Is Evidence-Based Medicine Evidence Based?

According to the U.S. Centers for Disease Control and Prevention, of the 2.4 million U.S. deaths in 2000, 400,000 were associated with unhealthy diet and lack of physical activity. These are deaths related to the particular way in which civilization has "progressed" upon this planet: high-fat, high-carbohydrate fast foods devoid of fruits and vegetables; a vast multitude of automobiles that make self-propulsion (walking) obsolete as a standard life routine; and couch-potato-creating television sets that not only replace the neighborhood kickball game and hide-and-seek activities that amused me when I was a kid, but also badger us to purchase those same automobiles and eat those same fast foods.

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How has the trillion-dollar-plus enterprise we call the health care system responded to this pervasive undermining of our health? By offering more inventions, which—like those cars, fast-food chains, and TV sets—are capable of making money for a small stratum of society. Instead of approaching the health effects of modern civilization through community-wide and public health interventions—banning cars and creating greenbelts within cities, spending more dollars on health education than the food industry spends on advertising, and creating more neighborhood physical activity programs than the auto industry creates cars—we have chosen to address those 400,000 deaths with a few rushed minutes in a sterile exam room populated by a highly trained physician, a passive patient, and a prescription pad.

John Abramson is a physician who spent more than twenty years in those exam rooms, filling out thousands of those prescription pads. But something happened to him that, sadly, happens to few physicians. He began to study epidemiology and research methodology, expanding his viewpoint from a close-up focus on the individual patient to a panorama of the entire population. Carefully reviewing the research literature, he found that spin doctors had been doctoring the evidence. The conclusions he reached from his careful literature review differed from the conclusions published by the authors of the universally accepted clinical practice guidelines—the "evidence-based medicine"—that are the yardsticks against which physicians’ quality of care is measured.

Abramson’s book, Overdosed America, provides detailed arguments on the false conclusions reached from research on such topics as the prevention of coronary heart disease and hip fractures. He explains why those conclusions are distorted: the web of interlocking monetary relationships among the pharmaceutical industry, academic research physicians, the Food and Drug Administration, leaders within the National Institutes of Health, and some of the hallowed organizations that promulgate evidence-based medicine—with the nation’s prestigious medical journals often serving as unwitting collaborators in the distortions.

Overdosed America presents a strong indictment of the evidence that dictates medical practice, a challenge that is credible only because Abramson backs up his statements with detailed analyses of the prevailing evidence. It is beyond the purview of this review to judge whether each of Abramson’s conclusions are scientifically and statistically valid. What can be said, however, is that the seriousness with which he explores clinical issues merits a major debate on those issues within the world’s leading medical journals—untainted by the almost ubiquitous monetary distortions. To give a sense of Abramson’s approach, it is worth summarizing his treatment of an important clinical problem: osteoporosis.

Twenty percent of women over age fifty have osteoporosis, and another 40 percent have osteopenia, thinning of the bones that puts women at risk for osteoporosis. Osteoporosis increases the risk of a serious medical event—hip fracture. Osteoporosis is diagnosed with a bone mineral density (BMD) test. About half of all American women who have a BMD test will be diagnosed with osteoporosis by age seventy-two. The market for pharmaceutical products to manage this condition is enormous. Accordingly, based in part on the work of an expert panel funded by drug companies, current practice guidelines recommend that all women have a BMD test at age sixty-five, or earlier if at greater risk for osteoporosis. The drug Fosamax (alendronate), which improves BMD, was found to reduce the risk of hip fractures for postmenopausal women with osteoporosis by 56 percent. Here, Abramson does what every journal article, newpaper report, and TV airing of a medical advance should do: report the absolute risk instead of trumpeting the relative risk. If, in a hypothetical example, 2 of every 10,000 women with osteoporosis sustained a hip fracture in a year, a relative risk reduction of 50 percent would mean that 1 of every 10,000 women would be spared a hip fracture—a very small improvement. If four of every ten women with osteoporosis sustained a hip fracture in a year, then a relative risk reduction of 50 percent would mean that two of every ten women would be spared a hip fracture—a very large improvement. Relative risk by itself can be highly misleading. Abramson reports the more illuminating facts: 81 women would have to take Fosamax for 4.2 years to prevent one hip fracture, and for women ages 70–79, Actonel (risedronate), a medication similar to Fosamax, had no effect on the number of hip fractures.

What is going on? Why do drugs that improve bone mineral density have little effect on hip fractures? It turns out, according to Overdosed America, that BMD is not a good test to predict hip fractures. BMD mainly measures the outer layer of bone (cortical bone), whereas much of the strength of bone lies in the inner structures of trabecular bone. Drugs such as Fosamax primarily strengthen cortical rather than trabecular bone, which improves the BMD score but may not contribute as much to fracture prevention.

Finally, women age sixty-five and older who engage in regular exercise enjoy twice the reduction in hip fractures achieved with Fosamax. Exercise not only increases bone density but improves muscle strength and balance, thereby preventing falls, the proximate cause of hip fractures. Yet physicians who prescribe drugs such as Fosamax for at-risk women, while ignoring or downplaying the greater importance of exercise, are viewed as "evidence-based" physicians.

Why this lengthy exposition of a clinical issue in a health policy book review? Because readers who might be inclined to view Overdosed America as simply another in the growing number of diatribes against drug companies should be aware that this book makes its arguments in a detailed, well-referenced manner. Moreover, responsibility for the overdosing of America goes far beyond the drug industry, resting equally with the nation’s physicians. I beg all of my physician colleagues to read this book and to think deeply about how we are practicing our chosen profession.

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From the British Medical Journal

The new [cholesterol lowering] guidelines will radically increase the number of people taking cholesterol lowering drugs, said Dr John Abramson, clinical instructor at Harvard Medical School, Boston, Massachusetts, author of Overdosed America: The Broken Promise of American Medicine, and one of the signatories to the petition [sent to the NIH calling for re-evaluation of the recent recommendations for treating cholesterol]. He told the BMJ: "In the one group that could benefit, men aged under 65 with multiple risk factors, you'd have to treat 238 men for one year to prevent one heart attack, and to prevent one death you'd have to treat 526 patients for one year." "While statins are clearly beneficial in certain high risk individuals," said Dr Abramson, "exercising, eating a healthy diet, and not smoking each individually appear to give more protection against heart disease, as well as the added benefit of preventing diabetes, osteoporosis, and multiple other diseases. One can't help wondering whether the ties between the authors and the statin makers contribute--consciously or unconsciously--to their focus on drugs."

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Washington Post: Sunday Book World

Cooking the Books

John Abramson, a clinical instructor at Harvard Medical School and the author of Overdosed America: The Broken Promise of American Medicine (HarperCollins, $24.95), has done what most physicians don't have the time or inclination to do: He's not only read the peer-reviewed articles upon which doctors base their prescribing habits but also has examined the actual study data for some of today's most popular drugs. As a primary care doctor in Massachusetts, he constantly found himself on the receiving end of drug-company pitches. And, he writes, he believed in the integrity of the medical information system -- until he sat down and examined the clinical trial results in detail.

The strength of Overdosed America is in these close readings of the research. Abramson walks the reader through the contradictions he's discovered between the exorbitant claims made for the products and the actual study data -- or between the data and the subsequent medical guidelines promulgated by government-sponsored panels, whose members, he reports, often have financial ties to the companies that make the drugs they're recommending.
Abramson argues, for example, that the benefits of the cholesterol-lowering drugs called statins are nowhere near as great as generally believed, and certainly do not approach the advantages conferred by lifestyle changes that would cost much less. Reviewing studies of the blockbuster anti-arthritis drugs Celebrex and Vioxx conducted years before the recent announcement of Vioxx's dangers, he reports that the two medications, although marketed as safer than an earlier and cheaper generation of products, can actually cause more severe side effects. And he recounts the now-famous story of how drug companies and doctors persuaded millions of menopausal women to go on hormone replacement therapy, which later proved to significantly increase the chances of suffering from breast cancer and heart attacks.
In one particularly enlightening section, Abramson analyzes various methods drug companies use to massage their research data and obtain the results they'd like. "Rigging medical studies, misrepresenting research results published in even the most influential medical journals, and withholding the findings of whole studies that don't come out in a sponsor's favor," he writes, "have all become the accepted norm in commercially sponsored medical research."
Beyond Abramson's focus on the details of medical studies, he covers much the same ground that Angell does, although not quite as comprehensively. Both authors offer a list of suggestions -- some practical, others probably wishful thinking -- for reducing the drug companies' influence. But these ideas remain overshadowed by the much larger and more compelling point: If this is the industry we hope will rescue us from disease, pain and unhappiness, we're in real trouble.
David Tuller is a contributing writer at Salon.com.

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San Diego Union Tribune Review

"Abramson, who has a background in statistics and health policy, took the time to read the full 284-page version of the panel's 2001 report, rather than the 11-page summary that most doctors saw. The results of his careful analysis are enough to shock a healthy heart into failure. He notes that data from the venerable Framingham study - a large, long-term study of risk factors for heart disease - show that elevated total cholesterol levels correlate with an increased risk of death only through the age of 40. Even more astounding is the finding that the risk of death from causes other than coronary heart disease increases significantly with lower total cholesterol levels for both men and women after the age of 50. And that doesn't even touch on the question of the long-term side effects - both known and unknown - of the statins themselves."

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British Medical Journal Review of Overdosed America

With so much negativity towards medicine these days, many doctors must be contemplating ear-plugs and wondering why they are bothering. Thanks to Harvard University researcher and family doctor John Abramson, that negativity is about to be turned up a notch. His book is the latest in a series of searing indictments of a medical profession apparently duped by the false promise of technology, and too often compromised by cold hard cash from the companies selling the drugs and devices. Yet this book comes with a refreshing respect for the healing potential of the doctor-patient relationship, and a clear commitment to making the healthcare system more humane. The title speaks of the United States, but the themes are global.

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Much of the material about drug companies distorting science will be familiar to many readers, but there is a freshness here that carries great appeal. The author combines his personal journey towards increasing scepticism with a clear analysis of where the American health system is failing. The book's focus is big pharma's unhealthy influence, but it places that subject within a much broader global context: the growing commercialisation of medicine; the limits of the biomedical approach; and the moves to widen the ways in which communities and nations can try to improve human health.

As Britain's House of Commons health select committee investigates industry's influence over the entire health system, as authorities in the United States and elsewhere continue to be convulsed by revelations about the dangers of widely prescribed antidepressants, and as a global campaign to re-invent academic medicine takes shape—part run by the BMJ—Abramson's book could not be more timely. What it lacks in terms of a compelling narrative, it makes up for with powerful and engaging insights.

The personal journey starts with this doctor's bewilderment at discovering the truth about COX 2 (cyclo-oxygenase-2) inhibitors, the overhyped new class of anti-arthritis drugs, and his sense of betrayal at finding out that such distortions are no longer uncommon. The story of celecoxib (Celebrex) and rofecoxib (Vioxx), and the far-too-favourable portrayal of their risks and benefits in both marketing materials and published trials, is told through anecdotes about interactions with real patients.

Particularly fascinating is Abramson's argument that marketing campaigns encouraging unnecessary demand are undermining the trust between a doctor and patient. It is not a new argument, but he has a moving formulation of it. With great discomfort, we hear how this family doctor wrote a prescription for a much advertised pill that he was convinced his patient did not need, in order to maintain a relationship with that patient. In another scene, the author wonders how many people he may have injured in the 1980s, by prescribing a notorious class of anti-arrhythmic drugs, belatedly shown to take life away rather than save it. Importantly no one is singled out for blame in this book, but rather "the enemy is us."

Moving from the personal to the political, the book explores the abundant evidence about the far-reaching pharma influence over medical practice, education, and research: from the friendly drug reps to the rigged trials, from the timid regulators to the bought-off thought leaders. "Doctors who allow their reputations and academic positions to be leveraged by drug companies for commercial purposes provide a crucial link in the chain of corporate influence," Abramson writes. The media also come in for criticism for their mindless "break-through cure" formulas in medical news stories, boosting sales more than enlightening readers or viewers.

As I read this book, and watched the wider global debates about commercial influences on medical science, one question kept demanding an answer. Given what we know now of the distortion of medical knowledge and practice, why aren't more doctors, health professionals, policy makers, and patients clamouring for a form of health care characterised by much greater independence from unhealthy commercial influences?

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American Medical Association, Allan S. Detsky

This book (or one like it) should be required reading for all medical students and doctors, who should be well informed about the potential for bias introduced by the conflicts of interest Abramson delineates. The book may also help patients if it turns the tide against a system that "leads patients to demand that a doctor prescribe a drug that provides no better relief and causes significantly more serious side effects" (p 36) at a substantially higher price and teaches people to understand what the phrase "ask your doctor" really means.

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Bookslut Review of Overdosed America

Anyone with a half dozen neurons still firing in the old noggin should realize that is what "direct to the consumer" advertising is all about. Those TV ads, magazine ads, newspaper ads, billboards, spam, junk mail and on and on ad nauseum don't care if you have received the correct diagnosis (you can decide that for yourself, can't you?), or know anything about other treatments. They want your money, stupid!

Dr. John Abramson opens the subject in Overdosed America: The Broken Promise of American Medicine by maintaining that these same companies are now able to twist the results of studies presented in what in the past has been regarded as reliable sources of information: medical journals! The esteemed New England Journal of Medicine, the Journal of the American Medical Association, the Lancet and others have reported studies in which the sponsoring medical/pharmaceutical companies have been able to adjust the results given or the manner in which they are given, solely to increase sales! "Rigging medical studies, misrepresenting research results published in even the most influential medical journals, and withholding the findings of whole studies that don't come out in a sponsor's favor have all become the accepted norm in commercially sponsored medical research."

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Those television ads are more than just annoying. They hurt the consumer two-fold. First, they can convince the consumer they have disorders or diseases they do not. The obvious example is the ad campaign for depression/social anxiety/premenstrual irritability, but it goes further back than that. In 1942, premarin was approved by the FDA for the treatment of menopause symptoms. The drug was originally created to treat a minority of women for only a few years, but Wyeth-Ayerst began to market the drug as Hormone Replacement Therapy (HRT) and convinced millions of women that menopause was a disease. Years later, studies were finally released showing an increased risk of heart disease, breast cancer, dementia, stroke, blood clots, etc. Even after this, HRT is still advertised on the television.

The marketing campaigns also hurt the consumer by wasting billions of dollars of the pharmaceutical companies' money, and allowing them to focus on renaming drugs and disorders instead of finding new treatments and cures. There is currently a shortage of tetanus vaccines because vaccines do not make pharmaceutical companies money. Drugs that consumers will be convinced they need to take the rest of the lives, like antidepressants and cholesterol medication, is where the real profits are. Out of the 78 new drugs approved by the FDA in 2002, only 17 of them contained new active ingredients.

As a practicing pharmacist, I agree with the doctor’s conclusions and his belief that it is only going to get worse, until there are some major changes in the regulatory agencies involved. He further charges that this bias not only decreases the quality of the treatment, but is responsible for the horrendous cost of medical treatment today, and explains why we, as Americans, pay more than anyone else in the world but are receiving far from the best treatment.

This book is well written and covers several areas of medical treatment to illustrate the author’s points. There may be too much statistical analysis for some, but you can skip the numbers and rest assured the author has done the math to back up his assertions. One thing I would have liked to have seen is more of the author’s recommendations on trustworthy information sources. He does include a few, and maybe that is all there is currently. This isn’t so much a happy ending story of "Here is the problem and we have fixed it." It is more a rallying the masses with "Here is the problem and this is what you can do to help (yourself and medicine in general)."

I recommend this book to anyone who has ever been sick, is being treated for something now, or realizes they make get sick sometime before they die. Did I leave anyone out? Obviously everyone has a stake in this, and here is some good information you need before you consent to anything.

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Overdosed America On About.com

This fascinating, informative and very readable book is written by a doctor who was so concerned about the pharmaceutical companies ability to distorting medical knowledge that he took a year out to research and write it. Dr Abramson believes we are risking our health, our bank balances, as well as the impartiality of our medical profession as they are often misled about the real results of drug research.

John Abramson focuses on a number of current concerns and illustrates some of them with case histories from a few of his own patients. His insights into the way the adverse research findings of Vioxx and Celebrex were handled is just one example of how he believes profit comes before health.

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He shows us how information was suppressed on the serious cardiovascular side effects that were evident in the research of these Cox-2 inhibitor medications, used in the treatment and control of arthritis. Vioxx and Celebrex were promoted for their minimal gastrointestinal side effects, but the deaths from sudden cardiac death, heart attack, unstable angina, TIA's and blood clots, were hidden.

Dr Abramson paints a worrying picture of U.S. healthcare. Doctor's research is biased by drug company salaries, medical journal printing research that they do not scrutinize or validate, the systems of the Food and Drug Administration that result in failure to correct misleading information and act as an independent watchdog, and the way we are influenced by drug company advertising to demand certain treatments from our medics.

There are some surprising statistics in his book too. For instance, the US spends twice as much per person on healthcare than other industrialized nations yet it ranks 22nd out of 23 countries on healthy life expectancy. Of 56 drugs approved for use between 1995 and 2000 only 13% contained new active ingredients.

The good news amongst his concerns about HRT (hormone replacement therapy) side effects, exaggerated claims of cholesterol treatments and the serious side effects of Cox-2 arthritis drugs, is that we can do a lot ourselves to improve our health.

A must read for you, your doctor and the medical profession.

John Abramson is currently a member of the clinical faculty of Harvard Medical School teaching primary care. His book Overdo$ed America: The Broken Promise of American Medicine is published by Harper Collins.

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Blogcritics.org

The medical profession which John Abramson writes about in Overdosed America does not resemble a Norman Rockwell painting in any way. The current state of affairs is rather more dangerous and damaging - for both Americans' health and their pocketbooks - than even your family doctor may realize. Overdosed America charts how this state of affairs came about, what the costs have been in both dollars and lives, and what Abramson, a practicing physician and teacher at Harvard, sees as the best case scenario to fix current problems and reform the system to meet current and future needs.

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Where the book really shines is in Abramson's detailed chapters exploring how the medical industry has, since World War Two, valued profits over lives when developing treatments for everything from menopause to heart disease. These chapters constitute the bulk of the book and have a tendency to feel long and dry, a problem for a book written for a lay audience. I fought the urge to skip ahead to the last three chapters, Abramson's recommendations, mainly out of a perverse desire to see how often the drug companies have defrauded and deceived the public. The facts disclosed here are truly stunning, and worth reading for shock value alone. But they also go a long way toward creating a fuller picture of the crisis in American health care.

Time and again Abramson painstakingly details the triumph of commercial interests over scientific evidence. As familiar as this refrain is to anyone familiar with the Bush administration, Abramson traces the beginnings of this state of affairs to the Food and Drug Administration's 1942 approval of Premarin (estrogen) "for the treatment of symptoms associated with menopause." (159) Wyeth-Ayerst still holds the patent for processing "PREgnant MARe's urine" into a drug effective at relief of symptoms felt by a minority of women, which "last no more than two to five years." (ibid.) Marketed as part of a hormone replacement therapy (HRT) to protect all women against the ravages of old age, over 20 million American women bought into this therapy. Effects of HRT included: a "66% higher chance of getting breast cancer," a 50% increase in the risk of developing Alzheimer's disease, and a 15% chance of suffering at least one "adverse event" - heart attack, stroke, blood clots, dementia, breast cancer, and so on - after five years of therapy. (ibid.)

Abramson discusses many other cases, all with the same bottom line: American pocketbooks are more important to the medical industry than American lives. If this doesn't sound like an urgent problem in need of an immediate solution, next time you're over at your grandparent's house, open up their Reader's Digest. About 40% of the advertisements are for new and popular drugs.

Abramson discusses in Part Three of the book alternatives to biomedical (drug and surgery) therapies, supporting options such as lifestyle counseling and increased exercise regimens with study after scientific study proving their effectiveness. This is not to the detriment of biomedical therapies, which he is careful to note are valuable in situations "from emergency surgery... to the treatment of strep throat." (204) However, when the U. S. Centers for Disease Control and Prevention report that "'half of all deaths that occurred in the United States in 2000 could be attributed to... largely preventable behaviors and exposures,'" it may be time to look beyond the latest and greatest and most expensive pill, and return to a little common sense and conventional wisdom.

Of course, the difficulty, which both doctors and patients face here, Abramson states, is that non-biomedical therapies are often strongly reliant upon behavioral changes. These behaviors - lifestyle choices - are more difficult to prescribe and adhere to. Just ask anyone who has tried to quit smoking.

Further, the extent to which the big drug companies are able to influence medical opinion reminds one of the great investigative journalism of the American press. Abramson writes "experts with financial ties to the drug companies dominate the FDA's Advisory Committees and the panels that write the clinical guidelines that define the standards of care for practicing doctors." (250) As if it isn't enough to control the testing and approval of new biomedical therapies, "the medical industry even funds the majority of doctors' [required] continuing education." (ibid.) This points toward a conflict of interest throughout the medical industry, but, as Abramson is right to point out, "the drug companies have no more responsibility to oversee the public's health than the fast-food industry has to oversee the public's diet." (ibid.)

With that information, plus all of the other facts, figures, and recommendations that Abramson reports in Overdosed America, it will be obvious to any reader that America's health care industry has become corrupt. Significant, long-term changes need to be made everywhere from medical school classrooms to drug company boardrooms. John Abramson's report is an eye-opening look beyond that Norman Rockwell façade. The lesson he wants us to learn is that an apple a day is still the right dose.

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therubins.com

Dr. Abramson traces the "industrial colonization" of medicine and academia by the pharmaceutical industry...His book is in line with past muckrakers, including Upton Sinclair, Ida Tarbull, Lincoln Steffens, Rachael Carson, I.F.Stone, Seymour Hirsch and many others.

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The take home message from Overdo$ed America is that we need to be more critical consumers of scientific evidence "and the recommendations of 'thought leaders' on the payroll of the drug and other medical industries." (P. 259). He invariably cites evidence of "false" information on how "the sponsors (drug company) presentation of 6-month data…are not statistically valid or supportable" (Note #30, p. 264). Pharmaceutical companies distort medical knowledge, mislead doctors and compromise patient’s health and reap the profits of this endeavor.

Dr. Abramson concludes with a challenge to his readers to "consider the responsibility of citizenship in this time of excessive medical profiteering and corporate influence, and to take up one of the most important challenges of our time: high-quality health care for all based on the translation of well-ordered science into accurate, unbiased medical information." (p. 260).

Part II: Substance

This is a well organized and easy to read book with references to "notes" in the back of the book that provides the source of his information. The notes are really his bibliography, and well worth reading. The inconvenience is that one has to flip pages back and forth from the body of the book to the notes.

The substance of the book is presented clearly, concisely and in a clinically pertinent way. However, the reader would like to read what the "other side" has to say about the same issues. The book will serve as a primer for anyone wanting to know more about the interaction between pharmaceutical companies, and medical care. The book strengthens the growing idea that the consumer take a more active role in health care and make a commitment to become more interactive with the treating physician, but not loosing sight how life-style also effects health. This could prove especially difficult for the frail elderly, a growing cohort group needing medical attention.

Part III: Structural analysis

Structurally, Overdo$ed America consists of three parts, totaling 260 pages, with 45 pages of notes and a bibliography of 4 pages. It has a retail listed price of $24.95.

Part I, A FAMILY DOCTOR’S JOURNEY OF DISCOVERY, lays out his personal journey to defining his biopsychosocial approach to medicine. The subtitles of the six chapters in part I clue the reader to the message he is trying to get across: "Medicine in Transition: Caring for Patients at the Crossroads"; "Spinning the Evidence: Even the Most Respected Medical Journals Are Not Immune"; "False and Misleading: The Misrepresentation of Celebrex and Vioxx"; "The Myth of Excellence"; "A Case in Point: The Saga of Hormone Replacement".

In these chapters, Dr. Abramson suggests instances of "unfortunate chapters in medical history" (p.52) and concludes, "that the commercialization of medicine wasn't just causing doctors to prescribe unnecessary drugs and procedures. It was actually subverting the quality of medical care. The only thing that appears to be certain about health care in our country is that we aren't getting the health care we're paying for." (p. 53)

Part II of Overdo$ed America is titled "The Commercialization of American Medicine" and has six chapters: "American Medicine's Perfect Storm": "A Brief History"; "The Commercial Takeover of Medical Knowledge"; "The Snake and the Staff: Duping the Doctors"; "A Smoking Gun: The 2001 Cholesterol Guidelines"; "Direct-to-Consumer: Advertising, Public Relations, and the Medical News"; "Follow the Money: Supply-Side Medical Care".

In these chapters, Dr. Abramson reviews the impact on medicine of the transition from traditional indemnity insurance to HMOs and managed care plans that now dominate the delivery of medicine in this country. Dr. Abramson corrects the impression that managed care companies do not serve patients well. "The data about the actual effect of managed care tell a very different story. The quality of care has neither improved nor deteriorated under managed care." (Italics added for emphasis) Yet, one could ask, why does the United States rank 37th in the world in healthcare, while we spend almost 15% of our GDP on care, a figure that is twice as high as countries that deliver better healthcare. Dr. Abramson places a lot of the blame on lack of primary care practitioners (his own field). He explains this dearth of primary care physicians as due to "less prestige among peers, intrudes more into one's personal life, and pays less than most other specialties." (p. 85) His facts may be right, but one wonders how his own bias may enter into these conclusions.

Part II shows how medical knowledge has been transformed from a public good, "measured by its potential to improve our health, into a commodity, measured by its commercial value." (p. 91) He traces medical research from an academic and scientific activity funded by public money to a commercial activity funded by private sources tied into the pharmaceutical and biotech industry. There is nothing intrinsically illegal about such arrangements, but Dr. Abramson questions whether it is possible to serve the public interest and commercial interests simultaneously. Are we paying an enormous amount of money for some mediocre medicines? Are we as patients’ demanding new medicines and techniques because we are ingrained with the idea that "new" is better?

Dr. Abramson at one point cites an editorial that appeared in the Journal of the American Medical Association (2003; 2128-2131): "Medical research, even if it is conducted by the pharmaceutical industry, is not solely a commercial enterprise designed to minimize personal gain or company profits. The responsible conduct of medical research involves a social duty and a moral responsibility that transcends quarterly business plans or the changing of chief executive officers." It is a simple organizational fact that the first priority of leaders of any company is survival of their company; they are for-profit companies. The companies’ highest priorities are their own goals of the survival, growth and financial well being of the company. The question is whether this is the best for the public or whether pharmaceutical companies have to integrate, along with their commercial interests, a social responsibility factor into their mission that is more reflective of the "public good"

Other interested players in the healthcare game will also have to reconsider their role. Dr. Abramson points out how the cost of care and health outcomes varies by regional, ethnic and socioeconomic levels in Medicare patients with a first diagnosis of heart attack, broken hip or cancer of the colon. The source of this data is a study from the Annuls of Internal Medicine, Principal Investigators Drs. John Weinberg and Elliot Fisher. (The reference in the Notes section fails to give the year the study was published.) He concludes: "The bottom line appears to be that once an adequate amount of care is being provided, as in the lowest-spending regions of the country for Medicare patients, more care is worse care. This seems to be particularly true for the kind of care that is pushed into service by supply side pressure." (P. 180-181). Citing four features shared by the medical services that are most vulnerable to overuse because of supply-side push, Dr. Abramson involves the patient, the medical technology service providers, the doctors and the hospitals in a process that disconnects costs from health care value.

Part III is titled "Taking Back Our Health" and has three chapters: "The Knee in Room 8: "Beyond the limits of Biomedicine"; From Osteoporosis to Heart Disease: What the Research Really Shows about Staying Healthy"; "Healing our Ailing Health Care system, or How to Save $500 Billion a Year While Improving Americans' Health". The headings of these chapters speak for themselves. If you do not have the time to read this book, the last chapter is a must read. It is a concise yet comprehensive guide for the reader to understand steps to provide quality healthcare to all Americans.

Part IV: Conclusions derived from Overdo$ed America

The public may have to rid itself of the notion that the answer to all health problems lies primarily in a pill or a fancy medical procedure. People need to take some responsibility for their health by staying mentally active, eating a well balanced diet, getting regular exercise, avoiding smoking and excess alcohol. These are all proactive, preventative steps that have a strong positive influence in the health of an individual.

At the same time, the government must maintain a level of responsibility to eliminate potential environmental pollutants that are a danger to health, as well as enforcing standards of health care and drug surveillance such that they minimize the risk of medication induced mortality or morbidity. This can only come about if the government enforces its statutory clout to penalize offenders without depriving them of their right to defend themselves. At the same time, the penalty has to be severe enough to get the offender to stop.

The FDA Division of Medication Errors and Technical Support (DMETS) is the place to start to achieve these goals. They will need additional financial and political support and stronger influence on other divisions within the FDA to which they report their findings. An alternative would be the establishment of, an independent panel, similar to the independent advisory panels that exist to give recommendations for drug approval. Those serving on such a panel would not have any connection to the pharmaceutical industry I.e. a consultant positions, no pharmaceutical grant money, no equity in pharmaceutical companies etc. The panel would act in an oversight role, monitoring research studies and follow-up when drugs and medical technologies are approved for clinical use.

Fixing blame with the pharmaceutical industry, or the FDA as a standard setting organization, or healthcare providers will not solve the problem; successful change requires a team effort. All key stakeholders must work together toward the lasting changes needed to providing much more information about the real benefits of the drugs in place as well as the various advanced medical technologies in use. At the same time, the consumer must take some responsibility for maintaining good health practices, as we must expect from drivers of cars to practice safety without excusing the drug manufacturer or car manufacturer from maintaining a high degree of public safety in their product.

Description of author

John Abramson, a family medicine physician who had spent time administering to the health needs of individuals in Appalachia, was a Robert Wood Johnson Fellow at Case Western University, and then worked for 20 years in a private family medicine practice in Massachusetts. His practice was integrated into the Lahey Clinic, and he is now on the faculty of Brandeis University School of Social Policy and teaches at Harvard School of Medicine.

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From one physician to another - THANK YOU

A reader who is "unsupervized" (Dallas, TX USA)

I have been a physician for 10 years. I have seen my profession gradually being taken over by the pharmaceutical industry. I have seen countless patients harmed - alas even killed - by drug reactions and polypharmacy.

I have sat and listened to countless drug representative presentations that were outright falsehoods and misrepresentations. It has been months - maybe even years that I have had available to me a medical education conference that was not somehow tainted by drug company money and therefore propaganda.

I have repeatedly had patients in my office begging me for medication that they do not need. They want it simply because it was on TV News last night - and came with a promise of metaphysical salvation. I spend much time every day dissuading patients from taking medication they simply do not need - indeed may even cause real medical problems.
The issues that are discussed in this book are very very real - and the scary part is I do not see my fellow physicians doing a single thing to address these huge problems.

Dr. Abramson - thank you for hopefully what will be the opening salvo in a very important battle.

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