We’ve seen it play out of late on a number of different fronts. In no particular order, the Susan G. Komen catastrophe that they ended up having to do a 180 on and apologize for – medicine and politics.
The big debate now as a part of, as I view it, this war on women, about contraception and where this debate’s going to end up – medicine and politics. I could give you a bunch of examples; I don’t need to do that because you’re the expert here. But give me your read on this increasing intersection between medicine and politics.
Brawley: Yeah, actually, I think the title of the book is actually perfect for this, because what we need to do in medicine is try to figure out how we can make people healthy. How we can promote health and try to keep people from getting sick, and if they are sick, how we can get them to cure.
Unfortunately, money can be made in medicine, and whenever money can be made, politics starts getting involved. We desperately, desperately need to try to keep politics out of it as much as possible and we need to focus, get the medical profession, and include not just doctors but people who are in the insurance business, people who are in the business of making medicines and running hospitals.
Everybody has got to change their mind-set and start thinking what is best for the patient. The meaning of the word “profession” is a group of people who put the interests of their clients – in this instance, the patients – ahead of their own best interests, and that group also polices itself.
We in medicine are not putting the interests of our patients ahead of our own interests right now, and we are also letting politicians delve heavily into medicine and starting to regulate it; unfortunately, not regulate it in ways that improve outcomes.
Tavis: So I asked you about medicine and politics. What about medicine and science? I know they’re one in the same, but here’s what I mean to suggest by that. We have the practice of medicine, and it’s never lost to me that there’s a reason why they call it “the practice of medicine.”
Tavis: I get that. But there are increasingly debates about science and what we’re going to rely on, so what about science?
Brawley: Yeah. Many doctors have forgotten the scientific part of medicine, or they don’t understand it. Unfortunately, in medical school they don’t teach you statistics and they don’t teach you clinical trial methodology and that sort of thing, and we talked about one lady who got a bone marrow transplant for breast cancer.
Bone marrow transplant as a therapy for breast cancer became very popular in the late 1980s. By 1998, 1999, there were more than 200 centers in the United States that actually offered bone marrow transplant for breast cancer. 1999 is when the four clinical trials were finally published to show that bone marrow transplant for breast cancer not only didn’t work, it was net harmful than the old standard therapy.
So here we have 200 sites around the United States who are doing something, and the science is finally completed 12 to 15 years after they start doing it. There’s so many things we do in medicine without the science. I’ve been outspoken. We did prostate cancer screening in this country.
Tavis: I was about to ask you about that, yeah.
Brawley: Yeah, we did prostate cancer screening in this country for 20 years before we had a clinical trial that suggested that it actually was beneficial. Indeed, I was so outspoken about prostate cancer screening because in the late 1990s I actually met a fellow who was a marketer for a large hospital system who had this wonderful business plan on how much money they would make off of prostate cancer screening at a mall – free prostate cancer screening.
It was very lucrative for this hospital, off of the guys who would have abnormals, the people who’d be diagnosed with cancer. They knew how many different treatments they were going to get, they even knew how many men would have urinary incontinence and impotence.
Then I asked the guy, “How many lives will you save off of this prostate screening,” and he tells me, “Don’t you know? There’s no scientific study to show that screening for this disease saves lives.” It was all about money. Unfortunately – now, it was based on making money with the possibility that it might be beneficial. We do this so often in medicine. Those are just two examples.
Tavis: Give me a read on the insurance industry. We talked earlier in this conversation about the whole healthcare debate, what some people call healthcare reform. I don’t go that far because I don’t think much got reformed, but give me your read on the insurance industry.
Brawley: Yeah, well, actually, what I think got reformed is payment. What we actually need, by the way, is healthcare transformation. We need to actually have a tremendous focus on prevention of disease instead of the current focus, which is on fixing people once they get sick.
Tavis: But there ain’t no money in prevention.
Brawley: Now, that’s exactly right.
Tavis: I got a story to tell you about that later. Something just happened to me a couple days ago. But anyway, go ahead, yeah.
Brawley: But that’s exactly right, there’s no money in prevention. The insurance companies have been a great gravy train. Twenty percent of their revenue is profits. It’s just amazing. They’ve had a great run for the last few years, and I don’t see it stopping
Unfortunately, even the not-for-profit health insurances that we used to have have become really for-profit health insurances, when you look at what some of the executives are getting paid.
Tavis: My mom watches this show every night so – hi, Mom – back in Kokomo, Indiana, and I don’t want to scare her, but I was literally in my doctor’s office the other day – I’m fine, Ma – but I was in the doctor’s office the other day and I was complaining about something, and I said to my doctor, “I’d like to get this tested.”
He thought it made sense and called the insurance company and asked them to test this thing. It was being done for preventative measures, and they absolutely refused to pay for it.
So I’m thinking, I’m Tavis Smiley, maybe if I get on the phone and maybe I can talk to the insurance company. After all, I’m the guy that pays the premiums here.
Tavis: So I get on the phone following my physician and try to talk them into it, and they just slammed – they absolutely would not budge on paying for this, and I found myself in this huge fight on the phone with my own insurer about why it is that they would not pay for something that I was asking to have done as a preventive measure, and absolutely wouldn’t do it.
It just – you can tell I’m getting upset – it made me livid the other day. So I guess the point is, as I said earlier, there ain’t no money in prevention, so when you try to stop something from happening before it gets there, they don’t care about that.
Brawley: Yeah. There are certain things that are scientifically based in prevention that we ignore and we simply don’t do, and then there’s certain things that doctors very frequently get into and start advocating that we actually don’t have science to promote.
So there needs to be a good interchange. There needs to be discussion with the patient about what the science is. Unfortunately, many doctors don’t know what the science is. When the U.S. Preventive Services Task Force last fall recommended or suggested that they might recommend that men not be screened for prostate cancer, there were a lot of doctors who were surprised at that recommendation.
I, by the way, don’t agree with their recommendation, but I wasn’t surprised by it. I understand where they were coming from and I understand that there’s significant harms associated with certain screening tests. There are harms associated with certain tests that might be done for preventative measures as well.
So we need to keep an open mind and there needs to be a discussion of what does the science say. We use the phrase, “evidence-based medicine,” those of us who are in medicine and want to get more science into it, but getting back to your original point, medicine is both an art that involves education and rapport with the patient, and it is a science that involves the use of evidence-based medicine, and we’re falling down on both of those things now.
Tavis: My time is up, but there are examples in this book, though, connected to this point that you cite where if X had happened early on, the 150, $200,000 that it cost later on to try to address the problem wouldn’t have been spent.
Brawley: That’s right.
Tavis: And the person might still be living today.
Brawley: That’s right.
Tavis: If something on the preventive side had been done early on.
Brawley: That’s exactly right.
Tavis: But I digress. The book is called, “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.” Otis Webb Brawley, M.D., is the author of the text. Dr. Brawley, good to have you on, and I know that this kind of truth-telling can get you in a little bit of trouble, but I appreciate you doing the book.
Brawley: Thank you, sir.
Tavis: Good to have you on.
Brawley: Thank you.
Tavis: That’s our show for tonight. Until next time, keep the faith.
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