How Medicine is Really Practiced in America in "How We Do Harm" by Dr. Otis Brawley

In his book How We Do Harm: A Doctor Breaks Ranks about Being Sick in America, Otis Brawley illustrates the battle between honest medical practice based on ethics and evidence-based science and corrupt medical practice that seeks greed, clinical experiments that cause harm and inadequate standards. Ethical importance encompasses: to do all things reasonable to prevent injury to patients, prevent medication errors, provide individuality of care to every patient, deal honestly and openly with patients and contemporaries, and take ownership of nursing/provider judgment and actions. The aspect of the book that had the greatest impact on me is the display of honesty and skepticism of how providers practice. Before I was a nurse, I was a patient. As a patient I believed that my providers were up to date on the best evidence and practice and that my provider would hold my best interest at stake. When I became a nurse, I realized that this is not always true. There are good knowledgeable honest providers and there are those that just get by with basic knowledge enough to provide care and make a pay check. Organizations tend to adhere to the same mold. It is time for honest providers to speak out just as Otis Brawley and call the standards of care to rise to the occasion to point to the evidence and not make up the rules as they go. “The hallmark of the health care professions is that our actions are directed by a code of ethics”. Inappropriate and inadequate polices and standards deny nurses and providers an opportunity to provide proper patient care thus it compromises their ethical responsibility.

The current “social mandate” of healthcare is largely influenced by the individual mandate of the Affordable Care Act (ACA) and how healthcare budget is affected through federal, state, and private insurances by directly linking quality to payment and patient satisfaction. Under the ACA, individuals are required to purchase insurance or receive a penalty if they are not covered by some type of insurance entity. In 2019 this mandate will end, and individuals will no longer receive a penalty. The upcoming year will bring many concerns as America eliminates the penalty for not having insurance, modifies Medicaid and Medicare, secures funding for the opioid crises, and attempts to decrease drug spending with decreased prices. Changes begin with those in leadership positions. Advanced Practice Registered Nurses (APRNs) can serve as great mediators to shape public policy and standards. APRN’s are educated in advanced communication skills/processes to lead quality improvement and initiatives in health care systems. APRN’s must seek support that esteems the profession of nursing and empower them by including them in the process as respected shareholders. In doing so, APRN’s are empowered to enhance the health of their patients. We as professionals of healthcare are bound by duty to serve our patients and give them quality care.

Dr. Brawley discusses in Chapter 20 and Chapter 21 how he witnessed the harm associated with unnecessary healthcare and screenings based on the thinking that screenings decrease mortality when they are found early (Brawley, 2012). He describes a man by the name of Ralph whose wife sees an ad for free prostate screening and is persistent her husband must be screened. This screening leads to a biopsy, an internist for hypertension, radical prostatectomy by use of da Vinci robot that causes impotence and incontinence, a remaining piece of the prostate that produces 0.9 Prostate Specific Antigen (PSA), and radiation that causes rectal proctitis that in turn forms a rectal fistula into the bladder that requires colostomy and ureterostomy. He explains that there are debates in the usefulness of prostate screening and how the studies he conducted missed as many cancers as it found. The type of cancer Ralph had based on the knowledge of that era left questions of to treat or not to treat. Ralph had now lost a high quality of health due to a screening, when in fact he may have been fine without treatment. Brawley compounds the need for defining disease criteria and evidence-based practices based on hard science verses relative risks and theoretical treatments. In the same chapter, he also expounds how trials found that the use of radiography exposure revealed more risk for mortality than life saving measures. One study suggests that screenings possibly will reduce cancer specific mortality, but that overall mortality is not decreased.

In chapter 5, Brawley describes Mr. Schmidt as an “insured,” white male with colon cancer seeking care from a well know physician whose specialty is not colon cancer. Brawley expresses his disgust with the system for the insured who accrue great expense through suboptimal care, medications, lost time at work, and eventually loss of insurance while the physician is making money. Mr. Schmidt was forced to go to Grady Hospital due to lack of finances but in turn he was treated with the right treatment and became disease free. One study of non-trauma center emergency departments (EDs) verses transfers to trauma centers emphasizes that patients need should come before the patient’s ability to pay; this article revealed that the insured are receiving less quality of care while paying out at a non-trauma ED when their critical illness requires transfer to a trauma center.

One ethical issue I found appalling in Brawley’s book was how the patient so easily influenced a physician to give unnecessary treatment upon the patient’s persistence even though it was against standards and evidence-based practice. Brawley sounds throughout his book that more is not better. Debbie Kurtz fears return of cancer and contacts several doctors about receiving more treatment for Dukes’ A colon cancer. Debbie received all proper treatment based on the most current medical evidence for Dukes’ A colon cancer. Debbie disregards this information, one doctor chooses to give her treatment based on the thought that if he did not someone else would, and the insurance pays for this unnecessary treatment due to limited information. Even though Debbie had surgery to remove the cancer and a clean post-op pathology report she chooses to do harm to herself. Providers should practice with the best interest of the patient in mind even if that means telling a patient NO, to ensure they are doing no harm.

Brawley addresses the culture issues of the African American population’s fear of medicine and physicians during his time. These fears derived from exclusion of the system, past unregulated trails that caused many deaths of African Americans, and fear that was conceived because they felt doctors were only practicing on them and really had no clue how to treat them. These outlooks produced distrust, suspicion, and skepticism for the system.

One health policy issue that stands out the most to me in Brawley’s book is the health disparities gap. He addresses the difficulty to attain good health based on economic status, race, and gender. He gives many examples of how Grady Hospital takes the uninsured, desperate, unwanted patients that have such poor health outcomes due to disparities. Edna Riggs admits she delayed seeking medical attention due to fear of dying and lack of insurance. APRN’s can be great mediators to policy makers to help reduce the gap in health disparities through bills and legislation that address social determinants of health that are directed at purging health disparities among underserved populations like Edna Riggs.

In conclusion, Brawley emphasizes that it absolutely takes more than one person, it requires everyone to be fed-up with the system. As healthcare professionals on all levels work together it demands methods to be deliberate, calls team members to have a clear role, to back each other up, and notice errors or weaknesses with the current way things are performed. For policies and standards, health resources and promotion, and health care as a whole; to be successful, the collaboration of all healthcare professionals within the health scope are needed to make decisions based on a reliable solid evidence-based science and a decision that is consistent. There is no better approach than for all healthcare professionals to join forces to recognize and reorganize the weakness of policies, standards, and medical unprofessionalism, that leads to increased cost, overtreatment or undertreatment, and a further increase in the gap among health disparities.