July 7, 2012

Review by Alasdair J Macdonald of Rethinking Aging (Hadler, 2011)

Invited review by Dr Alasdair J Macdonald, consultant psychiatrist (www.solutionsdoc.co.uk)

Hadler, NM (2011) Rethinking Aging: Growing old and living well in an overtreated society. University of North Carolina Press: Chapel Hill, USA. ISBN 978-0-8067-3506-7

This timely book examines the effects of corporate involvement in research and the financial incentives for doctors within the healthcare system. Hadler is a professor of medicine and microbiology/immunology in North Carolina. This book addresses the presentation of new research in medicine, especially that funded by external agencies and corporations. He remarks that a study of 10000 persons which shows a risk reduction from 6 cases / 10000 to 3 cases / 10000 does not justify the statement ‘50% decrease in risk’. Also, endpoints for studies may be chosen arbitrarily from available parameters, sometimes for marketing reasons. This may create false goals for treatment.


He regards meta-analyses (normally the gold standard for research) as being an attempt to show an effect from countless tiny (ie non-significant) results. He prefers small targeted studies, which he says will demonstrate any clear and true result. This is interesting to me, as the evidence base of solution-focused methods has a useful number of such trials: 11/22 show benefit against other treatments.

Hadler emphasises the pitfalls of ‘seeding’ or phase 4 trials. These are designed to encourage doctors to use a new drug for a small number of patients, often in return for a small incentive payment. Thus the doctor becomes an advocate for the new drug. Positive Psychology research has shown that giving your doctor a small present leads to a great increase in his commitment to you. Thus professional assertions that small incentives do not affect judgements are not to be relied on.

Hadler’s reanalysis of major studies suggests that factors such as diet, weight and lifestyle are only significant because they correlate with socio-economic class and absence of social adversity. His review of actual risks versus benefits supports hip surgery for the elderly, but does not support many common interventions for coronary heart disease or screening for certain cancers.

A randomised study of shoulder pain treatments showed that patients given their preferred treatment did better than those who did not receive their preference, regardless of which treatment they received (Thomas et al 2004). This supports Seligman (1995) in showing that choice and control are important in producing good outcomes. This fits the philosophy of the solution-focused approach.

Further, Hadler quotes Karasek and Theorell (1990) that the workplace is a good proxy for measuring social capital / social adversity. He summarises several studies from Finland, Sweden and Denmark showing that positive workplace relationships correlate with better social cohesion outside work and with better health in general. Solution-focused approaches may be of particular value here in view of their relative effectiveness across social classes. A Finnish study (Vahtera et al 2004) showed that the anxiety and health problems produced by downsizing organisations cost more than the money saved by downsizing in the first place. This seems to me a strong argument for sf – style interventions in troubled businesses and public sector organisations. Studies of solution-focused approaches to management demonstrate results in better productivity and staff morale, which will in turn reduce absenteeism and personal discomfort.

REFERENCES

  • Karasek R, Theorell, T (1990) Healthy Work: Stress, productivity, and the reconstruction of working life. New York: Basic Books.
  • Thomas E, Croft PR, Paterson SM, Dziedzic K, Hay EM (2004) What influences participants' treatment preference and can it influence outcome? Results from a primary care-based randomised trial for shoulder pain. British Journal of General Practice 54:93-96.
  • Seligman, M.E.P. (1995) ‘The effectiveness of psychotherapy. The Consumer Reports study’, American Psychologist 50:965–74.
  • Vahtera J, Kivimaki M, Pentii J, Linna A, Virtanen M, Virtanen P, Ferrie JE (2004) Organisational downsizing, sickness absence and mortality: 10-town prospective cohort study. British Medical Journal 328:555 doi: 10.1136/bmj.37972.496262.0D

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