Last Well Person: How to Stay Well Despite the Health-care System

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Last Well Person: How to Stay Well Despite the Health-care System

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From the New England Journal of Medicine, March 17, 2005
One of my favorite articles in the medical literature appeared in these pages a little more than a decade ago. "The Last Well Person" (N Engl J Med 1994;330:440-1) was an Occasional Note written by a Tennessee physician, Clifton Meador. It was a fictional scenario that was to take place in the not-too-distant future. The lone character was a 53-year-old professor of freshman algebra at a small college in the Midwest. Despite extensive medical evaluation, no doctor had been able to find anything wrong with him. But he was the only remaining person for whom this was true. Although it was just a story, Meador warned that "if the behavior of doctors and the public continues unabated, eventually every well person will be labeled sick." I share his concern about our proclivity for diagnostic labels and went on to write a book on the topic, specifically as it applies to the increasingly frequent diagnosis of cancer. In mentioning this, my intention is to disclose two opposing potential conflicts of interest -- a commitment to the topic and authorship of a competing work -- that might influence my review of Nortin Hadler's book, which pays tribute to Meador's article by using the same title. Hadler is worried about our increasing tendency to overtreat and overdiagnose. In the first section of the book, he assails the current practices that are relevant to the two most common causes of death in Americans: heart disease and cancer. He suggests that the current management of myocardial infarction and angina "veers towards Type II Medical Malpractice" (treatment is not needed), that coronary bypass surgery benefits only a fraction of the patients who undergo it, and that, although it is a gentler procedure, angioplasty is just as bad. He goes on to suggest that the reduction in absolute risk is too small to warrant cholesterol reduction in the population at large and that the efforts to address the so-called metabolic syndrome (lipid disorder plus obesity, diabetes, and hypertension) with diet and exercise are misguided. His assessment of cancer prevention is equally stark: screening for colorectal cancer will "not affect mortality from all causes," mammography produces "almost nothing of value," and "no man should think that [prostate] surgery will increase his time on earth." It is a brutal critique of much of what we do in medicine. Although Hadler has an extremely high threshold by which to call something beneficial (for a hard outcome such as death, his preferred cutoff is an absolute-risk reduction of at least 5 percent), and although he fails to highlight just how tricky it is to know which patients are among the few who will benefit, it is a critique that thoughtful clinicians will want to read. Hadler's message to the general public is simple: resist most interventions that promise to modify and mollify mortal risks through "hippie-dippie" (HP-DP -- health promotion and disease prevention). Unfortunately, the rationale for this resistance may be less accessible, since important concepts such as confounding, false positive rates, numbers needed to harm, and statistical significance are invoked but not explained. Hadler is also worried about our increasing tendency to "medicalize" common problems. In the second section of the book, he reviews what will be familiar ground for primary care practitioners -- that much of our work involves helping persons who seek relief from symptoms. Here he draws on his experience as a rheumatologist, questioning the usefulness of (or need for) treatment for backache, knee pain, fibromyalgia, and osteoporosis. But the point is more general: "None of us will live long without headache, backache, heartache, heartburn, diarrhea, constipation, sadness, [or] malaise." One choice is to "deal with it"; the other is to seek care and become "a patient or a client with an illness or a condition -- and, likely, forever." Hadler is clearly advocating the former, but his vision of how this might happen is less clear. Although the case he makes for staying away from medical care is compelling, he does not detail any alternative coping strategy. Unfortunately, when it comes to common medical symptoms, a coping strategy is what people really need in order to stay well. H. Gilbert Welch, M.D.
Copyright 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Reviews:

When Nortin Hadler's book, "The Last Well Person," came my way, I realized my mother fit his titular profile to a tee. She lived to 84, just one year short of the ripe old age Hadler believes may be the fixed limit for our species. Her death from cancer, after a full life, did not bankrupt her spiritually or financially. Her body was not wasted by debilitating treatments capable only of keeping her alive a little longer-because she chose not to have any. Her decline began only shortly before her death. She benefited greatly from the palliative care she sought when she could no longer cope with the symptoms she was experiencing. If you want to read her story, link to "Luck of the Dying" in the May-June 2005 issue of Health Affairs: http://content.healthaffairs.org/cgi/content/full/24/3/817?eaf. I practiced as a nurse for thirty-five years, twenty of them as a family nurse practitioner in a clinic providing primary health care to people of all ages and long term care to the elderly and dying in their homes. Close observation of my patients' experience with health care taught me that less is more when it comes to prescribing pills and procedures and that, especially for my elderly patients, supportive nursing care was, more often than not, the most effective treatment. Yes, there are sections in Hadler's book that may prove tough slogging for readers unfamiliar with medical terminology or statistical methods, but it's well worth the effort. I wish I could afford to put a copy into the hands of every one of the people I most care about.

The medical establishment is misinforming, costly and ineffective:
This is an outstanding book that decries many components of traditional and alternative medicine. The book is not easy to read (Fog Index 16.9 corresponds to years of formal education; Flesh-Kincaid Index 13.8 corresponds to grade level). However, it is very informative to manage your own health in a more independent, cost-effective, and dignified way than otherwise. According to the author all our ills that truly result mainly from the natural process of aging have been "medicalized" at no benefit to the patient. But in turn, this medicalization has generated huge profits for the health care industries. The author has impressive credentials to advance his views. He is a professor of Medicine at one of the top U.S. public universities, and he is a practicing rheumatologist. Additionally, he has a strong background in statistics that he uses to interpret the objective results of random trials before spin doctors promote questionable benefit of whatever drug tested. Also, his "opinions' are well supported by 60 pages of references to random trials mentioned in the "Annoted Readings" section of the book. Human beings have a mean expected life span of 85 years. Advances in medical technology has done nothing to extend this life span. With aging, a bunch of proximate diseases (cardiovascular, cancers, and others) compete with each other to end our days. Thus, often the well publicized reduction in mortality for a certain type of cancer due to a treatment has no implication in extending one's life span for a single day. A survivor of prostate cancer may die at the exact same time he would have died of cancer but from cardiovascular disease. The author has analyzed many related random trials that confirmed this. "Medicalization" is in his view an artificial social construct whereby a condition (back or knee pain) has been turned into a disease. It results in Type II malpractice whereby patients that are well have incurred treatments (sometimes invasive and dangerous) that were not necessary. The benefit from breast and prostate cancer screening is highly questionable. Both mammography and the PSA tests generate so many false positive as to render the tests useless. The ensuing investigation, treatment, and surgeries from incurring a positive test are often painful, dangerous, and offer no proven benefits of any reduction in mortality rate. He feels just the same way about bypass surgery that provides no benefit and is associated with a high risk of death as a result of the operation (2% to 8%) or depression (50%). It helps only 3% of the coronary patient who do have extensive plaque blockage in their left-main artery. For the other 97% of patients, bypass surgery represents an unfavorable risk/benefit trade off. Alternative medicine is not spared either. He sees no benefit in most herbal, vitamins and mineral supplements. Chiropractic, homeopathy, and other alternatives do not seem more credible than traditional medicine. Again, the above is supported by reference to random trials and studies. In his view, being a well person is coping well with the acceptable and natural imperfection of health as we age. This is a better alternative than to render ourselves patient of a medical establishment who will diagnose, test, and operate us at great profits for themselves but significant suffering to ourselves without adding a day to our life span, and often compromising our quality of life in the mean time.

Somewhat disingenuous
Dr. Hadler is a strong proponent of the controversial biopychosocial model of medicine advanced by the psychiatrist George Engel. He is also a strong proponent of the equally controversial evidence-based medicine movement. And he explains these narrow parameters quite well. Unfortunately, much of the book leaves out equally compelling and well documented evidence regarding diseases he dismisses out of hand. Medicine is and always has been a work in progress. While going back to the good old days of nontechnology has a nostalgic appeal it runs the risk of depriving medicine of the tools necessary to learn more about the human body and the difference between healthy and abnormal pathology. Many of the diseases Dr. Hadler dismisses are hot topics in the rapidly expanding field of viral research. Had Dr. Hadler written this book a century ago and had his view of the world been followed mankind might never have discovered viruses, germs, antibiotics, laser surgery etc. Viruses and germs are neither new or invented. They have been with mankind since the beginning of time, however it is progress that has benefited medicine and patients the most. At the turn-of-the-century, the neurological disease, multiple sclerosis (MS), presented as fatigue, muscle aches, cognitive problems, malaise etc. and was known as the "Faker's Disease." In general it was labelled a social construct. Fast forward 100 years and not only has the healthcare system been better able to mitigate the horror of this now widely known disease, but the role of viruses as a trigger of MS now has a rapidly expanding scientific following. The greatest downfall of this book is not the ideas, but their inappropriate application. While Dr. Hadler is entitled to his opinion, the deliberate absence of a large body of publically available and proven scientific evidence running counter to his opinion is the greatest downfall of this book. The result is more like falling down a rabbit hole than being enlightened.

Do you want to be well and feel well?? If so, read this book!!
Answer true or false to these ten statements: (1) Cardiovascular surgery clearly and unequivocally benefits the patient.
(2) Even though obesity (which is unhealthy) is on the rise in America, American life expectancy is increasing.
(3) There are very reliable methods for screening that spares us the risk of dying from colorectal cancer before our time.
(4) Mammography is of much value to the women screened.
(5) Prostate gland screening for males doesn't work.
(6) It is abnormal to live two years without a backache.
(7) One of the potentially dangerous acts physicians perform is to take a "history" from a patient.
(8) Bone thinning is an insidious illness.
(9) Psychological and social stress is not all bad.
(10) There is compelling evidence that acupuncture, physical therapy, massage, therapeutic touch, and distant healing work for physical complaints. If you answered true to any one of statements (1,3,4,8,10) or false to any one of statements (2,5,6,7,9), then you may benefit from this enlightening book authored by medical professor Dr. Nortin Hadler. Hadler explains the purpose of his book: "[This book] is written for all those well people who feel their sense of well-being is under attack...It is crafted to inform the reader who is well and how to feel well...[It] is a treatise on medicalization that is informed by science, clinical reality, and an analysis of life's morbid experiences-even episodes of disease...And I will explain how to avoid iatrogenicity-medical interventions that cause harm...Teaching the well how to approach the act of medical treatment critically is something of a heresy...Most of the lessons I will teach are heretical as well...This book is not for people who are already seriously ill." Below I will give the exact title of each chapter. For those titles that I feel are not descriptive enough, I will include some other material to give an understanding of what the chapter is about. (1) Interventional cardiology and kindred delusions. Topics covered include angina, cardiovascular surgery, interventional cardiology, and stroke.
(2) Fats, fads, and fate. Discusses such things as body mass index, blood sugar, high blood pressure, and lifestyle changes.
(3) You and your colon. Topics include colorectal cancer: its history, screening, and prevention.
(4) Breast cancer and how the women's movement got it wrong.
(5) (Male) prostate (gland) envy. Concentrates on the method used for screening for prostate cancer.
(6) Musculoskeletal predicaments. Discusses such things as backache, knee pain, shoulder pain, neck pain, and the drugs used to treat these pains.
(7) Medicalization of the "worried well."
(8) Turning age into disease.
(9) Health hazards of the hateful job.
(10) Why are alternative and complementary therapies thriving? Throughout this book are statistical tables Hadler uses as evidence to back up the surprising (at least to me) comments he makes. Some people will say that Hadler only discusses certain topics (as outlined above). Hadler explains: "Many more topics are worthy [of discussion]...However, I have space limitations-and there will be another day." If this means that he intends to write another eye-opening book like this one, I look forward to reading it. Personally, I would like to know how Hadler was perceived by his colleagues after this book was published. Finally, upon reading this book, the reader will notice one pervasive thing: the vocabulary used is above average. Personally, I like a good vocabulary workout but some readers may not. Thus, for these people, I recommend keeping a good dictionary around. Also, there are some basic medical terms Hadler uses. He defines many but some he does not. Thus, having access to a basic medical dictionary is advised. In conclusion, in my view, this is an amazing book that I feel every well person should read. I will leave you with actual comments Hadler makes in the last paragraphs of his book: "I ask you never to let your guard down or to relinquish your autonomy when you deal with the health-care delivery system...The system must be changed, but the stakes are high and many of the stakeholders are opposed to changes that do not benefit themselves...You will have to demand detailed responses before you acquiesce to any medical procedures and before you believe in any of the advice in the media, including the direct-to-consumer advertising of the pharmaceutical companies. It's a lonely task, but I wish you the conviction to take it on and to see it through. I wish you well." (first published 2004; acknowledgements; prologue; 2 parts or 10 chapters; epilogue; main narrative 205 pages; annotated readings; bibliography; index)

This book could save our health-care system
It is obvious to anyone who follows the news or pays health insurance premiums that U.S. medical costs are spiraling out of control. This book, simply put, could save the system. Dr. Hadler makes it clear that some of the most expensive items in our national health care budget, like cardiovascular surgery, have little or even no real benefit. If we followed Dr. Hadler's recommendations and eliminated surgeries and treatments of minimal usefulness, health care expenses could probably be cut by 3/4. This book should be read by every concerned person. I especially enjoyed Hadler's analysis of musculoskeletal problems--backaches, shoulder and knee pain, and the like. I found it very refreshing to find out that such pains are a normal part of life for nearly everyone and that modern medicine really doesn't have anything more effective than aspirin to treat them. I also liked Hadler's discussion of the recommendation that we eat more fish, out of concern for our cardiac health. Being an environmentalist, I have always been puzzled by this recommendation. If everyone really ate the amount of fish recommended by cardiologists the fish stocks of the world would be depleted in short order. I was relieved to find that in fact the "eat fish" recommendation rests on exceedingly slim evidence. I work in the patent field myself, and in years past I was employed by a pharmaceutical firm. I can tell you from my own experience that drug companies have long since reached a point of diminishing returns in their research. Obviously everyone would like to feel better and live longer, but pouring more money into R&D for new, patentable drugs is not likely to improve our overall health very much. Dr. Hadler's work makes it clear that funding huge clinical studies of thousands of patients looking for tiny effects is a process very subject to error. In my opinion, we should be seriously considering shifting our approach to medicine away from high tech and more towards having someone there to hold your hand when you are sick. Our society would be better off for it. My major complaint about the book is that it is too short. Dr. Hadler chose only a few health problems to focus on. I would love to see his analysis of treatments for depression, allergies, and autism, among others. I also thought he left out important factors related to obesity, such as the design of cities and neighborhoods to make them walkable, and agricultural and other subsidies which make food artifically cheap.