Nortin M. Hadler, M.D., author of Worried
Sick: A Prescription for Health in an Overtreated America, on
what every patient needs to know.
Q: You're an eminent physician and scientist
and a renowned clinician and clinical educator. In Worried Sick, you
call for evidence-based medicine that demands that the care of the
patient be tempered by the science that delimits clinical certainty.
What compelled you to become a reformer? Do you think that your message
will be controversial?
A: I never viewed myself as a
reformer, only as a physician who feels compelled to bring the highest
level of clinical scholarship to the bedside and to model such an
approach for my students. I have taught medicine at the bedside for 40
years with the same rigor I bring to Worried Sick. Furthermore, the
notion that medical practice should take advantage of whatever science
has to contribute is not controversial. That notion is a tenet.
However, "evidence based medicine" has become a shibboleth rather than a
process. All I am doing and all I am asking is that we closely examine
the "evidence" as to its relevance to the well being of any particular
patient. Worried Sick teaches how to do so, and how productive the
exercise can be. The result demystifies much that is common practice,
and informs the patient-physician dialogue. If the result flies in the
face of common practice, it is common practice that needs reform.
Q: How do you hope Worried Sick will
be used?
A: I have written Worried Sick to
serve three audiences: I want to teach all how to interpret medical
advice from any source and how to participate in a dialogue with anyone
we choose to serve as our clinical resource. I want to establish a new
standard for bedside teaching of all health care professionals. I want
to inform the health care policy debate. Overly ambitious? Certainly.
Overdue? Also, certainly.
Q: Why did you decide to include a shadow
chapter for each of the chapters?
A: A: Some of the lay readership
will desire access to the details of the science that supports my
assertions. In fact, I hope that all readers will feel such a need.
However, all health professionals who read Worried Sick should demand
ready access to such detail. After all, many of my assertions will seem
counterintuitive at first blush. I would not serve the readership well
without the shadow chapters and the extensive bibliography.
Q: How does this book differ from your
previous work, The Last Well Person: How to Stay Well Despite the
Health-Care System?
A: Worried Sick differs from The
Last Well Person in many important aspects: First of all, Worried Sick
picks up where The Last Well Person left off both chronologically (since
the literature of the 4-year interval is emphasized) and substantively
since much of the clinical science has matured. Secondly, several
important issues that were barely touched upon in The Last Well Person
are carefully dissected in Worried Sick. And I have gone to some length
to cast the inferences in a light that is directly relevant to health
policy considerations.
I have attempted to craft Worried Sick so that anyone who has read The
Last Well Person will feel well served by reading Worried Sick as well.
Many a medical journal club has used each of the shadow chapters in The
Last Well Person as a focus and stimulus; the same journal clubs can
productively return to the chapters in Worried Sick to good effect.
Q: Why is it so difficult for the average
patient to advocate for himself or herself in the contemporary
health-care delivery system?
A: It is not just the "average"
patient who has such difficulty. We all do, even those of us with
medical expertise. The role of the patient is one of inherent
vulnerability. We must countenance the probing of another human being
into aspects of our life story that we hold so very dear. We need to
trust our "provider." We reserve a special pedestal for our "provider."
We will feel a great deal of disquiet if that trust is lacking. "Health
care" is a philosophy. It may be informed by science, but it is always a
philosophy.
Today, trustworthiness is assaulted by a "health care delivery system"
that places little value on these human interactions and great value on
"efficiency" and profitability. Neither the patient nor the practitioner
is a primary "stakeholder" any longer.
Worried Sick leaves no doubt as to this emperor's clothing and tailor.
Q: What is "Type II medical malpractice"?
A: We all know about "medical
malpractice." It's when appropriate medical care is administered
inappropriately. I call this Type I medical malpractice. In Worried Sick
I repeatedly illustrate another form of medical malpractice, the
practice of doing the unnecessary very well. This Type II medical
malpractice demands recognition and expunging as much as Type I medical
malpractice. No one would argue. But you will learn in Worried Sick that
some of the most technologically sophisticated and expensive
interventions, interventions for which a great deal of training is
required and about which there is exuberant institutional pride,
interventions to which you and your neighbor are likely to submit are
shining examples of Type II medical malpractice.
Q: What does it mean to be well, and what
makes one's sense of well-being so fragile?
A: To be well is to have a sense
of invincibility, a sense that we can cope with much that life throws in
our path. This sense of invincibility is repeatedly challenged; none of
us lives long without such symptoms as backache, heartache, headache,
heartburn and much else. Furthermore, often these challenges from within
are confounded by challenges from without in our lives at home and at
work.
To be well is never to be taken for granted.
To feel well requires
well tuned coping mechanisms.
Q: What keeps us from having a rational health-care delivery system?
A: The simple answers: the
profitability of the abomination we currently underwrite and the
marketing that fools us all.
Q: What is the relationship between
socioeconomic status (ses) and longevity?
A: In the resource advantaged
world, medicine has little to offer for the longevity of the population.
Yes, we save lives. We save the lives of individuals with acute
infectious diseases, some with trauma, some with acute illnesses such as
appendicitis, and the like. But this saving of lives advantages a tiny,
albeit crucial, percentage of the public. Furthermore, the classic "risk
factors" such as some magnitude of BMI or of insulin resistance or of
cholesterol are "risk factors" indeed, but the risk they represent is
measurable in terms of months of longevity for the public. The majority
of your risk for not living to a ripe old age is captured by 2
questions: Are you comfortable in your socioeconomic status? And are you
comfortable in your employment? A negative answer puts years of
longevity at risk.
We don't understand the biological correlates of these real-world risk
factors, though there are clues. But we do know they subsume all that is
marketed as important including lowering you cholesterol or treating
your adult onset diabetes.
Q: Why is "iatrogenicity" a word that we, as
health consumers, should be more familiar with?
A: Iatrogenicity means diseases
and illnesses caused by doctors. Much is made of iatrogenicity in the
lay press, usually in terms of medical errors. I do not dismiss or
excuse such errors. However, Worried Sick focuses on errors of
commission that are not considered medical errors in the tradition of
"Type I" medical malpractice. Worried Sick considers the personal price
you pay if you learn that a PSA, or mammogram or cholesterol or bone
mineral density is not up to snuff. You will learn whether this
inference is a valid indicator of important consequences and whether the
interventions based on this inference actually advantage you. If they
don't, you are left with an altered perception of your health and
whatever toxicities you might derive from ineffective treatment. That is
also iatrogenicity.
Q: You consider interventional cardiology and
cardiovascular surgery the cash cows of the American health care
delivery system. Why? Don't many patients feel that they have benefited
from cardiovascular surgery?
A: Interventional cardiology and
cardiovascular are the leading "health care" expenses. The cash that
flows on their watch underwrites medical centers and their
administrators, many manufacturers, most insurance companies, and all
the other purveyors including the medical "providers." Furthermore, the
cash that flows rewards the various purveyors obscenely generously. It
would make sense if all this actually benefited the patients. It's a
scam.
However, no one can go before an American physician with anything
approaching heart disease without finding themselves in the
interventional vortex. No one can survive this vortex without assuming
they survived as a result and not despite all that was done.
A read through Worried Sick might spare you, if you have the courage of
your conviction and learn to ask the telling questions.
Q: You note that "normal body weight" is a
social construction, as is osteopenia. How so? What's harmful about this
kind of thinking?
A: How about some reality
testing? We will all die. The issue is not why, but when. We will all
age. The issue is not why, but how elegantly.
A concomitant of aging is loss of bone mineral density. A risk factor
for death is a body weight beyond "normal."
In the first instance, we need to know if a diminished bone mineral
density represents a meaningful hazard for our own quality of aging. In
the second instance, we need to know if "obesity" is a meaningful risk
for death before my time.
Read Worried Sick. Short of extremes, in both instances the hazard is
not worth worry, let alone any potential for adverse effects of drugs or
of being labeled abnormal.
Q: What fallacies surround the conclusions
drawn from the Harvard Nurses' Health study?
A: Let's talk about hubris.
Do
you really think you can generate meaningful data about such lifestyle
factors as nuances of dietary preferences over decades?
Do you really
think we can measure tiny differences in large data sets reliably, or
meaningfully? Read Worried Sick before answering.
Q: In your opinion, did Katie Couric's
decision to have a televised colonoscopy do the general public more harm
than good? Do the benefits of undergoing a colonoscopy outweigh the
risks of the screening?
A: Katie Couric's husband died
long before his time and that is truly sad. Colonoscopy at a very early
age might have saved his life.
However, death before your time from colon cancer is quite rare. We
would do more harm performing colonoscopy on healthy young people from
complications of the procedure than we would "do good" in sparing a rare
individual (one without a family history of colon cancer) death before
their time from colon cancer.
Likewise, finding colon cancer in the elderly is not likely to benefit
the elderly. They are more likely to die with colon cancer but from
something else.
Therein lays the debate. A single colonoscopy sometime in your 50s
probably has a tolerable risk/benefit ratio. Probably. I discuss the
"probably" in detail in Worried Sick.
Q: How difficult do you think it will be to
get patients to accept that it matters little what one dies of as long
as it's one's time to die anyway? Why are we so resistant to the idea
that we are mortal and likely to live only until about the age of 85?
A: Americans today are taught
that there is a scientific solution to all problems. We have no sense of
mortality. Furthermore, this sophism is highly profitable for many who
promote it, and highly seductive to all who listen. I wrote Worried Sick
to promote reality testing.
Q: According to Worried Sick, most male
physicians over the age of 50 have had Prostate Specific Antigen
screening (PSA). You are one of the few who have not. Why won't you
submit to this test that's considered almost a rite of passage?
A: PSA screening is a very flawed
test. You never want to do screening unless the test detects a disease
that should be treated. PSA screening is problematic. Firstly, by my age
all men have prostate cancer though nearly all will die with prostate
cancer and not from prostate cancer. PSA screening is very poor at
distinguishing those who will die from prostate cancer from those who
will die with it. As I say repeatedly, I will die but I am more
concerned about when then how. PSA screening offers no solace.
So why not remove all aging prostates? Or, why not remove all aging
prostates which happen to consistently secrete a lot of PSA? Very few
would die with prostate cancer and almost none from prostate cancer.
However, nearly all would die at the same time if they had not been
subjected to the surgery. Furthermore, about 15% of these "saved" men
would spend the rest of their life incontinent and 15% would be troubled
by their impotence.
No thank you.
Q: Why do you think that many women would be
better off if their breast cancer was never detected? Why do you think
that mammography offers so little of value to women screened?
A: I fervently hope that some day
we will have the ability to detect the breast cancer that is likely to
kill a woman before her time. I would applaud such a screening modality
and demand that we educate all women to be screened.
Mammography in all its current guises fails miserably in this regard.
All it accomplishes is widespread anxiety, enormous numbers of biopsies
that are irrelevant, and a great transfer of wealth.
Q: You say that "To be well is not to be free
of physical and emotional symptoms or to be spared physical and
emotional challenges. . . . To be well is to be able to cope effectively
with the challenges." As a physician, how difficult is it for you to get
patients and their families to accept this definition of wellness?
A: Medicine is a practice based
on trust and trust grows out of many interactions over time. Mine is a
subspecialty practice focusing on chronic illness. My patients know me.
We can discuss issues such as these without discomfort. My patients are
never "rheumatoids"; they are people who happen to be confronting
rheumatoid arthritis. There should be no "survivors" or "diabetics" or
"hypertensives" or the like—only people with an illness-colored
narrative of life. Such individuals are comfortable discussing the role
of coping in feeling well.
Q: It can be very stressful to resist a
health practitioner's advice. One can be afraid of displeasing one's
doctor by refusing to take a test or to fill a prescription. How would
you advise such a patient? Should one find another doctor?
A: Yes, one should find another
doctor. I wish that wasn't easier said than done. It takes 20 seconds to
write a prescription but 20 minutes not to. Physicians would like to
have the 20 minutes. In our "health care delivery system", they would be
punished fiscally for doing so. That's why Worried Sick is designed to
inform the policy debate.
Q: Why do most patients resist simply coping
on their own when symptoms arise? Why is it difficult to feel that one
can be well without the supervision of a physician?
A: Some of us go through life
feeling vulnerable. For some of these, this uncertainty is the product
of the child rearing style of their parents. That's not a condemnation.
It's an observation.
All of us are aggressively medicalized. Billions of dollars are spent in
marketing vulnerability. Sleeplessness, leg twitching, fatigue, sadness,
belching, being a brat, and so much more is medicalized so that taking a
pill is sensible. Life in general is medicalized; it's a minefield. Fish
is good for you unless there's too much mercury. This year if you feed
your child margarine you're a criminal; last year it was butter. The
billions spent on neutraceuticals, biologics, and supplements advantage
no consumer. It's endless, unless you learn to ask the critical
question. Is this evidence based health promotion or simply marketing?
Q: Why are alternative therapies so appealing?
A: I have two inter-related
answers: Whenever medicine gets as outrageous as it is today, and was a
century ago, "people" find safer ports in their storms. Furthermore, in
our complex society, more and more we need a port in the storm. That
doesn't mean the alternative is salutary. As discussed in detail in
Worried Sick, almost no "modality" purveyed as alternative withstands
scientific testing. Alternative therapy buys you another friend with
another mind set bolstered by another bundle of untested and often
fatuous theories. Just because an alternative port is less likely to do
you physical harm doesn't mean the experience is trivial. It is
guaranteed to change your sense of self, your idioms of distress, your
mode of coping, and your narrative of illness forever. Caveat emptor.
Q: You state that you know of no higher
calling than teaching medicine at bedside, and yet, you acknowledge that
you feel like an anachronism in your own and other American hospitals.
Do you think that other physicians feel the same way?
A: I know of many, and that many
feel the same way. The national emphasis is on "throughput". Patient
care is "managed" with efficiency (profitability) the goal. There are
few Socratic sessions, almost no references in charts, little argument
between consulting groups, nor are patients admitted for other than
"reimbursable" goals. The vaunted clinical scholarship of mid-century is
barely a ghost.
Q: What's the difference between the Quality
Movement in health care and the Effectiveness Movement?
A: There is a major emphasis on
efficiency and "quality" as cures for the inadequacies of the American
health care delivery system. There is no argument. However, efficiency
and quality is the cart; effectiveness is the horse. If the treatment is
ineffective, who cares how well or efficient it is delivered. That's why
CMS (Center for Medicare Services) studies of improved quality of care
for in-patient interventional cardiology demonstrate no improvement in
outcome. The "quality" of ineffective care was improved.
Q: Which groups have been most responsive to your message?
A: I've been asked to deliver
this message to many groups: Congress, leaders of industry, "health"
insurance and academic health center administrators, and many academics
here and abroad. All are receptive to the message. However, any would
pay a great personal and organizational price to act on it. After all
some 17% of the GDP is invested in the status quo, an investment that
captures many with its largesse. It would require a popular mandate for
anyone to act. Worried Sick is written to incite such a mandate.
