John Abramson is a clinical instructor of primary care at Harvard Medical School. He began his careerin Appalachia, serving in the National Health Service Corps. In 1982 he became a family physician in Hamilton, Massachusetts, and practiced there for 20 years. He was selected by his peers three times as one of the best family doctors in the state. After researching his book, Overdosed America, he says health care in the United States is becoming less effective than in other industrialized countries while becoming much more expensive.
What’s the evidence for your thinking that Americans aren’t getting better health care for all their spending? A:
In 2000 Barbara Starfield, University Distinguished Professor at Johns Hopkins University, wrote an article in The Journal of the American Medical Association showing that the health of Americans ranks second to last among 13 wealthy industrialized countries. And in 2001, the World Health Organization looked at the 23 countries that spend the most for health care. The United States spends by far the most in that group: roughly $6,000 annually per capita, which is twice the average of the other countries. But we have nearly the lowest healthy life expectancy, that is, total life expectancy minus the number of years of illness. Only the Czech Republic ranks lower.
Could it be that Americans simply eat more junk food and exercise less than people in other developed countries? A:
There isn’t a clear-cut boundary between medical care and lifestyle. For example, when a patient comes to a doctor for a physical exam in the United States, there is a 67 percent chance the doctor and patient will talk about cholesterol levels and less than half as much likelihood that they will discuss lifestyle choices like diet, exercise, and not smoking. The truth is that lifestyle is far more important than cholesterol levels in determining the risk of heart disease for the vast majority of people, but this is getting drowned out by the commercially fueled cholesterol-lowering frenzy.
Why do you say drug trials are losing credibility? A:
When President Reagan came into office in 1980, we started to get a small-government ethos. The budget for clinical trials funded by the National Institutes of Health shrank dramatically during those years. The drug companies were very happy to step in and fill the vacuum. Initially the change in funding didn’t have much impact on clinical research. Although the drug companies were funding 70 percent of the clinical trials by 1991, 80 percent of those trials were still being done in universities, where the checks and balances inherent in the academic environment were still in effect. But then things started to change: By 2000, universities were doing only 34 percent of industry-sponsored research; the rest was being done by for-profit organizations. Now we’re in the final stage: Private research companies are being bought by large advertising agencies. Ad agencies are now in a position to help design studies so that the results will create the best possible marketing opportunities for the drug companies.
Is there any proof that privately funded studies are biased? A:
When you look at the highest quality medical studies, the odds that a study will favor the use of a new drug are 5.3 times higher for commercially funded studies than for noncommercially funded studies. Drug companies are also sponsoring about 70 percent of the continuing education that doctors are required to participate in to keep their licenses to practice.
Is this an American phenomenon? A:
Absolutely. Germany is in many ways the most similar market to us, but we spend 12 times more per capita marketing drugs than they do. Half the statins used worldwide are used in the United States, and that was before the 2001 and 2004 updates of the National Cholesterol Education Program recommended more than tripling the number of Americans taking statin therapy. Direct-to-consumer advertising exploded more than 75-fold in the United States from 1991 to the present. We now spend $4.2 billion a year on it. Only the United States and New Zealand, which has less than 4 million people, even allow direct-to-consumer advertising.
You’re talking about all the “ask your doctor” ads? A:
Right. They work: Turns out that when you ask your doctor for a prescription drug, you get it between 50 and 80 percent of the time. But a study done by researchers in British Columbia showed that when a doctor accedes to a patient’s request for a specific drug, the doctor is ambivalent about it being the right choice 50 percent of the time. On the other hand, if doctors prescribe a drug that was not requested by the patient, they are ambivalent about it just 12 percent of the time. These ads drive a wedge between doctor and patient. For a while, I was both a family practitioner and a researcher, and I knew as much about the real data behind Vioxx and Celebrex as anybody. I knew they were neither safer nor more effective than the much less expensive alternatives and would tell my patients so. Nonetheless, many still demanded these drugs, which shows the tremendous power of marketing.
Is it true there is no requirement to release all the data in a privately funded study? A:
Yes. Not only that, all the authors of journal articles don’t even get to see all the data. In 2001 the editors of the 12 leading medical journals decried what they described as a “draconian” situation for academic researchers, but even that extraordinary joint statement went largely unheeded. Now universities have been forced into what’s been called a race to the ethical bottom. If they don’t conform, they will lose out altogether to the for-profit research companies.
What do you recommend? A:
All the authors have to have free access to all the data when they write a journal article. If the authors of those articles had to sign off and say they saw all the data, and they are responsible for the article being a full, unbiased representation of it, I think you would see some of this stop.
Is that all? A:
The most important step is that we need some disinterested body—perhaps the Institute of Medicine working with the FDA or maybe a new, independent body modeled after the Federal Reserve Board—that has complete access to research design, all data, and all analyses and can then certify the integrity of the conclusions that are drawn from that study. Good medical journals today are very frank that they can’t certify that the studies they publish are complete and accurate, so we need somebody who can. Then, good medical journals might refuse to publish articles that are not certified. This is important because a big part of becoming a doctor is learning which sources of information to trust. During medical training, if you make a decision that’s not based on the latest research published in medical journals, more senior doctors are openly critical, so you learn to follow the journals very closely. The journals play a central role in American medicine, and they have to realize that what they publish has real consequences.
In the meantime, what can patients do? A:
The first thing we have to do is become aware of how distorted much of our medical care has become. The net effect of this commercialization of our medical knowledge is to have created the impression that a good and healthy life requires a lot of medicine. The fact is, about 70 percent of our health has to do with how we live our lives. Doctors are not keeping up with this. In June 2003, the Rand Corporation published an article in The New England Journal of Medicine showing that when prescribing medicine, 68 percent of the time American doctors meet objective quality standards. But when it comes to lifestyle counseling—and this is simple stuff, like telling someone with emphysema to stop smoking—the quality standards are met only 18 percent of the time. Another big point is that every person needs to have a primary care physician they trust; that’s the basic unit of good health care. We need to get over the misconception that the best care is provided by a big repertoire of specialists. The number of U.S. medical students choosing careers in family practice plummeted by more than 50 percent in just the last eight years, but ironically, the more specialists there are in a state per capita, the lower the quality rank of medical care in that state and the higher the cost. It’s appropriate to talk to your doctor about where he or she gets information. I think it’s within a patient’s rights to say, “You know, doc, I’d rather you got your continuing education from non-drug-company-funded sources.”