Books

Unhealthy medicine

This book begins at the end. The end being your death at about age 85. No matter what you do, no matter how many miles you jog or how many vitamins you take or how many doctors you consult, one day the grim reaper will knock on your door. The question "Worried Sick: A Prescription for Health in an Overtreated America" aims to answer is how to get to your four score and five. Surprisingly, it argues against relying on many of the accepted practices of modern American medicine.

The author of this iconoclastic tract, Nortin Hadler, is a medical professor and practicing rheumatologist at UNC-Chapel Hill. His book is certain to stir up controversy among his colleagues and will likely raise a few hackles. His writing style may raise some hackles, too. It is loaded with complicated sentences that don't exactly roll off the tongue. Here's an example: "It was postulated that a particular clinical presentation was so likely to eventuate in cardiovascular disaster that it deserved denoting as a syndrome." Despite this over-the-top style, Hadler manages to get his message across.

He begins by examining common treatments for heart disease. Inserting stents in clogged arteries and coronary artery bypass surgery are the biggest guns in the cardiologists' armory. Both procedures are expensive and ineffective, according to Hadler. Neither has been shown to prolong life except in one particular form of heart disease. Both procedures, he asserts, "should be consigned to the annals of good ideas that proved bad."

He follows that startling conclusion with a look at another supposed cornerstone of good health, the mammogram, a procedure used to detect early signs of breast cancer. As usual, Hadler doesn't buy it: "The enthusiasm for cancer screening in the United States outstrips reason." Mammography, he proclaims, is a "blunt instrument" that gives false positive readings in more than one-third of the women tested, unnecessarily frightening patients and requiring unneeded biopsies.

Also, he adds, the benefit from regular mammograms is razor thin. Of 1,000 women over the age of 50 in a mammographic screening program, six will die of breast cancer. If those same women skipped mammograms completely, breast cancer would claim the lives of nine. Is the screening worth it? That is a question, Hadler believes, "that should be addressed to every woman before mammograms are ordered."

Hadler takes a similar skeptical tack on many other medical issues. He labels the craze for a diet rich in the omega-3 acids found in fish, for instance, as "much ado about the minuscule." Prostate cancer? "No elderly man should undergo prostate cancer screening." An annual physical examination? "Entirely useless." What about osteopenia, a condition in which the bones become smaller, weaker and more liable to break? Women, in particular, are susceptible to it, and many of them opt for a regular bone mineral density test to detect bone thinning. Hadler will have none of it: "Osteopenia is an example of a New Age social construction, propelled to its status in a decade by aggressive marketing and vested interests."

Are all tests, examinations and medicines useless or, worse yet, harmful? One might get that impression from Hadler's book. He does concede that a daily baby aspirin will help if you have suffered a heart attack. And treating severe cases of high blood pressure with medicines improves life expectancy. But Hadler contends that many standard medical interventions are not risk free and do little to prolong life.

So, what is the layman to make of this? Should we forgo treatment for heart attacks? Skip mammograms and prostate cancer tests?

The scientist Carl Sagan once said, "Extraordinary claims require extraordinary evidence." Hadler makes some extraordinary claims, but he does not always back them up with extraordinary evidence. In fact, some of his evidence could be interpreted differently. One example comes from a clinical trial aimed at determining the value of a cholesterol-lowering drug. For the outcomes listed -- number of heart attacks, deaths from heart attacks, and deaths from any cause -- people taking the drug fared better than those on a placebo. Hadler pooh-poohs the differences as too slight to matter. But if we felt at risk for heart disease, most of us would play it safe and go with the drug.

Readers may disagree with Hadler over the interpretation of specific trials. Few, however, will disagree with his main thesis that many well-to-do Americans take too seriously every ache and pain, including ordinary ones that are part of daily life. We take even minor ailments to physicians and demand they do something. The result is an overtreated segment of the population that prefers the newest flavor of stents to standard nonsurgical treatment.

The demand for, and ready supply of, marginally effective but stupendously expensive drugs and treatments has created a health-care system that Hadler calls "uneven, unwieldy, ineffective, and unsustainable." Hadler is not the first writer to notice these problems. Shannon Brownlee's recent book, "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer," drives home many of the same points. Like others before him, Hadler calls for a complete overhaul of America's health-care systems but holds out little hope that will happen.

The reason, of course, is money. Patients and insurance companies pay huge sums to doctors and pharmaceutical companies. "Most of the high-ticket items (procedures and pharmaceuticals)," Hadler laments, "are minimally effective or ineffective." But they are cash cows. And with billions of dollars at stake, the beneficiaries of the current system will oppose any meaningful change. The only hope lies with the patients themselves. If enough of them demand change, then it just might happen. Hadler's book should move some people in that direction.

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