The Last Well Person: How to Stay Well Despite the Health-Care System. By Nortin Hadler. McGill-Queen’s University Press, 320 pages, $29.95.
Do you need surgery for your back pain? Should you have a colonoscopy once you reach age fifty? Is bypass surgery the answer for heart disease?
According to today’s medicine, the answer to those questions often is yes. But Nortin Hadler says that all too often, this answer is wrong. Hadler maintains that many standard procedures and tests carry more risks than benefits. “I firmly believe,” he says, “that the institution of medicine, not the practitioners, has lost its way.”
Hadler wants people to think twice about the procedures their doctors may recommend. “I wrote the book to teach people how to advocate on their own behalf with medicine when it comes to managing their health and their illnesses,” says Hadler, professor of medicine and microbiology and immunology, and attending rheumatologist at UNC Health Care.
The book laments the “medicalization” of everyday life — “taking life’s predicaments and teaching people they are not life’s predicaments but diseases.” Back pain and headaches, for instance, are often “routine problems of body and mind,” he writes. Hadler argues that most musculoskeletal pain eventually improves on its own.
Timothy Carey, professor of medicine and director of the Cecil G. Sheps Center for Health Services Research, agrees that most back and knee pain improves with exercise and treatment. And Carey notes that in the chapter on musculoskeletal ailments, Hadler predicts the problems that have since occurred with COX-2 inhibitor drugs such as Vioxx, which has been recalled by the manufacturer because of cardiovascular complications. “He predicted that these drugs were more likely to have side effects than other agents, and that they really don’t work much better than what you can get over the counter in the drug store,” Carey says.
When you feel compelled to visit a doctor for routine ailments, Hadler says, the conversation should focus just as much on your job, relationships, and stress level as on medical treatment. Ideally, he says, you would ask your doctor, “Why can’t I cope with this episode?” Hadler suggests that people with chronic, localized, or widespread musculoskeletal pain may suffer more from an inability to deal with stress than from the pain itself. “These unfortunate people choose to be patients because they have exhausted their wherewithal to cope,” he writes. Once labeled with a bad back, fibromyalgia, high cholesterol, or high blood pressure, people feel vulnerable. “Their coping skills are challenged, and they can disappear from the ranks of the well forever,” Hadler writes.
Hadler doubts that medicine can extend your lifespan much past eighty-five. “While we can reasonably hope to live to our mid-eighties, anything beyond is a bonus and even a statistical oddity,” he writes. Hadler argues that if a disease is not likely to kill you before age eighty-five, then why take on the risks and discomfort of screening tests and the treatments that may follow? Colon cancer, for instance, moves slowly compared to other cancers. So if you develop colon cancer in your eighties, it’s likely some other disease will kill you first, Hadler writes.
Even for people at age fifty, which is when most doctors recommend regular screening for colon cancer, the benefits of colonoscopies may not outweigh the risks, Hadler says. Most statistical studies of colon-cancer screening consider the most important result to be whether the screening reduced the number of people dying from colon cancer. But Hadler argues that the most important question should be, does screening for colon cancer enhance my longevity? “If screening spares you death by colorectal cancer but you die at about the same time from something else,” he writes, “was the screening valuable?”
“It’s a very interesting argument, one that at a national level has not been resolved,” says David Ransohoff, professor of medicine. “If in medicine we held out all-cause mortality as the test that needs to be passed, we would not be doing many of the procedures that we currently do. It’s not an argument that very many people would support. But it’s actually a very fair thing to discuss. In my view, it’s underdebated.”
Colonoscopies, for example, do carry a small chance — about 0.3 percent per procedure — of a serious complication such as bleeding, colon perforation, even death. The sedation involved carries a small risk of a drop in blood pressure or of depressed breathing, says Ransohoff, who has studied colon-cancer screening.
“We are taking healthy people and subjecting them to risk,” he says. “It’s not a big risk, but it is a risk.”
In sections on cholesterol, breast cancer, prostate cancer, osteoporosis, back and knee pain, and the role of alternative providers of care, Hadler explains how to weigh the risks and benefits of various treatments and interventions.
Of the book’s ten chapters, the one that has sparked the most controversy at Carolina deals with interventional cardiology. Hadler names coronary artery bypass surgery as an example of “Type II medical malpractice” — performing a treatment very well, but on people who do not need it in the first place. Most coronary artery bypass graft surgery, he says, does not significantly increase survival or even decrease the chance of a heart attack.
“We started out with three major randomized controlled trials in the nineteen-seventies of coronary bypass grafting versus medical therapy,” Hadler says. “If you look at those original trials there is really no benefit to coronary artery bypass grafting.” Hadler writes that, with the exception of a very small subset of patients, these studies showed that even after ten years, patients who had heart surgery did not survive longer or have fewer heart attacks than those who received only medication. He concludes that the risks of heart surgery such as death, emotional distress, and memory loss outweigh the benefits, even for the small subset. These three studies were published in the New England Journal of Medicine (March 22, 1984; November 22, 1984; and August 11, 1988). Subsequent studies, Hadler says, generally compare one form of surgical intervention with another, assuming that any surgical intervention must be better than modern medical therapy. Hadler calls this assumption “unfounded.”
Some cardiologists disagree with Hadler and say that studies prove the value of coronary artery bypass surgery. Cam Patterson, associate professor of medicine and director of the Carolina Cardiovascular Biology Center, says that heart bypass surgery is generally performed only in patients with particular types of severe heart disease — disease in the left main artery, or three-vessel disease, or two-vessel disease with reduced function in the left ventricle. “In each of these cases, multiple randomized clinical trials have shown consistent, impressive, and statistically significant benefits that translate to a major benefit in morbidity and mortality,” Patterson says. “I think this book is dangerous to people who might neglect appropriate treatment because of the factual inaccuracies.”
For instance, Patterson points to the book’s statement that coronary artery disease is no longer a scourge in the United States. “That’s simply not true,” Patterson says. “The number of people who die with heart disease is increasing every year. It’s the number one killer in the United States. To give people the idea that heart problems are not serious problems toys with danger.”
In the chapter on cardiology and its annotated list of readings, Hadler cites the studies on which he relies and dissects the role of conflict of interest in the interpretation and application of those studies. He cautions that death from cardiovascular disease is not as crucial an issue as death from cardiovascular disease before your time. His goal, he says, is to provide information that will help people make up their own minds about which procedures, tests, and treatments to undergo.
“I don’t care what kills me on my eighty-fifth birthday,” Hadler says. “I don’t care how many diseases are vying to do me in. I only care that I reached my eighty-fifth birthday and that the leaving is as gentle as it could be.”