Your Medical Mind - Book Review. Best for Patients or Doctors?

I looked forward to reading Dr. Jerome Groopman’s new book, Your Medical Mind: How to Decide What Is Right for You , co-authored with Dr. Pamela Hartzband.  His previous work, How Doctors Think , shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions.  I always recommend my medical students read that book.

Unfortunately, his latest work fell quite short of my expectations.  In it, the authors try to understand and create a framework on how patients reach decisions about their medical care.   In the end, this was a book about human psychology wrapped in the doctor patient relationship.  Nothing particularly earth shattering here.

The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors?  Patients or doctors?

They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.”  Specifically, some patients want maximal treatment and others believe “less is more”.  To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms.  Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.

Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions.  Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later.  In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament.  Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference.  There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.

Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance.  Sometimes patients want full control.  Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician.  Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted.  Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation.  As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.

Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference.  Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient.  These seems rather ludicrous as already many current guidelines are not being followed.

The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want.  “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”

Completely agree. Perhaps this book is best suited for doctors.  While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.  

Required Reading for Medical Students, Interns, and Residents.

I have had the privilege of working at an organization which is actively improving the lives of its members and also was mentioned by the President as a model for the nation.  Over the past few years, I have also demonstrated to first year medical students what 21st century primary care should look and feel like - a fully comprehensive medical record, secure email to patients, support from specialists, and assistance from chronic conditions staff.

But as my students know, there are also some suggested reading assignments.  I'm not talking about Harrison's or other more traditional textbooks related to medical education.  If the United States is to have a viable and functioning health care system, then it will need every single physician to be engaged and involved.  I'm not just helping train the next group of doctors (and hopefully primary care doctors), but the next generation of physician leaders.

Here are the books listed in order of recommended reading, from easiest to most difficult.  Combined these books offer an understanding the complexity of the problem, the importance of language in diagnosing a patient, the mindset that we can do better, and the solution to fixing the health care system.

Which additional books or articles do you think current and future doctors should know?

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines or do research to see if current therapies are effective, special interests and politics kill the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

How Doctors Think
Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and are unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Jerome Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, yet Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence.

As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States.  Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded.  The world he trained in is far different than the world his trainees are about to enter.


Better: A Surgeon's Notes on Performance
A fascinating and quick read.   In each section there are plenty of inspiring stores about doctors making a difference. Dr. Atul Gawande, a general surgeon at Brigham and Women's Hospital and staff writer for the New Yorker has keen observation and insight to make single stories demonstrate not only the failings of our healthcare system but also the solutions to them because of individuals asking questions on how to do better. Ultimately, one of the questions he asks is how can doctors and hospitals be positive deviants? How does one become a positive deviant or an outlier that pushes beyond convention and advances patient care to new levels?

He gives examples of how over four million children need to be vaccinated in Northern/Southern India in three days to prevent a large polio outbreak. An immunization rate of less than 90 percent would be considered a failure.

Dr. Gawande talked about the evolution of obstetrics. After a damaging report in 1933, the specialty consequently committed itself to standardizing childbirth ensuring that with the new medical knowledge that it was applied consistently and routinely throughout the country. As a result maternal death in childbirth fell 90 percent from one in 150 in the 1930s to one in 2000 by 1950s. With continued innovations and the commitment to do better, the chance of a woman dying in childbirth is less than one in 10,000 today.

There are plenty of amazing examples that you don't have to be a doctor to relate on how truly inspirational these individuals are in times when the stakes could not be higher - life or death.

Until our healthcare system improves to its full potential as Dr. Gawande challenges us to do, unfortunately will always remain benefiting those who are insiders and harming those who are not. The real question is which one are you?  This failing is part of the reason for the rise of the empowered patient movement.


The Innovator's Prescription: A Disruptive Solution for Health Care
The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

The Best Book on Healthcare Reform (or Surviving It)

The best book on healthcare reform or surviving it is The Innovator's Prescription: A Disruptive Solution for Health Care .  The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors, respected Harvard Business School (HBS) professor Clayton Christensen, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School Jerome Grossman, and another doctor and graduate of the MBA program at HBS Jason Hwang avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it.  They authors have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Book Review - the Empowered Patient by CNN Elizabeth Cohen. Too Adversarial.

I understand the frustration and anger in CNN Senior Medical Correspondent Elizabeth Cohen’s new book, the Empowered Patient.  I agree that all of the horrible patient stories should have never occurred.  As a practicing primary care doctor who has witnessed near misses and bad medical outcomes affect family members, I too wrote a book encouraging patients to be informed and engaged about their care.

The problem is that the Empowered Patient is too adversarial.  If anything, it is biased, which is completely understandable given the failings of the healthcare system, and is not balanced.  If she had wanted a book that helped patients be informed, engaged, and a true partner in health, she falls far short.  Those of us working to make the healthcare system safer and more patient focused will find ourselves on the defensive as soon as we walk through the door if patients follow everything she says.

Chapter titles include How to Be a “Bad Patient” and How to Find Dr. Right (and Fire Dr. Wrong).  She reminds readers that “your relationship with your doctor is a business relationship… You pay her, and she takes care of your medical problems.  End of story.”  Readers should consider firing their doctor if they “repeatedly have to spend inordinate amounts of time in the waiting room (more than fifteen minutes or so)”.  Yet, she hopes readers can find Dr. Right, someone who is an excellent communicator and someone you can trust and feel good about.

Through her stories in How to Get Good Drugs Cheap and Don’t Fall for Medical Marketing, Cohen implies that all doctors are influenced by drug reps, on the payroll of pharmaceutical companies, and only write expensive brand name medications.  She completely ignores how direct to consumer advertising cause patients to demand these “me too” drugs.  She doesn’t highlight the studies that show doctors when faced with this situation, though ambivalent, often acquiesce.  Cohen suggests that readers ask their doctors if they have “any financial ties to a drug or device company”.

In the section How to Avoid a Misdiagnosis, she illustrates two patients who could have died because doctors were about to begin chemotherapy and radiation treatments based on erroneous diagnoses.  Using the internet, it was clearly apparent to the patients that the rare condition they supposedly had didn’t apply to them.  They didn’t fit the typical patient description for the illness.  The doctors’ failings were that they relied too heavily on the pathology reports. They should have looked at the complete picture and the pathology report in the context of the patient.  Instead, they anchored their decision solely on the pathology report.

Again, Cohen is completely silent about the patient aspect.  The same anchoring phenomenon can and has been occurring with patients.  Increasingly far more patients are focused on what the test showed, whether blood work or CT scans and MRIs, instead of what makes sense based on a patient’s history and examination.  Patients are also avoiding office visits relying instead on technology to provide answers when these are simply tools and not necessarily the truth.  Imagine the erroneous conclusions that might occur.

Armed with her information it is impossible to see if it is possible for anyone to find a Dr. Right or a time when patients can focus on getting better instead of being very vigilant at every point of care to the level of paranoia.  Perhaps that wasn’t her intent, but as a doctor on the frontline it is hard to see any other interpretation.

Though Cohen rightly notes that 99,000 Americans die annually from hospitalized infections and that 98,000 die from medical errors in the hospitals, she also ignored that 100,000 deaths could be averted if simple important interventions occurred.  Patients with hypertension had their blood pressure controlled.  Patients with heart disease had their cholesterol controlled.  Women at age 40 begin screening for breast cancer.  Both men and women at age 50 get screened for colon cancer.  Surely these are equally as important issues for empowered patients?

There were a few of sections that were worthwhile – How to Become an Internet MD, gives excellent and thoughtful advice on how patients can use the internet, Don’t Let a Hospital Kill You, and You vs. the Insurance Industry.

If there was any silver lining in her book, then it is as doctors working in an incredibly complex system comparable to environments associated with airline pilots, military aviators, and astronauts, we must do much better.  Saying medicine is different is not acceptable.  We need to adopt highly reliable systems, systematically improve training to minimize inherent unconscious bias, and a serious dose of humility in understanding that patients concerns are legitimate and must be addressed. 

Though her CNN colleague, Dr. Sanjay Gupta says this is “a book no household should be without”, I can safely say there are other books that can provide you the skills and knowledge to engage and partner with your doctor better than this one.

Book Review -- The Checklist Manifesto - Checklists and Team Communications Make Us Better

I’m a huge fan of Dr. Atul Gawande ever since meeting him at a patient safety conference in 2005, and then subsequently reading his books and following his New Yorker articles. Perhaps because I’ve been following his works closely or maybe because I’m a practicing doctor diligently making the healthcare system better is why I didn’t find his latest work the most compelling.

Dr. Gawande makes two points, checklists and clear communications among teams, are absolutely required to decrease errors and problems and increase the chances of absolutely the best outcome, whether in constructing buildings, flying airplanes, and performing surgery. We aren’t perfect. Systematic approaches make us better.

Only the last two chapters, “The Hero in the Age of Checklists” and “The Save”, which highlight the “Miracle on the Hudson” landing of US Airways flight 1549 by Captain Sullenberger and his crew and Dr. Gawande’s experience in the operating room of adverting a near catastrophe respectively, were the most gripping.

Ultimately, despite his points the irony will be that the healthcare system will not adopt these ideas, which are accepted as expectations in the aviation industry, because doctors still feel that we are somehow smarter or above checklists or teamwork. This failure to do what we are truly capable of is disheartening. As a result, individual patients will be the ones responsible in taking care of their health and asking questions. A good easy to read book or “checklist” in ensuring you get the right care every time is at Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System.

Although I wasn’t bowled over like his other works, nevertheless, I have my own checklist and that is to continue reading and learning from Dr. Gawande and many others who toil in making healthcare better and safer.

NutureShock - New Thinking About Children

I could not put down this fascinating book on the latest research regarding child development. What we've been told has been wrong. Chapters include - The Inverse Power of Praise - Sure, he's special. But new research suggests if you tell him that, you'll ruin him. It's a neurological fact. Another chapter - Why Kids Lie - We may treasure honesty, but the research is clear. Most classic strategies to promote truthfulness just encourage kids to be better liars.

A very shocking chapter - The Search for Intelligent Life in Kindergarten - Millions of kids are competing for seats in gifted programs and private schools. Admission officers say it's an art: new science says they're wrong, 73% of the time.

An easy read full of stunning and thought provoking research it will make you think hard about how you raise and interact with your children. A must addition for any parent's bookshelf.

Book Review - Innovator's Prescription: A Disruptive Solution for Health Care

Brilliant. Far and away the best book on health care reform.

The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

For those trying to navigate the increasingly frustrating, confusing, and expensive health care system as it current exists, Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be the perfect guide book.

Book Review - Critical: What We Can Do About the Health-Care Crisis

I had high hopes for this book. Except for the one innovative idea, the creation of a Federal Health Board, this was an average book compared to the many available which detail the challenges of our dysfunctional healthcare system far better. The book is an easy read, doesn't cover much in depth, but highlights all of the key points one needs to know to speak intelligently about the healthcare system (and presumably to be Secretary of Health and Human Services).

It is unclear whether creation of a Federal Health Board will be able to provide the impetus needed to make the American healthcare system higher quality, less costly, and more inclusive with universal coverage. One thing is clear from his book and that is Americans want a better healthcare system than currently exists. It won't be a pure single payer government run system. It won't be a free market private industry program. It will be a hybrid. What type of hybrid? Time will tell.

The book is divided into five parts. Part One details the healthcare system in crisis filled with individual anecdotes on how it has bankrupted, failed, and at times killed people without adequate insurance coverage or financial means to pay for care.

Part Two talks about the history of healthcare reform, which covers the beginning of the twentieth century. It highlights efforts by President Truman, Medicare and Medicaid legislation, as well as attempts in the 1970s, 1980s, and the early 1990s.

In Part Three, Daschle looks at why reform hasn't occurred. He begins to build his case for creating a new entity, a Federal Health Board, which is modeled after the Federal Reserve as well as the British National Institute for Health and Clinical Excellence (NICE).

Part Four he focuses in on how the Federal Health Board would be structured (a central board with several regional boards). As an independent body, it would recommend that only medications, treatments, and procedures backed by medical evidence and not by marketing be covered under government run insurance plans. It would also determine what criteria and benefits private insurers must offer to participate in expansion of the FEHBP (Federal Employees Health Benefits Plan). This new market would insure those unable to get employer-based or government run insurance programs currently.

Finally in Part Five, he makes the case on the likelihood for healthcare reform.

The best part of the book is Senator Daschle's perspective on the healthcare reform attempt by the Clinton administration, particularly how excitement and momentum moved the country towards reform only to see external events, special interest groups, as well as political missteps, caused it to die. Without a doubt, future leaders who hope to forward any healthcare reform package would best learn what not what to do.

Read my other healthcare / medical book reviews -
Overtreated -
How Doctors Think -
Medical Myths That Can Kill You
How To Save On Prescription Drugs

Book Review - How to Save on Prescription Drugs

Fairly good. Mostly accurate.

Dr. Edward Jardini, a family physician focuses on one aspect of healthcare costs, specifically prescription drugs. His 20 cost-saving methods break down into the following groups.

(1) eliminate nonessential prescriptions – stop medications no longer needed because the problem resolved, medications no longer worked, medications never worked, medications were never needed.

(2) think beyond the prescription bottle – treat whatever ails you with lifestyle changes (lose weight, exercise, eat healthier, quit smoking), nondrug treatments, prevent disease naturally.

(3) avoid overpriced me-too drugs – don’t asked for advertised drugs, don’t take free drug samples (it’s how drug companies get you hooked on their most expensive drugs), insist on generic drugs, insist on cheaper drugs in the same medication class, for a particular medical problem (i.e. allergies), get the medication class that is cheapest (antihistamines like benadryl are cheaper than nasal prescription steroids).

(4) be smart – split tablets, be prescribed the right dosage or amount (some medications cost the same for the 20 mg and 40 mg so if you take two 20 mg pills per day, it would be cheaper to tae a 40 mg pill), ask to see if another dosage exists, don’t treat one medication’s side effects with another, shop around, get it for free (take free samples that you absolutely need and enough for the short period of time you need it or if you’ll get insurance to cover the cost), and finally,

(5) use pill programs – programs from drug companies that give discounts (PPA Rx 1-888-4PPA-NOW or www.pparx.org), through the federal government like the VA, TRICARE, or state through Medicaid / Medi-Cal, and possibly Medicare Part D).

Overall the advice is good and we should always ask the doctor for generic medications that are effective for the problem at hand and not get fooled by slick advertising. An excellent free website listing drugs that are the best value for the conditions they treat is by Consumer Reports and found at www.crbestbuydrugs.org. I was surprised he didn’t include this important unbiased source. He also didn’t talk about how Wal-mart and other retailers offer $4 prescription medication and for 90 days, it would cost $10. Another cost saver.

At times, the advice given was misleading or overly optimistic. On page 3, he notes that the generic cholesterol medication lovastatin 10 mg tablet is 58% cheaper than the brand name Lipitor 10 mg pill which is true. What he failed to mention is that the generic drug is only ¼ as potent which means you’d need four times as many pills to get the same cholesterol lowering effect! For the area on think beyond the prescription bottle, yes lifestyle changes would be great, but for the vast majority of people they’ve tried dieting, exercising, and they ultimately need medications to address their medical condition. Telling us what we should do but despite our best intentions are unable to do so really isn’t a cost-saving method per se. Dr. Jardini focuses on one aspect of healthcare costs, specifically prescription drugs. His 20 cost-saving methods break down into the following groups.

(1) eliminate nonessential prescriptions - stop medications no longer needed because the problem resolved, medications no longer worked, medications never worked, medications were never needed.

(2) think beyond the prescription bottle - treat whatever ails you with lifestyle changes (lose weight, exercise, eat healthier, quit smoking), nondrug treatments, prevent disease naturally.

(3) avoid overpriced me-too drugs - don't asked for advertised drugs, don't take free drug samples (it's how drug companies get you hooked on their most expensive drugs), insist on generic drugs, insist on cheaper drugs in the same medication class, for a particular medical problem (i.e. allergies) get the medication class that is cheapest (antihistamines like benadryl are cheaper than nasal prescription steroids).

(4) be smart - split tablets, be prescribed the right dosage or amount (some medications cost the same for the 20 mg and 40 mg so if you take two 20 mg pills per day, it would be cheaper to take a 40 mg pill), ask to see if another dosage exists, don't treat one medication's side effects with another, shop around, get it for free (take free samples that you absolutely need and enough for the short period of time you need it or if you'll get insurance to cover the cost), and finally,

(5) use pill programs - programs from drug companies that give discounts (PPA Rx 1-888-4PPA-NOW or www.pparx.org), through the federal government like the VA, TRICARE, or state through Medicaid / Medi-Cal, and possibly Medicare Part D.

Overall the advice is good and we should always ask the doctor for generic medications that are effective for the problem at hand and not get fooled by slick advertising. An excellent free website listing drugs that are the best value for the conditions they treat is by Consumer Reports and found at www.crbestbuydrugs.org. I was surprised he didn't include this important unbiased source. He also didn't talk about how Wal-mart and other retailers offer $4 prescription medication and for 90 days, it would cost $10. Another cost saver.

At times, the advice given was misleading or overly optimistic. On page 3, he notes that the generic cholesterol medication lovastatin 10 mg tablet is 58% cheaper than the brand name Lipitor 10 mg pill which is true. What he failed to mention is that the generic drug is only ¼ as potent which means you'd need four times as many pills to get the same cholesterol lowering effect! For the area on think beyond the prescription bottle, yes lifestyle changes would be great, but for the vast majority of people they've tried dieting, exercising, and they ultimately need medications to address their medical condition. Telling us what we should do but despite our best intentions are unable to do so really isn't a cost-saving method per se. Also asking doctors about whether the evidence from various research studies on heart disease or osteoporosis means that medications can be stopped may be out of the reach of most patients. Often seeing a doctor is intimidating. Asking a doctor about not only the latest research but also then asking to stop the medication because of it may seem too high of a hurdle for some to do.

Nevertheless, he advocates that readers communicate with their doctors about prescription drugs and not to stop without checking in with their doctor. An excellent companion book which covers how to talk to doctors, offers the truth about herbals, dietary supplements, body scans, and also has a section on prescription drugs that would complement this book well is Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.

Book Review - Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life

As a practicing family doctor and author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System, I am a strong believer in empowering and educating patients so that they can make the right decisions to get the most out of life. As the only doctor in my family I don't think it is fair that only the people I know or care for are privy to the truth about staying healthy, so I looked forward to reading Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life, by Dr. Nancy Snyderman, chief medical correspondent for NBC News, which has a similar same perspective.

Overall, the book was a mixed blessing. It has interesting factoids, ideas we should all take to heart, but at times is misleading. As a consumer and a patient, I thought the truths and news you can use pieces were interesting. As a primary care doctor and patient advocate, however, I felt that many parts of the book were misleading. Perhaps one of the faults is it tries to be too ambitious and attempts to cover too many topics, which often are not in depth enough to be of much value.

Dr. Snyderman points out correctly multiple times that the path to good health is through prevention by adopting healthy habits, staying physically active, and maintaining a sensible weight. The structure of the book reflects this preventive focus and chooses to debunk many myths with these clever chapter titles - Annual Checkups Are Obsolete, Vaccinations Are Just For Kids, Doctor's Don't Play Favorites, Only Old People Get Heart Disease and Stroke, We're Losing the War on Cancer, Natural Means "Safe", and You Can Just Snap Out of Mental Illness. She tackles the truth about herbal and dietary supplements, the unproven value of full body scans, as well as the importance of vaccinations and preventive screening tests for cancer, heart disease, and diabetes.

Throughout the book there are plenty of truth tidbits including, "you cannot catch sexually transmitted diseases from toilet seats; you do not need to drink eight glasses of water every day", among many others and news you can use segments that will make some readers hopefully more aware of what is myth and what is fact. These small sidebars were very interesting. I think patients and consumers will find these factoids topics of conversation.

As a practicing doctor, however, there are many areas which are misleading and others that provide information too superficial to be of value. Dr. Snyderman is correct in one of her chapters that heart disease and stroke are the leading causes of death in this country. However, she uses two individuals, a twenty-six year old former beauty pageant winner, who suffered from a stroke, and a forty year old woman, who died suddenly from swimming, as reasons why we should be concerned. The problem is that these type of occurrences are extremely unlikely and rare for these age groups and gender. The typical cause of these problems, atherosclerosis, or hardening of the arteries didn't cause these cases. The former was most likely due to a heart wall septal defect or a blood clotting disorder, known as a hypercoagulable state. The latter was probably due to sudden cardiac death from a fatal arrhythmia, like ventricular fibrillation.

In the area of stroke, she talks about atrial fibrillation, a heart arrhythmia, as the leading cause of stroke. It is a cause, but this heart condition is typically found in patients over age 60 and far more common in people over 80 years old. She doesn't say that and one would naturally and wrongly assume based on the prior patient stories that it can happen at younger ages, which again is extremely unlikely.

Other areas that are covered superficially include when Dr. Snyderman discusses cancer and mental illness. She pushes for prevention as well as clarifies myths that still exist among the public. Unfortunately in the chapter on cancer, she also talks about various cancer treatments which isn't thorough enough and doesn't seem to fit in a book with this preventive theme. For the mental illness, one of the best written sections because of her personal experience, again the book is rather too ambitious and tries to cover anxiety, depression, and bipolar disorder and the various treatment options even as she admits that "it is impossible to go into as much detail as I would like to". Though she gives a website reference, perhaps it may have been better only to cover depression as she and her husband both had experienced it, and acknowledge the other conditions.

Overall, I wanted to like this book as I believe the intent of giving the public the facts about what they can do to stay healthy and well is vital. I think as a practicing doctor and insider, however, the book at times it is misleading, in some areas is too light in content and in others the information deviates from the book's intent of wellness and health promotion.

Book Review - Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines based on evidence or do research to see if current therapies are effective, special interests and politics kills the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

If you were asked to set policy for the White House, then this would be the book to get you up to speed on what makes our healthcare system the most expensive in the world and the worst at keeping us healthy. If however you are just trying to navigate through our healthcare system then the book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be a better bet.

Book Review - How Doctors Think

Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Jerome Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, but Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy it is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence. As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating. The book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System has more practical tips and suggestions on how to get the right care.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States. Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded and see that the world he trained in is far different than the world his trainees are about to enter.