This week I’ve been reading “How we do Harm, a Doctor Breaks Ranks about being sick in America” by Ottis Brawley, a contrarian view of modern medicine that challenges the myth that your doctor’s motives are driven purely by your wellbeing.

It’s a deep and challenging book from an oncologist with extensive experience of wending his way through the mired fields of morality in medicine, a reality check for those of us who live in the bright and bustling world of healthcare IT.

Otis Brawley, MD, Chief Medical Officer, American Cancer Society, Inc.
Otis Brawley, MD, Chief Medical Officer, American Cancer Society, Inc.

What I like about Ottis’ work is the recognition that changing the healthcare system in America isn’t as simple as writing a new iPhone app or even moving to value based reimbursement. He understands that the problem is deeper than that, and from his perspective as a black American, he draws a deep connection with the civil rights movements of last century, and the need for a fundamental change in ideology.

Many of us who have been in HealthCare are familiar with the concept of the “wallet biopsy”, an idea that Ottis wryly introduces in the first quarter of his treatise. Administered by the hospital financial aid counsellor, this simple test aggregates the so-called Social Determinants of Health into a single biomarker, “the ability to pay”, a number that can be measured with uncanny accuracy.

In the back rooms of American medicine, the analysis of the patient’s financial durability has a glib name: a wallet biopsy. If it returns positive, you stay in the hospital, you get more treatment, you can make a follow-up appointment. If it returns negative, you have little hope of getting consistent care.

This then is the well understood, and often forgotten, truth about healthcare in America. If you can afford care you will receive what you can afford and sometimes far beyond, resulting in massive loans and debt. Once the golden ticket is signed, the hospital owns the keystrings to your wallet and can administer a glut of healthcare services whose goal may be to boost their bottom line.

The other side of the coin is far worse. Ottis speaks of a patient who came into the ED asking to have her breast reattached after ten years of zero-care resulted in an amputation of sorts. Not only could this patient not afford care, she could not afford to obtain access to care for fear of being fired for absenteeism. In working class America taking an hour and a half off each week to go to the hospital is unacceptable, and cancer just has to wait regardless of pain. This is the Walmart way; price care out of reach, or fire sick employees for being sick, and let them heal off the clock.

My friend Samuel Broder, when he was the director of the National Cancer Institute, used to say that poverty is a carcinogen.

At least once a week somebody tells me this will all be fixed with a technology solution. If we “close the cycle”, “engage” patients and physicians, or provide an API we will drive the waste out of the system and it will self heal. This is, of course, completely asinine, and a dreadfully elitist view of healthcare that forgets the sick and homeless, as well as the middle class who have been living paycheck to paycheck and cannot afford to continue the care they had received in better times.

It’s the system that’s broken, but to speak of this hodgepodge of private and public insurers, welfare programs, and focus on the individual to carry overwhelmingly expensive costs as some kind of “system” is verging on insanity. The complex web of dependencies and flows of monies through the system are at odds with concept of western economics where a consumer prices their consumption based on information that can be used to make rational choices. There is nothing rational about this madness, and this is a theme Ottis threads through the book like a single burning thread.

To really fix healthcare, Ottis argues, it’s time for a new civil rights movement, a wholesale shout for change and a redefinition of the social contract that understands we are all patients, be it in moment, or in waiting.

Genuine health-care reform—like the right to vote—will not be granted magnanimously. Like civil rights, the right to good health care will have to be won in public struggle. To bring about real change, real people will have to say, “Enough!”

I’d recommend you give this book a read.

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