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

~ (Author) "Daily we hear of the greying of America..." (more)
Key Phrases: persistent widespread pain, regional musculoskeletal disorders, regional backache, United States, Last Well Person, American Medical Association (more...)

Editorial Reviews

From The New England Journal of Medicine

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.

Review

"'Hadler is a superb teacher. The reader learns to think independently and to reason critically about the many unsupported or unsupportable claims made on behalf of modern medicine, including much of modern pharmacology, surgery, and so-called alternative medicine. A must-read for both medical professionals and ordinary folk." Arthur Schafer, director, Centre for Professional and Applied Ethics, University of Manitoba"

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Product Details

• Hardcover: 313 pages
• Publisher: McGill-Queen's University Press; 1 edition (September 15, 2004)
• Language: English
• ISBN-10: 0773527958
• ISBN-13: 978-0773527959
• Product Dimensions: 8.9 x 6.2 x 1.2 inches
• Shipping Weight: 1.3 pounds (View shipping rates and policies)
• Average Customer Review: 4.3 out of 5 stars  See all reviews (24 customer reviews)
• Amazon.com Sales Rank: #389,552 in Books (See Bestsellers in Books)

Customer Reviews

Most Helpful Customer Reviews

60 of 64 people found the following review helpful:

5.0 out of 5 stars Words To Live By, May 17, 2005

By	Veneta Masson "Veneta Masson" (Washington, DC USA) - See all my 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.

37 of 38 people found the following review helpful:

5.0 out of 5 stars The medical establishment is misinforming, costly and ineffective., July 31, 2005

By	Gaetan Lion - See all my reviews (TOP 500 REVIEWER)    (REAL NAME)

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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.

34 of 35 people found the following review helpful:

5.0 out of 5 stars Do you want to be well and feel well?? If so, read this book!!, November 24, 2005

By	Stephen Pletko "Uncle Stevie" (London, Ontario, Canada) - See all my reviews (TOP 500 REVIEWER)

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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)

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