The Last Well Person
By Nortin M. Hadler M.D.
Ideal – Achieve a certain sense of well-being, avoid unnecessary medicalization and successfully cope with the inevitable predicaments of life.
How to avoid iatrogenicity (adverse health events caused by medical treatment – recently estimated to represent as much as 40% of all health problems) and to safely and effectively use modern medicine.
It’s reasonable to expect to live into one’s mid-80s, anything beyond is a bonus. Goal should be to arrive at the 85th birthday free of morbidities that overwhelm the ability to cope.
Medical Malpractice:
Type 1 – medical or surgical performance that is unacceptable
Type 11 – Doing something to patients very well that was not needed in the fist place
It is Type 11 malpractice that is the author’s focus in this book. It should be noted that he believes much of this takes place without the awareness of either the patient or physician. The following are those interventions, both diagnostic and therapeutic, that may fall into this category. Each person should be aware of this potential and be prepared to carefully assess the benefit/risk ratio and need for the procedure for his/her own particular situation.
Interventional Cardiology – The author offers a strong opinion, contrary to the prevailing opinion of the cardiovascular surgeon/interventional cardiovascular community, that all current efforts to compensate for reduced myocardial blood flow due to plaque formation are of little if any benefit while imposing significant risk to the patients. Neither coronary artery bypass grafting (CABG) nor angioplasty offer significant benefit over placebo. Adverse events, most notably dementia in as many as 40% of patients receiving CABGs yields a significantly negative benefit/risk ratio. Dr. Hadler acknowledges that a small subset (3% with blockage of the left main coronary artery) of those receiving CABGs experience significant benefit. However, there has been no objective demonstration of benefit for the other 97%, most notably those receiving multiple grafts. On the other hand, cardiovascular surgeons claim substantial progress since the controlled trials were conducted in the late 1970s and that many patients do enjoy significant benefit following CABG surgery. The decision for or against CABG surgery thus requires careful assessment by patients in consultation with their own professional advisors.
Cerebrovascular Intervention – Outcomes for the treatment of transient ischemic attacks (TIAs) with surgically placed vascular stents and stroke with cerebral angiograms and clot dissolving drugs are, on balance, reasonably beneficial to warrant their use.
Hypercholesterolemia - Hadler agrees that someone who has suffered a heart attack and has elevated cholesterol levels should probably attempt to pharmacologically lower those levels. However, he questions the wisdom of a well person with high cholesterol levels taking one of the statin drugs. He bases his argument on the results of the West of Scotland trial of Pravachol, which he feels produced unspectacular results of marginal statistical and clinical significance. While the results could be considered unspectacular, both fatal and non-fatal heart attack rates were lower in the treated vs. placebo groups. Non-fatal heart attacks occurred in 143/3302 men on Pravachol vs. 204/3293 men on placebo. While these results may not be spectacular to the statistician, one could say they represent a miracle to 60 or so men in the treated group who did not suffer a heart attack. Likewise fatal heart attacks occurred in 52 placebo treated men vs. 38 in the treated group. Could it be that the drug saved the lives of 14 men? You can bet that none of those 14 men (if they knew who they were!) would care a bit about statistical significance. I guess I disagree with Hadler that these results are also not clinically significant. Unless there would be a significant level of serious adverse events in those taking the drug, the potential for saving lives, even if it’s less than 1%, is worth the effort and cost involved in recommending treatment. I believe that more recent studies and the availability of more potent statin drugs have since confirmed this therapeutic approach for anyone having seriously elevated cholesterol levels.
Hyperglycemia (Type 2 Diabetes) - The author points out that normal blood sugar levels follow a U-shaped curve with age. Thus, somewhat higher blood glucose is to be expected as one ages. Furthermore, other than altering the surrogate markers, treatment with the oral hypoglycemic drugs has not proven to modify clinical events. Thus, diet and exercise treatment of type 2 diabetes is suggested.
Hypertension – The author points out the very limited established benefit of treating mildly hypertensive younger patients with antihypertensive agents. On the other hand, treatment of elderly patients with systolic hypertension with a single, mild, antihypertensive agent appears to be warranted on the basis of available clinical trials. Control of hypertension can often be accomplished with exercise, reduction of salt intake and weight control. In all cases, whatever methods deemed necessary should be used to control serious hypertension regardless of age (personal opinion).
Colorectal Cancer/Colonoscopies – Hadler suggests that routine colonoscopy screening for colorectal cancer should, perhaps, be limited to those considered to be at higher risk of the disease, i.e., the subset of people with a history of genetic predisposition to multiple colon polyps or colon cancer in young, first-degree relatives. Otherwise, the risk/benefit ratio does not favor the procedure. He further points out that the dwell time for colorectal cancers, i.e., the time malignant neoplasms spend in the pre-invasive state, has been estimated to be between one and two decades. Assuming this is true, it would seem to make little sense continuing periodic colonoscopies beyond the age of the mid-70s. As with all of the other health care decisions discussed here, such decisions need to be individualized and made on the basis of each person’s complete health information dossier.
Breast Cancer – In considering all available controlled studies regarding the usefulness of mammography in preventing breast cancer deaths, there appears to be no established benefit in women in their 40s and even questionable benefit in older women. Many false negatives and false positives characterize mammography results and lead to numerous unnecessary breast biopsies.
Prostate Cancer/screening – Controlled studies available at the time this book was written (2004) failed to provide objective support for prostate cancer screening and also suggested that, at best, simply altered the proximate cause of death and not life span. Hadler also points out the significant occurrence of urogenital side effects associated with prostate surgery.
Musculoskeletal Predicaments – The author provides a considerable body of evidence that most musculoskeletal pain that we experience should be considered a predicament that is best managed by allowing time for it to heal spontaneously. For the most part, medicalization does not provide added benefit. This includes a broad range of therapeutic modalities including pharmacologic, manipulative (chiropractic, osteopathy, physical therapy, etc.) and surgical. Among the musculoskeletal conditions discussed are knee, shoulder, back, neck and a variety of other regional pains.
Medicalization of The Worried Well - A wide variety of predicaments that might be categorized as psychosomatic are discussed. Hadler suggests that conditions with labels such as fibromyalgia, irritable bowl syndrome, diffuse generalized pain, etc. are likely to be more due to psychosocial, economic or cultural stresses arising from the family or work environment than to organic (structural) disease. In seeking relief from such psychosomatic maladies, such “worried well individuals” often become unnecessarily medicalized.
Aging – Osteopenia is discussed as an example of age-related changes in danger of being over-medicalized. Hadler goes to unusually great lengths to describe and discuss changes in bone mineralization and architecture that occur during the normal course of aging. He further points out that those with severe osteopenia, especially frail elderly women, are at a higher risk for suffering pathological fractures of the spine, hip and distal forearm. However, no available preventative measure including dietary supplementation with calcium and vitamin D, hormone replacement therapy, or use of the bisphosphonate drugs (Fosamax or Actonel) have produced compelling clinical results that would warrant their wide-spread use. While he doesn’t care much if people want to use calcium and vitamin D supplements since they can do little harm unless excessive amounts of vitamin D are ingested, hormone replacement therapy and the use of the bisphosphonate drugs have important adverse effects that, in Hadler’s view, results in an unacceptable benefit/risk ratio.
Alternative and Complementary Therapies – Hadler reviews the long history of therapies that fall outside the realm of science. This history began with the ancient Egyptians and Greeks and was largely focused on praying to a spectrum of Gods believed to be in control of human fortunes, including health and disease. More recently the emergence of non-scientific treatment modalities such as chiropractic, homeopathy and osteopathy emerged. More recently, both homeopathy and osteopathy have played down the non-scientific aspects of their approaches and have, in fact, blended in with traditional science-based medicine so that their practitioners now practice forms of medicine very much like their traditional counterparts. In addition to chiropractors, herbalists and acupuncturists continue to practice what might be termed non-science based medicine. In other words, no large-scale controlled studies support their methods that could be categorized as essentially faith based. While their methods of treating disease are not condoned by modern medicine, it should be pointed out that their services are sought by many and each has a following of true believers. There is also a strong following for the use of herbals and a variety of other over-the-counter medicaments, none of which have scientifically confirmed benefits in preventing or treating a wide range of ailments. In many cases, these treatment modalities are not harmful so there is little interest in restricting their use in spite of the lack of documented efficacy.
The Bottom Line
Hadler concludes by offering some personal advise for living to a “ripe old age”. His advice to the elderly is “Beware of medical schemes that are offered to prolong your life. The only reason for medical intervention should be an acute medical problem or emergency.”
A Personal Comment
Even though I agree with most of Dr. Hadler’s ideas, one cannot overlook another factor only hinted at by Dr. Hadler. That factor is the power of the human mind to somehow heal the body. While none of this has been established in a scientific sense, there are numerous examples of religious faith healing, the often observed healing in primitive people by medicine men, and the very significant “placebo effect” observed in modern clinical pharmacology. We all know that a sugar pill cannot heal disease but very often, the cure rate in the placebo group is nearly as great as in the group treated with the active pharmacologic agent. Additionally, it’s well documented that personal attention provided by a care giver, nurse or therapist, can significantly enhance the rate of healing of the sick. Finally, we probably all have experienced the sudden surge of “feeling better” that can suddenly modify our feeling of illness when we are treated to a surprise visit of someone important to us or awaken to a beautiful day or otherwise experience something unusually happy or pleasant. I think it would be a mistake to ignore the possible enormous healing power of our own brain. From this standpoint, whatever therapeutic modality a person feels strongly about or has faith in should be considered as long as associated serious adverse events are unlikely. In the long run, such modalities could be highly efficacious even though objective scientific proof is not available.
Addendum:
More on Type II Medical Malpractice
Iatrogenic Illness: A Growing Threat
By: Dr. Dale Peterson
(www.drdalepeterson.com)
The Nutritional Institute of America released a paper in 2003 entitled, “Death By Medicine.” Co-authored by 5 medical researchers, the paper documents the incidence of iatrogenic illness using articles from peer-reviewed medical journals and governmental health statistics. The findings are terrifying.
Using clearly documented statistics and using conservative figures, the authors found that nearly 800,000 people die each year as a direct result of injuries inflicted by diagnostic studies and medical treatment. The figure is undoubtedly higher. In 2001, the last year for which complete statistics are available, 699,697 people died from heart disease and 553,251 from cancer.
Today more people in the United States are dying from the adverse affects of medical diagnosis and treatment than are dying from heart disease or cancer. The number of people dying from iatrogenic disease is the equivalent of seven fully loaded jumbo jets crashing every day of the year.
Death By Medicine
By Gary Null PhD, Carolyn Dean MD ND, Martin Feldman MD, Debora Rasio MD, Dorothy Smith PhD
(c) 2003, All Rights Reserved
REPRINTED WITH PERMISSION
ABSTRACT
ABSTRACT
A definitive review and close reading of medical peer-review journals, and government health statistics shows that American medicine frequently causes more harm than good. The number of people having in-hospital, adverse drug reactions (ADR) to prescribed medicine is 2.2 million.1 Dr. Richard Besser, of the CDC, in 1995, said the number of unnecessary antibiotics prescribed annually for viral infections was 20 million. Dr. Besser, in 2003, now refers to tens of millions of unnecessary antibiotics.2, 2a The number of unnecessary medical and surgical procedures performed annually is 7.5 million.3 The number of people exposed to unnecessary hospitalization annually is 8.9 million.4 The total number of iatrogenic deaths shown in the following table is 783,936. It is evident that the American medical system is the leading cause of death and injury in the United States. The 2001 heart disease annual death rate is 699,697; the annual cancer death rate, 553,251.5
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