Review: How Medicine Works and When It Doesn't

 How Medicine Works and When It Doesn't is a book by Yale doctor and physician Perry Wilson. It is readable, funny in many parts, and well-written. For instance, he describes a surgeon's interaction with a family of a patient who's undergone surgery:

I remember listening to one of the cardiothoracic surgeons talking to a family after a large aortic arch repair. The patient had done well but was still unconscious, on the breathing machine. The surgeon, an expert by any definition, explained that the surgery was essentially flawless; in a few days, the patient would be up and around, out of the hospital within two weeks. “Thank God,” his wife said. “No, no. You do not thank God,” the surgeon said. “You thank me.” (pg 245)

I laughed out loud reading about it.  The book first describes what is very basic to scientists: correlation is not causation, and bayesian reasoning. He then points out that because of these problems the best way to identify causation is through randomized controlled trials. Even those are subject to errors and occasionally outright fraud.

He points out that even the best studies and the best outcomes from clinical trials of a new drug has to be done on a population statistical level, which means that in many cases, there's a ton of uncertainty as to whether or not a new drug or treatment will help you:

There is no “one thing” that will help you live longer. There are healthy things, and less healthy things, and unhealthy things. People who adopt multiple, broadly healthy lifestyle choices—from what they eat and don’t eat, to how much exercise they get, to the kinds of activities they take part in—live longer. The problem is no one wants to click on an article saying MAKE THESE 30 CHANGES IN YOUR LIFE TO LIVE LONGER. It is not easy to make thirty lifestyle changes. We all want simple solutions to complex problems. (pg 61)

Just as in investing there's no market for "get rich slow" when there are plenty of people touting "get rich quick" solutions. 

What makes medications special is not the fact that they are so incredibly good at saving lives, but that they are easy to use. You can’t change your age, and quitting smoking is tough, but popping a pill is a straightforward action that doesn’t demand too much change in your usual habits. The sobering truth is that drugs operate on the margins—they have an effect, but they aren’t as impactful as we like to think they are.  (pg. 139)

 Wilson even addresses the elephant in the room, which is the American healthcare system, notorious for being inscrutable, heartless, profit-driven, and liable to drive even insured folks into bankruptcy:

there is no industry that pays more money to Congress than the pharmaceutical industry. We may not have the kind of money pharma does, but we do have one thing it doesn’t have: the votes. I have never been a single-issue voter, but if you were to pick a single issue to vote on, I suggest you make it the one that has the most special-interest money thrown at it. That money tells me that the industry is scared—and while Congress members do like their drug money, they like keeping their jobs more. And drug pricing reform is incredibly popular. In a 2021 Kaiser Family Foundation poll, 88 percent of respondents favored allowing the federal government to negotiate what they will pay for specific drugs, including 77 percent of Republicans and 96 percent of Democrats. (pg 183)

Wilson acknowledges the huge amount of wasted money in the system, including on administrators who do not actually provide any healthcare:

In 2019, Healthline crunched the numbers and found that there were ten healthcare administrators for every one doctor in the United States. These administrators do not provide patient care, but they supposedly improve care. Most administrators argue they are making the system more streamlined, more efficient. But there is not much data to support that. The Harvard Business Review looked at the rapid growth of healthcare administration positions and concluded that the only meaningful difference for patients that correlated with increased administrative roles was a reduction in thirty-day hospital readmission from 19 percent to 17.8 percent. HBR also noted that this reduction happened to occur just when the Affordable Care Act imposed penalties on hospitals based on readmission rates.  (pg. 218)

 What about the frequently made statement that our doctors, nurses are overpaid and that's why we have the most expensive medical system in the world? Wilson debunks that too:

About 20 percent of healthcare spending in the United States goes to “physician services,” but physician salaries are only a fraction of that—just 8.6 percent, the lowest percentage of any Western country save Sweden. Since the majority of physicians now work for hospital systems or corporations, that money goes to headquarters and is parceled out from there. In other words, even if you slashed doctor salaries in half, you would save only 4 percent of the Medicare budget. (pg. 220)

Needless to say I found myself highlighting paragraph after paragraph of this book, taking note of new concepts such as NNT. I came away with this book knowing more than when I started it, which means that I recommend it to anyone.