Book Reviews - JPandS

Book Reviews

Priceless: Curing the Healthcare Crisis, by book’s indictment of “ObamaCare” as the solution, almost always involving Health
John C. Goodman, hardcover, 382 pp, $21, ultimate perversion of incentives, some- Savings Accounts of one type or another.
ISBN 978-1-59813-083-6, Oakland, Calif., thing to which he devotes the final chapter. As Austrian-School economist Yuri
Independent Institute, 2012. His tone is almost cynical in Chapter 4, Maltsev said, “HSAs, after all, are a second-
which in my opinion is the book’s best best solution, the best solution being that
This book takes an extensive but not chapter. all of our money is treated for all purposes
exhaustive look at the current state of Amer- as ‘pre-tax’.” Goodman is an advocate of
ican medicine, the perverse incentives Goodman shows how “managed Medicaid block grants, but I’m afraid he
caused by government interference (pri- competition” perverts insurance, and in sees block grants as an end in themselves,
marily the discriminatory tax code and particular how it leads to insurance plans’ not a stepping-stone toward the
various rules and regulations at the federal over-recruitment of the young and healthy elimination of the programs we seemed to
and state level), and what policy changes with“wellness”programs and other inanities do so well without until the early 1960s.
Goodman thinks would help. that he clearly shows have little or no
connection to better health outcomes. He Three more criticisms: First, I find it
After providing an insightful review on shows how companies simultaneously put curious that he never mentions the
medical economics and detailing the up health barriers to the chronically sick perverse incentive created by the practice
characteristics of health insurance as we when the companies consider that these of “PPO re-pricing (where insurers receive
know it, he provides a comparison with patients’ presence would hurt the plan’s fees for reducing exorbitant hospital bills),”
the more rational concept of casualty profitability. Price transparency and the an activity that perversely leads insurers to
insurance and how this difference is competition that would result are the seek out the most expensive providers.
perhaps the key to why the health subject of Chapter 5, another very good This scam, along with the“uncompensated
insurance industry has deteriorated into section of the book. care” scheme, to which he only gives lip
the quagmire that it is today. service in the next-to-last chapter, are two
Goodman poses and answers various of the most perverting influences in
This distinction, he makes clear, is why questions. Why is there a problem with medical economics, products of a cartel-
insurance companies see physicians and quality? Physicians and hospitals aren’t like arrangement between large hospitals
hospitals, and not the patients they insure, paid for quality. Why is there a problem and insurance companies. Secondly, his
as their customers. He also sees that this with access to care? It’s a matter of supply characterization of “out of network”
deviation from the casualty insurance and demand. Demand is high, because doctors as more likely to be high utilizers,
model is responsible for the appearance first-dollar coverage is provided to the poor and his criticism of patients who go“out of
that insurance companies are getting into through government programs, and network” is inexplicable and without
the practice of medicine, rather than supply is limited because non-emergent justification. Patients go “out of network,”
confining their roles to that of insurer and health issues are not treated by non- often at great expense to themselves, for
risk manager. physician personnel. This was the most the same reason that people lost their lives
radical and libertarian part of the book, and crossing the Berlin wall: because it was
He properly defends the insurance one that I think many AAPS members won’t better on the other side. Patients who go
companies in that their ability to manage like. He sees no problem with nurses and “out of network” typically do so for only a
risk has been almost completely ham- pharmacists diagnosing and treating short time, until they can escape the fraud
strung by state and federal regulations, in patients for minor problems. He appears to (restricting accesses to the best physicians)
particular guaranteed issue and mandatory agree with the libertarian concept that that “the network” inflicted on them.
basic benefits legislation. As an example, he licensure benefits those licensed, primarily Thirdly, it would have been nice to see a
cites the fact that a young, single male can’t providing a barrier to competition, quantification of the subsidy that the “not
buy an insurance policy that excludes courtesy of the state. for profit,” non-tax paying status of
pregnancy or breast cancer benefits. hospitals represents.
Unfortunately, Goodman does not
In Chapter 4, “What Being Trapped bring this same libertarianism to some of If you are a left-wing, pro-“ObamaCare”
Means for You,” he interestingly annihilates his other arguments, for example, his ideologue, you are not going to like this
the concept of practice guidelines by premise that healthcare is a right. book.Virtually every myth espoused by the
dissecting the methodologies of the study Government, using your money and mine, proponents of national healthcare receives
protocols provided for their development. is always there to catch the fallen. There is the flogging it deserves with Goodman’s
As if this were not enough, he continues to no mention of churches or civic organ- painstaking analysis. If, however, you are a
compare casualty insurance to current izations. There always seems to be a libertarian, sympathetic to the economics
health models with the perverse incentives gigantic, Newt Gingrich-style national
that follow. This is the first point in the

62 Journal of American Physicians and Surgeons Volume 17 Number 2 Summer 2012

promoted by Dr. Ron Paul and the Austrian Kabat writes that public health science scientific inquiry, Kabat met the self-
School, you, too, will be annoyed by parts and human effects research has been righteous fury of the zealots in the Church
of Goodman’s newest book. That hijacked by agencies that need a panic to of the Holy Smoke Haters.
healthcare is a right, for instance, is taken maintain their government funding, and
for granted in this book, as Dr. Goodman depart from any reasonable scientific Kabat was apparently shocked and
would have the government, through norms when reporting on the latest public dismayed to find out that UCLA would
manipulation of the current confiscatory health “crisis.” Despite rising life expec- attempt to destroy Enstrom’s 35-year
tax code, playing a predominant role in tancies, the theme is“be afraid.” career in 2010 and 2011, and that the anti-
provision and financing of medical services smoking crusade would unleash its
in this country. Kabat begins by discussing the assault on Enstrom and Kabat with no
sociology of science and the development regard for professionalism or traditions of
G. Keith Smith, M.D. of an anti-science, fallacious, “consensus” skeptical and thorough scientific inquiry.
Oklahoma City, Okla. approach that no longer maintains During the initial embargo period before
scientific skepticism or demands solid publication, the anti-smoking crusaders
Hyping Health Risks: Environmental evidence. This approach takes advantage staged a press conference condemning
Hazards in Daily Life and the Science of of public ignorance. the Enstrom and Kabat paper—without
Epidemiology, by Geoffrey C. Kabat, having seen it.
hardcover, 250 pp, $28.13, ISBN 978-0- In separate chapters, Kabat debunks
231-14148-2, New York, N.Y., Columbia some of the most prominent scares: en- The storm that this unleashed moti-
University Press, 2008. vironmental chemicals as a cause of breast vated Kabat to write this book about the
cancer; electromagnetic fields below the decline of epidemiology into savagery. He
Dr. Geoffrey Kabat, a cancer epidemi- threshold of effect as a cause of cancer; ra- explains how epidemiologists funded by
ologist at Albert Einstein College of don, a very short-lived isotope, as a lung political entities can be corrupted and
Medicine and the School of Medicine of cancer risk in housing; and finally an area become shills for their sponsors. The
the State University of New York at Stony that he knows very well—second-hand assertions and conclusions of public
Brook, writes an important recent addition tobacco smoke. health research should be reviewed with
to libraries of those who worry about junk skepticism, and always considered in light
science in the service of political agendas. An innocent who followed the data, of politics and the underlying motivating
Kabat was sensitized to the nonsense of factors—funding, power, prestige, and
He follows on the work of many, public health science in the service of ambition.
including Steve Milloy, Michael Gough, political agendas while collaborating with
Peter Huber and Ken Foster, Tom Bethell, James Enstrom, Ph.D., epidemiologist at the In his polite and erudite way, Kabat
Sally Satel, Michael Fumento, Indur UCLA Jonsson Cancer Center, in an emphasizes that “consensus” science is a
Goklany, and others who point out the American Cancer Society study of second- trap and must be measured by an objective
unreliability of government-sponsored re- hand smoke that followed more than 40,000 standard, free of political agendas. He
search in toxicology and epidemiology. people and found no adverse effect.1 explains how methodology and data
Kabat’s book is an excellent exegesis on Specifically, non-smoking spouses of management can be driven to produce
the problems of modern public health and smokers had no increased rate of cancer or desired results, and how small asso-
human health effects research, and the disease and premature death.This study was ciations are easy to“find”in a data dredge.
derivative policymaking by agencies that consistent with the results of a multicenter
sponsor unreliable science. European study published in the journal of The rule is to follow the money, which
the U.S. National Cancer Institute,2 but no comes from the federal government, its
As a former public health official and matter, Enstrom and Kabat had crossed the surrogates, and allied non-governmental
lecturer, writer, and researcher in public line. The international anti-smoking entities on the Left. The agenda has
health research, I consider human effects campaign was energized and began a nothing to do with public health, but is
public health science and environmental campaign of vilification and calumny. related to statist causes. Under the mantle
health science and policymaking to be a of “science,” charlatans and poseurs can
wreck, and Kabat explains in a lucid way The Enstrom and Kabat study was substitute loud talk for good evidence. It is
why that is. Policymaking on public health potentially devastating to anti-smoking a shame, but a reality.
problems and the regulatory and activists, who had adopted the strategy of
interventional activities of state and na- eliminating smoking by making smokers John Dale Dunn, M.D., J.D.
tional health officials are frequently pariahs, and if possible, quasi-criminals and Brownwood, Tex.
misguided, but never without effect. The a health nuisance—by making second-
problem has become worse over the last hand smoke a carcinogen and disease- REFERENCES
20 years, with more and more panic- causing toxin.
mongering. Consider public officials’ 1 Enstrom JE, Kabat GC. Environmental tobacco
behavior each flu season, for example, and In his book The True Believer, Eric Hoffer smoke and tobacco related mortality in a
how often their predictions about public writes that fanatics are not dissuaded by prospective study of Californians 1960-1998. BMJ
health issues are wrong. Recall, for evidence—they are joiners and believers. 2003;326:1057-1066. Available at: www.
example, the induced panics over avian flu They hate those who disagree with them, bmj.com/content/326/7398/1057.full. Accessed
and heterosexual AIDS. and are confident of their superiority and May 9, 2012.
righteousness. When he pointed out their
failure to uphold the standards of good 2 Boffetta P, Agudo A, Ahrens W, et al. Multicenter
case-control study of exposure to environmental
tobacco smoke and lung cancer in Europe. JNCI
1998;90:1440-1450.

Journal of American Physicians and Surgeons Volume 17 Number 2 Summer 2012 63

Tarnished Gold: The Sickness of proof” and “gold standard” methods. The The authors illustrate how this can harm
Evidence-Based Medicine, by Steve authors show that EBM removes the critical patients with two examples of a major
Hickey and Hilary Roberts, paperback, 342 authority in medicine from the decision- medical advance that repeatedly has been
pp. $39.95, ISBN 978-1466397293, making skills of the physician, that it harms rejected by mainstream medicine. In 1949,
CreateSpace, 2011. patients and suppresses medical progress, in the midst of a polio epidemic, Dr.
and that it suffers from a series of Frederick Klenner, a family physician in
“EBM erodes the autonomy of the fundamental errors that make it both North Carolina, reported at an annual
physician and restricts patient choice.” irrational and unscientific. meeting of the American Medical Asso-
“EBM is junk science…. It has no underlying ciation that he had cured 60 acute polio
rational structure…. There is little, if any, EBM is widely defined as “the conscien- patients with massive doses of parenteral
tious, explicit, and judicious use of current vitamin C. All recovered quickly without
prospect of a rational defense of its best evidence in making decisions about sequelae. Not one died or even developed
methods.” the care of individual patients,”where“best any paralysis. At least eight other physicians
evidence”is not defined. But as the authors have since confirmed his results.
“Unlike EBM, science does not rely on note, in scientific medicine there is no such
reaching a consensus.” thing as “best evidence”; there is only Their second example is the incredible
information, and information is not the story of Allan Smith, a 56-year-old New
Steve Hickey and Hilary Roberts same as knowledge or wisdom. Zealand farmer who contracted a severe
case of swine flu in 2009 and was given
Over the past several decades a To show why EBM is wrong, Hickey and Tamiflu. His condition rapidly deteriorated,
marked change has occurred in the Roberts explain the use of statistics and and he developed pneumonia. He was
science used in medicine. The change has probability, describe the difference placed on extracorporeal membrane
had consequences for patients and for our between accuracy and precision, and show oxygenation (ECMO) for three weeks. At
ability as physicians to practice effective, how to use a decision tree. They discuss the that point the hospital insisted on
rational medicine. It has led to the use of scientific method and the use of Bayes’s terminating his life support. His physicians
evidence-based medicine (EBM) with its theorem and describe the proper role of refused the family’s request to give paren-
reliance on statistics, large clinical trials, the clinical trial. They explain the problem teral vitamin C. (It was not an “evidence-
and meta-analyses. of bias in the use of “best evidence” and based” treatment.) But the family persisted
describe the curse of multiple risk factors in and intravenous vitamin C was given at 50
EBM was introduced around 1991, and epidemiological studies. They also show grams twice daily for six days. His lung
the following year the Journal of the why correlation is not the same as function rapidly improved, and ECMO was
American Medical Association launched causation, why evidence is not the same as stopped on day 5. He began breathing
EBM as a new initiative. Soon the British expertise, and why meta-analysis is without a ventilator. But the vitamin C was
Medical Journal and its editorial staff unscientific, biased, and irrational. then stopped, and his condition quickly
promoted it, and it was accepted by the worsened. The family had to hire a lawyer
British National Health Service. In this EBM is based on epidemiology, which is before his physicians would resume the
country, laws have been proposed in a the study of disease in populations. But a vitamin C treatment. Smith eventually
number of states to require its use. population value, from group statistics, recovered completely and returned to
cannot be applied to an individual patient. farming.
EBM has been promoted as a panacea Group averages tell us nothing about the
at the expense of medical science, yet it individuals who are in the group. This Finally, the authors explain how EBM’s
never has been subjected to empirical statistical blunder, the ecological fallacy, statistical approach provides a legal
testing. It exists in a world where has been recognized for many years and framework that supports management
epidemiologists and statisticians have has been well documented in the literature. and governance of medicine and
risen from technical support to become encourages totalitarian medicine. As they
arbiters of medical science. Another problem with EBM is its point out, its greatest value is for
reliance on the large clinical trial. EBM governments, corporate medicine, and
Many physicians have discredited its defines the clinical trial as,“a well-designed the medical establishment—not for
validity over the past 16 years, notably Dr. large-scale, double-blind, randomized, practicing physicians.
Bruce Charleton of Newcastle University, placebo-controlled, [clinical] trial.” The
UK, and Dr. Martin Tobin of Loyola authors assert that most of these large trials As Dr.Tobin has noted, utopian projects
University, Chicago. The EBM controversy are wrong and that they often find clinically aimed at eradicating uncertainty and
was featured in a 2008 point-counterpoint unimportant results that lead to ineffective introducing good have produced more
editorial in Chest, the Journal of the treatments. misery than good fortune. Tarnished Gold
American College of Chest Physicians. It has exposes EBM as a costly failure. Physicians
been spoofed as Eminence-based, EBM wants to cure the autonomy and and the public should hold the medical
Vehemence-based, Eloquence-based, authority of the physician and the establishment, public health professionals,
Providence-based, Diffidence-based, subsequent variability in care, but epidemiologists, and health economists
Nervousness-based, and Confidence- according to the authors, in practice it responsible. Eliminating the scourge of
based Medicine. creates a rule-based approach where the EBM from our profession will save money
freedom of physicians to treat their and lives, and improve our health.
Although many intelligent, well- patients is inevitably compromised. It
educated people still believe in EBM, their condemns the experience and obser- Jerome C. Arnett, Jr., M.D.
faith is based on an illusion. In Tarnished vations of physicians as anecdotal. Helvetia, W.V.
Gold, authors Steve Hickey, Ph.D., and
Hilary Roberts, Ph.D., challenge EBM’s
accepted claims of providing “scientific

64 Journal of American Physicians and Surgeons Volume 17 Number 2 Summer 2012



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