Author Q&A: Shannon Brownlee on overtreatment of patients

By Jessica Nuñez
Association of Health Care Journalists

Shannon Brownlee is a Schwartz Senior Fellow at the New America Foundation. Her book, “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer,” challenges one of the core beliefs of American health care: that more is better.

“Overtreated” was named the No. 1 economics book of 2007 by The New York Times, over books by Alan Greenspan and Robert Reich. David Leonhardt, the Times' economics corespondent, called the book, “the best description I have yet read of a huge economic problem that we know how to solve – but is so often misunderstood.”

Here, Brownlee talks to AHCJ about the book, how health care is playing into the presidential election, and what health reporters should be asking about and examining.

How did you first come across the concept of overtreatment?

About ten years ago, when I was working at U.S. News and World Report, I was doing a story about a new treatment for breast cancer that was gaining a lot of praise. It had been developed in the 1980s, but had become very popular in the 90s-high dose chemotherapy coupled with a bone marrow transplant. It was an awful treatment (in her book, Brownlee describes it as "a daredevil procedure that brought a patient to the brink of death and then snatched her back at the last moment") that killed many women, but it had become a medical juggernaut without any research to prove it actually worked. When results for a study were finally released, they showed that it, in fact, did not work. What people don't know about are the forces-mostly economic, some academic-driving procedures like this one. For 20 years, women had been receiving treatment that was ultimately deemed dangerous, and in the meantime it was hugely profitable for hospitals.

From that point on, I became interested in looking into what other medical procedures were being performed without research proving their effectiveness. I looked in the Dartmouth Atlas studies, and found that a lot of medicine isn't based on solid evidence-it is simply performed off assumption.

In the book, you describe overtreatment as care that's useless and potentially harmful to those who receive it. Why do you think this discussion has been left out of U.S. politics and is largely unknown to the general population?

I ask myself that question all the time! I think it's because medicine is largely based on tradition and on the belief that people in the field always know what they're doing. We trust doctors and medical researchers because the history of medicine is one of scientific hypothesizing, testing and then putting into practice.

So we have this very old tradition that has been very powerful for all these years, plus massive amounts of money. Health care spending, at $2.1 trillion, is the biggest part of the U.S. budget (according to Brownlee, U.S. spending on health care rivals the world market on petroleum at $3 trillion). There is a lot of money at stake, and somewhere down the line, someone is getting this money. If we change the spending patterns, it will naturally result in some of those people not getting money anymore.

Then, on top of all of that, we have this horrible problem of the uninsured, which politicians have been trying to solve since Teddy Roosevelt was in office. It is easy for people to understand that the people who have no health insurance and aren't receiving any care are at a disadvantage, but it is conceptually and intellectually much more difficult-even disturbing-to think that receiving too much care can be just as harmful. It's a cognitive dissonance-people trust doctors and it's hard to accept that someone you trust is giving you something that could hurt you.

The book was published when the 2008 presidential race was just getting started and you wrote that the candidates had thus far been vague about how to solve the problem of soaring costs in health care. Now that we are closer to narrowing down the nominees and they are providing more detailed health care plans, how do you think they are tackling the same issue?

First, both Democrats-Clinton and Obama-are aiming for universal health care, and there isn't much difference between the two plans. The only question really is whether or not to have mandates, which could end up being an important issue. In terms of unnecessary care, Clinton does address the issue and cite it as a problem. Obama references certain things related to unnecessary care, like geographic variation of health care spending, but doesn't specifically mention unnecessary care itself. I know some people on both campaigns, and they do know about this issue, it's just a matter of highlighting it as important or not.

On the Republican side, McCain has a standard market-based solution plan, which will not be very effective. His plan simply will not reduce the cost of medical care, nor will it reduce the number of uninsured.

For such a complicated topic, the book is easy to follow and easily related to by the reader. How hard was it to achieve this through writing?

It was very hard. I told myself I was writing this book for my mother, who is a very intelligent person, but knows nothing about public policy. My goal was for an intelligent person to be able to understand the economic and political issue involved without having a lot of prior knowledge of them. To get ideas, I read other successful science writers like New Yorker writers Malcolm Gladwell, Atul Gawande and Jerome Groopman.

How did you track down all the human stories you used to give the issue human faces?

Finding stories is always the hardest part! I scoured Web sites, emailed doctors and looked in newspapers to find people. A lot of this stuff has already been written about, for example the Josie King story in chapter two is one commonly associated with medical errors in hospitals. I didn't break that story, but I was the first to talk about it related to the problem of unnecessary care and put it into context.

What kind of reaction has your book gotten from doctors and other health care professionals?

I think I haven't heard from the people that hate it yet. I suspect that a lot of physicians, especially specialists, have a problem with the ideas in this book. I know that the Association of American Medical Colleges is against the idea of geographic variation, for example. Who I have heard from, however, are doctors and nurses around the country who said "thank you." They see problems in the system and they want to see big changes as well. A lot of times these professionals know that there are problems with what they are doing, but they don't understand the forces that drive what they do and how they do it.

What are some things that health reporters should be looking at when covering stories related to unnecessary care? What kinds of question should they ask that aren't usually thought about?

Again, a really good place to look is the Dartmouth Atlas. You can look up your region, and even your specific town and hospital, and see how they are performing in relation to others. That's how The New York Times broke the story on Elyria, Ohio, where doctors were doing angioplasties at rates higher than anywhere else in the country. This story actually has a happy ending, because it brought to the doctors' attention that they were doing something out of the ordinary. They were just doing what they thought was best for their patients, but when they found out how their numbers compared they began to look at changing the way they worked.

There are billions of stories about the drug industry just waiting to be told. It's highly corrupted-financial ties to the industry are tainting research, so you really have to look out when covering research studies. Reporters should always ask their sources "do you have any financial conflicts of interest?"

I think we just have to start getting really skeptical about medicine in general; we've given this industry a free ride. We're pill pushers-I feel like I'm a reformed pill pusher. In this way, AHCJ is such a great organization. It's an incredible way to change the direction of health journalism and the health care system.

There are people out there who don't want to do these kinds of stories. I remember a story I was interested in doing about cancer screening (which is another thing that needs more coverage by the way), the prostate-specific antigen (PSA) test in particular. Research showed that it was not saving anyone's life and was clearly causing the overdiagnosis of prostate cancer. I took it to my editor, and he said he didn't believe it. These are the things we have to go up against. We have to become as sophisticated as possible in our knowledge of health and try to seek out sources that can give us different perspectives.