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The book 'Diagnosis, Therapy, and Evidence' by Gerald N. Grob and Allan V. Horwitz examines the gaps and weaknesses in the American healthcare system through a series of case studies. It critiques the reliance on unscientific beliefs and practices in medicine, highlighting issues such as rising healthcare costs, lack of insurance, and distrust in medical professionals and pharmaceutical companies. The authors aim to shed light on these issues to promote better practices and understanding in contemporary medicine.

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302 views14 pages

Diagnosis, Therapy, and Evidence High-Quality Download

The book 'Diagnosis, Therapy, and Evidence' by Gerald N. Grob and Allan V. Horwitz examines the gaps and weaknesses in the American healthcare system through a series of case studies. It critiques the reliance on unscientific beliefs and practices in medicine, highlighting issues such as rising healthcare costs, lack of insurance, and distrust in medical professionals and pharmaceutical companies. The authors aim to shed light on these issues to promote better practices and understanding in contemporary medicine.

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guanngompho.at.tuong
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Diagnosis, Therapy, and Evidence

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Librar y of C ongr e s s C a t aloging - in - Public a tion Da t a

Grob, Gerald N., 1931–


Diagnosis, therapy, and evidence : conundrums in modern American medicine /
Gerald N. Grob and Allan V. Horwitz.
p. ; cm. — (Critical issues in health and medicine)
Includes bibliographical references and index.
ISBN 978-0-8135-4671-1 (hardcover : alk. paper) — ISBN 978-0-8135-4672-8 (pbk. : alk.
paper)
1. Social medicine—United States. 2. Diseases and history—United States. 3. Diagnosis.
I. Horwitz, Allan V. II. Title. III. Series: Critical issues in health and medicine.
[DNLM: 1. Medicine—trends—United States. 2. Diagnosis—United States. 3. Disease—
etiology—United States. 4. Therapeutics—trends—United States. WB 100 G8728d 2010]
RA418.3.U6G76 2010
362.1—dc22 2009008097

A British Cataloging-in-Publication record for this book is available from the British Library

Copyright © 2010 by Gerald N. Grob and Allan V. Horwitz

All rights reserved

No part of this book may be reproduced or utilized in any form or by any means, electronic
or mechanical, or by any information storage and retrieval system, without written
permission from the publisher. Please contact Rutgers University Press, 100 Joyce Kilmer
Avenue, Piscataway, NJ 08854–8099. The only exception to this prohibition is “fair use” as
defi ned by U.S. copyright law.

Visit our Web site: http://rutgerspress.rutgers.edu

Manufactured in the United States of America


To the memory of our fathers
Contents

Preface ix

List of Abbreviations xi

Chapter 1 Rhetoric and Reality in Modern American Medicine 1

Chapter 2 Medical Rivalry and Etiological Speculation:


The Case of Peptic Ulcer 33

Chapter 3 How Theory Makes Bad Practice:


The Case of Tonsillectomy 57

Chapter 4 How Science Tries to Explain Deadly Diseases:


Coronary Heart Disease and Cancer 84

Chapter 5 Transforming Amorphous Stress into


Discrete Disorders: The Case of Anxiety 111

Chapter 6 Depression: Creating Consensus from


Diagnostic Confusion 141

Chapter 7 Post-Traumatic Stress Disorder: The Result of


Abnormal Environments or Abnormal Individuals? 164

Epilogue Where Do We Go from Here? 192

Notes 199

Index 243

vii
Preface

Americans are besieged by advice about the efficacy of medical therapies and
drugs as well as behavioral and dietary modifications that will presumably
prevent disease, promote health, and extend longevity. Scarcely a day passes
without revelations about new medical breakthroughs that will presumably
overcome the ravages of age-old diseases. Faith in medical progress leads the
United States to spend far more than any other industrialized nation on its
health care system. Yet such health care indicators as longevity, infant mor-
tality, access to care, and the effective management of chronic illnesses lag far
behind other nations. Indeed, the claim that the United States has the world’s
best health care system belies the facts.
In this book we have collaborated across disciplinary lines and present
a series of case studies to illustrate gaps and weaknesses in the medical care
system. One of us (Grob) is a medical historian and the other (Horwitz) is a
medical sociologist. Both of us, however, share assumptions and beliefs that
transcend disciplinary lines, and we have produced an analytic work that
hopefully sheds light on a series of contemporary medical issues. We have
found that a substantial part of the contemporary literature dealing with
therapeutic efficacy, diagnoses, epidemiology, and evidence ignores longitu-
dinal and historical data, to say nothing about methodological inadequacies
and claims that rest largely on faith. Our goal in writing this book, however,
is not to denigrate the medical care system. It is rather to call attention to
some of its weaknesses and exaggerated claims that lead to dubious thera-
peutic and behavioral interventions and exacerbate the excessive costs of
both care and treatment.
We would like to thank William Rothstein, Janet Golden, and Doreen
Valentine, who provided valuable suggestions on an earlier draft of the manu-
script. Naomi Breslau and Jerry Wakefield made many astute recommenda-
tions regarding the PTSD chapter. Part of the material in chapters 2 and 3
is taken from Grob’s “The Rise and Decline of Tonsillectomy in Twentieth-
Century America,” Journal of the History of Medicine and Allied Sciences 62
(October 2007): 383–421, and “The Rise of Peptic Ulcer, 1900–1950,” Perspec-
tives in Biology and Medicine 46 (autumn 2003): 550–566. Both are reprinted
with the permission of Oxford University Press and the Johns Hopkins

ix
x Preface

University Press, respectively. Some of the material in chapter 6 is adapted


from Horwitz’s book with Jerry Wakefield, The Loss of Sadness: How Psychia-
try Transformed Normal Sorrow into Depressive Disorder (Oxford University
Press, 2007). We would also like to acknowledge the immense contributions
that David Mechanic, the director of the Institute for Health, Health Care
Policy, and Aging Research, has made to our research. Horwitz would also
like to express his appreciation to Rector Wim Blockmans, the staff, and the
fellows of the Netherlands Institute for Advanced Study for providing him
with resources, time, and an unparalleled scholarly environment to write a
draft of this book during his stay in the 2007–2008 year. He is also grateful
to Rutgers University for providing him with a Competitive Fellowship Leave
that allowed him the opportunity to visit NIAS.

Gerald N. Grob
Allan V. Horwitz
Abbreviations

ADHD attention-deficit/hyperactivity disorder


AIDS acquired immune deficiency syndrome
AMA American Medical Association
APA American Psychiatric Association
CDC Centers for Disease Control and Prevention
CFS chronic fatigue syndrome
CHD coronary heart disease
CT computed tomography
DSM Diagnostic and Statistical Manual of Mental Disorders
ECA epidemiologic catchment area
FDA Food and Drug Administration
FAS fetal alcohol syndrome
GAD generalized anxiety disorder
GDP gross domestic product
HDL high-density lipoprotein
HIV human immunodeficiency virus
HP Helicobacter pylori
HRR hospital referral region
ICD International Classification of Disease
LDL low-density lipoprotein
MDD major depressive disorder
MRI magnetic resonance imaging
NCI National Cancer Institute
NCS National Comorbidity Survey
NIMH National Institute of Mental Health
NSAID non-steroid anti-inflammatory drug
PSA prostate-specific antigen
PTSD post-traumatic stress disorder
RCT randomized controlled trial
RLS restless legs syndrome
SSRI selective serotonin reuptake inhibitor
T&A tonsillectomy/adenoidectomy
WHO World Health Organization

xi
Diagnosis, Therapy, and Evidence
Chapter 1

Rhetoric and Reality in


Modern American Medicine

Most Americans believe that their health care system is the best in the world.
Yet they do not recognize the extent to which many claims about the causes of
disease, therapeutic practices, and even diagnoses are shaped by beliefs that
are unscientific, unproven, or completely wrong. To so argue is not to con-
demn American medicine, which admittedly has many strengths, but rather
to point to rhetorical claims and practices that rest upon shaky foundations.
What we have chosen to do in this book is to present a series of case studies
that illustrate the weaknesses of many prevailing beliefs and therapies. In so
doing we can not only learn from these examples, but fi nd ways to do better
in the future.

The Contemporary American Health Care System


For much of human history death was associated with the infectious diseases
that took their heaviest toll among infants and children. Beginning in the late
nineteenth century—for reasons that are not clearly understood—infectious
diseases began to decline as the major causes of mortality.1 The reduction
in mortality among the young permitted more people to reach adulthood
and thus to live longer. Under these circumstances it is not surprising that
long-duration illnesses—notably, cardiovascular-renal diseases and a variety
of neoplasms—became more prominent elements in morbidity and mortal-
ity patterns. These diseases were associated with advancing age; the longer
individuals lived, the greater the risk of becoming ill or dying from them. In
one sense the increasing prominence of long-duration (or chronic) diseases

1
2 Diagnosis, Therapy, and Evidence

was in part a reflection of the fact that more and more people were enjoying
greater longevity.
To be sure, the decline in mortality from infectious diseases preceded
antibiotic drug therapy. Yet the introduction of these and other drugs after
World War II reshaped both medical practice and public perceptions. If
infectious diseases could be conquered by antibiotic drugs, why could not
long-duration diseases also be eliminated by new medical therapies? Slowly
but surely Americans, for a variety of reasons, came to believe that the medi-
cal care system could play a crucial role in conquering disease and extend-
ing longevity.
Yet Americans manifest ambivalent and even contradictory attitudes
about their health care system. They take it as an article of faith that a sci-
ence-based system has the capacity to reduce morbidity and mortality and
thereby improve the quality of their lives. They point with pride to a health
establishment that in their eyes is superior to that of any other nation. They
believe that medical schools turn out the best-trained physicians; that a vast
hospital system with its array of imposing technologies provides the most
up-to-date therapies; and that pharmaceutical companies have the capacity to
develop innovative drugs that both treat and prevent disease.
Beneath the surface, however, there is considerable unease. Constantly
rising health expenditures remain a source of concern. Millions of Ameri-
cans lack health insurance and many are forced into bankruptcy because of
huge medical bills resulting from various illnesses. The increasing bureau-
cratization of the medical care industry has diminished the element of trust
between patient and physician, giving rise to fears that doctors do not always
act in the best interest of patients. There is concern that insurance compa-
nies, in an effort to contain costs, shape treatment protocols in ways that are
in their fi nancial interests. Faith in medical therapies is tempered by fi nd-
ings that question their efficacy as well as by the prevalence of iatrogenic
diseases (illnesses induced inadvertently by a physician, surgeon, or health
care professional, or by any medical treatment or diagnostic procedure, or
from a harmful occurrence that was not a natural consequence of the patient’s
disease). Distrust of the pharmaceutical industry is widespread because of
revelations that harmful side effects of drugs are sometimes hidden, that
the efficacy of many drugs is exaggerated, and that fi nancial relationships
with physicians have adverse consequences for patients. After an explosion
of psychotropic drug use during the 1990s and early years of the twenty-fi rst
century, controversies have arisen about their effectiveness, negative side

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