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The Last Well Person: How to Stay Well Despite the Health-Care System Paperback – April 18, 2007

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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. --This text refers to the Hardcover edition.


"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

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Product Details

  • Paperback: 313 pages
  • Publisher: McGill-Queen's University Press (April 18, 2007)
  • Language: English
  • ISBN-10: 0773532544
  • ISBN-13: 978-0773532540
  • Product Dimensions: 8.9 x 6.2 x 0.7 inches
  • Shipping Weight: 15.2 ounces (View shipping rates and policies)
  • Average Customer Review: 4.2 out of 5 stars  See all reviews (30 customer reviews)
  • Amazon Best Sellers Rank: #894,830 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 and was promoted to Professor of Medicine and Microbiology/Immunology in 1985. He serves as Attending Rheumatologist at the University of North Carolina Hospitals.
He 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. He was selected as an Established Investigator of the American Heart Association and has been elected to membership in the American Society for Clinical Investigation and the National Academy of Social Insurance. He has been elevated to Master of the American College of Physicians and the American College of Rheumatology and is a Fellow of the American College of Occupational and Environmental Medicine.
The molecular biology of hyaluran and the immunobiology of peptidoglycans were the focus of his early investigative career to be superseded by his fascination with what he initially termed "industrial rheumatology." For 30 years he has been a student of "the illness of work incapacity"; over 200 papers and 12 books bear witness to this interest. He has detailed the various sociopolitical constraints imposed by many nations to the challenges of applying disability and compensation insurance schemes to such predicaments as back pain and arm pain in the workplace. He has dissected the fashion in which medicine turns disputative and thereby iatrogenic in the process of disability determination, whether for back or arm pain or 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 the past decade, he turned his critical razor to much that is considered contemporary medicine at its finest. His assaults on medicalization and overtreatment appear in many editorials and commentaries and 4 recent 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), and Rethinking Aging. Growing old and living well in an overtreated society (2011). A fifth book, Citizen Patient, is in press and scheduled for release early in 2013. Les Presses de l'Université Laval / Les Éditions de l'IQRC is the publisher of French translations: Le Dernier des Bien Portants (2008), Malades d'inquiétude (2010), Poignardé dans le dos (2011) - won Prix Prescrire in 2012, and Repenser le vieillissement (2012, in press).

Customer Reviews

The benefit from breast and prostate cancer screening is highly questionable.
Gaetan Lion
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.
Paula L. Craig
The book is very well written, very understandable for the layman and the references are documented.
Mikael Rabaeus

Most Helpful Customer Reviews

56 of 59 people found the following review helpful By Gaetan Lion on July 31, 2005
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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72 of 79 people found the following review helpful By Veneta Masson on May 17, 2005
Format: Hardcover Verified Purchase
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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49 of 53 people found the following review helpful By Stephen Pletko on November 24, 2005
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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