The Chief Complaint - Features - Atlanta Magazine

The Chief Complaint

In an excerpt from his forthcoming book, Emory professor and former Grady cancer director Dr. Otis Brawley pulls back the curtain on the medical machine

Photograph by Audra Melton

For a man with such respectable bona fides—University of Chicago medical school graduate, trained in oncology at the National Cancer Institute, Emory professor, and currently chief medical officer at the American Cancer Society—Dr. Otis Brawley sure knows how to piss people off. Since long before October, when he spoke out to the New York Times Magazine, he’s been accused of prosecuting an irrational “vendetta” against use of the prostate-specific antigen (PSA) test to screen apparently healthy men for prostate cancer. Some critics say he’s killing men by steering them away from this test, which in the best cases leads to lifesaving treatment but in worse cases leaves men impotent and incontinent after treatment for growths that posed no danger.

Brawley is no stranger to controversy. He jokes that he’s the “Forrest Gump of medicine” because he has been in the thick of historic medical advances and debates for thirty years. Mere fortune made Gump a war hero and a shrimp tycoon. But it wasn’t luck that joined Brawley with the team that pioneered the first effective AIDS drugs, or with Surgeon General David Satcher in the battle against health disparities, or with President Clinton in apologizing for the infamous Tuskegee experiment.

In 2002 Brawley became chief of oncology and hematology at Grady Hospital. Though no longer in a leadership position at Grady, Brawley still practices there. His experiences at Grady partly inspired his new book, "How We Do Harm: A Doctor Breaks Ranks About Being Sick in America" (with Paul Goldberg, St. Martin’s Press). In what he calls “a guided tour through the back rooms of American medicine,” Brawley not only takes on the unfolding catastrophe of U.S. healthcare, but also hits closer to home with chilling stories about irresponsible doctors here in Atlanta, such as some who dispense inappropriate, even life-threatening chemo. To accompany the following excerpt, veteran health and medical journalist Patricia Thomas talked with Brawley about his new book.

In your book, you say that instead of having a healthcare “system,” we Americans live in a fragmented universe where famine and gluttony exist side by side. What do you mean? Cervical cancer is a good example of famine and gluttony. Ten years ago, most organizations that issue screening guidelines started saying that women who had two or three normal Pap smears in a row, and who were in a stable relationship, could go to every three years for Pap smears. And many doctors and many middle-class and upper-class women were outraged. They wanted their annual test. Every year about 4,290 women die from cervical cancer. The majority of them have never had a Pap smear, ever. And of those who have, the overwhelming majority had not had one within ten years of their diagnosis. The women who died never got the services they needed. Then you’ve got all the folks who are upset because we say they should be tested every three years instead of every year.

How does practicing at Grady affect your view of what’s happening in healthcare? I see a lot of people who suffer with undiagnosed chronic disease. These are folks who need healthcare and for one reason or another can’t get it. Sometimes they aren’t sophisticated enough to get into the system, or sometimes healthcare is just not available.

You’ve been thinking about the problems of American medicine for years. Why did you do this book now? I actually think we need to transform how we think of healthcare. Most of it is about responding to illness, not about preventing illness in the first place. Last year healthcare costs were 17.5 percent of our gross domestic product. That’s one and a half times the amount in the next most expensive country. On a per capita basis, it’s approaching $8,000 per person. When organizations like the American Cancer Society or the American Heart Association go to hire a clerk who makes $25,000 per year, we have to think about the fact that healthcare coverage for them—if they have a family of four—is upwards of $16,000 per year. If healthcare costs keep growing at the present rate, they’ll be 25 percent of our GDP by 2025. Healthcare is choking our economy.

But don’t some people believe that all this money buys us the best healthcare in the world? When we look at outcomes, such as life expectancy, we rank fiftieth. We have very high infant mortality rates. Even if you look at white male life expectancy in the U.S., it’s lower than places like Canada, whose healthcare system we criticize. We have tremendously more CT and MRI scanners than Canada per capita. People in the United States may not live longer than people in Canada, but we sure as hell do a better job taking pictures of them. We do not get what we pay for out of our healthcare system.

If you were the healthcare czar, what would you do to make healthcare better? We need to change how we reimburse for care. We need to reimburse doctors to coach patients about leading a healthy life. We pay doctors tremendously for sticking things into people and cutting on them, and instead we need to reimburse for teaching patients. [We should teach] kids about healthy eating and physical fitness habits starting in third grade. I don’t see health promotion happening in the United States. Some hospitals have gyms, and we need more of that. Hospitals should be advertising more about nutrition and cooking classes and less about diagnosing your disease early.

Last October you were featured in a New York Times Magazine article about the PSA screening controversy called “Can Cancer Ever Be Ignored?” Why aren’t you convinced that PSA testing saves lives? According to epidemiologic studies, many of these things we find in the early stages are never destined to grow or metastasize and cause harm. Some are; some aren’t. It’s a shame when a man is screened for prostate cancer and not told that his cigarette smoking is more likely to kill him than prostate cancer. I believe men should be told truthfully what the potential benefits are and what the potential risks are. They need to be allowed to make an informed decision.

How do you feel when you are denounced as an enemy of men by patient advocates or even your fellow physicians? Quite honestly, criticism doesn’t scare me very much.

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  1. KatherineL_2082 posted on 02/29/2012 10:51 PM
    Please read my story about my own experience with breast cancer and you will see how duplicitous are many people associated with the disease. My story is posted at (mammograms and dcis). You'll be shocked about

    what we aren't told.
    1. Nathan, MD posted on 04/28/2012 01:33 PM
      @KatherineL_2082 Great article. Unfortunately, the above poster's site doesn't address MANY of the relevant issues regarding the larger picture of nationwide breast cancer screening (I understand it's a huge issue, but what is left out is pretty important), and her misleading representation of the story and her assumptions about the medical system are disingenuous. In the above article, Dr. Brawley briefly touches on prostate and cervical cancer screening issues, but what he says can certainly be more broadly applied. Our medical SYSTEM is deeply flawed, and doctors' medical decision making DEFINITELY isn't perfect, but there's no system-wide "secret" as she alleges that prevents good care.

      Bad doctors here and there, sure. Unethical doctors here and there, sure. A system that makes it difficult for large populations to get good care (like Dr. Brawley focuses on), sure. But read what Dr. Brawley says about cervical cancer screening (Pap smears) at the beginning of the interview section above. A recommendation of less frequent testing for CERTAIN low risk populations of women who have had multiple recent normal Paps caused outrage. "You’ve got all the folks who are upset" Dr. Brawley says, "because we say they should be tested every three years." Yes, IN THOSE POPULATIONS, the evidence says that yearly testing isn't necessary, and all it does is waste money and lead to more false positive tests.

      The same thing applies to breast cancer screening. If your doctor is up-to-date on the latest recommendations, the doctor won't be a burden on the system by ordering too much testing and he or she won't cause unnecessary worry for patients by ordering testing that has a high risk for false positives.

      And, yes, every now and then someone will get cancer, and that sucks. But doing testing the way that Katherine proposes would further bankrupt and cripple our system, and we wouldn't even be doing our patients any favors.
    2. Karen Thomas posted on 04/29/2014 06:12 PM
      @KatherineL_2082 A very vompelling poignant yet uplifting and enlightening communication Katherine. I was immediately captivated and could not stop reading until the end. Thank you for your courage and sharing.
  2. Jeff Kinz posted on 05/01/2012 10:34 PM
    Gee, wow - a person dies because their employer won't allow them to take off a half day instead of a whole day, and they work for the phone company? The Phone Company? which is Verizon, who has a quarter of a million employees, that is to say - 250 hundred thousand people on staff, couldn't find a way to let this lady go see her doctors for a few hours every month?
    2 things need to happen here:

    #1 - Verizon needs to be strongly fined for having policies that contributed to this lady's death
    #2 - legislation needs to be passed to make it illegal for companies to have policies that prevent people from seeing their doctors.

    Third and MOST IMPORTANT: Health care is a service industry for the public. WHY THE HELL ISN'T IT OPEN EVENINGS AND WEEKENDS?????
  3. Accipiter posted on 05/02/2012 11:17 PM
    When I was a student in Atlanta, a girl in my dorm had what I could only call a mental breakdown. She went completely ballistic, was running around half-naked, collapsing, screaming. I called 911 and the first question the operator asked me was, "what is wrong with the woman?" The second question she asked was, "is she black?"

    When the ambulance finally arrived, they kind of dicked around, not really willing to bring the gurney all of 50 feet to the front door (they couldn't drive up to the front door because the dorm was in an arts center and there were pillars in the way. They didn't seem concerned at all, even as they looked at the hysterical girl.

    I found out these guys were sent from (and taking her to) Grady. The way they treated this girl was absolutely insulting and disrespectful. They treated her like she was on drugs (she wasn't. All her friends and roommate said she was strictly anti-drug. Later blood tests showed she was completely clean). They took their time and seemed to not give a single care about this black girl writhing on the floor.

    Eventually they gave her injections of something to calm her down, and then took her off to Grady. I still wonder to this day if I should have lied to the 911 operator and said she was white. I bet you anything they would have sent an ambulance to take her to a different hospital, and maybe the ambulance that came would have treated her more respectfully.
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