This is the author's third book investigating medicine shortcomings. The first two were:
The Last Well Person: How to Stay Well Despite the Health-Care System and
Worried Sick: A Prescription for Health in an Overtreated America (H. Eugene and Lillian Youngs Lehman). They are all excellent. Hadler has extensive firsthand experience as a doctor, a med school professor, a clinician, and a medical investigator. Thus, he is well equipped to evaluate what works and what does not in modern medicine.
Hadler's main beef is that U.S. health care "medicalizes" normal conditions by undertaking treatments and prescribing drugs that are costly, do not work well and have side effects. He calls such malpractice a Type II error (doing something that is unecessary that may cause harm). Hadler supports his assertions by referring to numerous studies.
Medicalization becomes increasingly costly to the patient and taxpayers (and lucrative for the medical complex) as we age. A large percentage of health care dollars are spent on patients' last year of life. And, those expensive procedures are of no benefit to the elderly in terms of quality of life and lifespan. This book is interesting as it focuses primarily on the medicalization of the aging population. Meanwhile, the first two books looked at the overall medicalization phenomenon.
Hadler, more than in his other two books, uncovers the relationship between socioeconomic status and health. Referring to a study of 10,000 British civil service individuals, he shares that the major determinant of lifespan was one's position on the socioeconomic gradient. Health adverse behaviors and cardiovascular risk account for only 25% of mortal hazard. In Chapter 4 The Aged Worker he explores this issue further. Individuals happily employed fare better health wise than others. Those health benefits carry into retirement. He calls this theme "social capital."
The relationship between weight and lifespan is unexpected. Three studies from Australia, Canada, and the US. confirm that health and lifespan outcomes are not materially different for BMI ranging from 22 to 30. Thus, Hadler feels we spend too much time worrying about our weight. He personally does not know how much he weights. If one wants to lose a bit of weight, he recommends simply eating less as he acknowledges we are conditioned to overeat in a supersizing society.
Regarding cardiovascular disease (CVD), Hadler, just like Uffe Ravnskov (check out his excellent
The Cholesterol Myths: Exposing the Fallacy That Saturated Fat and Cholesterol Cause Heart Disease), reveals that cholesterol and saturated fat risks of CVD are not on strong scientific footing. Thus, both cholesterol and saturated fat are not bad for you. Statin drugs have a bad trade off as they have little effect on reducing CVD events and may cause serious side effects including muscle impairment, kidney disease, and higher incidence of diabetes. Hadler is also skeptical of the most recent CVD risk factor: C-reactive protein. The science is not convincing.
Cholesterol and diabetes prescription drugs for the elderly are huge businesses. None has been shown to make a material clinical difference in reducing related diseases incidents and improving longevity. He feels little lifestyle modifications are more effective without negative side effects.
Hadler notes that authors of medical studies with financial ties to the supplier of the health product they test are several times more likely to write a positive review than other investigators with no related financial ties.
Hadler indicates that treating what appears like high blood sugar, high cholesterol, high blood pressure (Systolic 140) in otherwise healthy older patients is not beneficial. All those markers increase with age. The revised threshold for hypertension (140/90) are too low. He states: "by this definition, more than 90% of people who have a normal blood pressure at age 55 will develop hypertension as they age." This is medicalization.
In terms of CVD treatments, he considers both preventive bypass surgery and angioplasty to be a travesty. "The benefit/risk ratio of bypass surgery and angioplasty is zero since we can't demonstrate any benefit. There is a tiny subset with a particular blockage that might be benefited by bypass surgery (about 2% of the patient with left blockage)." He refers to five studies who demonstrate no benefit for either of those procedures resulting in no fewer cardiovascular events or deaths (pg. 51-52). Considering the costs of such procedures, he states on page 54: "We are mortgaging our country to support an industry that scorns scientific rigor. That's irrational."
Regarding screening for breast cancer with mammography, he indicates there are no benefits to undergo this test for women under 50 or over 70. And, for women within this age range the benefits are marginal. In table 3, page 67, he shows that based on an extensive study related to women in their fifties undergoing mammography every one to two years for ten years the probability of dying from breast cancer was hardly lower vs women not screened (0.46% vs 0.53%). Yet, the probability of false positives requiring unnecessary biopsies and further invasive intervention was up to 20%.
Screening for prostate cancer is an even more egregious medicalization. Some presence of prostate cancer is normal in older men. He states on page 75: "By age sixty, every man should assume he has [some] prostate cancer... nearly all men die with prostate cancer but very few from prostate cancer... Of those who die from prostate cancer, most would have died about the same time from something else (usually heart disease)." Digital rectal exam and PSA test are highly inaccurate, resulting in a majority of false positives. Even when they do detect prostate cancer in the majority of cases it would not have lifespan implications. And, the most common procedure to treat this cancer (removing the prostate) results in frequent chronic impotence and incontinence.
Regarding colon cancer screening, he recommends individuals undertake a sigmoidoscopy just once, if at all, that examines the lower intestine where cancer is most frequent. Undergoing colonoscopy is associated with a non negligible risk of intestine perforation (about 0.2% per procedure). Sigmoidoscopy is much safer.
When he moves on to osteoporosis and osteopia, he indicates that our focus on bone mineral density (BMD) has little predictive power regarding probability of bone fractures. He states on pg. 130: "I see no [evidence based] reason for any well woman to submit for BMD at any age." Our focus to boost BMD through prescription drugs, calcium, and vitamin D has not demonstrated convincing results. He feels we get enough calcium and vitamin D in our diet as both are added to dairy products. Also, vitamin D that is not activated like the one we get from sun exposure does not do that much.
Hadler is skeptical of many orthopedic surgeries. On pg. 139 he adds: "elective orthopedics is coauthoring the bleakest chapter in the history of Western medicine with the interventional cardiologists." He indicates that total knee replacement surgeries have had dismal results. Studies on arthroscopic knee surgeries have demonstrated they do not work. However, his assessment about hip replacement is much more positive.
Many prescription drugs do not work that well. But, their results are often much worse for the elderly that are often more susceptible to their side effects and reap fewer of their benefits. Antidepressants have unfavorable benefit-risk trade offs for the elderly. Meanwhile, Aricept show no benefit over a placebo in the likelihood of progression Alzheimer's and Dementia.
In one of the last chapters, Hadler teaches us how to live and die well. In one's ninth decade (80+), both the quality of living and the quality of dying should be primarily health concerns. This means passing away at home in a loving environment surrounded by relatives and specialized nurses providing comforting palliative care. Instead, elderly often die alone, anxious, without dignity while being overtreated and overdrugged in a hospital.
As we age into our seventies and beyond, we all have some latent cardiovascular and cancer issues. Yet, Hadler says on pg. 175: "It makes no sense to cure the disease one will die with, in the ninth decade and little sense to cure the disease that one will die from in the ninth decade if another is to take its place in short order."
