First, Do No Harm
In an environment where doctors are paid by the test, Nortin M. Hadler is convinced that many tests are useless, or worse, harmful.
Ethan Hill for Proto
Heart bypasses, mammographies and screenings for prostate cancer are all mainstays of modern medicine that Nortin M. Hadler, author of The Last Well Person: How to Stay Well Despite the Health-Care System (McGill-Queen’s University Press, 2004), considers a waste of time and money—and worse, procedures that usually cause more harm than good. While Hadler’s ideas may be outside the medical mainstream, he is no outsider. A professor of medicine at the University of North Carolina at Chapel Hill, he is a graduate of Harvard Medical School who trained at the Massachusetts General Hospital and has been a practicing rheumatologist for more than 30 years.
Q: Why did you write The Last Well Person?
A: It’s a treatise on Type II malpractice. We are all familiar with Type I—medical or surgical care that is performed unacceptably. Type II procedures may be done well but without valid reason. Tonsillectomies would be one example. But in my opinion, much in modern medicine is Type II malpractice. I’d include coronary artery bypass grafts, angioplasties and stents, as well as most spine surgery and elective orthopedics.
Q: You mean most heart surgery is unnecessary?
A: I judge any treatment by whether it increases patient longevity or improves quality of life. Studies of coronary by–pass surgery show that for 97% of patients—those without a major blockage of the left main coronary artery—there is no meaningful improvement in longevity. Weigh that against the chance of dying on the operating table, and the increased likelihood of post-operative emotional distress and depression. There is no compelling evidence that angioplasties are more effective. The argument that any of these procedures improves quality of life is based more on myth than on substantive evidence.
Q: Then why are so many of these procedures performed?
A: We live in a time of unbridled medicalization. Sometimes that is to our benefit—if you have a fever, headache and a stiff neck, you had better be medicalized or you may succumb to meningitis. The problem is the tendency to medicalize despite science, promulgating the belief that medicine can fix everything. Such claims are promoted by the vested interests in our health-care system, including drug companies, hospitals and doctors themselves. Rather than encouraging critical thinking, peer review displaces it. Cardiologists review each others’ studies as to whether one treatment is better than the other without first asking if either really helps the patient.
Q: You also worry about the widespread use of screening for breast, colon and prostate cancer. What’s the harm in a test?
A: When a test comes back positive, it alters the patient’s self-perception—he or she is now a cancer patient. Yet this testing barely increases longevity, if at all. Mammography, for example, often leads to the removal of harmless lesions while missing many that are dangerous. Evidence shows that mammography does little, if anything, to reduce the chance that a woman will die from breast cancer. The same case can be made for PSA screening for prostate cancer. Screening healthy people for high cholesterol or low bone mineral density is similarly indefensible if one examines the relevant science. Colonoscopies, on the other hand, are borderline defensible.
Q: If much of medicine is unnecessary, why has life expectancy risen so much in the industrialized world?
A: In the United States, 80% of mortality risk—the chance you will die before the expected age for your birth cohort—is attributable to socioeconomic status. This isn’t simply your income; it’s your income relative to that of others in your ecosystem, which could be the whole country or just your neighborhood. If you are substantially less advantaged than others around you, it will cost you years of life.
Q: So medical care addresses only 20% of mortal risk?
A: Exactly. We would do far more for longevity and quality of life if we spent money on increasing job security, facilitating job mobility and reducing income inequality rather than expensive health procedures whose effectiveness remains elusive or trivial. But such an agenda has limited advocacy because it generates no profit—there is no pill for socioeconomic status.
Q: What’s your advice to would-be patients?
A: Try to find a doctor willing to have an honest discussion about the risks and benefits of any medical treatment and about what medicine knows and doesn’t know. I have been an educator all my career, and I can tell you that many practitioners would love to have this conversation with you. But the health-care system provides no financial incentive. Giving a pill takes no time, but not giving one requires a discussion. If the rheumatologists I trained practiced the way I taught them to, they would starve.