Worried Sick: A Prescription for Health in an Overtreated America

H. Eugene and Lillian Youngs Lehman Series

by Nortin M. Hadler

At a time when access to health care in the United States is being widely debated, Nortin Hadler argues that an even more important issue is being overlooked. Although necessary health care should be available to all who need it, he says, the current health-care debate assumes that everyone requires massive amounts of expensive care to stay healthy. Hadler urges that before we commit to paying for whatever pharmaceutical companies and the medical establishment tell us we need, American consumers need to adopt an attitude of skepticism and arm themselves with enough information to make some of their own decisions about what care is truly necessary.

Each chapter of Worried Sick is an object lesson regarding the uses and abuses of a particular type of treatment, such as mammography, colorectal screening, statin drugs, or coronary stents. For consumers and medical professionals interested in understanding the scientific basis for Hadler's arguments, each topical chapter has an accompanying source chapter in which Hadler discusses the medical literature and studies that inform his critique.

According to Hadler, a major stumbling block to rational health-care policy in the United States is contention over the very concept of what constitutes good health. By learning to distinguish good medical advice from persuasive medical marketing, consumers can make better decisions about their personal health and use that wisdom to inform their perspectives on health-policy issues.

Genres: Nonfiction, Medical, Health, Medicine, Science

392 pages, Hardcover

First published June 1, 2008

Reviews

[Lena · Rating 3 out of 5]

Nortin Hadler is a rheumatologist with a mission. That mission is to overhaul the US healthcare system to eliminate "Type II Medical Malpractice." If Type I Medical Malpractice is doctors doing their job poorly, Type II is doctors doing their job unnecessarily. According to Hadler, unnecessary medical procedures are at the root of many of our health care woes.

His stated goal in writing this book is to educate patients about what science really says regarding the effectiveness of many common procedures so that they can make truly informed decisions. Towards this goal, he outlines a number of concepts that are important for anyone with medical problems to understand. One of these is the distinction between relative and absolute risk. If a procedure is said to reduce the chance of developing a certain problem by 50%, that may sound impressive until it's revealed that the absolute risk drops from 1% to .5%. Hadler stresses that understanding the reduction in absolute risk is crucial to knowing whether the costs and potential side effects of a procedure are really worth it.

Hadler proposes that any medical treatment that requires intervention on 20 or more patients before one of them experiences benefit is simply too inefficient, costly and risky to be subsidized by our insurance system. The book contains detailed individual chapters that address how he uses this criteria to reject many common treatments including coronary artery bypass grafts, angioplasties, and stents, surgery for backache, statin therapy to reduce cholesterol, PSA screenings and radical prostatectomy, drugs for decreased bone density, and screening mammography. Supplementary readings in the back of the book address his rational for rejecting these treatments in more depth.

Having recently turned 40 and dutifully received my first "baseline mammogram" along with strict instructions to return every year from now until eternity despite my lack of overall breast cancer risk, I found a great deal of Hadler's information extremely valuable. Though I disagreed with him on some points, he makes a compelling case that the pushing of many of these procedures by those who stand to profit from them is done at the expense, rather than the benefit, of most patients.

As fascinating as I found many of his arguments, however, I did not particularly enjoy reading this book. Though ostensibly written for patients, it was a step above what I could easily understand and certain things were not explained as clearly as I would have liked. In addition, Hadler's tone comes across at times as grumpy and arrogant, so while he has a lot of interesting things to say, he's not very much fun to be around.

In addition, I find it hard to be optimistic about Hadler's chances of reforming our current health care system (which he has already been trying to do for years.) Though his ideas may be grounded in scientific rationality, people diagnosed with a scary illness are rarely functioning from a rational place. I think it would take a radical shift in American consciousness before people could accept the fact that treating certain diseases, particularly later in life, just doesn't make sense. Humans are just too prone to thinking that we will be the exception who would really benefit from the expensive options our vested medical profession is all too happy to offer us.

[Kamil Salamah · Rating 5 out of 5]

As a practicing Consultant General Surgeon, I have not come across any such writing on the subject in such detail. I have been touched deeply reflecting on how I and my colleagues have practiced: quoting studies, reviews, articles, editorials, etc to defend what we do and subscribe to our patients.

Knowing some of the historical Type I and Type II malpractices that occur daily, knowing the false claims of the Pharmaceutical studies, knowing the major forces of power at play for the precious dollars that are made available to hoard of interest lobbyist groups( particularly in the USA), I am in full agreement with has been outlined by Dr. Hadler.

I believe the time is just right for this writing to be brought to the fore front for the decision makers in the US government in Health Department to revisit what he outlines as the solution to fix the very expensive broken health care system.

He has my voice as an MD as well as a consumer of health care.

[Christina Jain · Rating 1 out of 5]

Hadler strives to show where doctors in various fields continue to prescribe treatments that have been proven to be ineffective because we live in a society that expects, or even requests treatment when none is needed. But his book is one tiresome tirade, written in verbose language --and I typically enjoy picking up new vocabulary from reading!-- with a bellicose slant that nearly discredits him entirely. Hadler seems to go on and on and on, even though each topic is fairly short. It was a struggle to get to chapter 2, at which point I gave up. I'm eager to read more on the subject but I'll save my time for an author more measured to listen to.

[RoyceAnn · Rating 4 out of 5]

This book was an eye opener for me. So much of the medical system is set up for profit and not the welfare of the patient and this book points out how to be a better consumer in this unfamiliar setting. There was a lot to like about the philosophy of health that Dr. Hadler promotes. I especially appreciated his parsing of the medicalization of "problems" that earlier generations understood as issues we have to cope with as part of being living, mortal creatures. I did get bogged down in the statistical details but felt that it was necessary to bolster his point of view. My physician gave me this book to read and suggested that after reading it I might not want to come back to him and laughed. I think it will help with our conversations about treatment options in the future and I appreciate his offering me this opportunity to increase my knowledge of the challenges in health care.

[Chel · Rating 4 out of 5]

This book is fascinating, troubling, and very abstruse. I have 3 college degrees, including a B.S.N., and I've taken several statistics courses, but I found it very difficult to follow the parts where he is objecting to generally accepted interpretations of medical research. Each chapter has a "shadow chapter" of supplementary material to back up his claims. I assume the purpose of this was to keep the main text itself from being too dense, but parts of it are nonetheless quite dense.

Ultimately, Hadler's argument is that it would be far more to the human good, and far more fiscally sound, to completely rethink how we manage health care in this country -- something that is only likely to be possible if there aren't huge profits to be made by private interests. He reports that the public policy makers he talks to frequently agree with him, but feel helpless to go up against the power of pharmaceutical companies and others profiting (or profiteering) from our present system.

But I also read this book as an individual with personal questions--ones I have already been wrestling with. Should I stop getting mammograms? Should I stop taking certain medications. How do I get more information to help me decide? Whom do I trust? I still don't know.

I discussed some of Hadler's arguments at dinner with friends and heard a convincing story about how a certain procedure that the author says helps only about 3% of the people who get it -- and may harm an equal or larger number -- nonetheless reinvigorated a fast-failing family member who went on to have 20 more vigorous years of life. As long as we have such experiences among us, how do we deny patients their shot at being among the 3%? Hadler is very convincing in his arguments that we would could increase the lifespans of Americans much more effectively by investing the money in improving the welfare of those at the bottom of the economic ladder. How can we live in a society that does very little to help the economic security and quality of life of its ever-expanding poverty sector, but clamors for a health insurance system that would offer everyone an angioplasty, from which a few make great profits?

But even with so many remaining questions, I am glad I read this book. I have a feeling that the swamp of confusion and skepticism in which I am currently mired is a more accurate representation of what we know about medical needs and medical treatments than the simple answers I get from my doctors and most websites.

[Monte · Rating 5 out of 5]

At a time when access to health care in the United States is being widely debated, Nortin Hadler argues that an even more important issue is being overlooked. Although necessary health care should be available to all who need it, he says, the current health-care debate assumes that everyone requires massive amounts of expensive care to stay healthy. Hadler urges that before we commit to paying for whatever pharmaceutical companies and the medical establishment tell us we need, American consumers need to adopt an attitude of skepticism and arm themselves with enough information to make some of their own decisions about what care is truly necessary.
Each chapter of Worried Sick is an object lesson regarding the uses and abuses of a particular type of treatment, such as mammography, colorectal screening, statin drugs, or coronary stents. For consumers and medical professionals interested in understanding the scientific basis for Hadler's arguments, each topical chapter has an accompanying source chapter in which Hadler discusses the medical literature and studies that inform his critique.
According to Hadler, a major stumbling block to rational health-care policy in the United States is contention over the very concept of what constitutes good health. By learning to distinguish good medical advice from persuasive medical marketing, consumers can make better decisions about their personal health and use that wisdom to inform their perspectives on health-policy issues.

[Kim · Rating 4 out of 5]

Currently reading. In short, a book about conscious choice and a our culture becoming "medicalized." An eye-opening look at the abuse of particular treatments, medical testing,and public dependancy on what pharm companies and the medical community tell us we need. Everyone needs to read this. Can get dull at times but very informative.

[Martha · Rating 3 out of 5]

Difficult for me to read - sometimes a bit too scientific for a science-phobe like me, but overall a fascinating look at many of the "best practices" of modern medicine, and how they differ from what is objectively known.

[Sally · Rating 4 out of 5]

Covers the same ground as "The Last Well Person," with updated data from studies. Don't read both books, since some of the material is exactly the same - word for word - in this second book. The earlier book is a bit more conversational, this one is more focused on the health care debate.

[Khankins1]

These first few chapters are VERY difficult to get through. EGADS, why use 8 words when you can use 1? It's such an important message and such a terrible read. Let's hope I can get through it!

[Jillian · Rating 3 out of 5]

This book makes a lot of good points about the problems with our current healthcare system.

[Feck · Rating 3 out of 5]

Shows how many of our supposed advances in health care are more about profit than science. Specifically heart cath/angioplasty, statins, cancer drugs.

[Elisabeth · Rating 3 out of 5]

This book explores the evidence available and the evidence to have spurred on many different types of medical treatment and screening. Each chapter focusses on different process. For example, he argues that for a justified screening process, there needs to be evidence of efficacy in it, ability to detect, effectively treat and thereby improve and lengthen healthy living. He argues for many screenings there is no basis for it, for example, with breast cancer, for routine screening, most women will go through this uncomfortable process to not have found anything. He compares the false negative and false positives amongst correct results, and the % of women who would die of the breast cancer were it not screened for. Not a large number.
I do get the point, that there is excessive medicalisation in our lives in the Western countries, and especially in the States where it is a paid service by the service user, it can get very expensive very quickly. But it also carries the risk of serious cases of malignancy, for example, going unmissed and timely treatment therefore foregone.

[Anita · Rating 5 out of 5]

So much uncovered about what we are led to believe by the powerful medical industrial complex. Easy to follow and practical.

[Gurleen · Rating 2 out of 5]

The foundation of this book was interesting and I did learn from it but on a whole, felt like a rant more than a concise argument.

[Josh · Rating 4 out of 5]

Eye opening views into modern medicine. I wouldn't have a surgery of any sort without researching the outcomes on my own. Hospitals are set up as profit centers instead of healing centers. Nortin's book takes an insightful look at what is happening inside the sterile walls.

P17 Coranary artery bypass graft, angioplasty, stents, stents coated with drugs. In sum, none work, but doctors keep trying to make it work. Cardiologist and cardiac surgens still have this bee in their bonnet. They talk about new procedures, new widgets and gizmos, the particular timing of the procedures, and anything else rather than wonder if their basic belief is wrong. They manage to sting over a million American hearts each year with the bee in their bonnet.

P43 There are genetic differences between populations with differing ancestral continents of origin. However, the genomic similarities are far more striking than the differences.

P105 We are a country of obese, hypercholesterolemic, hypertensive, diabetic, osteopenic, depressed, pitiful creatures perched on the edge of a cliff staring at condors: cancer, heart attacks, strokes, dementia, fractures, and worse. We fear for our future. We teach our children that they, too, must live in fear for their futures.

P161 The data to support a public health recommendation as to calcium and vitamin D supplementation of a normal diet or as to diary-food consumption are quite inconsistent and any such recommendation is controversial. However, there is one subset of well people for whom a diet deficient in calcium or vitamin D is a risk for osteopenia. That subset is the elderly, particularly the institutionalized elderly and most particularly institutionalized or homebound elderly women. This is the only subset in which there is scientific support for supplementing the diet with calcium and vitamin D. The support is tenuous.

P168 No one should be screened for any disease, ever, unless:
1. The test is accurate
2. The result has meaningful predictive value
3. There is something meaningful to be done if the test is positive

P204 Or are vitamin and mineral supplements a waste of billions of dollars? The answer to the last question is an affirmative with a couple of items of uncertainty. … there is no compelling reason, other than your comfort in the vitamin envelope, to take multivitamin/mineral supplements. One unequivocal exception is that the daily recommended intake of folic acid is too little in the first trimester of pregnancy. Many large and expensive trials have been/are being undertaken regarding vitamin supplementation. … it turns out that some of the most compelling effects to emerge from these trials are negative.

P211 Regarding homeopathic medicine - “So what?” you ask. “Who cares if the modalities (treatments) are fatuous (idiotic), as long as the treatment act is not harmful and the clinical effect is palliative (soothing)?”
I do. I care if fellow citizens are being duped into thinking that they are participating in a therapeutic contract that is more than magical. I care that I am being forced to underwrite such magical therapies.

P294 Trials regarding the benefit of calcium and vitamin D have only shown small benefits in a small subset of the population - debilitated, institutionalized elderly. These benefits have proven difficult to reproduce. Several large randomized-controlled trials can discern no benefit in terms of fragility fractures from calcium and vitamin D supplementation in elderly women.


www.veggierunner.com

[Kali · Rating 1 out of 5]

dude needs to:
1) maybe get a good massage
2) work on his "layman" tone. maybe just his tone? words he loves: fatuous (he says this soo much!), nonagerian (i'd never heard this one before, it means person in their 90's), octogenarians (you guessed in, person in their 80's). really?
3) check himself before he wrecks himself

memorable quotes
*page 143: "After all, it would not have been far-fetched to have constructed sociocultural models for the pathogenesis of pulmonary tuberculosis and AIDS were it not for the superseding microbiology." Uhhhh, it wouldn't have been far-fetched as it happened. does he not know history? and it was incorrect and unjust. has he not read Illness as Metaphor or AIDS as Metaphor? this is exactly what it is completely incorrect in our society to do, place sociocultural constructs on medical issues.
*page 145: "Diagnostic banter such as Sjögren's, Raynaud's, lupus, Crohn's, fibromyalgia, chronic fatigue syndrome, TMJ syndrome, candida, EB virus, and many more are pressed into service." glad to know this is all banter...

tuberculosis, at one time, had the sort of fantasy surrounding it that hadler would like us to create around chronic pain and other health issues today. tb was seen as afflicting the careless and passionate, the young and intense. it would turn your face white and your lips bright red. it was called "consumption" and it was believed that a strong yearning or craving could bring it on. and then, the news: a bacteria. all these people, corralled in sanitariums, thinking they needed to tone down their desires.

sontag says in "illness as metaphor": "Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it." (p. 57)

and here lies the injustice of Worried Sick. illness has stigma, still. we all have a right to feel well. hadler has defined feeling well as just sort of getting over an individually defined level of discomfort which he has no business defining. hadler would take us back to victorian times, taking those of us seeking relief from an unbearable backache with no provable cause to the sanitarium for an inability to cope, an inability to just get on with it. the great thing is we don't have to live like that.

there is a lot in this book about overtreatment that has been covered better elsewhere: statins, mammograms, prostate cancer screening. where this book gets dangerous is when it starts recommending that you not seek solutions for problems, and when he starts deciding what problems are in people's heads.

[Cym Lowell · Rating 4 out of 5]

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!

[Marie · Rating 2 out of 5]

This is a book of regurgitation of medical statistics. Blech. Hadler grumpily drones on and on about one scientific study after another possibly using a thesaurus that specializes in obscure, little known words in the English language.

I found it interesting that his assertion that the most common source of 'regional low back pain' is one's inability to cope with your work or home life and yet, when was the last time any doctor took the time to take into account your lifestyle choices, coping mechanism or even your diet for that matter when developing a treatment plan? Then in a subsequent chapter, he asserts that 'alternative treatments all focus on the symptom rather than the person with the symptom'. As a licensed acupuncturist I can say that this statement is unequivocally false.

I can appreciate that many of the medical tests we subject ourselves to are useless and are doing nothing more but lining the pockets of our for-profit medical system and he could have just left it at that. However, why Hadler felt compelled to round out his argument with marginalization of vitamins, supplements, herbs, complementary and eastern therapies as well is baffling. The overall theme is 'western medicine is smoke and mirrors and there's no scientific evidence to support any of these modalities either so making it to age 85 and maintaining good health is a crap shoot of epic proportions.'

The most valuable information I gleaned from this book as it pertains to Western medicine:
NO ONE SHOULD BE SCREENED FOR ANY DISEASE, EVER, UNLESS:
1. The test is accurate
2. The result has meaningful predictive value
3. There is something meaningful to be done if the test is positive.

[Nancy · Rating 3 out of 5]

In some ways this is a really good book. Dr. Hadler provides information you don't see in other places about the marginal health benefits we derive from many of the tests and drugs that are recommended to us.

One good point that comes through is that companies who develop a drug desire to find "benefit" such that half the population will "need" the drug. It is a good idea to get on the internet and read about the studies that proved the benefit of any drug prescribed for you. I did that a few years ago with Actonel and was able to learn that the benefits were pretty small for women in my situation so any risk was too much.

However after reading chapter after chapter saying that this or that test or drug barely helps, it occurred to me that most things we do barely help. The average person probably clicks a seatbelt 100,000 times over the course of his or her life with no life saving event. Still it is worth doing. Perhaps not to Dr. Hadler. If so many drugs and tests really aren't even worth considering how come a 50 year old man can expect to live almost 6 years longer than he could in 1970? I really wish he he'd covered that.(I didn't quite finish the book because the library wants it back for another patron. If I missed a section where Dr. Hadler covered additional longivity, let me know.)

[Danielle · Rating 2 out of 5]

In this book, Hadler explains in a very snooty tone how conventional medical wisdom is totally wrong, and how doctors are intent on overtreating you to death. Maybe not an insane premise, and especially timely with today's healthcare debate, but I couldn't get past his tone. It was like he was completely astonished that you (the reader) could have been so stupid as to believe the advice of doctors. Seriously, what's wrong with you? And he just states his opinions as irrefutable facts, condemning the medical community for relying on inconclusive studies, yet not offering the reader much justification for his position other than "They're wrong; I'm right."
I didn't read much of this book. Just the introduction and first chapter, and then skimmed some more, so it could be there is material in here that would be worthwhile to read. I doubt it, though.

[Irene B. · Rating 4 out of 5]

This book sums up what I've been thinking about how going to the doctor (unless its a specific crisis) makes you more sick and how often medical tests have caused me more problems when actually nothing was wrong with me in the first place. The author shows how all the research regarding testing and medications are actually statistical numbers games and not in the patient's best interests at all. No wonder I feel much better when I don't do what the doctors say to do! They are just in league with the pharmaceuticals and they all listen to each other and begin to believe their own hype. He's a bit hard on alternative medicine, but again our western research provided the data, so who knows. I want to read his latest book.

[Linda · Rating 3 out of 5]

This is for the audio version. The information in this book would benefit the general public but the book is a challenge with its technical terminology and focus on research statistical results. One is also left with the impression that the author is greatly weighed towards traditional medicine and less focused on complementary or alternative approaches that are gaining in popularity. However, the author raises excellent points about the overall efficacy of treatments or medical interventions that the consumer should consider. I didn't have access to the actual book to examine the supporting references so I do wonder whether these sources are easily readable for the general public for even more recent topics, such as the use of stem cells to address a wide range of health issues.

[Laura · Rating 5 out of 5]

Well-written, thoughtful, passionate and persuasive. The author breaks ranks with many in his profession and offers viewpoints that are worthy of serious consideration both by individuals seeking optimal healthcare for themselves and for concerned citizens who care about addressing the flaws on our system. Hadler's descriptions of Americans' cultural constructs around concepts of health and illness are fascinating. Highly recommended for fans of The Spirit Level and Crazy Like Us, both of which touch upon and extend some of his arguments.

[SallyStenger]

Presents the point of view that many medical tests are unnecessary and a lot of treatment is unnecessary. His viewpoint coincides with mine to some extent that I favor minimal treatment. I sometimes felt when reading it that he does not give the medical establishment as much credit as it deserves for the advances it has made. I feel that he could have done more to make the book accessible to a non-medical audience as he uses a lot of medical terminology and analyses of medical studies with which a general audience member such as myself probably is not all that familiar.

[Liz · Rating 2 out of 5]

I didn't finish the entire book because it was difficult for me to read... it is awfully technical at parts and I just never had the brainpower to get through it. BUT I tend to agree with the basic underlying assumption that we over-treat and under-care, and that we're all basically going to die around 85 anyways, so why do we put so much time, energy, and money into prolonging our lives for 1-5 years, especially at the expense of our quality of life?

[Will G · Rating 2 out of 5]

Upon further consideration: He fails to divide STEMI and NSTEMI type heart attacks, thus making his blanket "no caths" advice both dangerous and poorly informed. This large oversight has made the rest of his book questionable.

However, I will keep the phrase "mortal primacy".

[Erin · Rating 5 out of 5]

Everyone needs to read this!

[Judith]

Difficult scholarly style, but the information is extremely interesting. Read this if you have a chance, especially if you are a baby boomer or older. Wish the print had been a little larger.

[Shirley]

The most important book I've read for a long time.