34 of 37 people found the following review helpful:
4.0 out of 5 stars
Inventing an illness and the system that makes people sick, December 8, 2009
This review is from: Stabbed in the Back: Confronting Back Pain in an Overtreated Society (Hardcover)
Using back pain as his subject, Nortin Hadler, M.D., presents a forceful critique of much of what is wrong with the American health-care system today and the disability bureaucracy that sustains a broken conception of illness and health. "Stabbed in the Back" is a lucid, informed and well-researched discussion of one of modern post-industrial society's greatest and costliest sources of physical and mental suffering -- regional low back pain. He excludes from the analysis unusual sources of back pain such as cancer, infection and inflammatory diseases and focuses on the run-of-the-mill suffering that causes millions of Americans every year to complain to their doctors, "I threw my back out and I don't know if I can go back to work."
Back pain is an unavoidable reality of modern life, Hadler argues. About 75 percent of cases are inherited. Disc degeneration, thought to be the primary culprit in back pain, is a normal part aging, somewhat like grey hair or balding. Modern medicine simply has not found a way to relieve back pain, despite a huge industry whose existence depends on the notion of back pain as a disorder or illness warranting a cornucopia of treatments (none of which work over the long term).
If Hadler had his way, doctors would tell back-pain patients to tough it out and go back to work. "Individuals with regional backache might fare less poorly by managing as best they can," Hadler writes, "perhaps with some lay advice, than by choosing to become patients."
He suggests pain sufferers would be best off telling their doctors, "I can't cope with this backache," rather than seeking an elusive cause and cure for their travails in a medical system that promotes illness rather than health. But such an approach is unlikely in the current system in which so much is at stake for physicians, surgeons, physical therapists, chiropractors, medical device makers and drug companies, to name just a few.
Hadler acknowledges that his view will be met with resistance and outright hostility by pain sufferers, who are tired of being told their pain is "all in your mind." Hadler does not go so far as to say patients imagine their pain, but he comes close by pointing to studies that link psychological difficulties with back pain.
Low back pain ranks second only to the common cold as a reason for doctor's visits in the United States, and the cost of diagnosing, treating and indemnifying, through worker's compensation or Social Security Disability Insurance, is staggering, somewhere around $100 billion annually in the United States. Upwards of 80 percent of the population experiences low back pain at some point in life
The Lumbar Spine: Official Publication of the International Society for the Study of the Lumbar Spine. And yet there is no cure.
Surgery, increasingly in the form of hugely invasive and expensive fusion procedures that immobilize the painful part of the spine through titanium screws and rods and metal implants designed to promote a rigid bony construct, accounts for much of the direct cost of back pain, Hadler notes. The use of fusion surgery is rising precipitously despite any scientific support for its effectiveness in reducing pain. In fact, various studies have found that surgical patients fare no better than physical therapy patients in attaining long-term back pain relief.
The path to surgery is always paved by modern technological innovation, the holy grail being magnetic resonance imaging, or the MRI scan. The extraordinary sensitivity of MRI technology in detecting herniated discs, pinched nerves and irritated spine joints gives patients the "evidence" that their pain is not imaginary, and that they have a "disease" called degenerative disc disease, or DDD. And it gives surgeons the crucial rationale for getting back pain sufferers into the operating room, at tremendous cost to society as the bill for a typical fusion surgery runs from $50,000 to easily upwards of $150,000, depending on how much of the spine is fused.
Hadler, however, points to research showing that MRIs are essentially useless in finding the source of low back pain. Even people with no pain will have bulging discs and other signs of degeneration in an MRI scan. And many people with great pain will show no sign of any problem on an MRI.
Hadler goes on to discuss the role of various indemnification schemes in the United States, such as disability insurance and worker's compensation, in promoting and prolonging back pain and expensive treatments. "Disabled" workers, in particular, are prone to think of themselves as chronically ill to ensure that their benefits are not taken away.
In the end, Hadler makes a convincing case for changing the current system of benefits and rewards in approaching low back pain. He gives a timely critique of the U.S. medical system and the various social contracts that perpetuate useless and senseless treatments of injuries that are really not injuries but are a normal part of life.
There is, as Hadler acknowledges, a certain insensitivity to individual sufferers in this discussion of systems, modalities, social constructs and indemnification schemes. An experienced physician specializing in rheumatoid arthritis, Hadler knows first-hand the suffering that pain produces.
My main critique of this book centers on this insensitivity, bordering on callousness. Hadler shows no compassion for the millions of people who try to cope daily with debilitating, awful, indescribable low back pain. This is a pain that goes far beyond the muscle strain or discomfort that follows prolonged sitting, for example, or a hard workout at the gym. It is unbearable.
While those seeking worker's compensation benefits or social security insurance may well be tempted to exaggerate their suffering, millions of others continue working, or take relatively short breaks from work to try to find relief.
Hadler pays no heed to the voluminous scientific evidence showing that repetitive motions, particularly bending, twisting and lifting heavy loads, or sitting at an office desk all day, actually cause spine discs to herniate and produce immediate unbearable pain that can leave people virtually immobilized or terribly soar for many months. Much of this evidence is presented in great detail, and very scientifically, in Stuart McGill's
Low Back Disorders, Second Edition, an excellent book for anyone interested in causes and treatments for low back pain.
McGill acknowledges the literature pointing to psychosocial factors in low back pain but discusses in detail the very real injuries, to use a word that Hadler hates, that produce horrible pain.
It's important to remember that intense low back pain, like any pain, is by definition undesirable. Life is spent pursuing pleasure and avoiding pain, after all. People will go to great lengths, embracing just about any treatment that seems reasonable, to avoid pain. The fact that pain is associated with psychological stress is not at all surprising: perhaps pain causes the psychological stress in the first place. In any case, modern pain medicine, which increasingly rejects the Cartesian distinction between mind and body, knows very well that physical and psychological pain are but two sides of the same coin. Both types of pain are experienced in the same parts of the brain. Major depression is every bit as painful as the worst imaginable physical injury.
The real culprits are the purveyors of "cures," treatments and remedies that have no track record of success and often make pain sufferers even worse. How many millions of people have undergone barbaric fusion surgeries only to find themselves worse off than before their operations? Those with back pain are besieged with snake-oil salesman in white gowns and surgical scrubs masquerading as healers when they really just want to get rich.
I still recommend Hadler's book as an excellent expose of a system gone wacky, one that is no better than ancient or medieval superstition about the cause and treatment of illness. But do not turn to this book seaking solace in your suffering.
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12 of 12 people found the following review helpful:
5.0 out of 5 stars
Hadler has done it again!, February 13, 2010
This review is from: Stabbed in the Back: Confronting Back Pain in an Overtreated Society (Hardcover)
"Stabbed in the Back is an expose of a contrived "disease" and the enormous enterprises it has spawned that conspire to its "cure" and provide fallback when a "cure" is elusive. That industry has developed a life of its own, despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American's wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. An assault on the backache industry is long overdue. No reader finds all of the chapters that follow resting easily within his or her preconceptions."
The above words are from Dr. Nortin hadler's new book Stabbed in the Back: Confronting Back Pain in an Overtreated Society.
Dr. Hadler is is a professor of medicine and microbiology/immunology at University of North Carolina at Chapel Hill, author of Worried Sick: A Prescription for Health in an Overtreated America and 14 other books, and more than 200 medical papers. He is also a consultant to ABC News.
Stabbed in the Back is an overview of the history of back pain, its many diagnoses and treatments over the decades, as well as its personal, financial, and social cost. Dr. Hadler's care and concern for patients with regional back pain permeates throughout the book as he discusses the many aspects of this "contrived disease."
My favorite chapter is Chapter Six, titled "Invasion of the Spine Surgeon," where he takes on the surgical treatment for back pain showing that there is no evidence for efficacy of surgery and that most surgeons financially benefit from recommending and performing surgery. This has contributed to the high cost of treating back pain. One ineffective surgery is spinal fusion, which has become a multibillion dollar industry, where one screw costs $1000.
This book gives a comprehensive look at current state of diagnoses and treatments for back pain, which helps readers decide what is the best course of action and perhaps, most importantly, which treatments to avoid.
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