One-Minute Book Reviews

March 1, 2011

‘Early Diagnosis Is a Double-Edged Sword’ — Quote of the Day

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Early diagnosis can hurt you, three doctors argue their new Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 228 pp., $24.95). Too many Americans are being treated for conditions that will never cause symptoms, let alone death, say H. Gilbert Welch, Lisa Schwartz, and Steven Woolshin. Some people contend that no harm can come of the “epidemic of diagnosis”:

“But the truth is that early diagnosis is a double-edged sword. While it has the potential to help some, it always has a hidden danger: overdiagnosis—the detection of abnormalities that are not destined to ever bother us. …

“the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease.”

You can read the introduction to Overdiagnosed on Scribed.

© 2011 Janice Harayda. All rights reserved.

 

November 26, 2010

Lionel Shriver’s National Book Award Finalist, ‘So Much for That,’ a Novel About America’s Misplaced Faith in Its Health-Care System

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Shep Knacker’s surname is British slang for testicle, but will he have the balls to resist financially ruinous U.S. medical practices?

So Much for That. By Lionel Shriver. HarperCollins, 436 pp., $25.99.

By Janice Harayda

Knacker, the surname of the hero of So Much for That, is British slang for testicle. Lionel Shriver is an American who lives in London, so it’s safe to assume she knows this. It’s also safe to assume that a man named Shepherd Knacker has symbolic weight, or stands for more than what he is: a 48-year-old married father of two and a home repairman who has spent his adult life saving for an escapist retirement.

Whom does Shep represent? Try this: The good Shepherd does carpentry and anticipates redemption in what he calls an “Afterlife.” Still stumped? Shep has a wife named Glynis, which means “holy,” and a best friend named Jackson, a variation on John. He’s the son of a Gabriel Knacker, a Presbyterian minister, and has a psychological resurrection after persecution by his boss. His story involves significant fish, water and palm imagery.

Okay, we can see a few religious parallels here. But Shep isn’t a Jesus figure in the usual sense, a charismatic leader whom others worship. He’s far too low-keyed and accommodating. Nor is this book about Christianity. Quite the opposite: It’s a novel about an America in which people entrust their lives not to Jesus but to a broken health care system that betrays even those who can afford to use it.

For years Shep has been a good and faithful servant of mammon, a man who built a home-repair business that he sold for a million dollars. He planned to use to the cash to underwrite his retirement on a palmy island off the coast of Africa. But his wife learns that she has mesothelioma on the day he announces that, with or without her, he’s leaving his job and country to begin his Afterlife on Pemba. Suddenly Shep can’t leave his company or country because Glynis needs his medical insurance, and if he doubts it, he needs only to look at his friend Jackson’s daughter, who has a ravaging degenerative disease.

This jury-rigged opening is the first of several plot contrivances that are less believable than the withering assault on U.S. health care delivered by So Much for That. After years of writing for the Economist and the Guardian, Shriver may be America’s best reporter-novelist now that Tom Wolfe has entered his lifetime-achievement-award years. She’s unafraid of research. This has allowed her to gather the details needed to skewer plausibly a raft of medical indignities: the dubious procedures such as penis-enlargement surgery, the so-called “Medicare spend-down” that requires the elderly to use up their assets before the government will pay for a nursing home, the gung-ho doctors who bombard the dying with unproven treatments that won’t save them and at best will prolong their lives briefly and torturously.

Shep has a natural wariness of the physicians’ impulses toward overkill and feels like “a religious skeptic” when Glynis’s internist refers her to Philip Goldman, a world-class, out-of-network expert on her rare peritoneal mesothelioma. But Shep tries to buy into the medical tent-revivalism when he sees how much it means to his wife: “Since the internist produced more tangible redemption than either Gabe Knacker’s traditional Presbyterianism or [his sister-in-law] Deb’s barmy born-again sect in Tucson, it was time to convert. To become a loyal, tithing parishoner of Philip Goldman’s church.”

For all his doubts, Shep looks like a saint next to the friends and relatives who, in their ignorance or egocentrism, add to his wife’s pain. Glynis is in the hospital after debulking surgery when her born-again sister Deb tries to convert her with a condescending variation on Pascal’s wager: “Like, if a lottery is free, why not grab a ticket? All your teachers said you were so smart.” Glynis resists, and Deb blunders on by telling her sister that at least her asbestos-related cancer made her thin. “Yeah, right,” Glynis says. “The Mesothelioma Diet. The book’s not out yet, but you could still get a head start by chewing on some old insulation.”

Much of this is heavy-handed, an inelegant cross between a protest novel and domestic fiction about a family tested by illness. So Much for That is issue-driven, and some of its characters emerge as vehicles for ideas, or embodiments of arguments made by Susan Sontag and Barbara Ehrenreich about the language of cancer, more than as credible people. Shriver tends to spell her messages in neon: Her book has three medical subplots when two might have made her point.

But Shriver has a moral fearlessness rare among novelists. Health care is one of the three great issues in America today, along with war and the economy, and she wrestles with it perhaps more ambitiously than any fiction writer of her generation. And if she is a polemicist, she can deliver subtle blows. Consider the surname of one of Glynis’s doctors: Knox. In context the name appears to nod to the fiery – and, some say, pernicious – founder of the Scottish Presbyterianism. It also suggests Fort Knox, the U.S. gold Bullion Depository. With one word, Shriver suggests the essence of her novel: a tale of the intersection of money and a misguided belief in the godlike abilities of doctors.

So Much for That isn’t a plea for people to trust in Jesus instead of health-care providers. Shriver has said that she deplores all religions, and nothing in her book suggests otherwise. In this novel she tells us that you are saved neither by God nor by doctors who play Him. You are saved by reason, or pursuing your own vision of a good life. In America, money helps. But you can choose to live elsewhere. Will Shep have the balls to make that choice? Suffice to say that if he often disagrees with his wife, he has something of the spirit she shows when she complains that nobody ever put on a gravestone: “Here Lies, etc., She Swiffered the Kitchen Floor.”

Best line: Glynis rages against the saccharine, kid-glove treatment she gets from family and friends after she develops cancer: “I feel as if I’m trapped in a Top Forty by the Carpenters.”

Worst line: “‘Ipso facto!’ Shep chuckled.”

Editor: Gail Winston

Published: March 2010

Reading group guide: A Totally Unauthorized Reading Group Guide to So Much for That appeared on this site on Nov. 26, 2010, in the post just before this one.

Furthermore: So Much for That was shortlisted for the 2010 National Book Award for fiction. You may also want to read the comments Mark Athitakis made about the novel on his American Fiction Notes blog on Jan. 11, 2010, and on March 14, 2010.

About the author: Shriver wrote We Need to Talk About Kevin, which won the 2005 Orange Prize, and other books.

Janice Harayda was the book columnist for Glamour and the book editor of the Plain Dealer in Cleveland. You can also follow Jan (@janiceharayda) on Twitter at www.twitter.com/janiceharayda.

© 2010 Janice Harayda. All rights reserved.
www.janiceharayda.com

A Totally Unauthorized Reading Group Guide to Lionel Shriver’s Novel ‘So Much for That,’ a 2010 National Book Award Finalist

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10 Discussion Questions for Book Clubs and Others
So Much for That
By Lionel Shriver
Source: One-Minute Book Reviews
http://www.oneminutebookreviews.wordpress.com

This guide was not authorized or approved by the author, publisher or agent for the book. It is copyrighted by Janice Harayda and is only for your personal use. Its sale or reproduction is illegal except by public libraries, which may make copies to use in their in-house reading programs. Other reading groups should link to the guide or check the “Contact” page on One-Minute Book Reviews to learn how to request permission to reproduce it.

Shepherd Knacker hardly resembles a modern-day Robinson Crusoe. He’s a 48-year-old married father of two who lives in Westchester County, New York, and suffers the daily humiliations inflicted by the new head of the home-repair company he once owned. But for years Shep has been saving money for what he calls an “Afterlife” of subsistence living on an island off the coast of Africa. Just when he has enough cash, his wife develops a rare asbestos-related cancer, peritoneal mesothelioma. Suddenly Shep can’t leave the country or his company because Glynis needs his health insurance. How will the withering physical, emotional and financial cost of his wife’s treatments affect his marriage? Can his dream survive it? And if so, will it be worth it? Lionel Shriver, an American who lives in London, explores these questions and other in So Much for That, a novel shortlisted for the 2010 National Book Award for fiction.

Discussion Questions:

1. Many Americans dream of escaping to the tropics but see the idea as unrealistic. Did Shriver convince you that Shep’s fantasies were plausible for him? How?

2. Glynis tells Shep, when he says he wants to leave the country, “You don’t know what you want out of, much less what you want in on.” Shep says he does know: “I want to buy myself.” [Page 18] Who was right? What did Shep mean when he said that he wanted to “buy” himself?

3. More than half of the chapters in So Much for That begin with a statement of the value of a bank account or investment portfolio. What purpose does this literary device serve? Does Shep strike you as mercenary? If he isn’t greedy, why might Shriver have included financial the statements?

4. In addition to its main plot about Shep’s Afterlife, this novel has three medical subplots: about Glynis’s cancer, Jackson’s botched penis-enlargement surgery, and the degenerative disease familial dysautonomia, which afflicts the daughter of Jackson and his wife, Carol. Did the novel need all three subplots? If not, which could have been cut? What would the novel have lost or gained by eliminating it?

5. The story Shriver tells has parallels with the life of Christ. For example, Jesus is known as the Good Shepherd, and he was a carpenter whom Christians believe will lead them to eternal life. So Much for That is about a good Shepherd who does carpentry and hopes to lead his family to an Afterlife with him. You can read these parallels as a commentary on an America in which people have faith not in Jesus but in a broken health-care system. How would you interpret the similarities? A fuller discussion of the religious parallels appears in a review posted on One-Minute Book Reviews on Nov. 26, 2010.

6. So Much for That deals with timely issues. “But good fiction ultimately has to justify itself in the years beyond its pub date, and such PR lines will become increasingly irrelevant,” Mark Athitakis writes in his American Fiction Notes blog. Will this novel appeal to Americans in 10 or 20 years? Why or why not?

7. Late in the novel Carol asks Shep, “Do you by any chance have a really, really big dick?” [Page 433] Shep reflects that he would “understand the context” of her remark the next day. What was the context? Did Carol ask that question because she hoped to sleep with him or for another reason?

8. Leah Hager Cohen wrote in a review in the New York Times Book Review that So Much for That has merits but lacks “a fullness of wisdom about its characters’ potential for growth.” What did she mean? Do you agree?

9. Glynis rails against the saccharine, kid-glove treatment she gets from people after she gets mesothelioma: “I feel as if I’m trapped in a Top Forty by the Carpenters.” [Page 310] Barbara Ehrenreich raised similar objections to the good cheer expected of cancer patients in her bestselling Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America (Metropolitan, 2009). Did either book affect your views of how Americans treat cancer patients? If you’ve read both, which made its case better?

10. On the basis of this novel, you might expect Shriver to favor almost any kind of health care reform. But in an interview she faulted President Obama’s health care plan as well-intentioned but unlikely to help. Does her view surprise you now that you’ve read So Much for That?

Vital statistics:

So Much for That. By Lionel Shriver. HarperCollins, 436 pp., $25.99. Published: March 2010

A review of So Much for That appeared on One-Minute Book Reviews on November, 26, 2010, in the post directly after this one.

Janice Harayda is a novelist and award-winning critic who has been the book columnist for Glamour, book editor of the Plain Dealer and a vice-president of the National Book Critics Circle

Totally Unauthorized Reading Group Guides are a free alternative to publishers’ guides, which are not unbiased analyses but marketing tools designed to sell books. One-Minute Book Reviews does not accept free books from editors, publishers or authors, and all reviews and guides offer an independent evaluation of books. Totally Unauthorized Reading Group Guides appear frequently but not on a regular schedule. To avoid missing them, please follow Jan on her Twitter feed at www.twitter.com/janiceharayda, where she lists new guides and reviews.

© 2010 Janice Harayda. All rights reserved.
www.janiceharayda.com

April 29, 2010

Does Acupuncture Work as Anesthesia? Quote of the Day / ‘Nothing to Envy’

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In Nothing to Envy, Barbara Demick tells the true stories six North Korean defectors, including a doctor she calls Kim Ji-eun, who worked in a small hospital during the devastating famine in the 1990s. Demick spoke with Kim about North Korean health care, including the use of acupuncture for anesthesia. She reports in her her book:

“For years, North Korean hospitals had been using herbal remedies in combination with Western medicine. Instead of painkillers, the doctors used cupping, a technique in which a suction cup is applied to stimulate circulation to parts of the body. Another technique borrowed from the Chinese involved lighting sticks of mugwort next to the afflicted area. With anesthesia in short supply, acupuncture would be used for simpler surgeries, such as appendectomies.

“‘When it works, it works very well,’ Dr. Kim told me years later. And when it didn’t? Patients would be strapped to the operating table to prevent them from flailing about.”

October 27, 2009

‘Smile or Die’ – Barbara Ehrenreich’s ‘Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America’

Taking aim at the “prosperity gospel,” “positive psychology” courses, and teddy bears designed for breast-cancer patients

Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America. By Barbara Ehrenreich. Holt/Metropolitan, 235 pp., $23.

By Janice Harayda

When I was a book editor, I often had to reassure freelancers that they had the right to give negative reviews. Critics never apologized for praising books, but they did apologize for panning them – even when they had done so brilliantly.

At first, I thought freelancers were worried that they would get fewer assignments if they wrote unfavorable reviews, because some editors do prefer to publish praise. But many seemed reluctant to criticize books even after I had explained that I didn’t care whether reviews were positive or negative: I cared whether they were fair, honest and well written.

Barbara Ehrenreich suggests a possible explanation for the reluctance in Bright-sided, a spirited broadside against enforced optimism in medicine, psychology, business, religion and other fields. She argues that faith in “positive thinking” has become so ingrained in American society “that ‘positive’ seems to us not only normal but normative – the way you should be.”

Ehrenreich found when she was diagnosed with breast cancer that a cult of optimism pervaded articles and books about the disease that made her feel isolated instead of supported. “No one among the bloggers and book writers seemed to share my sense of outrage over the disease and the available treatments,” she writes in a chapter ironically called “Smile or Die: The Bright Side of Cancer.” “What causes it and why is it so common, especially in industrialized societies? Why don’t we have treatments that distinguish between different forms of breast cancer or between cancer cells and normal dividing cells?”

Instead of finding answers, Ehrenreich kept coming across articles by women who claimed that they owed their survival to a “positive attitude” – even though the death rate from breast cancer has changed little since the 1930s and there is no consistent evidence that staying upbeat extends the life of those who have the disease, though it may have many other benefits. She also found that “positive thinking” can exact a terrible price in self-blame if a cancer defies treatment. As the oncology nurse Cynthia Rittenberg has written, the pressure to think positively is “an additional burden to an already devastated patient.”

“Smile or Die” recycles some of the material from Ehrenreich’s award-winning essay, “Welcome to Cancerland,” but is still the strongest chapter in Bright-sided. Other sections of the book describe the wholesale effects of “positive thinking” better than they show their retail cost to ordinary Americans. Ehrenreich argues cogently that the emerging field of “positive psychology” is based heavily on bad or no science. But the same is also true of some older forms of therapy that apply similar principles, as the Robyn Dawes documented in his superb indictment of the betrayal of scientific standards in psychotherapy, House of Cards (Free Press, 1996). So why focus on “positive psychology” when other types of therapy have done more damage, if only because they are more widely used? Ehrenreich describes an unflattering interview with the high priest of “positive psychology,” the psychologist Martin Seligman. But she seems to have talked to no one burned by his teachings – which shouldn’t have been hard to do, given that more than 200 schools and colleges offer courses in his field.

In a chapter called “God Wants You to Be Rich,” Ehrenreich faults the so-called “prosperity gospel” preached by superstar pastors like Joel Osteen, whose churches offer “services that might, in more generous nations, be provided by the secular welfare state,” such as pre- and after-school programs. Certainly those ministries may foster self-blame. (If God wants you to be rich and you’re not, you don’t have enough faith.) But if the churches that promote the “prosperity gospel” are offering low- or no-cost day care that enables parents to seek prosperity by holding jobs, doesn’t that count for something? You sense that such programs are exactly kind of thing that Ehrenreich might love, if only they weren’t endorsed by pastors who wear too much gel in their mullets.

No less important: A blurred line exists between innate optimism – which may be genetic — and the enforced optimism of disciplines like “positive psychology” and the “prosperity gospel.” To what extent are advocates of “positive thinking” creating an attitude and to what extent are tapping or reinforcing one that’s already there? Ehrenreich sidesteps the question. But if optimism is in our genes, it may do little good to argue as she does that we need replace “positive thinking” with a “vigilant realism.” Joseph Hallinan takes a less extensive but more practical approach to the subject in his Why We Make Mistakes (Broadway, 2009), which deals in part with the research on errors based on overconfidence – a trait often indistinguishable from “positive thinking.”

Overall Bright-sided is much more theoretical than Nickled and Dimed, for which Ehrenreich took a series of low-wage jobs to show how corporations exploit blue-collar workers, or her more recent Bait and Switch. But it makes a needed assault on an idea that too often goes unchallenged in America: that “positive thinking” is always a good thing. Ehrenreich is right that a deep and unacknowledged anxiety often underlies efforts to block out unpleasant thoughts. “Positive thinking” requires a continual effort to deflect “negative” ideas, she notes, and it can be exhausting. “The truly self-confident, or those who have in some way made their peace with the world and their destiny within it, do not need to expend effort censoring or controlling their thoughts,” she writes. “Positive thinking may be a quintessentially American activity, associated in our minds with both individual and national success, but it is driven by a terrible insecurity.”

Best line: Ehrenreich notes that breast cancer has given rise to a highly commercialized industry of products for patients, including “infantilizing” teddy bears: “Certainly men diagnosed with prostate cancer do not receive gifts of Matchbox cars.”

Worst line: “All the motivators and gurus of positivity agree that it is a mistake to watch the news.” How does Ehrenreich know? Has she talked to them all? In my experience the self-styled motivators, with a few exceptions including Rhonda Byrne (The Secret), urge people to limit – not eliminate – exposure to bad news.

Editor: Sara Bershtel

Published: October 2009

Read an excerpt (the first pages) from Bright-sided or listen to an audio excerpt.

Furthermore: For more on optimism and illness, see the post “‘The Tyranny of Positive Thinking’ and Cancer Patients — A Physician-Author Says That It’s Not Always Best to Tell People to ‘Be Optimistic’.”

© 2009 Janice Harayda. All rights reserved.
www.janiceharayda.com

October 7, 2009

The Moral Failures of U.S. Health Care – T.R. Reid’s ‘The Healing of America’

A specialist in Tibetan herbal medicine wanted to taste T.R. Reid's urine.

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. By T. R. Reid. Penguin, 277 pp., $25.95.

By Janice Harayda

This elegant polemic argues that the American health-care crisis is, above all, a moral one: Alone among well-off democracies, the U.S. has never made a moral choice to guarantee health care for all. Americans have decided that everybody has the right to an education and a legal defense, regardless of the cost or difficulty of providing these, T.R. Reid reminds us. But we’ve never decided that everybody has the right to health care. Because we haven’t, the U.S. is the only country in which medical bills can bankrupt people. It’s the only one in which patients who have paid their health insurance premiums for years can — and do — have their policies canceled while they’re fighting for life from a hospital bed.

Fewer than half of all Americans are satisfied with this state of affairs, according to a 2001 study by researchers at the Harvard School of Public Health. But many critics of the system believe that all the alternatives involve conditions too onerous to accept – long waiting lists, the rationing of care, no choice of doctors, or “socialized medicine.”

T.R. Reid offers a powerful rebuttal to that idea with fascinating and well-written portraits of the health-care systems in five countries that have universal coverage: France, Germany, Japan, the U.K. and Canada. Japan, for example, hardly has “socialized medicine.” Its widely admired approach to health care uses private doctors and hospitals and nonprofit insurers. The system involves no gatekeepers, no rationing, and no waiting lists. It offers high-quality care and ample choice for patients. People split the cost of insurance with their employers or if they are unemployed, with their local government. And the Japanese lead the world in life expectancy (85.5 years for women, 78.7 for men).

Reid also evaluates the health care systems in India, Taiwan, Switzerland and other countries. And he found an ingenious way to dramatize some of their differences after an American orthopedist suggested that he have surgery on an injured shoulder. As he traveled around the world, Reid asked foreign doctors how they would treat the problem. In Nepal, he met a specialist in Tibetan herbal medicine who wanted to taste his urine before making a diagnosis. At an Ayurvedic hospital known as “the Mayo Clinic of traditional Indian medicine,” he submitted three times a day to massages of “warm sesame oil laced with forty-six herbs and medications.” These encounters add color and suspense to The Health of America without taking its focus off the moral imperatives of health care reform.

Reid doesn’t urge Americans to adopt any country’s model or a “public option” of care paid for by the government (although he notes that we have a public option in Medicare, a system that its beneficiaries generally like). But he appears to believe we can’t reform the system if we continue to allow insurers to make a profit on basic health care, something no other first-world country permits: The solution lies in a nonprofit model, whether run by the government or a nonprofit group. Reid has suggested in interviews that if Congress can’t enact the needed changes, Americans may have to reform the system on a state-by-state basis, though he damns the Massachusetts approach with faint praise.

The most admirable aspect of The Healing of America is that – like any skilled polemicist
– Reid has an exceptional ability to keep his eye on the ball. He deals forthrightly with the economic and other realities that health care reform would involve, such as controlling costs and creating an effective delivery system. But Reid never allows such issues to transcend the moral dimension of allowing tens of thousands of people each year to die and countless others to suffer needlessly. His powerful indictment shows why health care reform is ultimately not about politics or economics: It is about fairness, justice, and doing what is right for all Americans.

Best line: No. 1: “All developed countries except the United States have decided that every human has a basic right to health care.” No. 2: “ … foreign health insurance plans exist only to pay people’s medical bills, not to make a profit. The United States is the only nation that lets insurance companies extract a profit from basic health coverage.” No. 3: “The design of any nation’s health care system involves political economic, and medical decisions. But the primary issue for any health care system is a moral one.”

Worst line: “British women tend to have their babies at home; Japanese women, in contrast, almost always give birth in the hospital – and mother and child remain there an average of ten days after delivery.” The National Childbirth Trust says that in the U.K., 2.7 percent of women give birth at home.

Editor: Ann Godoff

Published: September 2009

About the author: Reid is a former foreign correspondent for the Washington Post.

Further comments on The Healing of America appeared in the posts “Excuses Aetna, Prudential and Blue Shield Have Used to Deny Claims” and “Going to the Doctor in Japan — Please Don’t Tip the Proctologist.”

Listen to a podcast of T.R. Reid talking about The Healing of America.

© 2009 Janice Harayda. All rights reserved.
www.janiceharayda.com and www.twitter.com/janiceharayda

September 28, 2009

Excuses Used by Aetna, Prudential and Blue Shield to Deny Health-Insurance Claims — From T. R. Reid’s ‘The Healing of America’

I was going to read The Lost Symbol over the weekend but picked up T. R. Reid’s elegant indictment of health care in the U.S., The Healing of America (Penguin, 277 pp., $25.95). And I was hooked after the first sentence: “If Nikki White had been a resident of any other rich country, she would be alive today.”

Reid had his bad shoulder examined by doctors in other well-off democracies that included France, Germany, Great Britain, Japan and Canada. And he uses the results as a springboard for exposing flaws in arguments made by insurers and others against adopting practices that work overseas: “It’s all socialized medicine over there,” “They ration care with waiting lists and limited choice,” “Those systems are too foreign to work in the United States,” and more.

Until I can review The Healing of America, here’s a brief excerpt from the book about the excuses used by major insurers to reject claims:

“In other developed countries, insurers are required to pay every claim. But U.S. insurance companies deny about 30 percent of all claims, although some of these are eventually paid through an appeal process. The reasons cited for denying valid claims can be ingenious. When our family lived in Japan, the friendly adjusters at Prudential used to deny our claims for medical or dental care on the grounds that the bills we submitted were denominated in yen. Somebody at Prudential had determined that the Japanese yen was a foreign currency; that violated the rules. My company later switched our health insurance to Aetna, which employed a similar dodge: The adjuster said she couldn’t pay our claims because she couldn’t call the doctor’s office to verify the bills. It seems that Aetna had a phone system for its adjusters that didn’t allow international calls, so our claims had to be denied.

“The most maddening of all the profit-maximizing mechanisms in the U.S. health insurance industry is the practice known as ‘rescission,’ a legal term that means ‘We’re canceling your coverage.’ This occurs when an injured person who has been paying premiums for months or years has a serious accident or contracts a serious disease, which can mean serious bills for the insurance company to pay. At that point, the insurer’s Rescission Department digs through all the records, looking for a reason to cancel the sick person’s coverage. For example, Steven Hailey, a machinist in Cypress, California, paid his health insurance premium every month. Then he was hit by a truck. He was still being treated for his injuries when Blue Shield of California wrote to tell him that his coverage had been canceled because his weight was too high. He would have to pay the hospital bills himself – about $450,000 worth of bills.”

December 28, 2007

Take One Misdiagnosis and Call Me in the Morning – Jerome Groopman’s ‘How Doctors Think’

A Harvard Medical School professor says that physicians’ faulty logic can kill

How Doctors Think. By Jerome Groopman, M.D. Houghton Mifflin, 291 pp., $26.

By Janice Harayda

It’s flu season, and that’s bad news for you if you have an obscure disease with flu-like symptoms. Your doctors’ diagnoses might reflect a confirmation bias (a tendency to find what they expect to find), an availability error (a decision based on how easily examples come to mind) or other cognitive flaws that Jerome Groopman describes in this engaging bestseller.

Groopman’s thesis is that a doctor’s state of mind strongly affects clinical decision-making. And many of his examples are eye-opening if paradoxically commonsensical. Do doctors’ friends get better care? Not necessarily, Groopman says. A doctor might hesitate to prescribe a necessary but painful test for a friend. Do doctors favor the sickest patients, who may need their care the most? Actually, they prefer healthy ones. One social psychologist found that “the sickest patients are the least liked by doctors, and that very sick people sense this disaffection,” Groopman writes. Apparently many doctors feel they have worked in vain when a disease resists treatment and stop trying to help. How Doctors Think

Much of this is so interesting that you wish this book didn’t reflect biases of its own. One is that it slights mistakes that result from factors other than cognitive flaws, such as fatigue, poor training and inadequate supervision.  “Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes,” writes Groopman, a professor at Harvard Medical School and staff writer for The New Yorker.

But when you go to the end notes of his book to look for the source of that hard-to-believe “majority,” you read: “Although the frequency of misdiagnosis has been studied, few researchers have focused on its relationship to physician cognition.” So who are those “experts” who found that most errors result from doctors’ thinking?  The notes name only one expert who found such a “majority,” a researcher who had studied “serious errors that led to malpractice claims.” But Groopman says that the majority of all errors result from physicians’ thinking, not the majority of errors that lead to malpractice suits. Either his end notes are incomplete or he misrepresents in the book some of the material he cites in the notes.

At the very least How Doctors Think leaves a different impression of the causes of mistakes than the chapters on medical errors and problem doctors in Atul Gawande’s Complications, a more cogently argued book by another physician who writes for The New Yorker.  Gawande quotes from a landmark series of papers in the New England Journal of Medicine that reported that one percent of all hospital admissions involved negligence that prolonged the stay or led to death or disability of the patient. A smaller study of the treatment of cardiac arrests found that “27 of 30 clinicians made an error in using the defibrillator – charging it incorrectly or losing too much time figuring out how to work a particular model.”

Groopman is a bit like a coach who blames the problems in baseball on the character flaws of individual players instead of the culture that produced them. He says that doctors “desperately” need patients to “help them think.” If that’s true, it reflects badly on the entire American system of medical education, training and certification, not just on individual physicians. Clearly many doctors need more than “help” thinking logically – they need to learn how to work the defibrillator.

Best line: “When a patient tells me, ‘I still don’t feel good. I’m still having symptoms,’ I have learned to refrain from replying, ‘Nothing is wrong with you.’ The statement ‘Nothing is wrong with you’ is dangerous on two accounts. First, it denies the fallibility of all physicians. Second, it splits the mind from the body. Because sometimes what is wrong is psychological, not physical. This conclusion, of course, should be reached only after a serious and prolonged search for a physical cause of the patient’s complaint.”

Worst line: Groopman says his book is for people who aren’t physicians “because doctors desperately need patients and their families and friends to help them think.”  Isn’t it bad enough that we have all those TV commercials telling us to ask our doctors if we need a certain drug because, basically, they’re too dumb to figure it out on their own? Do we need this kind of smarm from doctors, too? Groopman doesn’t mention that there are 285 doctors for every 100,000 people in the U.S. and, if he’d written his book for doctors, he might make a lot less money.

 

Recommendatiom? A good but one-sided book. If you’re interested in medical errors, consider reading the chapters called “When Doctors Make Mistakes” and “When Good Doctors Go Bad” in Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science (Holt/Metropolitan, 2002) www.gawande.com instead of or in addition to How Doctors Think

Editor: Eamon Dolan

Published: March 2007  www.jeromegroopman.com  and www.houghtonmifflinbooks.com

One-Minute Book Reviews is for people who like to read but dislike hype and review inflation. It is also for people who dislike long-winded weasel reviews that are full of facts and plot summaries but don’t tell you what the critic thought of the book.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

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