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The Last Well Person: How to Stay Well Despite the Health-Care System 1st Edition

4.3 out of 5 stars 31 customer reviews
ISBN-13: 978-0773527959
ISBN-10: 0773527958
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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.


'"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

Product Details

  • Hardcover: 328 pages
  • Publisher: McGill-Queen's University Press; 1 edition (August 31, 2004)
  • Language: English
  • ISBN-10: 0773527958
  • ISBN-13: 978-0773527959
  • Product Dimensions: 6 x 1 x 9 inches
  • Shipping Weight: 1.3 pounds (View shipping rates and policies)
  • Average Customer Review: 4.3 out of 5 stars  See all reviews (31 customer reviews)
  • Amazon Best Sellers Rank: #1,360,769 in Books (See Top 100 in Books)

More About the Author


Nortin M. Hadler, MD

Dr. Hadler is a graduate of Yale College and The Harvard Medical School. He trained at the Massachusetts General Hospital, the National Institutes of Health, and the Clinical Research Centre in London. He was certified a Diplomate of the American Boards of Internal Medicine, Rheumatology, Allergy & Immunology, and Geriatrics. He joined the faculty of the University of North Carolina in 1973, was promoted to Professor in 1985 and transitioned to Emeritus Professor of Medicine and Microbiology/Immunology in 2015. He served as Attending Rheumatologist at the UNC Hospitals till 2015. In recognition of his clinical activities, he was elevated to Mastership in both the American College of Physicians and the American College of Rheumatology.

The molecular biology of hyaluran and the immunobiology of peptidoglycans were the focus of his early investigative career. Because of the contributions of his laboratory, he was selected as an Established Investigator of the American Heart Association and elected to membership in the American Society for Clinical Investigation. The focus on basic biology was superseded by what he initially termed "industrial rheumatology." Over 200 papers and 12 books bear witness to his analyses of "the illness of work Incapacity" including the sociopolitical constraints imposed by various nations faced with the challenges of applying disability and compensation insurance schemes to predicaments such as back pain and arm pain in the workplace as well as for a more global illness narrative such as is labeled "fibromyalgia." He is widely regarded for his critical assessment of the limitations of certainty regarding medical and surgical management of the regional musculoskeletal disorders. The third edition of his monograph, Occupational Musculoskeletal Disorders, was published by Lippincott Williams & Wilkins in 2005 and provides a ready resource as to his thinking on the regional musculoskeletal disorders. In recognition of this work he was elected to the National Academy of Social Insurance and is a Fellow of the American College of Occupational and Environmental Medicine.

Fifteen years ago he turned his critical razor to much that is considered contemporary medicine at its finest. Assaults on medicalization and overtreatment have appeared in many editorials and commentaries, and in 6 monographs: McGill-Queens University Press published The Last Well Person. How to stay well despite the health-care system in 2004 (paperback 2007). UNC Press published Worried Sick. A prescription for health in an overtreated America (2008, paperback 2012), Stabbed in the Back. Confronting back pain in an overtreated society (2009), Rethinking Aging. Growing old and living well in an overtreated society (2011), Citizen Patient. Reforming health care for the sake of the patient, not the system (2013) and By the Bedside of the Patient. Lessons for the twenty-first-century physician (2016). Les Presses de l'Université Laval published the French translations: Le Dernier des Bien Portants (2008), Malades d'inquiétude (2010), Poignardé dans le dos (2011 and won Prix Prescrire in 2012), Repenser le vieillissement (2013) and Citoyen et Patient (2014).

Dr. Hadler has lectured widely, including many named lectureships and is a frequent commentator for the print and broadcast media. He has garnered multiple awards and served lengthy Visiting Professorships in England, France, Israel and Japan. In 2015 he assumed a leadership role in an initiative designed to provide rational health care as an evidence-based, cost effective, employer-sponsored, defined contribution, insurance benefit.

Customer Reviews

Top Customer Reviews

Format: Hardcover Verified Purchase
This is an outstanding book that decries many components of traditional and alternative medicine. 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.
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Format: Hardcover

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...
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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:


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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