Book Review

Might COVID Enable Structural Reforms?

Disclosures

December 18, 2020

When an advanced copy of Code Blue: Inside America's Medical Industrial Complex arrived in my mailbox last year, I was instantly bored, even though I know and respect the author, Mike Magee, MD. Every reading American already knew that our healthcare "system" was a serious long-term mess, generated by a century of failures, as experienced by a public which for millennia had viewed medicine as a service profession — and a century of successes, as experienced by the many planners and players in American Money-Driven Medicine.

How could this roiling chronic conundrum be painted as a sudden "code blue" emergency?

My related 2000 book, Severed Trust: Why American Medicine Hasn't Been Fixed, was a memoir of my 50 years in medicine, how we got into the mess and how to fix it. While it sold well and generated some buzz, nothing really changed much, aside from passage of the Affordable Care Act (ACA) in 2009 — which was a big deal and did make a lot of positive improvements, but which, in order to get the big players to support its passage, further institutionalized American Money-Driven Medicine.

In 2017, I published a Medscape column that asked, "How many books will it take?" listing several titles that were intended to provoke repairs or rebuilds. Still nothing happened.

Then came COVID, adding massive insult to injury of our already overpriced, overworked, bloated, inefficient, ineffective megalith American procedure-driven medicine. It also exposed the long-time squeezed budget that disabled and disrespected primary care and public health systems. It was certain disaster, and spring 2020 was exactly that for much of the United States.

But guess what: America (and many other countries) discovered that medical professionalism is alive and well, even brimming with heroism. Yet as the pandemic roars on, clinical medicine is booming while public health (which depends on government intelligence, coordination and funding) is languishing. Unfortunately, clinical medicine at a physician to patient level will not beat this cascading pandemic; only public health prevention will beat it.

Back to Mike Magee's book. It is now very timely, because the mass stress brought by COVID makes major structural reform much more likely.

"Every system is perfectly designed to get the results it gets."

Thus, in order to redesign a system to achieve different results, it would be helpful to understand how the system became the way it is.

That is what Dr Magee's book does, in 15 chapters and about 400 pages in total, including some 70 pages of numbered references. I won't bore you by repeating the litany of damning facts that both the author and I consider to be "problems" in need of fixing, rather than successful "results" that should be preserved.

What Magee does, perhaps better than anyone else in a single location, is name the people, the organizations, the dates, the decisions, the supporters, and the enablers, as well as the victims and the beneficiaries, in sometimes excruciating, even tedious, detail. Often, the author describes unintended (as well as intended) consequences.

Consider some of the players he discusses: DaVita Inc, Vioxx, Alex Azar, the American Medical Association, Mary Lasker, Joe McCarthy, George Merck, John D. Rockefeller, Estes Kefauver, Frances Kelsey, Antonio Gotto, Vannevar Bush, Lister Hill, Richard Nixon, the Tobacco Industry Research Council, Arthur Sackler, Ralph Nader, Pat Robertson, Jerry Falwell, the American Cancer Society, Michael DeBakey, Pfizer, McKesson...you get the picture. They (and many others) all contributed to the ways things are.

Mike Magee has performed the Herculean task of explaining all this intertwining stuff so that readers can understand how we got here.

Why Magee? His experiences range from country doctor to senior hospital executive, medical journalist, medical university scholar, political insider in organized medicine and American hospitals, and, ultimately, head of Global Medical Affairs at Pfizer.

What to do? Magee provides a succinct but detailed list of basic steps to reform the medical industrial complex. Five actions involve medical education, seven involve clinical research, five involve publications, and six regard marketing.

Incremental, to be sure, but in aggregate, system-shaking, even convulsing.

Of course, Dr Magee opines that universal health coverage is the starting point for a civilized society and states that the total package of reforms must answer the question: "How do we make America healthy?"

Do not expect this to be a quick read, but do expect to learn a large amount of truly interesting information that you did not know and from which you can benefit.

George D. Lundberg, MD, is a contributing editor at Medscape and president and chair of the board of directors of the Lundberg Institute. Dr Lundberg has more than 30 years' combined experience in medical publishing, having previously served as editor-in-chief of JAMA and the 10 American Medical Association specialty journals. Follow him on Twitter.

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