Reviewed by David A. Bennahum
The Pharos, Winter 2007
The Last Well Person: How to Stay Well Despite the Health-Care System
By Nortin M. Hadler
McGill-Queen's University Press, 328 pages
In a remarkably well-written and stimulating book Nortin M. Hadler, professor of Medicine and Microbiology/Immunology at the University of North Carolina, challenges a number of medicine’s most cherished certainties. Written for the general public, the book should, however, be read by all physicians and then recommended to their patients. Surveying the plethora of health information and medical advice to which the average healthy American citizen is subject he writes that “The Last Well Person is written for all those well people who feel their sense of wellbeing is under attack.” p4 Hadler hopes “to inform the reader who is well how to feel well.” p4 and to accomplish that goal builds his book, as he says, on four footings:
1. Recalling the teachings of Karl Popper, who taught the author’s generation to question all certainties, and of Daniel Federman, his mentor at Harvard who expected students to become insightful and questioning physicians. In effect, to be compassionate yet critical thinkers.
2. To understand the social consequences of disease and its impact on a patient’s daily life and employment.
3. The understanding that to be well is to be able to cope with morbidity.
4. To understand that the author is not against medical science, rather he favors a critically rigorous science.
As he writes, “The Last Well Person is a treatise on medicalization that is informed by science, clinical reality, and an analysis of life’s morbid experiences—even episodes of disease. . . .armed with skepticism and a critical intellect it is possible to benefit, safely and effectively from modern medicine without being harmed in the process.” p6
Chapter 1 is a critical analysis of what the author entitles “Interventional Cardiology and Kindred Illusions.” He points out how much less common heart attacks are today then a generation ago:
• My chance of having a heart attack at sixty is about 50 per cent less than my father’s chance when he
was my age.
• If my father had suffered his first heart attack when he was my age, his five-year potential for survival would have been about 50 per cent. If I have a heart attack, my likelihood of living another five years is at least 95 per cent—without any specific interventions.
• If I take a baby aspirin daily from the time of my first heart attack, the likelihood of surviving five years rises to better than 97 per cent. pp 7– 8
In effect he asks why “heart attacks and strokes . . . hold North Americans in thrall.” p18 p 8 Having reviewed a large number of the major studies he then goes on to challenge the conventional wisdom that coronary artery bypass surgery and angioplasty, except for the three per cent with left main coronary
artery disease, extend life, over medical therapy alone. He then sadly points out that, while the emperor has no clothes, this is a $100 billion annual business.
To abandon this theory would be to shut down interventional cardiology, nearly all of cardiovascular surgery, and many surgical supply houses and biotechnology firms. It would dramatically downsize most
hospitals and critical-care units in the United States and free up over $100 billion annually. Since 1987,
cardiovascular disease has been the largest source of health-care spending in the country and the costs keep escalating, with cardiologists and cardiovascular surgeons providing fodder for an enormous supporting industry.p27
This is an extraordinary challenge to the certainties of mainstream medicine. When I discussed this book with a cardiovascular surgeon, an old friend and university professor, he became indignant, but was unable to bring me a single paper in refutation of Dr. Hadler’s assertions. On the other hand, another cardiologist ruefully conceded that there was much truth in Hadler’s critique of the surgical treatment of heart disease.
Hadler continues with an evaluation of diet, lifestyle, and health. He argues that for most people economics determine diet and exercise and that community and economic class are crucial to lifestyle change. Always the iconoclast, he agrees that the cholesterol and low-density lipoprotein (LDL) lowering
statins can offer a modest benefit to those who have experienced a myocardial infarction and for those who have had a stroke, but where is the proof that statins can prevent cardiovascular events in the worried well? Interestingly, the October 3, 2006, issue of the Annals of Internal Medicine questions the target numbers for LDL cholesterol set by the National Cholesterol Education Panel. The plethora of benefits attributed to statins includes Alzheimer disease, rheumatoid arthritis, and possibly other autoimmune diseases. This sounds to my mind distressingly like a new panacea in the making.
The author continues with an analysis of colon screening for colorectal cancer. He concludes that:
I suspect that a defensible approach to screening that spares us the risk of dying from colorectal cancer before our time will remain a will-o’-the-wisp for some time to come.p76
In a quite thorough analysis of breast cancer treatment, the author again challenges the prevailing wisdom of the medical community. First reminding the reader that in the 1960s the famous surgeon Oliver Cope realized that radical mastectomy had not improved the survival of women with breast cancer, yet no medical journal would publish his observation. After reviewing the data on mammography in the diagnosis of breast cancer Hadler concludes:
If we take the most optimistic approach to these data as they relate to women in their forties, it is much ado about almost nothing of value. Much the same perspective applies to mammography in women fifty years of age or older.p9
His chapter on prostate cancer screening is brief, but again he questions the wisdom of screening and the psychological and physical harm that can result. Whether the American population can become educated rather than frightened remains to be seen. In his opinion, “PSA screening is disappointing at best and probably harmful.” p99
In Part Two, “Worried Sick,” the author hopes to prepare the healthy person for the promise of medicine.
The Last Well Person is the one who is able to confront clinical science without being medicalized and to
harness it for personal benefit. I have written this book to prepare the reader for this task.p 0
In subsequent chapters he examines “Musculoskeletal Predicaments,” “Medicalization of the ‘Worried Well,’" “Turning Aging into a Disease,” “Health Hazards in the Hateful Job,” and “Why Are Alternative and Complementary Therapies Thriving?” Each of these chapters is not only stimulating, but will be very helpful to patients.
In “Epilogue: A Ripe Old Age,” the author offers a summary of his thinking and then follows with an extended annotated bibliography which will be of great interest to physicians. He suggests that:
Standing up to the moral entrepreneurs and the health-care delivery system they have nurtured is a lonely and demanding task. It is painfully so for your physician, if she is so inclined, and very time
consuming. Common practices, algorithms (therapeutic roadmaps), guidelines, and reimbursement schemes all stand in the way of independent thinking. Your physician can arrange for a cardiac catheterization far more readily than he can manage the considerable time to discuss why it may not be necessary. There are many physicians, including my own students, who would gladly assume that latter role if the health-care delivery system made it feasible. If you find such a stalwart iconoclast in the current climate, you are fortunate.p204
This is a wonderful book that I have greatly enjoyed reading and rereading for this review. It has already formed the basis for a Grand Rounds in Internal Medicine, “On the Ethics of Prognosis,” that I and several of my gerontology and palliative care colleagues presented several months ago. In preparing that presentation, I returned to Alvin Feinstein’s 1967 book, Clinical Judgment, the book that arguably initiated the search for an evidence-based medicine. And that is precisely what Nortin Hadler argues for, that in the absence of solid evidence we should not hesitate, as physicians and patients, to trust our intuition and respect our critical faculties in our encounters with the health care system.
Dr. Bennahum is the book review editor of The Pharos, and a member of its editorial board. He is emeritus professor of Internal Medicine at the University of New Mexico School of Medicine. His address is:
707 Notre Dame Drive NE
Albuquerque, New Mexico 87 06
E-mail: [email protected]
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