Tuesday, August 31, 2010
Book Review: Worried Sick
In Worried Sick, Nortin M. Hadler, a physician and rheumatologist, makes a strong case for evidence based medicine. He exposes the very weak base underlying many pharmaceutical interventions and invasive procedures, such as cardiac bypasses and stents, and encourages patients to do two things: educate themselves and -- this is the tricky one for Americans -- accept their mortality. As he points out, over time the mortality rate for being human is 100%.
Dr. Hadler notes that there is a definite biological limit to how long any of us is going to live. If we're lucky, we'll make it into our 80s, possibly our 90s, but by the time we get there we're going to be carrying a bunch of comorbidities with us, most of which we have no control over. The big question is whether or not any of the many procedures and drugs that get shoved at us will actually make it more likely that we will get to be a nonagenarian. For most of us, sadly but realistically, the answer is no. Also sadly but realistically, almost none of us are willing to admit that.
This point about longevity is a no-brainer: if average life expectancy for someone alive today is, for example, 78, that means that only half of our birth cohort (all the other people born the same year as ourselves) is going to make it that far. Granted, there are reasons why that mean may be skewed a little low, but not by much.
So if all the various procedures physicians, pharmaceutical companies, and surgical device manufacturers push at us don't really prolong life, what about quality? If I can't live longer, can I at least live better? That's where it gets tricky. Is it worth it to go through the pain and prolonged healing of a multiple by-pass? For people for whom the procedure goes well and healing is rapid, the answer might be yes. They may not live any longer or have fewer heart attacks than they would without the surgery, but they feel better, so for them getting their chest cracked feels like it was a good choice, even if they do end up filing bankruptcy because they can't pay the medical bills. But are those people with the good results the rule for the aftermath of the surgery or the exceptions? Good question. Personally, and I know that anecdotes don't count as data, having observed several people who survived the surgery but then experienced some very predictable aftereffects from blood clots, if my cardiologist ever suggests slicing me open, he's out of luck. I might buy into valve replacement, but never bypass -- but that's me, someone else might make a different choice.
Dr. Hadler spends much of the book talking about medicalization -- the process by which we as a culture take something that was normal and turn it into a condition that has to be treated. Along the way he describes the way the medical community keeps changing the definitions for what's good and bad, making the threshholds for "healthy" ever lower (a process which just coincidentally advantages companies such as Pfizer). This section really resonated with me. The normal range for blood glucose in a nondiabetic is 70 to 120; I had a blood glucose test done recently where the result was 103 -- and, lo and behold, I'm now "prediabetic" and I "really should think about taking metformin." (I'll think about taking metformin the same day I decide I'd like to live with chronic diarrhea; over 50% of metformin patients report that particular side effect.)
This process of adjusting "healthy" down has also happened with cholesterol -- the "normal" range has been moved lower, making it less and less likely the average person will fall into it without pharmaceutical interventions. It's like they're all forgetting that cholesterol is in the body for a reason -- it's needed for Vitamin D retention, among other things -- and have decided all cholesterol, regardless of whether it's HDL or LDL, is "bad" and has to go.
And weight -- the much hyped explosion of fat in the 1990s occurred not because people suddenly started binging like never before, but because the ranges on the BMI for underweight, normal, overweight, and obese were shifted downward by several points. People who had been considered in a healthy weight range suddenly found themselves Too Fat, all without gaining a pound. Result? Instant Obesity Epidemic. Does anyone even know what a "healthy" weight is? We all know what a culturally defined aesthetically pleasing normal weight is, although that shifts over time, too (compare the Gibson girls circa 1900 with the women considered attractive today), but what's actually healthy? A lot of fat is obviously bad -- no one would argue that those folks having to be removed from their homes with forklifts have embraced health at every size -- but where's the cutoff between no problem and too much? Overweight old people live longer than thin ones, so where does the argument that losing weight will help you live longer come from?
Dr. Hadler raises these questions, and many others. He notes the skyrocketing cost of health care in the United States, reminds us that rising numbers of people do not have access to health care at all, and pushes hard for evidence-based medicine. The U.S. spends more as a percentage of gross domestic product (GDP) than any other industrialized country, but has more uneven outcomes and lower life expectancy. There's obviously a lot of money being wasted when the results are so poor. How many procedures are being done that benefit only Medtronics or Pfizer's bottom line while adding nothing to patient longevity or quality of life? He recognizes that there are some diagnostic procedures that have become so socially entrenched in our collective conscious that they may be impossible to dislodge -- annual mammograms for all women over 50 regardless of risk factors being the prime example of a procedure that has almost zero benefit but has such a strong constituency you can't get rid of it -- but he encourages readers to not allow themselves to be bullied into spending their money (or their insurance company's) on procedures or drugs that they don't need.
Worried Sick also examines alternative or complementary medicine. After providing a good overview of the area and the history of practices such as chiropractic medicine, Dr. Hadler's attitude toward chiropractors, herbalists, naturopaths, and others is to advise us, in essence, "If you want to waste your money, go ahead." He also warns the reader that because the standards for "natural" products do not include much in the way of quality control, you really don't know what you're getting in your ginseng tea or gingko biloba tablets. The actual herbal content might be very low and it might contaminated (as has been found to be very common in products from China). Caveat emptor.
This book covers a wealth of material. It also includes an extensive bibliography and supplemental readings that further explicate the studies Dr. Hadler cites so the reader knows where to go looking for more information. It wasn't easy reading, but it was worth it.
Update: After thinking about it, I feel compelled to add that Dr. Hadler isn't saying that all medical treatment is unwarranted or unproven. He's saying be an informed patient. Some procedures are necessary, some drugs do work -- but not all of them, not all the time, and not for everyone. Do your homework.