To start off 2015, I offer my list of the seven most memorable healthcare books of the last year. The list includes three books that confront head-on the difficult issue of patient death, three more on politics and money in healthcare, and finally, my vote for The Most Memorable Book of 2014.
Looking Death Straight In The Eye
Because questions about the end of life are so profoundly embedded in our cultural understanding of healthcare, it will be critical to address them as we journey forward with health care reform. Yet relatively little has been written recently about questions regarding the end of life. Three memorable books this year changed that, reflecting on patient death from very different perspectives.
The first book takes a no-nonsense approach to what happens in the emergency room. ER physician Steven Bentley's fascinating memoir, A License To Heal, recounts amazing feats of medical heroism and savvy: car wreck victims stabilized, chest X-Rays pinpointing hidden bullets, spinal meningitis diagnosed just in time. I was raised on the TV image of the ER, so I read each story waiting for the patient to recover. But in fact, most of the time the patient died, a fact Bentley treats as unremarkable.
Atul Gawande's 2014 Journey
Bentley does not believe that medical intervention is a failure when the patient dies -- some people are very sick, and though clinicians try their best, recovery is not possible. Not all physicians have similar ease with the subject. Dr. Atul Gawande writes about patient mortality with searing candor in his book Being Mortal: Medicine and What Matters in the End.
Gawande describes his journey to understand how American medicine's concept of patient death as a medical failure can lead to a very harsh and avoidable cruelty to patients. When the end of life comes as it inevitably does, many people succumb in isolation and agony when more comforting options existed -- often because their doctors or nurses never really communicated with them about those choices. He calls on hospice nurses and others for advice, and observes some of the questions providers best ask people facing life's most difficult choices.
Hospice nurses figure into another notable book this year, by an ICU nurse who spent a year doing home care nursing. Like Gawande, in Bringing It Home: A Nurse Discovers Health Care Beyond The Hospital, Tilda Shalof is critical of the way patients often die in the hospital. "I have witnessed some horrific deaths," she recounts. She describes the hospice center as championing the experience of death as aligned with the desires of the patient, concluding "there should be midwives for death as there are for birth."
Three Books On Politics And Money In Healthcare
Once upon a time, people would be denied insurance coverage for preexisting conditions, or they would worry about their uninsured 20-something kid. These things still happen, but the safety net has now tightened. Ezekiel J. Emanuel's defense of Obamacare, Reinventing American Health Care, is a powerful and articulate reminder of what the groundbreaking legislation was designed to fix. In the book, Emanuel describes some of the lesser-known provisions of Obamacare that change the way payments flow to providers, aimed at creating the right incentives. He's bullish on accountable care organizations (ACOs), digital medicine, and the cost and quality advantages of competition on the state exchanges.
Wall Street Versus Washington
Another book in 2014 was the yin to Emmanuel's contemplative yang: Where Does It Hurt?, by Jonathan Bush and Stephen Baker. Though the scion of a legendary political family (he's the nephew and cousin, respectively, of Bush 41 and 43), Bush has approximately zero tolerance for Washington politics. Bush doesn't have time for coming up with the perfect regulatory environment or designing overarching payment reforms that will structure incentives that work for the populace at large. Instead, Bush wants entrepreneurs to bang down the doors of healthcare and compete with the hospitals and health systems he sees as inefficient dinosaurs that don't know how to satisfy their patients.
Yet, neither Emanuel nor Bush fully addresses a problem in healthcare that causes untold suffering and wastes upwards of a quarter of health dollars: the problem of unnecessary care. But Paul A. Ruggieri's brave book, The Cost of Cutting: A Surgeon Reveals The Truth Behind A Multibillion-Dollar Industry, confronts the problem head-on. In his brutally candid writing, he describes an encounter with a patient referred for removal of gallstones: "For a brief moment -- and this is difficult to admit -- I found myself tempted to schedule the surgery. A completely unnecessary surgery. The operation would have taken 20 stress-free minutes. Mrs. Brogan would have gone home a few hours after the operation, and I would have been paid close to $1,000."
The problem, as Ruggieri sees it, is that surgeons are paid by volume, not by the success and necessity of the procedures they do. Right now, neither the Affordable Care Act nor the unleashed fury of healthcare entrepreneurship alone can address the profound problems raised by Ruggieri. Books like these help peel back the veil of healthcare to enable us to see clearly enough to forge ahead responsibly, through the confusion of money and politics.
The Most Memorable Book: Rethinking How We Stay Healthy
So far, all the books on my list have focused on the treatment of disease, on caring for the sick. But my vote for the most memorable book of 2014 focuses on keeping us healthy: Nina Teicholz' The Big Fat Surprise: Why Butter, Meat & Cheese Belong in a Healthy Diet. For 10 years, Teicholz dissected the studies and interviewed the scientists, and found that for decades, Americans have relied on precisely the wrong advice about pursuing a healthy diet. The evidence is overwhelming, as Teicholz convincingly demonstrates: Saturated fat does not clog your arteries. It is, in fact, good for you.
Sure, this sounds preposterous. But Teicholz cannot be consigned to the loony bin. She's a credible reporter and diligently sticks to the facts. The book has been favorably cited by the toughest media critics at the Wall Street Journal and the Economist. Still, it's hard to believe that over the decades, hundreds of scientists and nutritional authorities have been flat-out wrong, or worse, deliberately misleading. But that's what makes the Teicholz book so memorable: She deftly explains how the confluence of science and politics that permitted highly questionable public health recommendations to be treated as settled facts.
Have we built an edifice of nutrition science on the foundation of a false hypothesis? The case in the book is convincing. It might explain why so many efforts to improve nutritional health have proved futile. For instance, policies to improve the nutritional profile of school lunch programs are sparking outright revolt from students. Americans are desperate to lose weight, fueling a $2 billion diet industry, but the rising prevalence of obesity continues unabated. Large- and medium-sized employers are investing in prevention and wellness to an unprecedented degree, but independent studies have not found that these programs achieve meaningful ROI.
If Teicholz is right, and some of the fundamental assumptions of nutrition science don't stand up to the evidence, we have lost unfathomable time and money going down the wrong path. The health of the population has suffered. Teicholz may be the Rachel Carson of the nutrition movement, and I hope her book is remembered long enough for us to reverse course and begin to make real progress for the next generation.