Book review: Overtreated

Title: Overtreated: why too much medicine is making us sicker and poorer (2009)

Author: Shannon Brownlee

Publisher: Bloomsbury

There appears to be many books on the topic of overtreatment, overdiagnosis, medicalization, medical error and what’s wrong with modern medicine in general. This book covers all of those topics, but focuses on the simple theme that more medicine does not lead to better health. Instead, it leads to higher costs and worse health.

This book targets the general public, health care providers and policy makers, because they are all part of the problem and can also be part of the solution. They just need to have the problem explained to them.

Brownlee walks us through the problems, starting with the work of John Wennberg, whose initial work on regional practice variation was initially based on the assumption that some people were missing out on healthcare and that there was a need for more. This assumption has led to regulators throwing more doctors at the problem, something that has led to increased costs, increased healthcare, and increased complexity, and worse health. On an individual basis, the assumption that more tests and more treatment are better continues to be the ‘practice style’ that junior doctors are absorbing.

The message is punctuated with reports of individual encounters with the health system. I feel that the over-reliance on case reports and under-reliance on numbers (hard data) makes the case weaker, but it probably makes it more readable.

The book is also entirely US focussed. Some international comparisons would be helpful, but I found the history of medical care in the US  (such as the AMA’s campaign against ‘socialized medicine’) interesting. I can speak from experience that many of the problems flagged in this book are not isolated to the US. I see similar problems here in Australia, and they are occurring in countries like Germany, Japan and even China.

Ascribing causes for overtreatment is not as simple as blaming the doctors; the patients, industry, hospitals and government also contribute. Underlying much of this is the perverse incentives of a system that pays for care, not health. Brownlee reminds us that there are many forces driving increased care (many of them financial) and there is little pushback to stop them: “Doing what’s best for patients is bad for business”. The financial incentives driving industry practice are well known, but I find the influence of financial incentives on expert medical panels particularly worrying – they are the people we are supposed to trust.

The usual areas of overtreatment are targeted, such as spine fusion, cardiac stents, anti-depressants. Interesting to those who are not aware of the problem, but well known to readers of similar books.

Brownlee offers solutions, and takes us through some systems that deliver better health with less ‘medicine’ already exist. The advice for planning future health systems and the patient advice are reasonable and are often based on current working systems.

This book broadly covers what I consider to be the biggest problem in healthcare today, but despite the publication of this book and others like it, the message is slow to penetrate the psyche of the public and the health care providers. Shannon Brownlee is continuing to push her message, beyond this book, and she is one of many who will change medicine for the better.