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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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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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Everyone should read this book then ask your physician tough questions about your healthcare.
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. It results in Type II malpractice whereby patients that are well have incurred treatments (sometimes invasive and dangerous) that were not necessary.
The benefit from breast and prostate cancer screening is highly questionable. Both mammography and the PSA tests generate so many false positive as to render the tests useless. The ensuing investigation, treatment, and surgeries from incurring a positive test are often painful, dangerous, and offer no proven benefits of any reduction in mortality rate.
He feels just the same way about bypass surgery that provides no benefit and is associated with a high risk of death as a result of the operation (2% to 8%) or depression (50%). It helps only 3% of the coronary patient who do have extensive plaque blockage in their left-main artery. For the other 97% of patients, bypass surgery represents an unfavorable risk/benefit trade off.
Alternative medicine is not spared either. He sees no benefit in most herbal, vitamins and mineral supplements. Chiropractic, homeopathy, and other alternatives do not seem more credible than traditional medicine. Again, the above is supported by reference to random trials and studies.
In his view, being a well person is coping well with the acceptable and natural imperfection of health as we age. This is a better alternative than to render ourselves patient of a medical establishment who will diagnose, test, and operate us at great profits for themselves but significant suffering to ourselves without adding a day to our life span, and often compromising our quality of life in the mean time.
it is the 3rd leading cause of death in the US. Read why 97 % of heart by-pass
surgeries do not extend life. Research your ancestors: those who passed childhood
without dying, usually lived to a ripe old age without any modern medical
interventions. This doctor speaks the truth.
Most recent customer reviews
This book isn't the easiest to read....it gets into many technical issues of research design etc.....Read more