Nortin M. Hadler

Two statements to preface this:
I read this several days ago, and had put so many book darts in the book that I was too intimidated at the thought of collecting the notes from them all, until now, to face writing the review.
And,
I have no idea why some reviewers say this is challenging or dry or a slog. I found it very easy to read & to understand. Good science, clearly & directly written.

So, the other reviewers did most of the work for me, as it turns out. Basically, yes, the premise is that we should treat only those conditions that are proven treatable, and that, if left untreated, would be very likely to kill us before age 85 or our personal determined lifespan, whichever comes first.

So, for an example probably common to many of us, don't take statins for cholesterol if you're a decade or so from death anyway. They'll just make your last years more miserable, and, besides, cholesterol levels are a marker only, high cholesterol is not in & of itself a disease.

He also points out that normalizing glucose levels of those with Type II diabetes is not proven to be effective in helping them avoid complications of diabetes or death. And he therefore refuses to prescribe to his patients any oral hypoglycemics.

He is absolutely incensed that angioplasties and stents are still performed, after numerous studies have shown *no* benefits to patients.

One thing he discusses at length applies to anyone reading any sort of scientific or even economic report, really, any statistics. Absolute risk is very different from relative risk. Be sure you understand ratio measures, odds ratios, etc., so that you don't get suckered by a campaign that says '50% reduction.' If the numbers are 6/10,000 and 3/10,000, it's a 50% reduction, sure. But the odds are, really, that you're one of the other 9,994 and so you don't need that expensive medicine or that risky surgery.

He's never had his cholesterol checked. Here's why:
To restate the mantra, one never wants to submit to screening unless the test is accurate, the disease is important, and we can do something about it."
The mantra applies to testing of Bone Mineral Density - "Screening by BMD for the risk of fragility fractures fails on all scores. It is basically an expensive way to ask ask a thin white or Asian woman her age." The story of the patient overtreated for her fragility fracture is both appalling and heartbreaking.

And just one more example (many more in the book; read it yourself!), of treating natural consequences of aging as if they are curable diseases:
"Do not assume that because these joint hurt, they are damaged.
Do not assume that whatever osteoarthritis is present is the cause of the joint pain.
Do not assume that the joint pain is the cause of the compromise in mobility or quality of life."

Can't get much clearer than that, can you?

And now I'm off to read one of his other books, Worried Sick.
"… (mere)

Not as easily comprehensible, esp. for the vulnerable in the target audience, as [b:Rethinking Aging: Growing Old and Living Well in an Overtreated Society|12022065|Rethinking Aging Growing Old and Living Well in an Overtreated Society|Nortin M. Hadler|http://d202m5krfqbpi5.cloudfront.net/books/1348290973s/12022065.jpg|16987674]. However, well worth reading. Good science that busts not only alternative treatments such as homeopathy but established procedures such as angioplasty, statins, and even routine mammograms.

I've always been a skeptic, and proud of it, and I know about controlled randomized double-blind trials, placebo effect, and absolute vs. relative percentages. I also have excellent role models - my 71 yo parents are healthier than I am because they're too busy working & playing and loving life to get sick or to complain of normal aches & pains. Neither take any medicines except, rarely, aspirin. So I'm predisposed to agree with Hadler's message, to the point where I didn't read any of the supplementary material.

So, I tried to counter my bias by looking for flaws in his lessons. The main one is that he generally looks at end outcomes. If a treatment or procedure doesn't prolong life itself, he implies he's not interested. But some treatments make the final few years more enjoyable, despite not delaying the inevitable, and he doesn't address them.

One exception is heart surgery. The angioplasty/stent therapy did not save a life; it didn't even spare anyone a heart attack over the next five years."

He also doesn't talk about treatments that are worth getting. What should a doctor do, if not the long list of things s/he shouldn't do, according to Hadler? Treat injuries, of course. And dangerous contagious diseases, I'm sure (as opposed to contagious diseases that will run their courses without interventions).

I figured out, too, that it's ok with Hadler to see a Dr. if you've a complaint that you suspect might be a marker for something that actually can and should be treated. Hadley's big on the illness-disease paradigm. If the illness (say, rheumatism) is, in a particular patient, marking a disease (rheumatic fever), and we have a proven effective treatment for the disease, we can treat the disease.

For example, though, aging is not a disease. There are a lot of illness that are indicative of aging, but to treat them would be to commit what Hadler calls Type II Medical Malpractice - good treatment that should not be performed. Ex: Osteopenia is a social construction, BMD screenings are a waste of resources, and biophosonates are more likely to harm than to help.

Back to the example of my parents. The main predictors of health and longevity are career satisfaction and a comfortable lifestyle (SES). Hadler relates: Two different UPS shipping warehouses. Both with standardized procedures, wages & benefits. One with a despised boss, one with a respected boss. Guess which had lots more worker's compensation claims for back injuries? Were those workers really getting injured more often? No. Were they shamming? No. They unconsciously felt twinges to be debilitating because they hated their job and couldn't cope with the pain on top of that.

Hadler's advice is basically to buck up and cope if you can, and if you need help, don't turn first to pills & potions & procedures. Recognize that your mind is a part of your body, and is powerful enough to affect the well-being of your body, and address your state of mind. Don't let yourself be defined as a patient. Retain your personhood.

Ex: "Fibromyalgia denotes nothing more than persistent widespread pain. However, in the labeling, the patient is forever changed.... In the community, the majority of people with persistent widespread pain improve with time, but those labeled as 'fibromyalgia' seldom do.... the treatment is iatrogenic.'" (Hadler does of course admit that efffective treatments may possibly be developed soon, but this book is 2008, and I, for one, would not take a drug that was developed only five years ago.)

I'll leave you to read the book so you can see the further example of the prostrate. Hint - about what this review has taught you so far, and predict what the author will discuss in "The Prostrates of Seattle vs. the Prostrates of Connecticut."

Bottom line: "If any clinical interaction has been studies and cannot be shown to be meaningfully effective, it is worthless at any cost."

An interesting resource: Memorial Sloan-Kettering Cancer Center's herbs website - http://www.mskcc.org/aboutherbs."… (mere)

RETHINKING AGING—Growing Old and
Living Well in an Overtreated Society, by Nortin
M. Hadler, MD, UNC, 2011
“Aging, dying, and death are not diseases.” (Page 1)
Yet, we will all die.
Hadler tells of the many who are dying in distress
after major medical interventions, multiple days in
institutions and months of disabilities. He clears
away much of the confusion regarding aging and
provides suggestions for a better end.
1. If you arrived at adulthood in the 1960s, you
will likely die an octogenarian... Your time of
death is predictable in terms of the decade. But it
is not predictable in terms of the year—let alone
the month, day, or hour.” (Page 175)
2. Quality of life rapidly deteriorates in the
eighties.
3. “It makes no sense to cure the diseases one
will die with in the ninth decade and little sense to
cure the disease that one will die from in the ninth
decade if another is to take its place in short
order.” (Page 176)
4. THEREFORE, “There need to be frank
discussions of your desires as to end-of life
care.” (Page 179)
Plan for a better end. Talk to family and friends.
Reduce the screening tests. Stop some of the
common pills. Refuse some common surgeries.
Fill out the Advance Directive and a POLST
(physician orders for life sustaining treatments).
Our time is valuable, too valuable to spend the
majority of time undergoing medical treatment.… (mere)

This tome on the over-treated, over diagnosed, over drugged world of America is interesting. The author’s premise is that we are beset with rampant Type II Medical Malpractice – the performance of unnecessary testing, diagnosing, and prescribing. He seems to perceive that we are, as a culture, drug addicts of the first order, responding to the programmed prescription of pharmaceuticals by doctors who mindlessly follow the lead of drug companies and studies financed by the same folks. In the course of this herd-like plunge off the cliff, we are engaged in a huge wealth transfer from all of us to the medical establishment. What is our reward? The lowest life expectancy of any major country!

Of course, this is the issue of the moment for our new President Obama, who seems obsessed with expanding this process.

Whether your concern is cholesterol, blood sugar, blood pressure, breast cancer, prostate cancer, dietary supplements, hormone replacement therapy, osteopenia, backaches, over or under-working, or whatever, Dr. Hadler offers a critical evaluation of the practical realities of studies, most of which are read to mean that current treatments are no better than placebos.

Dr. Hadler’s view seems to be that we all live, on average, to be about 85. By that time, we will all have our fair share of diseases and will die from one or more of them. We will be best advised if we have a trusted physician who will evaluate our maladies, advise of the realities of the treatments, and then let us take a proactive role in our own self-medication. He nowhere exactly says this, but the result seems clear enough.

This is a marvelous book that should be must-reading for anyone who is concerned about any of these things – which is all of us.

For me, Dr. Hadler’s excellent analysis made me revisit my own mother’s breast cancer treatment in the 1950s. I think that she endured a mutilation that was probably needless, did not extend the length of her life, and surely devastated the quality of her life. I hope that you are all spared such a fate. Read about being worried sick!… (mere)