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.
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"A brutal critique of much of what we do in medicine." New England Journal of Medicine "Like a veteran umpire, he calls 'em as he sees them. Much of what modern medicine advocates bears scrutiny, and Hadler examines it critically. Must reading for the public and for physicians." Journal of the American Medical Association "Hadler attempts to disabuse his readers of the pervasive and arguably mistaken belief that there is good evidence to support the broad application of such things as coronary artery bypass grafting for angina; cholesterol, blood pressure, and blood glucose monitoring; and screening for colon, breast, and prostate cancer." Canadian Medical Association Journal