Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine (review)

Medical historian Gerald Grob and medical sociologist Alan Horwitz provide an important and carefully crafted interdisciplinary analysis of how numerous therapies are introduced into clinical practice in the absence of clear and compelling data and kept alive by a combination of faith, analogy, tradition, ideology, inertia, and politics. As the authors explain, their objective is to call attention to the “weaknesses and exaggerated claims” in the medical care system, especially those that “lead to dubious therapeutic and behavioral interventions and exacerbate the excessive costs of both care and treatment” (ix). In a series of case studies that include peptic ulcer, tonsillectomy, cancer, heart disease, anxiety, depression, and posttraumatic stress disorder (PTSD), the authors explain the extent to which medical practice—both old and new—has been shaped by claims that are frequently unscientific, unproven, and even wrong.

Drawing statistics from Yale physician Paul B. Beson, they note that of 362 diseases accounted for in 1927, over two hundred were treated with therapies found to be “either harmful, useless, of questionable value, or simply symptomatic” (13). They also expertly illustrate this point with examples of newly created illnesses such as fibromyalgia, osteoporosis, PTSD, restless leg syndrome, and chronic fatigue syndrome whose pathobiologies remain unknown and with little agreement as to their diagnostic boundaries. Attempts to explain disease not from any hard-based empirical data but by broad-based social currents anchored in changing environmental conditions illustrate the tenuous ground on which many medical diagnoses and interventions presently rest.

The authors offer sobering lessons surrounding patient advocacy groups for AIDS, breast cancer, and PTSD that have insinuated themselves into the regulatory approval process, including classification and the fundamentals of the randomized clinical trial (RCT). They show how the interdiction of ideological beliefs and fashionable paradigms have seriously impacted the clinical research process and suggest that many interventions have had little relation to the rigors of reductionist science. For example, the challenge of transforming the amorphous symptoms of stress anxieties and depression into discrete categories that include distinctions between normal and abnormal was not resolved with the introduction of the RCT but through coalitions of interested parties such as scientists, clinicians, and pharmacy companies. Nor did the tightly bound categories explained in the multiedition Diagnostic Statistical Manual of Mental Disorders create consensus. In the absence of a biological marker or gene, resolution remains unlikely as neither medical explanations nor therapies reflect rational scientific behavior.

While the authors reiterate several times that their goal is not to denigrate the American medical care system, they nonetheless raise significant questions concerning the validity of many medical explanations, diagnostic categories, and therapeutic claims. Beneath the surface of their critique is clear and compelling evidence that, despite the jingoistic rhetoric expressed in the popular press by those who should know better, the nation’s healthcare system faces serious problems, many of which are systemic in nature. While the nation wallows in the myth that its healthcare system is the best in the world, millions are unable to afford health insurance and many face bankruptcy from billings due to unwanted and unnecessary procedures. Added to this are the exaggerated claims of the pharmaceutical, biotechnology, and device industries which, along with the investment community with its insistence on exponential growth, have co-opted the medical profession and the autonomy of its academic institutions whose clinicians face ever-increasing demands to generate revenue. Statistics showing the United States ranks forty-sixth in life expectancy, forty-seventh in infant mortality, and last among nineteen industrialized nations in terms of deaths that are preventable, provided timely intervention, belie the posturing of politicians. With 44.7 million Americans currently living on food stamps and an ever-growing disparity between socioeconomic classes, is it any wonder that the United States is falling behind as a world power? For Grob and Horwitz, the telltale evidence for...