Worried Sick

Dr Hadler thinks American health care is on the wrong path, offering up tests and treatments that provide no benefit or miniscule benefit not worth the cost and aggravation.

I'm a long-time critic of our so-called "healthcare system" in the US, so I agree with Dr. Hadler. But also found his book and his ideas flawed in a number of ways.

LOTS OF MEDICAL JARGON & SARCASM

Let's start with the language he uses, lots of medical terminology, some explained, some not explained. He also can't resist throwing in plenty of sarcasm about the wrong practices of his colleagues that often left me unable to grasp his actual point. Between wading through the medical language and trying to figure out who or what institution he was lambasting, I frequently found myself confused.

I wish he had plainly stated his idea/opinion at the beginning of each new section, then delved into the often voluminous data that was supposed to prove his point. In plain English.

He also uses an unusual format, with each regular chapter having a "shadow" chapter intended to provide more backing for his position. I found though that both regular and shadow chapters seemed to have a lot of the same kind of content. I think he wanted to use the chapter to tell his story of what needs fixing and why, then use the shadow chapter to give more of the actual studies and data that are the basis for his reasoning. However, I don't think he really succeeded with this format. Understanding his points is an unnecessarily difficult chore for the reader.

WHAT IS ILLNESS?

Dr. Hadler has some interesting insights into illness that go to the issue of when we should seek medical care. He says that 75% of what we perceive as illness is really what he calls a "social construct" or could be deemed "artificial epidemic" (an insight from Rudolph Virchow over 100 years ago). People living under poor conditions and working at jobs and tasks they dislike are more likely to become "sick" than people living in "advantaged" situations. In plain language, people whose lives are characterized by wealth and social advantage will be "healthier" than poor people. It follows from this truth that medical measures such as drugs and surgery will not "cure" people whose main problem is their socioeconomic status.

Dr. Hadler is especially tough on the idea of work-related "illness" that society has decided to "compensate" with such measures as Workman's Compensation. People claiming backaches, sore arms, wrist pain and the like are really unhappy with their work. Not that Dr. Hadler is unsympathetic; he does not say they do not actually hurt or are "making it all up," but that they are unable to cope with what are really the ordinary aches and pains of life.

More advantaged people also have backaches, headaches and creaky knees, but they continue on with their lives, tuning out their pains and waiting for them to go away, which, Dr Hadler tells us, they generally do. What I glean from this is that there is no need to visit the doctor because you have one of these "ordinary" conditions (backache, headache, pains in your knees, hips, etc). Nothing the doctor can do will take these pains away, but time WILL take them away and we should all just cope in the meantime.

I think of all the times we are all urged to "see your doctor" about this or that. I am old enough (old enough for Medicare) to have come to pretty much the same conclusion as Dr. Hadler, but I still find it difficult sometimes to know where the line is between "ordinary" and "might be a symptom of something worse." I admit I avoid doctors partly because the contact with the medical establishment is usually unpleasant and almost always ridiculously expensive (even if I'm not actually paying for it myself -- SOMEONE is paying for it.)

TREATMENTS THAT DON'T WORK

Dr. Hadler is big on quoting studies — those "randomized" groups of people who are followed over time, divided into two groups, those getting the treatment and those getting a placebo (something that looks like the treatment but isn't). He thinks we spend too much time on the cost (which he readily admits is excessive) rather than the effectiveness of what doctors do. He also doesn't think much of "efficiency" as a way to improve our health care. If it's inexpensive and efficient, but does not actually work, then it is still a waste of money. It is even worse than just a waste of money if the treatment causes actual harm or carries a risk of harm. Those studies or "clinical trials" of groups of people can shed light on whether a treatment actually provides benefit, or not.

I am glad he included screening tests, which seem to constantly proliferate and be urged on us by various medical establishments and big charities. I am personally convinced most of these tests, some invasive and harmful, are just a money-maker for the people who promote them. Lots of studies have been done (and Dr Hadler gives a good summary of them) on screening mammograms and the conclusion is that mammograms do not save lives, but they do result in lots of medical treatment on women who might never have had any impact from the tiny spot seen on a mammogram. (A really good book on this is Dr Gilbert Welch's book, Overdiagnosed - see a link to my review of this book and others below.)

Dr. Hadler barely mentions the actual harm from mammograms in the form of unnecessary invasive biopsy and surgery, and from the radiation from each view of each mammogram; radiation harm is cumulative. Obviously, doing mammograms is a huge money-maker for companies that make the equipment and for the personnel involved in their use, but of what benefit to women? Isn't it time we woke up to the fact that the supposed life-saving efficacy of these tests might just be flim-flam?

Dr. Hadler is pretty hard on the Cardiologists, with their angioplasty, catheterizations and stents. None of these, he tells us, prolong life. Neither does he think obsessing over your cholesterol will reduce your chances of heart attack or stroke. All kinds of really expensive procedures a Cardiologist might recommend are mostly useless and hold the possibility of causing you harm. Both my husband and I have been to a Cardiologist in the past and I came to the conclusion that nothing done for either of us had any benefit, but of course, my own experience is anecdotal. Dr. Hadler has all the data, in this book.

YOUR NATURAL LIFESPAN: ABOUT 85 YEARS

Dr. Hadler goes against the philosophy of "doing everything possible" to save a life, which many advocate. He boldly states that the human lifespan is about 85 years, and we all need to face the fact that sometime around our 85th birthday (if we are lucky enough to last that long) our biological clock has run out. There is not much point in endless medical intervention, or doing mammograms to "save" us from breast cancer. These interventions are costly and futile. SOMETHING is going to get us, so fighting each possibly fatal condition we may have serves no purpose except to make profit for the medical establishment. On this, I agree completely with Dr. Hadler. Sometimes, we get a longer lifespan, of course (my mother is still alive and alert at age 96), but the point is to stop doing screening tests, stop taking medications that are supposed to reduce your "risk" of some disease or other and eliminate surgery for conditions of aging. Accept your own mortality.

WHAT ABOUT "ALTERNATIVE" MEDICAL SYSTEMS?

Not surprisingly, Dr. Hadler does not think highly of alternative medical systems like Chiropractic, Acupuncture, Homeopathy, Naturopathy or even Physical Therapy. Here, I think he protests too much. I found it interesting that studies show people are more likely to feel they got benefit from Chiropractic care than from the treatments of an MD. Dr Hadler seems to think this is because the Chiropractor spends more time with them and explains what he is doing. Gosh! Why don't MDs do more of that?

I don't want my social problems "medicalized" into phony diseases (like fibromyalgia and osteopenia, two targets of Dr. Hadler's wrath), but I do want some kind of medical equality in this country, with everyone having the same access to needed heathcare, and I don't see it. Nor do I think Dr. Hadler should be complaining about having to pay (in taxes or insurance) for treatments others get that he thinks are ineffective unless he includes all the things doctors do to wring more money out of us poor "patients" (I really don't like that word!). Well-insured patients are going to get more medical care (effective or not) than the underinsured or uninsured, and that runs up the cost for all of us. Randomized clinical trials are not practical for every treatment method, and some of these "alternatives" may impart some unmeasured benefit. I can cite one from my experience: Vitamin E seemed to be a big help for me with menopause symptoms.

SO WHAT ARE WE TO DO TO MAINTAIN GOOD HEALTH?

Dr. Hadler discounts so much of what passes for medical treatment in the US that it leaves me wondering what he wants most of us to do. I have long felt that medical care provides the absolute worst value for the money of anything we spend money on in this country. I have put all my frustrations and anger (and there is lots of it!) with the so-called "health care system" into a long rant on my website, What's Wrong With American Health Care?. I've updated and improved it from time to time, and it is one of my most popular pages (according to the stats on visits to each page).

I appreciate that Dr Hadler is willing to take on his own profession and point out their numerous sins. He, with his medical credentials and honors, can obviously make more difference than I can. He may be right that a lot of "sickness" is about social conditions, and I applaud him for speaking out about that. But I do think he is a bit over the top in just dismissing any sort of medical intervention for people suffering with "aches and pains."

HOW DO WE FIX IT?

Dr. Hadler ends his book with a proposal about how to reform health care delivery in the US. He seems to think any kind of take-away in terms of what's covered by insurance (public or private) will be seen as "rationing." He DOES want to limit coverage to treatments with some proof of effectiveness, and that would eliminate most of the so-called "preventive care" items that are currently covered by Obamacare, like mammograms, colonoscopies and prostate screening. I think coverage for these expensive but ineffective screening programs SHOULD end, for the reasons Dr Hadler gives. They line the pockets of big industries, but do not help us ordinary people cope with our daily aches and pains, nor do they ultimately extend our lifespan. But Dr. Hadler is up against a giant PR machine that constantly tells people these tests and procedures will benefit them.

Dr. Hadler does want to devote part of the money going into his proposed health care plan to letting people choose and fund ways to improve their social environment, presumably thereby improving their coping skills and giving them better lives. Money not spent on medical stuff would flow into that fund, thus keeping critics from charging that the plan was trying to "save money" by not paying for their colonoscopy or whatever.

Here's My Take

I think we should have a "healthcare system" that delivers the same services to every American, and these services should be those shown to deliver the best bang for the buck. There should be no "million dollar treatments." The most effcient way to make this happen is to adopt a government-funded plan and eliminate the current role of the insurance companies. All insurance companies add is an extra layer of expense. There may be a role for voluntary insurance to cover items not covered under universal coverage (those that are priced too high, are experimental or not proven to be effective). But, figuring out how to take care of the health needs of Americans is not a simple task, and so many powerful interests are always poised to block anything that might interfere with their profits. Dr. Hadler's approach has some merit, and he is right that we should not be paying for services that are ineffective, but we ARE paying for them in our insurance premiums and our taxes.

Worried Sick: A Prescription for Health in Overtreated America