Bad Medicine : How the American Medical Establishment Is Ruining Our Healthcare System

by Lawrence J. O'Brien

The author, Lawrence J. O'Brien inlob@erols.com , December 2, 1998
says America's healthcare system is headed toward collapse.
I am the author of Bad Medicine: How the American Medical Establishment Is Ruining Our Healthcare System (Prometheus Books, January 1999). Most ordinary Americans have a sense that there is something seriously amiss with the medical care system in the United States. They are not wrong about this. One of the most serious problems, rarely mentioned and badly understood, is the huge excess of physicians, mainly "specialists," functioning in a predominantly fee-based system. In most instances, these doctors dictate the demand for their own services. The doctor, and not the patient, usually decides how much medical service and what kind of testing and treatment will be needed. Patients usually have little say in these decisions.

Since there are now nearly twice as many licensed doctors as would be optimal for the society, this huge excess supply of physicians is actively producing a huge excess in doctor-dictated demand for medical services, because the oversupply of physicians causes them to need the work. This need for work by doctors has been driving expenditures for medical care sky high, over $1 trillion a year today, and projected to reach $2 trillion within five years.

Thirty years ago, U.S. healthcare expenditures averaged $204 per person per year. Today, the average exceeds $4,100 per person per year, an increase of 2,000 percent. If this pattern is repeated during the next thirty years, the expenditure average will reach $82,000 per person per year, and the U.S. will be bankrupt.

These topsy-turvy realities of American medical expenditure are not only failing to produce improvements in the nation's health status, they are making Americans statistically less healthy as compared with the people of many other industrialized nations.

Bad Medicine was written in order to share with readers the lessons learned during twenty-five years of effort in building health plans that would provide members with the right thing, provided in the right way, at the right time, using the right resources.

The changes that are needed now will be difficult to bring about, but the alternative for the society is too grim to be imagined. Again, most Americans have a sense that there are serious problems with our medical care system. Bad Medicine is all about these problems, and about the things that must be recognized and understood in order to use the current system with reasonable safety. Bad Medicine is also about what must be done in order to radically improve the U.S. healthcare system.

An excellent critique of American Medical priorities. September 26, 1999
Reviewer: David McGill (dmcgill@ix.netcom.com from Cambridge, Mass
O'Briens' Bad Medicine is an excellent discussion of how medical schools and teaching hospitals have contributed to the current health care crisis. As a family health psychologist on the clinical faculty of Harvard Medical school these last 20 years and an advocate for the collaborative family health care paradigm, I welcome this hard hitting, insightful, philosophically grounded presentation of how American medical priorities have often given us both poor health care and impossibly high health care costs. Many of my colleagues, health care practitioners and medical school faculty are unhappy with what is happening, for our patients and ourselves. Some of us are beginning to see that we as doctors, medical school faculty and teaching hospital administrators, have been part of the problem. An example is an editorial (Aug 1,l999 Boston Globe) by Dr. Bernard Lown, senior physician at Brigham and Women's Hospital and Professor Emeritus at Harvard University School of Public Health. Dr. Lown writes, "Our health care system is on the verge of collapse..it began when doctors were seduced by financial incentives, with unquestioning third-party payers providing an open till. Care was fragmented among a bevy of super-specialists, with multiplication of mindless procedures, encouragement of un-called for office visits, and exposuer of patients to a glut of unnecessary surgical intervention. Each procedure was converted into a profit center". Larry Obrien has written a strong book on the problem, tracing the history and philosophy of this medical/financial train wreck using his 25 years of experience in HMO administration. Bad Medicine is a great public policy contribution because it shows how and why the American government has colluded over the course of the 20th century. Congress has subsidized too many medical schools producing an oversupply of specialists, functioning for profit, with extraordinary high technology, to do often unnecessary procedures on individual body parts with an 18th century mechanistic mind set of repairing bodies like they were broken clocks. All this is still going on, when we health providers, consumers, administrators and legislators could and should be maintaining health defined as dynamic biopsychosocial functioning of human beings as we understand ourselves from the perspective of 20th century neuromolecular biological medical science and philosophy. Bad Medicine concludes with recommendations for collaborative health care, treating whole human beings by teams led by primary, family generalist health care doctors in local settings, in organizations given financial incentives to maintain health care with information systems that really help care and cost.

A treasure trove of insight August 20, 1999
Reviewer: A reader from Luray, Virginia
As a former federal health policy analyst I can't help but say "right on" to Lawrence O'Brien's thoughtful analysis of the problems endemic in the U.S. health care system and his carefully laid out steps for reform.

Certainly, the medical economic system and its incentives are awry, with demand set by the seller and the true price hidden from the consumer. But O'Brien also succinctly shows that the product is flawed explaining how and why the U.S. falls so far behind many other countries in indications of health and well being.

The litany of problems, linked to their roots, is a treasure trove of insight. Among them: How medical records are stored and handled contributes to the dearth of clinical science and evaluation. How medical schools create and then reinforce system problems. The effect on both medical outcome and economics of too many doctors practicing the wrong specialties. How federal interventions have exacerbated problems.

Perhaps most instructive is O'Briens clear description and examples in everyday medicine of the important distinction between advances in true medical science, which discovers the causes and preventions of illness and disease, and advances in medical technology, which develops interventions designed to lessen the impact of disease for which no cure has yet been found.
This is reflected not only in the banks of blinking and beeping machines in today's hospitals, but in the increasing specialization of physicians where technical skills are rewarded highly and payment for services aimed at preventing disease is almost non-existent.

O'Brien outlines steps needed for significant health care reform, acknowledging that the full-scale upheaval needed will be difficult to achieve. Nevertheless, he serves up an insightful and cogent framework for reform and, perhaps most importantly, prompts consumers to view the system in a different light. And that is perhaps the hardest task of all, convincing the patient that changes need to be made.

As a physician, Bad Medicine strikes me as a keen analysis. December 20, 1998
Reviewer: Charles A. Branthaver, M.D.(CBranthave@aol.com) from Sacramento, California
In 1965, I left a busy pediatric practice for academia (the School of Medicine at the University of Minnesota) to join an expanding group of health care professionals who were committed to a restructuring of medical education and training so as to promote more responsive and more comprehensive health care. It soon became apparent that those who had selected family medicine and who completed their residencies were having difficulty in finding a niche in the mainstream of medical care which was dominated by the technologically oriented specialists.

Because of my frustration over the fate of these dedicated family doctors, in medical school and in their practice, I seized an opportunity to leave academia to be the medical director of an integrated health care system with a family practice base. This was several years before the name "health maintenance organization" had been coined. The fortunate choice to head this remarkable, embryonic organization in 1974 was the author of this book, Lawrence J. O'Brien. Because of that choice, I was fortunate to have had a seventeen year professional and personal relationship with an individual blessed with a vigorous intellect, an encompasing concern for human dignity and an insatiable curiosity as to the logic of people's behavior. The fact that Larry O'Brien's professional education was in the discipline of philosophy and not in the health field was not only unique, but allowed him to have a perspective that was insightful and different from the health administrators who became his colleagues. Larry approached health care as a personal social service with all of its human variables. However, he was often puzzled by the mind-set of the medical establishment and the strange logic that seemed to drive it. It is not surprising that, with his background in philosophy and logic, combined with a long and in-depth involvement in the medical care system, Larry should bring us the penetrating analysis of the current system that is represented in his book: Bad Medicine: How the American Medical Establishment Is Ruining Our Healthcare System. He has presented to us a whole fabric of basic logic applied to the medicine establishment which expresses the "wrong-headedness" of our current approach. I would hope that this scholarly but also pragmatic treatment of the need for change in the medical establishment will contribute to a restructuring that will result in better health care. We are fortunate, indeed, that Larry has shared with us the ideas that have evolved from his experiences.

From Book News, Inc.
A health industry insider targets physician mindsets of infallibility and a clockwork cosmos as the bulls-eye of the system's cost and other crises, and prescribes mega-dose reforms in medical education, a pecking order skewed toward specialists, and DOA government policies. Alternative medicine trends are not discussed. Book News, Inc.®, Portland, OR

Synopsis
Reformers have tried to solve the U.S. healthcare crisis by focusing on costs, coverage, and benefits. But this doesn't get to the heart of medicine's problem, says veteran health services consultant Lawrence J. O'Brien, who argues here that the real solutions require a complete overhaul of the medical mindset of doctors and the institutions that train them. O'Brien prescribes needed reforms to doctor education and reconstruction of the government's policies within the healthcare system to clean up the growing medical mess.

The cost of the American healthcare system is spiraling out of control at $1 trillion annually. Bad Medicine argues that the real solutions require a complete overhaul of the medical mindset of doctors and the institutions that train them. By recognizing physicians themselves as the principal cause of the crisis now facing the nation, it becomes possible to arrive at some explanation for the house of cards which is the American medical establishment today. O'Brien contends that American medicine has gone from being general-practitioner based to being overrun by specialists who treat only certain parts of the body and certain ailments, who recommend unneeded surgeries, and who ignore the important questions of ethics. He also exposes the perverse supply-and-demand formula within the medical system with doctors determining the demand for their services while patients have little say in these decisions. Bad Medicine outlines needed reforms to physician education, reconstruction of the medical pecking order, and redirection of government policies. By following this clear and distinct path toward reconstruction and reform of medicine, America will have the health care it needs and deserves in the twenty-first century.

A treasure trove of insight August 20, 1999
Reviewer: A reader from Luray, Virginia
As a former federal health policy analyst I can't help but say "right on" to Lawrence O'Brien's thoughtful analysis of the problems endemic in the U.S. health care system and his carefully laid out steps for reform.

Certainly, the medical economic system and its incentives are awry, with demand set by the seller and the true price hidden from the consumer. But O'Brien also succinctly shows that the product is flawed explaining how and why the U.S. falls so far behind many other countries in indications of health and well being.

The litany of problems, linked to their roots, is a treasure trove of insight. Among them: How medical records are stored and handled contributes to the dearth of clinical science and evaluation. How medical schools create and then reinforce system problems. The effect on both medical outcome and economics of too many doctors practicing the wrong specialties. How federal interventions have exacerbated problems.

Perhaps most instructive is O'Briens clear description and examples in everyday medicine of the important distinction between advances in true medical science, which discovers the causes and preventions of illness and disease, and advances in medical technology, which develops interventions designed to lessen the impact of disease for which no cure has yet been found.
This is reflected not only in the banks of blinking and beeping machines in today's hospitals, but in the increasing specialization of physicians where technical skills are rewarded highly and payment for services aimed at preventing disease is almost non-existent.

O'Brien outlines steps needed for significant health care reform, acknowledging that the full-scale upheaval needed will be difficult to achieve. Nevertheless, he serves up an insightful and cogent framework for reform and, perhaps most importantly, prompts consumers to view the system in a different light. And that is perhaps the hardest task of all, convincing the patient that changes need to be made.

The right answer to the right question August 17, 1999
Reviewer: A reader from Corvallis, Oregon

Finally, someone who's asking the right question.

Washington policymakers and the media ask the wrong questions about health care. How do we provide access? Control expenses? Pay the bills?

O'Brien asks: What are we buying? His answer is: "not much."

O'Brien is not a brainless firebrand. He drags us through the history of Western thought to make sure we understand the underpinnings of medical thinking. He wades through studies and statistics. Footnotes are everywhere.

In the end, he makes a levelheaded case: Medicine may not be good for you. His material about nosocomial infections--diseases you pick up in the hospital--was particularly frightening.

Pundits and policymakers are so busy yakking that they won't read this book. So you should.

Maybe you can convince them to stop trying to find the right answer to the wrong question.

And, you can be very careful when you go see the doctor.....