Sickening health care? | |
The last well person. How to stay well despite the health-care system. Nortin M Hadler. Montreal: McGill-Queen’s University Press, 2004 (viii + 313 pp) ISBN 0 7735 2795 8. |
Somewhat paradoxically,
reading this book left me disturbed and critical, despite my wholehearted agreement with most of the imperatives presented in this critical analysis of modern medical practice.
The basic message is accurate and important: too many with minor ailments who enter the health care system are convicted of being ill when in fact they are healthy. Well people, Hadler suggests, are those individuals yet to be investigated by a doctor! The health care system is, he argues, poorly evidence-based in far too many areas. Over-diagnosis and the reflexive resort to the prescription pad, rather than reassuring dialogue, is endemic. There is much truth in this of course, but he “doth protest too much, methinks”. For example, Hadler’s views on modern cardiological practices fail to avoid the bias and selective reporting of data he so strongly criticises in others. Individuals with suspected angina are advised to enter into a contract with their doctor that will exclude both angiography and bypass surgery as diagnostic or therapeutic options. In warning patients that much of what a doctor recommends may be of questionable benefit, he fails to educate the lay reader of the possible advantages of early diagnosis and intervention in a person who indeed still feels “well”. Hadler tells us that the book is written for those who are well but nonetheless tempted to stray into a doctor’s office from which they will undoubtedly emerge medicalised. In fact, the contented well are unlikely to pick up this volume while the worried well are unlikely to be persuaded that their concerns are baseless. No, this book is one for students and practitioners of clinical medicine. It is laudably academic in discussing most of the topics covered, with an extensive bibliography and no less than 56 pages of annotated critiques of the studies that, when analysed accurately, support the author’s contentions. Being challenged to re-analyse investigative and therapeutic approaches that are entrenched but by no means evidence-based is, of course, no bad thing, nor hardly revolutionary. Hadler’s challenge to improve statistical analysis to provide outcomes that are undoubtedly clinically relevant is welcomed. Meta-analyses and the Cochrane library have not served our patients well, he argues, wanting us to better define real rather than relative risk. A rheumatologist, Hadler is perhaps at his best when discussing the myriad dubious approaches to the management of musculoskeletal discomfort, turning many patients into invalids entangled in a nightmare of medico-legal wrangling. Such patients, he argues, will receive more help from their therapist than their pharmacist. It is modern medicine’s emphasis on investigations and pharmacy that is driving many patients, who want to ventilate their problems, into the offices of unscientific “alternative” practitioners. Hadler is on shakier ground when he argues that most of us have genes that program us to live for 85 years (plus or minus a few), and will do just that whether or not we treat high cholesterol or moderate hypertension. He doubts the ability of human strategies to have us live longer (a brave assumption given the remarkable increases in longevity achieved even in the post-antibiotic era), and opines that we have made too much of the obesity epidemic in modern societies. He argues that our approach to the diagnosis and management of prostate cancer is often too aggressive, but fails to call for better decision-making that may well save the lives of many who currently die in much discomfort from this malignancy. I’m glad I read this book and have no hesitation in recommending it. We have a long journey ahead of us before we consistently avoid the pitfalls forthrightly identified by Hadler. Doing so will give us our best chance of having many more people remain chronically well because of rather than despite the health care system. John M Dwyer
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