Customer Reviews

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

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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.

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.

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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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I've waited quite a long time for this book to be published. The author is to be congratulated for his courage to show what`s really going on in the health care industry.

A common error when it comes to the media is that they rely on press releases when reporting about scientific findings. This way information unfortunately gets distorted beyond recognition.
Doctor Hadler did the right thing: he used the original data and conducted an independent analysis. This way the whole truth comes to light.

You don`t have to be a statistician to understand the simple difference between relative and absolute risk reduction - that`s actually quite simple to explain. The question for you - the patient (or better yet the well person) is: is it worth it?
And as the recent scandal over Vioxx showed the answer is (mostly) no.
By the way: Doctor Hadler shows that the evidence that Vioxx is unsafe was available in 2000 already; a recent study in the Lancet came to the same conclusion.

The author covers topics like breast cancer, colon cancer, muskuloskeletal disorders and many more. Illnesses that are literally worth billions of your dollars. If you want this to stop read this book and stay well; if you want to be medicalized to death - don`t read it.

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.

Have you ever wondered why our health care system is the most expensive in the world, yet Americans live no longer and appear no healthier than people in other developed countries? The answer, per Dr. Hadler's book,"The Last Well Person," is that many sophisticated and expensive medical procedures provide marginal benefits at best for the patients on which they are used.

Take the use of "statin" drugs ("Lipitor" et al.) to lower cholesterol levels, a regimen relentlessly touted by "talk to your doctor" ads on television. Millions of Americans seem to be listening, given the sale of these drugs, but Hadler is skeptical. Lowering cholesterol with drugs makes sense for patients who have already suffered a heart attack, he says, but clinical studies don't demonstrate a statistically significant benefit for people who have not.

Also, statins can cause a severe destruction of muscles. One of these drugs (Baycol) was pulled from the market after fifty or more fatalities, Hadler points out, and long-term experience with statins is limited. "For all I know," he continues, "insidiously progressive muscle disease, liver disease, or cognititve impairment lurks in the distant future of some of the men who[are taking them]."

Hadler also questions the widespread acceptance of many other medical procedures, including heart bypass surgery (no discernible survival advantage for 97% of patients with angina), PSA screening for prostate cancer ("there's only one problem: it doesn't work"), and the use of Celebrex and Vioxx in lieu of older analgesics (written before accumulating evidence of a linkage between Vioxx and heart attacks caused Merck to pulled their drug from the market).

There's lots of medical terminology in "The Last Well Person," and many people won't want to read it from cover to cover. However, readers can readily scan the table of contents and pick the chapters of greatest interest to themselves.

When you go to a doctor, should you passively accept and follow whatever advice you get? In this book, Nortin Hadler advises you to take active control of your medical treatment. Many common treatments lack scientific justification, do nothing for you, or put you at risk for unwanted side effects. You can protect yourself from these practices. Hadler offers some information and tools to help you.

The first practice Hadler examines is bypass heart surgery. He discusses studies comparing it to simple drug therapy. Bypass surgery provides no survival benefit to 97% of the patients who get it. Additionally, it is based on an outdated theory that severely clogged heart arteries cause heart attacks; so the surgery bypasses those severely clogged arteries. Current theory is that ruptures of smaller early-stage plaques cause most heart attacks. Bypass surgery does not address that problem.

Somewhere between 1% and 8% of bypass patients die on the operating table or shortly thereafter. If any drug was known to have such deadly effects, it would be promptly banned. Why do we tolerate such a death rate for surgery but not for drugs?

Hadler then discusses the testing and treatment for colon, breast, and prostate cancer. The tests are rife with false positives and false negatives. The effects of the surgical treatments can have a mutilating effect on both your psyche and your body. There is no assurance that you will rid yourself of the disease once you subject yourself to the medical treatments offered. Unless you have an indication of a high risk for any of these conditions, (e.g. family history or other symptoms) you might reasonably decline the tests for these diseases.

Hadler also gives you an education on the use/misuse of statistics. One of the examples he uses is baby aspirin. Studies show that your likelihood of 5-year survival after a heart attack are about 97.5% if you take a baby aspirin daily. The same studies also show that you reduce your risk of a second heart attack by 50% by taking the baby aspirin. These statistics sound very impressive. You are never told that if you do nothing (i.e., take no baby aspirin), your likelihood for 5-year survival is 95%. So taking the baby aspirin bumped you from the 95% ranking to 97.5%. Yes, taking aspirin reduced your heart attack risk 50% relative to not taking aspirin. But the absolute benefit is only 2.5% better. Is that significant to you? Do these statistics have a "margin of error" like all other statistics? Once fully informed, you might sensibly decline to take the aspirin.

Hadler does give aspirin credit where credit is due. It is the cheapest and safest NSAID: non-steroid anti-inflammatory drug. Hadler is suspicious of new drugs which promise only modest improvements on older established drugs. His book was written before the recall of Vioxx. But he had the foresight based on the scientific studies of Vioxx to publicly criticize its use before the recall. Hadler is definitely a doctor whose opinions you want to pay attention to.

In multiple ways, Hadler shows that "advancing technology" and new drugs do not necessarily mean better medical care. When the underlying scientific theory and analysis is faulty, its products will not serve you well.

Hadler also describes a phenomenon called "medicalization." Medicalization is a tendency to treat life's normal problems as a curable disease. Hadler regards things such as bone and muscle aches, random pains, and aging as normal. They are not diseases. Modern medicine has not found a cure for these predicaments and never will. A well person can be afflicted with many such predicaments, but copes with them and still enjoys life. Unfortunately, like generations of quacks throughout history, modern medicine promises to find cures for predicaments that are inescapable. This is dangerous and wasteful. Modern medicine has many notable successes, but it cannot do everything for you. If you want to be a well person, you must learn for yourself what medicine can and cannot do for you. Then choose accordingly. This book can help you do that.

Hadler doesn't try to sell you on any other kind of treatment. He criticizes alternative medicine, vitamin and mineral therapy, and is even skeptical of lifestyle change advocates. His analysis is always scientifically based. He is a scientist, although certainly a maverick among them. His ability to see the weaknesses and strengths of science makes him always engaging. Even when you disagree with him, you respect him.

Dr Hadler's book is of very great interest. It is clearly provocative, raising many questions that are very politically incorrect.
As a professionnal involved in cardiovascular prevention for the last 25 years, I have progressively been led to develop the same conclusions as Dr Hadler. I am well placed therefore to realise the tremenduous effort and courage it requires to take a standpoint that is in direct opposition to what is commonly proposed. In particular, the chapter on the immense overuse of revascularisation procedures and cholesterol treatment is very much accurate and to the point.
Obviously, there are statements that are debatable, but that is the purpose of a book like this.
The book is very well written, very understandable for the layman and the references are documented.
Please take time to read this book, it is worth it and it will make you change your views on many aspects of the "medical terrorism" that is so quick to appear in prevention, but that can be avoided.

This book attempts to arm the reader against the medical establishment's growing insistence that we are all likely to be diseased and that we all need to subject ourselves to numerous screenings and treatments to keep us going.

One criticism - Hadlin's writing tends to be rather clotted. The fact that he refers to his work as a "monograph" rather than simply as a "book" is a good example of this galumphing tone. A more individual perspective and a friendlier bedside manner would have served the reader better.

I realize that might have been just the sort of tone Dr. Hadler was hoping to avoid because it would smack too much of the "anecdotal." And anecdotal is anathema to writers wanting to impress readers with the objective, strictly scientific nature of their report. A major theme of this book is, after all, the idea that research/evaluation should be conducted with strict objectivity, apart from any considerations of personal gain. Researchers shouldn't be swayed by the thought of future payments they might receive from pharmaceutical companies if they find a drug effective, or by the prospect of hospital/career advancement if they find that an invasive procedure "saves lives."

Still, I think it would have been valuable to put more of a human face on the vast waste of time, money, and energy that most medical intervention tends to be. I was hoping the book would trace the course that iatrogenesis tends to follow - the course of small bureaucratic bungles, overlooked details, and indifferences. To get a broader philosophical sense of this waste, I recommend the controversial, but enlightening "Confessions of a Medical Heretic" by Dr. Robert Mendelsohn, and "Medical Nemesis" by Ivan Illich.

However, Dr. Hadlin is better than those preceeding books at exposing the fallacies of many medical statistics. His best chapters alert one to the questionable statistical methods used to back claims for the efficacy of new medicines and treatments. For example, he points out the difference between relative improvement in outcome (cited by most sales pitches), and absolute improvement (rarely mentioned). If 200 people are enrolled to test a new medicine (100 of whom receive the new medicine and 100 of whom are in the control group receiving a placebo) - 4 people may die in the control group of the condition the medicine is supposed to correct - and only 2 may die in the group given the actual medicine. In that case, the medicine will be heralded by its manufacturers as having reduced mortality by a whopping 50% (from 4 to 2). But that's the relative reduction in mortality. Only an absolute number of 2 people have been saved.

That might still make the medicine seem very worthwhile. However, Hadler goes on to point out that the statistics often obscure the fact that those two "saved" people may have suffered severe side effects and/or died soon anyway of some condition other than the one that the medicine presumably treated.

If you want to read a more accessible, lively explanation of the pitfalls of putting your trust in quoted medical statistics - I recommend Marilyn vos Savant's book of collected magazine columns, "The Power of Logical Thinking."

Finally, Hadler launches off with the proviso that his counsel to refuse or be skeptical of many treatments is applicable only to those who are currently "well." However, most people submit themselves to screenings in the first place precisely in order to determine whether they are well or not. So like the book's title, this initial proviso is only confusing and circular.

However, these faults aside, I still found the book valuable enough to add to my permanent reference collection. And if I should be faced with a Doctor's insistence that I take a certain medicine or have a certain procedure - I'll consult the book before making my decision.

The Last Well Person by Nortin Hadler is highly recommended and is a must read. Dr. Hadler is a brilliant physician who has a passionate love of humanity. He gives readers an invaluable insight into the medical field, and educates them on important health issues. Although a medical scientist of the highest caliber, he is also a deep thinker in social and philosophical areas. I have learned much from his writings him over the years and he has influenced my practice tremendously. This book is recommended for non-medical people, in addition to medical people.