Image source: Gary Schwitzer: Is this test really necessary?
In 1994, Dr. C. K. Meador published a now classic, tongue-in-cheek essay called “The Last Well Person.” It appeared in The New England Journal of Medicine and starts with a great anecdote.
A supervising doctor asks a medical resident “What is a well person?” With a straight face — evidently — the resident confidently replies: “A well person is a patient who has not been completely worked up.”
Fortunately, we can recognize the humor in this, but it does give one pause.
Technological advances in diagnostic testing give modern medicine the ability to detect disease. Testing is also used to measure health “markers” that may indicate risk for diseases we do not yet have. Along with this comes an enormous increase in
- the number of things a healthy individual can worry about
- a health regimen of lifestyle options that presumably prevent disease
- the obligation to continually monitor one’s health.
The compulsive pursuit of wellness
Dr. Meador’s essay starts with recollections of a dinner party where everyone talks about their health complaints. People who consider themselves well seem to be a vanishing species, he says, and goes on to speculate that by 1998 there may be only one well person left.
His description of The Last Well Person – a 53-year-old algebra professor at a small mid-western college – illustrates the compulsive pursuit of wellness. The professor quit his job as a stockbroker after attending a workshop on stress. His new occupation gives him adequate free time to attend to the maintenance of his health.
He has himself tested regularly for cholesterol, blood sugar, PSA (prostate-specific antigen), hematocrit (a marker for anemia and COPD), and a number of other diagnostic markers. He regularly tests himself for blood in his stool. He videotapes the health reports on the morning news so he can watch all three networks. He modifies his diet, home, and lifestyle in response to the news he hears.
He eats no saturated fats, limits fat calories to 15 percent, and avoids salt, sugar, red meat, and additives. He takes vitamins, kelp, seaweed, baby aspirin, and bulk laxatives, eats bran, and drinks eight glasses of water a day. He uses a pulse-rate analyzer, blood-pressure monitor, and ear oximeter to monitor his aerobic exercise. He flosses three times a day and paints his teeth with a fluoride solution. He uses sunscreen and dark glasses to protect his skin and eyes. Once a year he measures and records the moles over his entire body (with the assistance of his wife).
He has been screened for all known psychopathological disorders and has tried Rolfing, transactional analysis, primal-scream therapy, gestalt therapy, neurolinguistic programming, and channeling. And finally, he has had extensive medical workups: endoscopy of all orifices, computed tomographic scans, magnetic resonance imaging scans, positron-emission tomography, biopsies of the thyroid and prostate, complete profiles of blood and urine chemistry.
Obsession is no longer a disease
OK. That was meant to be a bit overwhelming. Dr. Meador attempts to cover all the bases by combining the issues of diet, exercise, the media, diagnostic testing, psychological health, alternative health practices … all in one person. He also includes the general sense of risk that goes beyond health: smoke detectors, a rope ladder from the second floor, and a “well-grounded electric razor.”
There are a number of bottom lines here. One, this is an essay by a doctor, published in a medical journal widely read by other doctors, pointing out a problem. He’s assuming other doctors will know what he’s talking about – that they also see patients who are at least moderately compulsive about their health. Today – sixteen years later — patients have even more opportunities to obsess about their health thanks to the Internet.
Dr. Meador states that a patient with this behavior would have been labeled obsessive-compulsive in earlier times. But these days “Obsession is no longer a disease, but an essential attribute of staying healthy.”
Another bottom line is that various forces – not only the availability of diagnostic testing, but the amount of health information disseminated by the media, market forces that profit from the sale of anything related to health – combine to create essentially unhealthy behavior.
There is no test for wellness
Meador’s explanation for obsessive health-related behavior focuses on diagnostic testing. Patients want reassurance from doctors that they are well. But diagnostic testing can only find disease. There is no test for wellness.
As clinical tools become more refined, it becomes possible to find more and more evidence of disease or of the risk factors for disease. “And false positives are the arithmetically certain result of applying a disease-defining system to a population that is mostly well.” An excellent exponent of this subject in 2010 is Dr. H. Gilbert Welch.
This is, in part, an American problem. Not all countries define the risk of disease as broadly as American medicine does, as Lynn Payer discussed in her book Medicine and Culture. It might be reassuring to patients to learn that if they lived in France or the UK, not only would everyone have guaranteed health care, but their cholesterol levels and blood pressure readings might be defined as healthy compared to American standards.
Update: I was pleased to see Dr. Meador’s wisdom featured in the documentary Money Driven Medicine, based on Maggie Mahar’s book of the same title. See Doctors in the trenches speak out – Parts One, Two and Three for excerpts.
C. K. Meador, The Last Well Person, The New England Journal of Medicine, Volume 330:440-441, February 10, 1994, Number 6
Lynn Payer, Medicine and Culture: Revised Edition