[Book Review] Next Medicine: The Science and Civics of Health

We all want to believe that medicine is firmly based on reality, that research systematically identifies important problems and that information is easily transmitted to doctors who apply it unerringly. Unfortunately, the truth is that the practice of Medicine is not base firmly on reality, that the transmission of research information into practice is precarious, and that the results are too often used selectively by practitioners.

The authoritative Dartmouth Atlas of Health Care notes, "Spending continues to increase without evidence that what we're doing results in either better outcomes or better patient satisfaction."
Walter M. Bortz, II, M.D., Next Medicine: The Science and Civics of Health p 81

Yikes!!! I don't know how well I'm going to sleep tonight.

Actually, reading this is a relief. It gives credence to the doubts I've accumulated over time. For years I was put on one drug after another either to run into hideous side-effects, no benefit whatsoever, or a benefit that failed over time. I've been through expensive nerve blocks that did nothing. Doctors are as much victims in this themselves. Dr. Bortz quotes Voltaire, who said:

Physicians are individuals who prescribe drugs about which they know little, for diseases about which they know less, to persons of whom they know nothing.

The way our system is set up with corporate medical system, insurance and Big Pharma all reinforces this trap. Our health needs are serving capitalism rather than the other way around, Dr. Bortz argues. Only 18% of doctors go into general practice. They're considered 'sniffle doctors' or low-level bureaucrats for specialists. That's where the money is. But in a case like mine where I have overlapping ailments, my care quickly turns into the blind magi looking at the elephant, and it was left up to me to put the pieces together (as my GPs were in over their heads). This system serves no one but shareholders: the ones with the pocketbooks. Any why are they the primary driving force in all this? They certainly aren't the folks with needs the system is supposed to address.


I have a problem with his numbers and his solution, however.

He mentions chronic illness as the number one drain on health resources: "It is now reported that 72% of physician visits are due to chronic conditions, as are 76% of hospital admissions. Chronically ill persons use three times as much medical manpower as those with acute: 7.4 versus 1.7 doctor visits per year." p 72 (He doesn't site the source, but it's "Medical Expenditure Panel Survey 1998" by US Department of Health & Human Services.)

He then goes on to focus his "Next Medicine" on the 55% of cases of premature death that are preventable through lifestyle changes (diet, exercise, not smoking) and his new medical structure is geared towards that 55%. But these are numbers for premature deaths, not chronic illness; the number one drain on resources. That's like the drunk looking for his keys under the street lamp even though he dropped them a block away because "the light's better over here."

I think he's excellent at identifying the ills of the heath care system. I believe, however, he falls victim to the same problem most doctors do: they don't like to talk about what we still know very little about.


So I went and did a little of my own research. 11.5% of the US population has a severe disability (a disability that interferes with daily living). Of that population, alcohol & drugs accounts for 0.7%, diabetes 5.7%, heart trouble 10.8%, high blood pressure 12.8%, stroke 3.2%, head or spinal cord injury 1.6%, hernia or rupture 1.8%, mental or emotional problem or disorder 2.8%, cancer 2.3%, arthritis or rheumatism 5.3%, broken bone/fracture 1.5%... No numbers for "obesity" (a big focus in his book). But adding it all up, if you assume that *all* diabetes and cardiovascular trouble is preventable (which it is *not*) that only accounts for 25% of the chronically ill. That leaves (for sake of argument) 75% of the chronically ill out of his "Next Medicine" equation. Not good, especially since they're they highest cost generators.

Dr. Bortz is great at diagnosis of the ills of the medical system. But, also like most doctors, can't prescribe solutions well-fitted to its chronic ills. I think the truth is closer to what it's always been. Physicians are individuals who prescribe drugs about which they know little, for diseases about which they know less, to persons of whom they know nothing. Chronic illnesses are the biggest drain because there is so little we can do. We try treatment after treatment and return again and again because the problem can't be fixed or managed. This is a basic failing of our ability to treat, not the system.  So I fail to see how his radically proposed changes would do any good.

Part I of the book gets an A+
Part II of the book gets an F