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    Worried Sick: A Prescription for Health in an Overtreated America
    Worried Sick: A Prescription for Health in an Overtreated America
    Worried Sick: A Prescription for Health in an Overtreated America
    Ebook660 pages11 hours

    Worried Sick: A Prescription for Health in an Overtreated America

    By Nortin M. Hadler, M.D.

    3.5/5

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    About this ebook

    Nortin Hadler's clearly reasoned argument surmounts the cacophony of the health care debate. Hadler urges everyone to ask health care providers how likely it is that proposed treatments will afford meaningful benefits and he teaches how to actively listen to the answer. Each chapter of Worried Sick is an object lesson on the uses and abuses of common offerings, from screening tests to medical and surgical interventions. By learning to distinguish good medical advice from persuasive medical marketing, consumers can make better decisions about their personal health care and use that wisdom to inform their perspectives on health-policy issues.

    LanguageEnglish
    PublisherThe University of North Carolina Press
    Release dateFeb 1, 2012
    ISBN9780807882719
    Worried Sick: A Prescription for Health in an Overtreated America
    Author

    Nortin M. Hadler, M.D.

    Nortin M. Hadler, M.D., M.A.C.P., M.A.C.R., F.A.C.O.E.M., is professor emeritus of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill and attending rheumatologist at UNC Hospitals. He is author of several books, including Stabbed in the Back: Confronting Back Pain in an Overtreated Society and Rethinking Aging: Growing Old and Living Well in an Overtreated Society.

    Read more from Nortin M. Hadler, M.D.

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    • 4/5
      This tome on the over-treated, over diagnosed, over drugged world of America is interesting. The author’s premise is that we are beset with rampant Type II Medical Malpractice – the performance of unnecessary testing, diagnosing, and prescribing. He seems to perceive that we are, as a culture, drug addicts of the first order, responding to the programmed prescription of pharmaceuticals by doctors who mindlessly follow the lead of drug companies and studies financed by the same folks. In the course of this herd-like plunge off the cliff, we are engaged in a huge wealth transfer from all of us to the medical establishment. What is our reward? The lowest life expectancy of any major country!Of course, this is the issue of the moment for our new President Obama, who seems obsessed with expanding this process.Whether your concern is cholesterol, blood sugar, blood pressure, breast cancer, prostate cancer, dietary supplements, hormone replacement therapy, osteopenia, backaches, over or under-working, or whatever, Dr. Hadler offers a critical evaluation of the practical realities of studies, most of which are read to mean that current treatments are no better than placebos.Dr. Hadler’s view seems to be that we all live, on average, to be about 85. By that time, we will all have our fair share of diseases and will die from one or more of them. We will be best advised if we have a trusted physician who will evaluate our maladies, advise of the realities of the treatments, and then let us take a proactive role in our own self-medication. He nowhere exactly says this, but the result seems clear enough.This is a marvelous book that should be must-reading for anyone who is concerned about any of these things – which is all of us.For me, Dr. Hadler’s excellent analysis made me revisit my own mother’s breast cancer treatment in the 1950s. I think that she endured a mutilation that was probably needless, did not extend the length of her life, and surely devastated the quality of her life. I hope that you are all spared such a fate. Read about being worried sick!

      1 person found this helpful

    Book preview

    Worried Sick - Nortin M. Hadler, M.D.

    Praise for Worried Sick

    "Worried Sick is for anyone who wants to make wise decisions about how to care for themselves and their loved ones. Dr. Hadler lucidly reveals the expensive tests that determine little and the quick fixes that boost nothing but cost to point the way toward a health system that we can’t afford not to have."

    —Scott Simon, National Public Radio, author of Pretty Birds and Windy City

    A withering critique. . . . Reject[s] the false coin of commerce and technological hype . . . to reassert the primacy of the patient.

    —New England Journal of Medicine

    [Dr. Hadler] is a longtime debunker of much that the establishment holds dear. . . . Reviewing the data behind many of the widely endorsed medical truths of our day, he concludes that most come up too short on benefit and too high on risk to justify widespread credence. . . . Raise[s] serious questions.

    —The New York Times

    Case by case, drug by drug, test by test, and procedure by procedure, Hadler exposes the excesses, the unjustified costliness, and the ineffectiveness of the present medical scene. He presents a proposal for a health-care insurance system that will increase the health of the nation, provide only effective care, and reduce costs. All self-funded employers must read, absorb, and install Hadler’s well-founded ideas.

    —Clifton K. Meador, M.D., author of A Little Book of Doctors’ Rules

    A serious diagnosis of what ails modern American medicine which will surprise and educate even the most savvy reader. Hadler exposes the fallacies that drive unnecessary and often harmful treatments and offers a hard-hitting series of remedies that could benefit us all.

    —Jerome Groopman, M.D., Harvard Medical School, author of How Doctors Think

    Having guidelines for reimbursement that went through a Hadlerian analysis is not a bad place to start reducing medical care costs without reducing the quality of patient outcomes. A much more politically attractive, and potentially quite effective, reform would make it routine for patients to be exposed to Hadler’s kind of analyses whenever they are asked to consider any significant medical intervention.

    —Journal of the American Medical Association

    Challenging conventional medical wisdom, [Hadler] advises a healthy skepticism about the benefits of drugs, routine tests, and many common medical procedures. . . . Educate[s] [readers] on being far better health-care consumers. . . . [A] provocative look at the U.S. medical system.

    —Library Journal

    An important book. . . . The reader will understand symptoms and their causation and will be richer for it—intellectually and in pocket.

    —Journal of Rheumatology

    This book challenges readers to alter their notions about health maintenance, discarding beliefs about the efficacy of certain medications, screening tests, and procedures. . . . This thoughtful message from an experienced medical practitioner has merit and may convince the general public to advocate more forcefully for change.

    —Fore Word Magazine

    To change unrealistic expectations about longevity or lives without pain or illness bucks vested interests, but that is what Hadler does. . . . He knows that the changes he proposes are a long shot, but when people demand that medicine stop doing unnecessary things well, reform becomes possible.

    —Choice

    It is impossible to read this monograph and remain complacent with the current medical model. . . . [Hadler] very clearly states a series of provocative tenets which deserve serious consideration.

    —The Pharos

    Provides readers with the perspectives and skills necessary to advocate for themselves in the contemporary health care delivery system.

    —Journal of Economic Literature

    Hadler documents that many Americans receive health care that is useless and often harmful because their physicians do not follow scientific standards of effectiveness. He makes a strong case that these standards should be the basis of payment and should guide patients in selecting physicians and consenting to treatment.

    —Daniel M. Fox, Milbank Memorial Fund

    Thought-provoking, and one of the better critical treatments of our health care approach.

    —DTC Perspectives

    This is recommended reading even if you are determined in advance to despise it. You will be better off having wrestled with [Hadler’s] arguments and . . . probably will not find them easy to refute.

    —Journal of American Physicians and Surgeons

    Worried Sick

    Also by Nortin M. Hadler, M.D.

    The Last Well Person: How to Stay Well Despite the Health-Care System (2004)

    Stabbed in the Back: Confronting Back Pain in an Overtreated Society (2009)

    Rethinking Aging: Growing Old and Living Well in an Overtreated Society (2011)

    Worried Sick

    A Prescription for Health in an Overtreated America

    Nortin M. Hadler, M.D.

    With a new preface by the author & a new foreword by Shannon Brownlee and Jeanne Lenzer

    The University of North Carolina Press

    Chapel Hill

    This book was published with the assistance of the H. Eugene and Lillian Youngs Lehman Fund of the University of North Carolina Press. A complete list of books published with the assistance of the Lehman Fund appears at the end of the book.

    © 2008 Nortin M. Hadler

    Preface to the paperback edition © 2012 Nortin M. Hadler

    Foreword © 2012 The University of North Carolina Press

    All rights reserved

    Designed by April Leidig-Higgins

    Set in Minion by Copperline Book Services, Inc.

    Manufactured in the United States of America

    The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources.

    The University of North Carolina Press has been a member of the Green Press Initiative since 2003.

    The Library of Congress has cataloged

    the original edition of this book as follows:

    Hadler, Nortin M.

    Worried sick: a prescription for health in an overtreated America /

    Nortin M. Hadler.

    p. cm.

    Includes bibliographical references and index.

       1. Medical care — United States. 2. Medical policy — UnitedStates.

    3. Older people — Medical care — United States. 4. Medical care — Utilization

    — United States. 5. Health care reform — United States. I. Title.

    [DNLM: 1. Delivery of Health Care — utilization — United States — Popular

    Works. 2. Aging — psychology — United States — Popular Works.

    3. Health Policy — United States — Popular Works. 4. Health

    Promotion — United States — Popular works. 5. Unnecessary

    Procedures — utilization — United States — Popular Works.

    W 84 AA1 H131W 2008]

    RA395.A3H332 2008

    362.10973 — dc22 2007042147

    ISBN 978-0-8078-3187-8 (cloth: alk. paper) (2008)

    ISBN 978-0-8078-7233-8 (pbk.: alk. paper)

    paper 16 15 14 13 12 5 4 3 2 1

    To a generation of students

    and generations of patients

    for all they taught me,

    and to

    Carol S. Hadler,

    who made the last forty-five

    years full, fun, and complete

    Contents

    Foreword by Shannon Brownlee and Jeanne Lenzer

    Preface to the Paperback Edition

    Acknowledgment

    Introduction

    one The Methuselah Complex

    two The Heart of the Matter

    three Risky Business: Cholesterol, Blood Sugar, and Blood Pressure

    four You Are Not What You Eat

    five Gut Check

    six Breast Cancer Prevention: Screening the Evidence

    seven The Beleaguered Prostate

    eight Disease Mongering

    nine Creakiness

    ten It’s in Your Mind

    eleven Aging Is Not a Disease

    twelve Working to Death

    thirteen Alternative Therapies Are Not Complementary

    fourteen Assuring Health, Insuring Disease

    Supplementary Readings

    Bibliography

    About the Author

    Index

    Tables

    TABLE 1 The West of Scotland Pravastatin Study 35

    TABLE 2 The Efficacy of Aspirin Prophylaxis 74

    TABLE 3 The Malmö Trial of Mammographic Screening 79

    TABLE 4 Survival of the Women of Ontario 83

    TABLE 5 Five-Year Mortality Rates in the Scandinavian Trial Comparing Radical Prostatectomy with Watchful Waiting 99

    TABLE 6 Adverse Effects in the Scandinavian Trial Comparing Radical Prostatectomy with Watchful Waiting 100

    TABLE 7 Offensive Diagnoses 138

    TABLE 8 Women’s Health Initiative HRT Randomized Controlled Trial 163

    TABLE 9 Number of Fractures in the VERT Trial 167

    TABLE 10 Adverse Effects of Herbal Concoctions 204

    TABLE 11 Therapies Frequently Used by the 10 Percent of American Adults Turning to Alternative Providers 209

    TABLE 12 Incidence of Vertebral Fractures over Four Years of Treatment with Alendronate Versus Placebo 298

    Foreword

    Anyone who has gone up against a powerful establishment knows that assuming the role of a dissident can be a lonely place, and there are few enterprises more powerful, both economically and culturally, than American medicine. In Worried Sick, Dr. Nortin Hadler bravely takes on both his own profession and the industry it serves, along with the culture of medicalization that has grown in parallel with the expansion of health care as the dominant sector of the nation’s economy. There are two central and vital messages in this book. First, Hadler clearly believes that many of the medical services— the treatments, tests, drugs, and surgeries — that have been developed over the last century have enormous potential for improving and extending patients’ lives. Hadler’s second message, however, is the more powerfully essential: not everybody needs to become a patient to enjoy a long and healthy life.

    We live in a society where we are constantly being exhorted, by public health officials, the media, patient advocacy groups, drug and device companies, and our own physicians, to be ever vigilant for the first signs of incipient disease. We constantly worry that every little ache and pain is a harbinger of an infectious disease, cancer, an incipient heart attack. Every stuffy nose requires a trip to the doctor, even though it is almost certainly caused by a virus and will run its course without medical intervention. Every headache is a possible brain tumor. Every child who won’t stay put in his seat has attention deficit disorder and needs to be treated with psychiatric drugs. Catch it early is the watchword, know your numbers, or, as one advertisement for virtual colonoscopy put it, Bad news can be good news if you get it early enough. Then there is the slew of new syndromes and disorders to worry about — restless leg syndrome, social anxiety disorder, osteopenia, irritable bowel syndrome, Lyme disease — many of which are inventions of the pharmaceutical industry, which is perennially anxious to find new markets for its products.

    Hadler puts much of the hype and fear-mongering into proper context, marshalling science to show that most of us need to worry less and live more. In the process he takes on some of the sacred cows of both alternative and mainstream medicine, including homeopathy, back surgery, mammography, the prostate specific antigen test, and cardiac stents and bypass surgery.

    Studies have found that patients are astonishingly misinformed about many medical technologies, chief among them cardiac interventions, which rank among the most profitable and common treatments in the United States. Stents, for example, have been shown in several clinical trials to offer little to no benefit in terms of mortality or prevention of future heart attacks. Yet in one recent study, more than three-quarters of patients undergoing this invasive procedure believed the stent would protect them from a heart attack and extend the length of their lives. (Surprisingly, nearly one-quarter of cardiologists surveyed were under the same impression.)

    Why are patients so poorly informed? For a constellation of reasons, including a gullible press that is besotted with the latest surgery and breakthrough technologies. This is nothing new. The media have long been instrumental in the public’s positive view of new medical technologies, many of which are ultimately shown to cause less good than harm. Frontal lobotomy and whole-body CT scans come to mind. You’d think we would have learned by now. Yet the press continues to hail every new vaccine as the next best thing since Jonas Salk, surgical robots as the greatest invention since R2-D2, and every new screening test as the latest way to save lives.

    But medical reporters are not entirely to blame. They simply amplify a message that originates with the health-care industry itself — with device companies in the case of stents, drug companies in the case of the newest antipsychotics and antidepressants. The message also comes out of academic medical centers, those venerated institutions that are considered our beacons of medical science — and by rights should be playing that crucial role — yet have served instead in many instances as covert marketers for drug and device makers and promoters of their own interests as purveyors of profitable procedures. The other reason patients are so clueless is that they are not being well informed by their physicians, some of whom do not know their own scientific literature or who have a vested interest in not understanding or conveying its lessons.

    These are painful realities, and it would be very surprising if the majority of doctors see Hadler’s message in a positive light. Worried Sick has undoubtedly been viewed by many of his peers as the work of a therapeutic nihilist, a physician who does not believe in the value of medical treatment. This is a misreading of Hadler, who is no therapeutic nihilist. He does not wish to ration care, and he’s not a member of any death panel. He simply wants medical science to guide the way patients are treated and informed. Worried Sick represents an effort not to condemn all of medicine, but to prevent harm, to sort truly effective and beneficial treatments from those whose benefits have been exaggerated, those that are effective in one population but are routinely delivered to a much larger group, many of whom will not benefit and may even be harmed.

    Hadler’s thesis is particularly important today, as the nation begins a historic effort to reform the delivery of health care and control how much we spend on it. He’s up against big money. Enormous forces are likely to oppose real change in the system, from hospitals to medical specialty societies to drug and device makers, many of whom stand to lose financially if the status quo shifts in the ways that it must in order to improve the delivery of medical services. Patients and citizens, who will be the winners in this reorganization, would benefit from a wider understanding of Hadler’s arguments.

    We are all looking for certainty and relief from the terror of disease, pain, and ultimately death, but not all aspects of being a living, breathing, and aging human being have a medical fix. This book speaks to the importance of compassion in medicine and to the role that physicians have always played in comforting the afflicted and helping patients make sense of suffering and disease, which continue to be a part of our lives, despite the many advances in medicine. Those who are sick deserve the best treatment, and above all compassion and comfort. Those who are not would do well to take Hadler’s message to heart: devote less time and energy to worrying that disease is right around the corner and more to celebrating life.

    Shannon Brownlee, M.S., Washington, D.C.

    Jeanne Lenzer, Kingston, N.Y.

    Preface to the Paperback Edition

    In the fall of 1964 the first-year class assembled in a large amphitheater in one of the neo-classic marble buildings that defined a quadrangle as awe inspiring as any in the Roman Empire. The purpose of the assembly was to hear an address that welcomed them to Harvard Medical School and to medicine. The address was delivered by George Packer Berry, dean of the flagship of American medicine. He was in the last year of his tenure. Under his leadership, Harvard Medical School had sailed relatively smooth waters to safe harbor behind a breakwater rendered ever so sturdy by the application of a progressively more substantive and compelling science. It was on George Packer Berry’s watch that medicine finally made therapeutic strides that would withstand the test of time, such as the introduction of antibiotics. Yet George Packer Berry stood before this assemblage of exceedingly eager, committed, and accomplished young scholars and told us that at least half of what we would learn about the care of patients in the next four years was wrong and, embarrassingly, he had no way to identify the chaff.

    This medical school class was embarking on careers of celebrated accomplishment. We stand witness to enduring and reproducible advances in the understanding of human biology and how it can go awry. Nonetheless, if George Packer Berry were alive today, he would be quite safe forewarning a first-year class that well over half of what they learn about the care of patients in the next four years will be wrong. The difference, fifty years later, is that we have the means to identify the chaff and an ethical mandate to do so before patients pay the price of inefficacy or worse. The greatest advance in my lifetime in medicine is not in the science of biology; it is in the science of efficacy. Good scientific ideas are a dime a dozen. Good scientific ideas that translate to the bedside to benefit the ill and spare the well are not a dime a dozen. Their cost is the painstaking, meticulous demonstration of meaningful clinical benefit. Since we now have the wherewithal to establish efficacy or the lack thereof, why is it that half of what we teach is still chaff?

    The mandate to eschew harmful treatments has been a banner of my profession for millennia. The modern corollary is to eschew treatments when meaningful efficacy proves elusive in adequate scientific tests. This tenet is no match for the agendas, vested interests, and conflictual arrangements that are nurtured by much of the largesse the American medical enterprise has co-opted. This distortion of the ethical compass of my profession causes cognitive dissonance in society and outrage for those of us who value the tradition that George Packer Berry represented. So much of what is perpetrated on Americans for their health has been tested and found to be lacking in efficacy. This is particularly true of the high-ticket items among the trumpeted surgical and pharmaceutical interventions. And they are trumpeted in pervasive, unavoidable marketing schemes that capture providers’ attention as well as recipients’. Seldom are purveyors called on the carpet. On those rare occasions when they are, either there’s a lame excuse (such as I do it differently or I can identify the proper candidate) or a penalty that is considered the cost of doing business. The American medical enterprise has deep pockets and an enormous investment in the status quo—literally, including funding about six lobbyists for every congressman. It’s the Titanic, and its leadership owns the lifeboats.

    A decade ago, this dialectic caused me to stick my head out from the safe, comfortable, ivy-covered world I had created. I was driven to do so by the increasing challenge of practicing and teaching medicine according to my conscience. I chose as my weapon skills I had honed in forty years as a clinical scholar and academician. I taught informed medical decision making to my patients and to many, many students at all levels of experience. Now I would teach it to the general public; I would write a series of five books, each rigorously setting forth principles that the public needs in order to confront the American medical enterprise and emerge with as much benefit as reason can promote. All these books are anchored in clinical science. I demonstrate the evidence that can inform medical decision making. I comprehensively reference primary source material. I teach the reader how to interpret such evidence and how to apply the interpretation to the value-laden question, Will this provide me with a meaningful advantage? These books are detailed to reflect the demanding nature of the exercise of informed medical decision making. They are not comprehensive texts; I chose topics that are illustrative to teach a mind-set one can apply to any individual circumstance. But each book isolates a segment of the human condition:

    The Last Well Person: How to Stay Well Despite the Health-Care System (McGill-Queens University Press, 2004) is a treatise on medicalization. It emphasizes commonplace symptomatic predicaments and asks whether clinical recourse is worthwhile.

    Worried Sick: A Prescription for Health in an Overtreated America (UNC Press, 2008) takes this theme a step further and examines whether the average working-age adult is advantaged by some of the most heavily marketed medical and surgical advances.

    Stabbed in the Back: Confronting Back Pain in an Overtreated Society (UNC Press, 2009) demonstrates how and why backache has become a window on the social construction of health in modern America.

    Rethinking Aging: Growing Old and Living Well in an Overtreated Society (UNC Press, 2011) applies these decision-making skills to the challenges of the last decades of life.

    All these books have been well received and all have garnered very gratifying reviews. The same pertains to the French translations of the first three. They are informing the health-care debate in ways that strike a chord of satisfaction with this clinical educator. I am driven more by a personal and private reward system than by titles and accolades. For me, the most meaningful rewards come from a productive therapeutic collaboration with individual patients, from students who feel drawn to becoming a peer, and from the fashion in which my ideas gain traction whether or not they are recognized as mine. I am grateful to every reader who felt the effort of reading any of these books worth his or her while. The language, even the idioms, I crafted to teach these principles are increasingly making their way into parlance. Many of the conclusions that readers might draw from my discussions of the evidentiary basis of medical decision making no longer seem counterintuitive. Slowly but surely, the body politic is becoming better informed.

    The Last Well Person was first published in 2004 and then released by the publisher in paperback in 2007. I am far more experienced as an educator writing for medical audiences than for a general audience. I was told that the paperback version reaches another segment of the audience, and indeed it has done so. The United States is heading into the cacophony of the election season. Health care will continue to be very much a hot-button topic. I wrote Worried Sick to arm working-age individuals with a perspective that will assure that their personal medical decisions are as informed as possible. This perspective generalizes from the health of the person to the health of the public in a fashion that is highly relevant to the health-care debate. All the object lessons in Worried Sick, chapter by chapter, are relevant today, and the discussions of evidence are current. The literature that has appeared since I penned the book is entirely confirmatory. Most is readily available in my subsequent books. A paperback edition of Worried Sick is timely.

    My next book, the fifth in the series I envisioned a decade ago, will explain why I felt compelled to write the four earlier books. In it I will demonstrate the aspects of the American health-care enterprise that are morally bankrupt. Sadly, it is highly unlikely that anything about the American healthcare enterprise will turn more enlightened and progressive by the spring of 2013, when we will see our next presidential inauguration and when the book should appear. But it is likely that by the spring of 2013 the body politic may be sufficiently enlightened to override vested interests and demand meaningful reform.

    October 2011

    Acknowledgment

    Publishing books has been a major part of my career, books written for physicians and scholars who share my research interests. Publishing books for a general audience is an entirely different exercise, but I grew to relish the process with Worried Sick. The reason in part is the encouragement and support of David Perry and the staff at UNC Press. What a privilege to have such a resource on campus, just a few blocks from my office.

    Introduction

    The social construction of health in the United States, and to a lesser degree elsewhere, has features that are counterproductive. We are becoming increasingly medicalized, made to think that all life’s challenges demand clinical intervention, when the science dictates otherwise. We are at grave risk of what I call Type II Medical Malpractice — doctors doing the unnecessary, albeit very well (as opposed to Type I Medical Malpractice, which is doctors doing the necessary unacceptably poorly). Until the public at large comes to recognize the dangers of medicalization and Type II Medical Malpractice and decries both, there will be no pressure to reform an egregiously self-serving national medical enterprise. We will continue to condemn its costliness rather than its abysmal lack of cost-effectiveness.

    My primary objective in writing Worried Sick is to provide readers with the perspectives and skills necessary to advocate for themselves in the contemporary health-care delivery system. I have spent over three decades honing the ability to communicate complex issues to patients, mostly in clinical settings. Lately, I have produced a series of essays on health-care matters for ABCNews.com that I’ve crafted for a very wide audience. While I can’t do as well in print as I could face to face, responding to an individual’s questions and challenges, I am confident that the message of this book will be loud and clear. I have written as if I were conversing with a patient rather than speaking to a colleague. Each chapter provides a fresh, often startling, even counterintuitive take on topics that we all hear about almost daily. All of these topics are darlings of the health journalists; each supports an industry. It requires an open mind to look at them critically and then to turn them inside out. I hope that I’ve eased readers into this exercise. If so, I will have transformed them into very sophisticated guardians of their own health.

    However, I am very uncomfortable asking the reader simply to accept my arguments. I need to provide the detailed, rigorous support for the exercise. Hence, each chapter has a shadow chapter in the supplementary readings, which are much more than annotated bibliographies. The shadow chapters are more detailed, technical, and heavily referenced than their counterparts but are still designed to be instructional and accessible to the interested general readership while satisfying the most demanding of my peers. My intent is for all readers to feel the need to read the shadow chapter once the thrust of the main chapter is apparent. The shadow chapters highlight the many crucial papers published in the last few years.

    I have a second agenda in writing Worried Sick, beyond teaching the reader how to make informed personal choices regarding his or her well-being. This book teaches how such a perspective translates into informing issues in healthcare policy that are relevant to all of us. I am convinced that the major stumbling block to rational health care in the United States is not the entropy nurtured by the interests vested in the status quo but the social construction of health. Americans think their medicine is the best, if only they could afford it. This book is the catwalk for the displaying of the medical emperor’s new clothes. My patients, my students, my children and grandchildren, as well as yours, need to recognize and decry medicalization and Type II Medical Malpractice. Only then will physicians be able to cast off the shackles of the contemporary medical enterprise and be able to minister to the sick once again. Only then will rational health care be possible. I return to this prospect in chapter 14.

    Desperately Well

    This book is not written as a resource for people who are no longer well. It offers few insights into developing the courage to cope with particular diseases and the illnesses they cause. Many of the skills and perspectives regarding therapeutic choices that are developed here are as relevant to those who are sick as to those who are well. But I am writing this book mainly for all who consider themselves well despite occasional or even persistent nagging doubts. Your sense of well-being requires conviction to withstand the badgering assaults of health-promotion programs. Some of you are overcoming encounters with illness; others are still trying to put such encounters into perspective. Some of you are burdened with forebodings; others are fatalistic. If you feel you are well despite all this, you have an unshakable inherent sense of invincibility. This book is written to provide the wherewithal to bolster that conviction. It is not designed to obviate the need for seeking help when your conviction seems shaky. If you feel such a need, Worried Sick is designed to make you an active participant in the choosing of treatments among the many that various professional purveyors promulgate and even aggressively market. It is written so that you will have the courage to take responsibility for rationally considering these options.

    We all need to become the most sophisticated of health-care consumers. We have all experienced heartburn and heartache, backache and neck pain, unfamiliar bowel function, peculiar sensations, days in the doldrums, realizations of physical limits, insomnia, and myriad other predicaments — and we will again. These are unpleasant, disconcerting, personal, even noxious experiences; these are morbid events that test the limits of our sense of invincibility. Worried Sick is written to bolster the personal resources that facilitate coping, whether we attempt such on our own or we negotiate professional guidance. And our coping is in dreadful need of bolstering. The wealth of health information disseminated by all sorts of health-care vendors, including those in the medical profession, may be intended as helpful but often is not. Much of this information does violence to our sense of invincibility without doing equivalent good for our health or longevity. This book levels the playing field.

    My approach is imbued with the teachings of Karl Popper. Popper moved the philosophy of science into the modern era. He placed on us all the responsibility to doubt, to question, and always to try to refute each successive putative truth. Truth, he taught, is only the hypothesis that is yet to be disproved. I have spent my career as a medical educator under this banner, teaching at the bedsides of a vast array of very sick patients at my home institution and as visiting professor at over a hundred others. Worried Sick is crafted to inform the well reader how to feel well. Rest assured I understand the plight and circumstance of those who are not so fortunate as to be well. Otherwise, I could not appreciate the challenges to the sense of wellness faced by those who are well. When I’m done with you, you will not be as vulnerable to pronouncements that are presumptuous if not self-serving.

    In crafting Worried Sick, I have relied on an experience that is typically uncommon for mainline academic physicians. Thirty years ago I realized that nearly all my patients were faced with a plight that was barely mentioned during the years I spent learning to be a physician; patients leave the office or hospital and then contend with the impact of their illness on daily life and on their expectations. Thirty years ago I commenced a study of one aspect of that plight: the need to maintain substantial gainful employment. My interest in the illness of work incapacity has taken me far afield, forcing me to explore workplaces, analyze work and work contexts, and probe the sociopolitical constraints imposed on the interface between the medical community and the permanently and transiently disabled. This book is imbued with my understanding of the social consequences of illness.

    Likewise, an understanding of medicalization permeates the book. The study of the interplay between illness and work demanded a more intimate knowledge of the perceptions of illness and of its consequence for people who had not sought medical attention. From the perspective of the physician, these people who were not yet patients were well. However, my work, some work by predecessors, and a vast current literature has dissected the construct well as it pertains to life in the community. To be well is not to be free of symptoms — of morbidity — continuously or for long periods of time. It is abnormal to escape heartburn and heartache, backache and headache, sad days and days when we’re aware of our bowels. Sometimes we tell others of our predicaments, describing our plight as we perceive it in our own idioms of distress. But whether we tell someone or not, we are challenged to cope with these predicaments of life and of living. To be well is to be able to cope with morbid episodes. And coping may not be easy. It can be thwarted by the intensity of the morbidity, or by complicating and confounding factors.

    Medicalization is one such confounding factor. Medicalization is the process by which the morbidity is framed by the person as a medical illness for which medical treatment could or should be sought. To do so, it must seem reasonable to ascribe the symptoms to a medical disease. The Victorians could medicalize the female orgasm, whereas we can medicalize its absence. Medicalization superimposes a scientific idiom of distress on the common sense. Common sense is not common, temporally or geographically, and if it is sense, it is sense that is highly susceptible to presuppositions, magical thinking, and market pressures.

    Most importantly, Worried Sick is imbued with critical, rigorous science. I’ve already admitted to being a committed refutationist, a follower of the teachings of Popper. I started my investigative career as a geneticist, moved on to study immunochemistry, and spent my first decade on faculty as a physical biochemist. I only closed my laboratory when I found that contending with the other three passions of my academic career was more than a plateful. However, I have a keen appreciation for the scientific method at its most rigorous. I have applied that razor to my own epidemiological studies and to the relevant epidemiological studies of others. The result is a definition of uncertainty, even a quantification of uncertainty. The result is not — not now and maybe not ever — a definition of certainty. The best I can tell you is how uncertain I am about any assertion of fact I make, and how certain I am about any tenet I declare to be rubbish. This is an elegant philosophy of science but a demanding philosophy of life. How much uncertainty we tolerate about any fact relates to our own personal value system. Suppose I tell you that if 1,000 well people take a particular drug every day, all will be living in five years’ time, whereas only 500 will survive without the drug. Most of us would value the drug greatly, even if its longer-term toxicities were unknown. Would you value the drug if I told you that after five years, there were only 510 survivors? Do you think it is possible to reliably measure the difference between 510 surviving on the drug and 500 surviving without the drug? If so, do you think it is meaningful? Is it worth the bother of swallowing the pills, the risk of short-term toxicities, and the uncertainties in the long run? Would 550 survivors on the drug seem more compelling? We will revisit this scenario in chapter 2 and the notion of medical uncertainty from the patient’s perspective repeatedly throughout the book.

    Worried Sick is a treatise on medicalization that is informed by science, clinical reality, and an analysis of life’s morbid experiences. I intend to suggest ways of coping with some of the morbidities that are unavoidable in the course of living as a well person. I intend to demonstrate how to discern instances when medicine can offer you insights in that regard. And I intend to teach you how to avoid iatrogenicity, medical interventions that cause harm. Armed with skepticism and a critical intellect, it is possible to safely and effectively benefit from modern medicine without being harmed in the process. Armed with informed skepticism, it is possible to design a rational health-care delivery system. It is not my intent to speak ill of your doctor, or even of doctors generally. I am examining the institution of medicine that molds the behavior of physicians and that waits upon your complaint. I have no compunctions about sharing the bad with the good that results from that examination. I have no compunctions about suggesting a system of health insurance that underwrites only the good, only those items among all that have been studied that have been shown to have a meaningfully advantageous benefit-to-risk ratio.

    This book has fourteen chapters. Several confront the inevitability of death. Yes, we will all die. The issue for me is not so much how or why we die, but when and how we lived. In the academy and in the lay mind, the proximate cause of death is foremost, so that great energy and great wealth is expended trying to spare you death from a particular cause without considering whether you will die at the same time from some other cause. This medicalization of dying hides under the Orwellian banner of Health Promotion, Disease Prevention, affectionately termed hippie-dippie for the acronym HPDP by the self-important insiders. The idea is that all of us are time bombs. We harbor bundles of risk factors and face potential hazards that someday will rise up, smite us ill, and carry us off. Hippie-dippie promises to modify and mollify our mortal risks. Who can resist? Anyone who has read Worried Sick.

    Other chapters step back from the myth of immortality to examine the medicalization of the morbid predicaments of life. This theme will make you uncomfortable at first blush. Once I educate you, you will be able to go before your physician with such complaints as Doc, I feel awful. Could it be in my mind? or Doc, my back is killing me. I can’t figure out why I can’t cope with this episode. I daresay most of you would find the first complaint off-putting if not infuriating, and the second counterintuitive. I will undertake this exercise in semiotics to change your idioms of distress so that they reflect your predicament rather than personal and medical presuppositions. You will learn how psychosocial challenges to our sense of invincibility can cause us to focus on physical and emotional symptoms so that the symptoms seem more the issue than the challenges that caused us to focus in the first place. Don’t read something abnormal, weak, or weak-minded into this assertion; it is describing a normal dynamic. Until this concept is grasped, myriad approaches offered by others to help with the symptoms will seem seductive. Pursuing help for the surrogate complaint seldom provides relief, often exacerbates the symptoms, and always and forever changes your sense of well-being.

    Teaching the well how to critically approach the medical treatment act is something of a heresy. After all, I am teaching that neither naïveté nor trust can be counted on to serve you well. Most of the lessons, the object lessons I will teach, are heretical as well. Without criticism and controversy, the weaknesses of our beliefs never surface. My goal is to provide readers with the skills to assume responsibility for assessing their health status in the face of the barrage of information that they will confront in the days and years to come. Each of the fourteen chapters is an object lesson; each tackles a topic of immediate relevance and teaches a particular skill set. I have ordered the topics so that the skills complement and build on one another. It is certainly reasonable to skip to the chapter you find most relevant to you. I have made some allowances in the design of the chapters for picking and choosing. However, I urge you to read the book in sequence. I am not setting out to turn you into biostatisticians and epidemiologists. I am setting out to mold your critical skills so that you can recognize and contend with the unfounded assertions, tortured and massaged data, and egregious marketing that has always been present but is now industrialized. There is no other way to avoid sacrificing the sense that you are well to medicalization, or worse yet, losing your actual wellness to iatrogenicity, the illnesses that are caused by medical treatments. And there is no other way to recruit you to my hidden agenda: fomenting a debate that demystifies modern medicine so that we can promulgate a rational health-care delivery system and underwrite its cost.

    Chapter One

    The Methuselah Complex

    Man has no dominion over the breath of life, neither to retain that flicker of life nor the power to determine the day of death.

    — Ecclesiastes 8:8

    Do you know when you want to die?

    If you could, would you choose the date?

    Never is not an option; the death rate is one per person. When? is the profound and bedeviling enigma. Ending one’s own life raises great issues in moral relativism, as great as does ending the life of another. Prolonging life also raises issues in moral relativism. Should we go to lengths to prolong all life, or just life we deem sufficiently high in quality? Hence, When? is pregnant with, How goes the journey?

    These are questions for the ages. The authors of the Old Testament weighed in: foreknowledge of the time of one’s death would be a heavy burden, not a blessing. Furthermore, if a world without death becomes a world without birth, the specter is bleak and joyless. Rather, death is viewed as inevitable and the imponderability of its imperative assuaged with notions of afterlife. Longevity is treated as a sign of purposefulness if not holiness. The Old Testament offers up Abraham, Moses, and that statistical outlier for the ages, Methuselah, the grandfather of Noah, whose age at death is usually translated as 969 years. Some scholars choose a different Sumerian dialect for translation or convert to lunar years and come up closer to eighty-five — exceptional, not too shabby for the time of the Great Flood, and not fatuous as is 969. Are we, the residents of the modern resource-advantaged world, likely to live to be eighty-five? Can we aspire to be purposeful for eighty-five years? Are highly functioning octogenarians still statistical outliers?

    Daily, we are offered the image of the baby-boom generation going on forever, making impossible demands on successive generations to provide pensions, health care, and community. That, too, is fatuous. However, more of us are living longer than did our parents. Clearly, the likelihood that we will enjoy life as an octogenarian has increased over the course of the twentieth century. Far less clear is whether the likelihood of becoming a nonagenarian has increased similarly. It has certainly not done so at anything like the same rate as the likelihood of being an octogenarian. The effect is so striking that it has caused many of us to wonder if there is not a fixed longevity for our species, set around eighty-five years of age. Some have likened this to a warranty: you are off warranty at eighty-five, beyond is a bonus, and well beyond is a statistical oddity. This projected demographic is consistent with current population trends. With one caveat, these hard facts seem unlikely to change. It is possible that molecular biology can alter the fixed longevity of our species. But don’t hold your breath. None of us will live to see that — and maybe no one ever will.

    Eighty-five (± a little bit) appears to be the programmed life expectancy for our species. I grant that the science is imperfect. But eighty-five is a linchpin of my personal philosophy of life. I, for one, do not care how many diseases I harbor on my eighty-fifth birthday, though I prefer not to know that they are creeping up on me. I, for one, do not care which of these diseases carries me off as long as the leaving is gentle and the legacy meaningful. Perhaps the best we can reasonably hope for is eighty-five years of life free of morbidities that overwhelm our wherewithal to cope, then to die in our sleep on our eighty-fifth birthday.

    Unfortunately, not all of us will arrive at our eighty-fifth birthday with tranquility or, having done so, have a peaceful passing. Fortunate, indeed, are the octogenarians of today who have the wits and faculties to contend with life’s demands. But time soon whittles away even their higher level of functional capacity. Month by month they face days when they do not perform as usual and even feel the need to take to bed. Inexorably, activities of daily living, activities they always took for granted, become an insurmountable challenge. They will come to take their place among the frail elderly. They will lean on canes by the grave-side of their friends. They do not merit a disease label, such as Alzheimer’s; they merit awe, compassion, and community.

    The hope is faint that contemporary medical science will shepherd more of the high-functioning octogenarians into the very meager ranks of the high-functioning nonagenarians. It is, however, possible to provide comfort and support for these octogenarians through the transition toward decrepitude and in their final passage. Friendship, community, and love are defensible as prescriptions, clinical interventions, and targets for public policy and expenditure. To advocate otherwise, including measures purporting to increase the lifespan beyond eighty-five, is to harbor delusions of immortality. Heroic efforts on behalf of the highly functioning octogenarians will accomplish little of substance. We can, perhaps, alter the proximate cause of death — that is, the diagnosis on the death certificate — but I am aware of no data to support the premise that we can alter the date of death. This is not to advocate therapeutic nihilism. It is the invoking of the age-old ethic of medicine to contend with the reality of our aging and our mortality. When the high-functioning octogenarian declines, it is because her or his time is nearing. When death supervenes, it is because it is her or his time. That is the real proximate cause of death. It does not matter how many diseases are vying for coupe de grâce. It only matters that the journey was as gratifying as possible.

    One might be tempted to ascribe the increasing longevity in North America to past medical programs that promote health and to ongoing medical care. Science tempers any such hubris (we return to this realization in chapter 14). Health-adverse behaviors and cardiovascular risk factors may relate to the proximate cause of death, but they account for less than 25 percent of the hazard to longevity. This might explain why multiple assaults on health-adverse behaviors and cardiovascular risk factors have uncertain effects on all-cause mortality. They might change the proximate cause of death, but they do not alter its timing.

    While the best clinical management of frailty in octogenarians may be only support, comfort, and community, I welcome aggressive efforts to increase the likelihood that more members of future birth cohorts will close the story of their lives as highly functional octogenarians. Many people in the resource-advantaged world still lag behind. Who die before their time? Who live to a ripe old age?

    Understanding the good fortune of vibrant octogenarians requires understanding the hazards to well-being that lurk in the course of living. These life-course hazards are aspects of our interactive and integrative worlds, our ecosystems, that can powerfully influence our biology and, thereby, our fate. Much of this is captured by measures of socioeconomic status (SES). There is an incontrovertible relationship between SES and longevity. But do not be misled into assuming SES is simply a measure of income status. Longevity is more dependent on how poor you are relative to those who are advantaged in your ecosystem. For example, the greater the gap in income between the rich and the poor (the Robin Hood effect) across states in the United States, the sooner the poor die. This relationship between income gap and longevity holds across the advanced world. Also, do not be misled into assuming SES is a measure of health-care expenditures; it isn’t, not in North America or elsewhere. SES is a measure of the salutary nature of the neighborhood in which you live and the context in which you pursue gainful employment.

    A handmaiden of SES is educational status. For example, people born between the world wars who managed to average twelve years of education are likely to live some seven years longer than the low-SES strata of their birth cohort. For the advantaged octogenarians, the transitions to doldrums, decrepitude, and demise are telescoped into the last year or so of life. The disadvantaged in their birth cohort commence these transitions earlier in life and suffer through their painstaking unfolding. They labor in jobs that are less rewarding, satisfying, or secure (see chapter 12). They live under clouds of persistent pain and pervasive work incapacity. Their life is shorter and less sweet.

    The octogenarian and great German pathologist Rudolf Virchow (1821 – 1902) developed a notion of natural as opposed to artificial diseases and epidemics. He considered typhus, scurvy, tuberculosis, and mental disease to be artificial because they were primarily due to social conditions: "The artificial epidemics are attributes of society,

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