Nortin Hadler, a professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, has been warning for years about the lack of evidence supporting many popular medical treatments and tests.
His work is controversial. In books such as "Stabbed in the Back: Confronting Back Pain in an Overtreated Society" and "Worried Sick: A Prescription for Health in an Overtreated America," Hadler argues for holding medical interventions to a high standard: Do they reduce mortality or substantially lessen the burden of illness? Do potential benefits significantly outweigh potential harms? Unless research proves this, the interventions should be avoided, Hadler insists.
In his newest book, "Rethinking Aging: Growing Old and Living Well in an Overtreated Society," the 69-year-old Hadler turns his attention to older Americans and the challenging medical decisions they face
Hadler's conversation with Judith Graham has been edited for clarity and length.
Q: You’ve called your book "Rethinking Aging." What do you want readers to understand about aging?
A: This book is a celebration of the fact that the baby boomers and the traditionalists — the generation that came before the boomers — are the first in the history of the world to hit age 60 and to be able to say, rationally, "What do I want to do with the next 25 years of my life?"
We shouldn’t worry so much about what will kill us; instead, we should be focusing on making it to age 85 and having a pleasing journey along the way.
Q: You’re concerned about the medicalization of aging. Explain why.
A: You can be healthy well beyond 60, but you’ll be different than you were when you were 20. You’ll have different posture, wrinkles and a lot of other changes that are less obvious but age appropriate. We have to be very, very careful about calling any difference from when we were younger an illness or a disease. And we have to be even more careful about telling people that we have things we can do to "fix" these differences, but this happens all the time. That's the medicalization of aging.
Q: What’s the alternative?
A: Helping people understand what’s normal for their age and how to accept and adjust to those normal changes.
Q: You talk a lot about the importance of older people making informed medical decisions.
A: For the first time in the history of medicine, we have a tremendous amount of information about efficacy: what makes sense to do medically and what doesn’t.
What I want to teach people is that it's perfectly appropriate for patients to ask their doctors, "How certain are you that what you are offering me will produce meaningful benefits? What does the evidence show about the possibility of harm?"
Q: Can you suggest some other questions people might ask?
A: People should want to know the likelihood that death will be postponed by doing something. What is the likelihood of the same outcome, or close to the same, if one doesn’t have the treatment? Out of every 100 people, how many are helped by this intervention?
Q: What about people who face really serious, life threatening illnesses?
A: You want to know whether a proposed intervention will be effective given your context: your age, your degree of frailty, other illnesses that you have. How much benefit will you get: an extra three months, an extra year? If it’s a year, what kind of year will it be? Will I feel absolutely awful? What will the quality of my life be?
I once took care of a very, very famous physician. He was an octogenarian with heart disease, but he was very active and sharp as a tack. Well, he found out that in his belly was an expanding aortic aneurism – a surgically treatable potential killer. He and I had multiple conversations about what to do and each time he would say, “I’ll be damned if I let them do surgery on me.” He knew there was a high risk of surgical mortality because of his age and his frailty. He knew that urological complications were almost guaranteed and cardiac complications were probable. He didn’t want to try to live through that. And he didn’t have to because he died of a stroke, unrelated to the aneurism, several years later.
Q: What about common problems like lower back pain? You say surgical treatments aren’t effective. But what are older people supposed to do?
A: I’m not belittling the pain. In many cases, however, it will resolve over time without medical interventions. The job of the doctor, once the doctor does an exam and realizes there isn’t something extraordinary going on, is to help people deal with the discomfort to minimize suffering. The most effective way to do that is not with surgical violence or even with powerful pills. The doctor helps the patient adapt and address the contextual issues in their life that might interfere with coping while they wait for healing.
Take an older woman who comes in complaining of knee pain. There are no surprises on examination. She’s been your patient for a long time; you know her husband died recently. In our culture, we are primed to assume that the knee pain is interfering with coping with her loss. Science suggests the opposite: the grieving makes the knee pain seem more intense.
With time and trust, a physician can help a patient see this clearly and discover coping skills in the process. Pills, arthroscopy and surgery are missing the forest for the trees.
Q: You have very strong and controversial opinions about medical procedures commonly performed on older adults — without adequate justification, you say. Which would you put at the top of the list?
The first would be interventional cardiology and cardiovascular surgery for coronary artery disease. This includes coronary artery bypass surgery, angioplasties and stents. These were designed to spare one from fatal and nonfatal heart attacks. I think these procedures should not be done. We have multiple trials comparing doing them versus taking care of people conservatively, and these studies show that essentially no patient is advantaged by these interventions.
The second would be arthroscopic surgery for knee pain. Again, studies show that patients gain no advantage from arthroscopic surgery. They do as well, even better, with appropriate exercise, a little Tylenol, a supportive community and patience. But going the nonsurgical route calls for coping skills, which many physicians don’t even talk about with older patients.
Q: One of your chapters is called "decrepitude." How do you define that?
I think of it as gray hair of the musculoskeletal system and other parts of the body. There are many age-dependent changes that increase the challenge of doing things physically.
My question is: Do we want to call gray hair a disease or do we want to reframe this period as an essential time of life? I want to reframe it by talking about what we can do to circumvent limitations and how to cope when we can’t.
We’re taught and marketed that all changes in appearance and in function in older people are forms of disease that demand treatment. But often, that isn’t true. Much that is termed a disease is a normal aspect of this time of life and needs to be viewed as such. Sure, there are challenges, but we’re less inclined to label life challenges as diseases in other phases — puberty for example. We need to examine our preconceptions in open dialogue with our physicians and others in our community.
Q: In the next chapter, “frailty,” you say this chapter of life has joyful features. What do you mean by this?
A: Frailty is a challenging time, but in caring for the frail, we can be enlightened about what it means to be human. There’s an awful lot that you can learn from frail people. Children feel it more quickly than we do because we’re too busy to really pay attention.
Of course, there are elements of frailty that can take away humanity. Dementia is an example of that. But generally, there is no reason to warehouse the frail, not to talk to the frail, not to be loved by the frail. They may not be the people they once were, but they are human beings and there is great value to be found in them.
This article was produced by Kaiser Health News with support from The SCAN Foundation.