Overdosed America (8 page)

I realized how little even the best doctors understood the risks of Vioxx when a colleague, a prominent cardiologist, underwent arthroscopic surgery on his knee. His surgeon prescribed Vioxx for his postoperative pain, no doubt convinced that he was treating his VIP patient with “the best.” My colleague subsequently developed deep-vein thrombophlebitis, a blood clot, in the leg that had been operated on. Neither one of these very well informed doctors had been aware of the significant cardiovascular risk associated with Vioxx.

By the end of 2001,
57 percent of all the money spent on prescription arthritis medication
in the United States was spent on Celebrex and Vioxx, and both were among the top 10 selling drugs in the United States. My research into statins, and now Celebrex and Vioxx, was showing that what was being presented by the most trustworthy sources as the best medicine was often quite the opposite, and that the commercial distortion of our medical knowledge had become a major impediment to good medical care.

One sunny spring
day in the mid-1990s, Ms. Fletcher stopped me on the brick walk outside my office just as I was opening the front door. With only a few minutes before the start of afternoon office hours, I was feeling pulled by a couple of phone calls that still needed to be returned. She asked if I was Dr. Abramson. When I said yes, she said that the HMO she had just enrolled in had required her to choose a primary care doctor. Ms. Fletcher wanted to know if she could list me as her doctor because she had heard that I was interested in alternative medicine. I said that was partially true; I am interested in any kind of treatment that helps. But I also made it clear that I was interested only in therapies—alternative or not—that were supported by good scientific evidence.

Ms. Fletcher, who appeared to be a healthy though harried woman in her mid- to late forties, then told me that she had breast cancer. The pressure I was feeling to get to the telephone faded. She quickly added that the only therapy she had received, or wanted to receive, was alternative therapy—no surgery, no radiation, and no chemotherapy.

My mind flashed back to Ms. Card (who had insisted I call her by her first name, Wendy), a woman I had taken care of several years before who had made the same decision. By the time I got involved in her care, the tumors in her breast and under her arm were growing quickly, and actually eroding through the skin. I prescribed medication to control her pain and the local infection around the tumors, but there was little chance that any therapy could control her underlying disease. As her physical condition deteriorated over the next few weeks, I made several house calls. We talked about what could be done to make her more comfortable; she told me about her friends and her spiritual practice, both of which were very important to her; and we talked about her family. She had been estranged from her parents for several years and was struggling with the decision about whether to let them back into her life. She invited her parents to visit for a couple of days. During their visit she decided to go home to New York with them, to let them take care of her in her last few weeks. I arranged for hospice to get involved as soon as she got to her parents’ home. Wendy’s capacity to heal the wounds in her life as best she could in preparation for her death brought a sense of hope to the tragedy of her situation.

My attention returned to Ms. Fletcher. I suspected that in this seemingly casual conversation—interrupted as it was by office staff, patients, and the Fed Ex guy walking between us on their way into the office—she was asking for my approval of her decision to use only alternative therapy. After visualizing what Wendy’s upper chest and underarm had looked like before she left for New York, I wanted to be careful not to leave Ms. Fletcher with the impression that I supported her decision to forgo conventional therapy. I told her that I would be happy to be her doctor, and that she should make an appointment so that we could get to know each other and discuss her options.

Ms. Fletcher did sign up as my patient, but she never came in for an appointment. I think she knew that I would try to engage her in a discussion about her medical situation and that I had reservations about her approach. Sometimes just the process of engaging in a doctor-patient relationship is the most effective alternative medicine—using the safety and trust of the doctor-patient encounter as an opportunity to connect with deeper concerns, to be able get these issues out on the table so that they can be addressed and progress made: physical, emotional, or both. But I also thought it was her right to choose not to engage in this kind of relationship with me.

I had not heard from Ms. Fletcher for about a year, when I got a message that she had called my office requesting a referral to see an oncologist in Boston. To avoid creating an uncomfortable telephone encounter, I suggested through a nurse that she come in to see me first. She declined. I approved the consultation.

The oncologist soon called to inform me that Ms. Fletcher’s breast cancer had metastasized widely throughout her body and asked for my approval, as Ms. Fletcher’s primary care physician, for her to receive high-dose chemotherapy followed by bone marrow transplantation. The goal of this treatment is to administer an otherwise lethal dose of chemotherapy—enough to destroy all of the rapidly dividing cells in the body, including the blood-forming cells in the bone marrow—in the hope of destroying all of the cancer cells in the process. Before the therapy, bone marrow cells from Ms. Fletcher would be “harvested.” After the chemotherapy, Ms. Fletcher would then be “rescued” by “reseeding” her marrow with her own bone marrow cells, thereby restoring her ability to make red and white blood cells. The procedure required about two weeks in a sterile room, to avoid infection while her immune system was suppressed, and up to a month in the hospital. This was a rough ride, with the volume turned all the way up on all the discomfort and risks of chemotherapy: hair loss; nausea and vomiting; ulcers on the inside of the mouth and the gut; possible damage to the heart, kidneys, and nerves; and the risk of serious infection until the immune system recovers.

Knowing how sick Ms. Fletcher would become from the therapy itself and sadly aware of how advanced her breast cancer was, I asked the oncologist if she was sure this was the right thing to do. She said that high-dose chemotherapy and bone marrow transplantation was the best therapy for women like Ms. Fletcher, that is, women with advanced breast cancer. I had little experience with this and had to trust the oncologist’s opinion. I certainly wanted my patient to get the best therapy available.

As this conversation was going on, I was thinking about the contrast between Ms. Fletcher’s complete rejection of conventional medicine and her abrupt return to the most aggressive therapy in the face of her advancing disease. Even though she had eschewed conventional therapy early on, now it seemed that she may have been taking comfort in the belief that modern medicine could rescue her if her disease got out of control. I also thought about her unwillingness (or inability) to engage in a doctor-patient relationship with me, and wondered whether she had been able to explore with anybody the important issues in her life. And I wondered whether her oncologist thought of death as the final defeat against which all-out war must be waged, even though there was no real hope of winning.

Although the decision to go forward had already been made and the oncologist seemed to be calling more as a courtesy than for a real discussion, I still regret that in that rushed moment on the telephone I was so deferential. I feared that Ms. Fletcher and her oncologist were, each for her own reasons, grasping at straws, and I hoped I was wrong. In the end I kept my doubts to myself, approved the procedure, and got back to the patient I had left to take the phone call.

In retrospect, I realize that there was something else going on. Ms. Fletcher, her oncologist, and I were all emboldened by our implicit trust in the efficacy of the most advanced medical care that was to be provided in a top-notch academic medical center. Most Americans share this great faith in the superiority of American medicine. It is easy to see why. During the twentieth century alone longevity in the United States increased by 30 years. During the last 50 years medical science has made tremendous progress in improving health and the quality of our lives.

The elimination of polio, the most feared disease of my childhood, is a perfect example of the triumph of American ingenuity. In 1953 about
one out of every 100 Americans
below the age of 20 had experienced some degree of paralysis caused by polio. Then, with well-deserved fanfare, the Salk vaccine was launched for use on April 12, 1955, exactly 10 years after the death of our most famous polio victim, President Franklin Delano Roosevelt. The vaccine was immediately put into widespread use. I remember lining up in the elementary school gym as a third-grader to get my first polio shot, my childhood fear eased (mostly) by the understanding that I would no longer have to worry about getting polio.

Huge strides have also been made in biomedical engineering and surgical techniques in the last 50 years. The cardiopulmonary bypass machine, which pumps blood through an artificial lung, replacing carbon dioxide with fresh oxygen, and then back into the body, allows surgeons to perform intricate heart surgery. The first successful surgery using
cardiopulmonary bypass was done in Sweden in 1953
, on an 18-year-old girl with a congenital heart defect. By 1960, surgery to bypass blockages in the arteries that supply the heart muscle with blood (coronary arteries) could be performed with relative safety. Surgical replacement of poorly functioning heart valves soon followed. By the time I was in medical school, in the mid-1970s, these operations had become routine.

Dialysis, to filter the blood
of people with chronic kidney failure, became a reality in the 1960s. In 1972 the Social Security Act was amended to extend Medicare coverage to all patients with end-stage renal disease, covering all the costs of chronic dialysis. About 250,000 Americans are alive today because they have access to ongoing dialysis. Successful transplantation of hearts, lungs, and livers have been lifesaving. Transplantation of kidneys and corneas allows people to live normal lives. Hip and knee replacements have restored comfort and function to millions of Americans.

There has been great progress with new drugs, too. Tagamet first became available when I was just starting my two years in the National Health Service Corps of the U.S. Public Health Service, in 1977. I remember the first patient I treated with Tagamet: a state policeman who had already had one stomach operation because of an ulcer and was developing the same symptoms again. He thought he was headed for a second and more extensive operation, but Tagamet suppressed the acidity enough for the lining of his stomach to heal. Zantac was perhaps a slight improvement, reputedly causing fewer side effects. The vast majority of people with ulcers and ulcerlike symptoms improved with these drugs. In 1989 Prilosec came on the market, the first of the proton-pump inhibitors, suppressing acid formation many times more powerfully than Tagamet or Zantac.

The mortality rate from AIDS in the developed countries has gone way down as new drugs have been developed that control HIV infection.
Gleevac is a true miracle
of modern medical science. This treatment for a slow-acting form of leukemia (chronic myelogenous leukemia) specifically blocks the body’s production of an enzyme that causes white blood cells to become malignant. (Unfortunately it’s priced at $25,000 per year of treatment.)

The introduction of magnetic resonance imaging (MRI) into clinical practice in the mid-1980s is
rated, in a survey of well-respected primary care doctors, as the most important development
in clinical medicine over the last 25 years. In the early 1980s, when the chief radiologist at my local hospital first explained how this soon-to-arrive technology produced its images, I thought he was joking. (Nuclei of the body’s hydrogen atoms are aligned by a powerful magnet. FM radio beams are focused on the area to be scanned, causing “resonance” of the aligned nuclei. Minute amounts of energy are emitted as the radio beam is turned off and the nuclei return to random orientation. This energy is measured by sensors and sent to a computer, which produces exquisite three-dimensional pictures of the human body.) Now these scans are commonplace.

A number of my patients are alive only because of recent medical advances: massive heart attacks completely reversed by “clot-busting” drugs, exquisitely delicate lifesaving cancer surgery on a child, successful liver transplantation, and an implanted cardiac defibrillator that senses and automatically treats several episodes of potentially fatal cardiac arrhythmia, to name just a few of the more dramatic examples. After the satisfaction of providing good medical care based on ongoing trusting relationships with my patients and the pleasure of working with an incredibly dedicated group of people in my office, my greatest satisfaction as a doctor has been working with my specialist colleagues to ensure that my patients get the full benefit of the most up-to-date care available.

Clearly these medical breakthroughs have contributed to increased longevity and improved quality of life; this is why I, too, believed that Americans received the best medical care in the world. Then I saw an article in the
Journal of the American Medical Association,
in July 2000, claiming that
“the U.S. population does not have anywhere near the best health in the world.”
On first read, I thought that surely the author was overstating the case.

In a
comparison of 13 industrialized nations
that will surprise most Americans—and certainly most American physicians—Dr. Barbara Starfield, University Distinguished Professor at Johns Hopkins School of Public Health, found that the health of Americans is close to the worst on most measures and overall ranked second to last. Contrary to common wisdom, the poor ranking of the United States cannot be attributed to our rates of smoking, drinking, or consumption of red meat. Surprisingly, Americans rank in the better half of the 13 countries on these measures, and have the third lowest cholesterol level. (Deaths due to violence and car accidents were not included in the data.)