Health for the People and for the Person: An Interview with Dr. Nortin Hadler

This is part of our Campus Spotlight on the University of North Carolina at Chapel Hill.

I first met Dr. Hadler two decades ago—not as a student in medical school, not as a patient in the hospital, but as a member of the Chapel Hill community (North Carolina). Humanist, curious observer, and scientist, Nortin Hadler is the epitome of the very polymath he laments the current health care delivery system has rendered atypical in the medical profession. He is as comfortable explaining medical science as he is discussing French philosophers, politics, history, art, the theater, music, or avant-garde contemporary dance. A prolific writer, he has been committed to analyzing and deciphering a vast medical and public health literature for specialist and lay audiences. In giving individuals the tools they need to make informed decisions about their bodies and the therapies available to them in the face of sickness, he has reconceptualized “disease” away from over-medicalization trends. For this special feature on Public Health, Dr. Hadler speaks about the ways in which medicine and public health intersect, how he sees the patient-physician dialogue as the essential basis for health care delivery, and how culture mediates wellbeing. Experienced in various healthcare systems across the world, he also shares his lasting effort at designing an alternative healthscape in the United States that repositions the person at its center, starting with a new approach to medical education that would uphold a lost ethics of care as prime again.

—Hélène B. Ducros for EuropeNow

EuropeNow What is the difference between Medicine and Public Health? How do physicians/medical scholars and public health scholars work together and inform their respective fields?

Nortin Hadler Today, Public Health is an academic institution. Like Medicine, Public Health is not monolithic; it houses many distinct, dynamic, and complex disciplines from nutrition to health policy, biostatistics, epidemiology, or even health communication. In the eighteenth and nineteenth centuries, epidemiology was the study of epidemics. For example, when cholera occurred in London, it affected the populations of certain districts of the city. It was thought that cholera came from the miasma, the air people breathed. John Snow postulated that the local water supply was a more likely culprit. People did not believe him, so he conducted an experiment by taking out the source of drinking water in the district subject to cholera breakouts. Absent the Broad Street Pump, cholera epidemics ceased. Since then, epidemiology has expanded from epidemics to observational data on large populations, thanks in great part to European works, for example out of Oxford. In contrast to discrete epidemics, epidemiology shifted to probing for risks and causes that afflict a fraction of the general public, such as lung cancers. Observational data allowed us to say that cigarettes were a bad thing, even though that was heavily debated by the tobacco industry. However, the association of smoking and lung cancer in the general population was so compelling that there was no longer any room for counter-arguments. The question for modern epidemiology becomes: How do we live with each other in a complicated world in ways that afford us reasonable longevity and reasonable quality of time on this Earth? This question is compounded by the success of wealthy countries to support populations with considerable longevity. We don’t die young anymore. Hence, epidemiologists consider who is not living as long as others among us and look for subtle biological risks and adverse social determinants of health to explain health discrepancies across the population.

Logically, schools of public health have slowly evolved from the epidemic to a much broader notion of the health of the people, while medical schools have stuck with the health of the person. In the US, there are many schools of public health. In Europe, they are usually departments within medical schools, with enormously important work being done there, for example at Oxford and University College London. Medicine and public health have cross-purposes. Inferences drawn from large populations can pertain to the average person. What is good or bad for the average person? Medical doctors use epidemiology to know how far a patient deviates from the average person. The problem is that no doctor sees the “average person” in the clinic. We see “the person.” Very few people are unidimensional; they have many things going on. The public health literature is incredibly important in informing the conversation, but less important in determining the outcome of the discussion between a patient and a physician.

EuropeNow You draw a difference between the health of a person and the health of a people. Can you explain what you mean and how that difference might translate as far as practice and/or policy?

Nortin Hadler CEOs live longer than the labor. I’d like everyone in the working class to be a CEO. At London’s University College, Sir Marmot started following Britain’s civil servants decades ago to find out their risks of cardiovascular disease and death. This is the Whitehall study (there have been similar studies subsequently all over the world). Initially, the risk factors that were quantified were those that were considered the most important then (cholesterol, weight, gut-butt ratio, what you ate, etc.). He noticed that the higher a person ranked in the civil service, the longer the person lived. Keep in mind that this is in Britain where medicine is available to all under the National Health Service, unlike in the US where a low level of income means you may not be insured and so you may not receive needed care. In Britain, this variable is controlled for. Marmot showed that there were correlations between the cardiovascular risk factors, civil service rank, and longevity, but that correlations were not very robust. He then went on to do something brilliant. He asked people “do you like your job?” If you said no, it cost you time on Earth. The risk that is imparted from saying no outweighs the small risk of the cardiovascular factors and the benefit of a higher civil service rank. Marmot spent his career parsing with this observation trying to discern which of many reasons why people don’t like their job was telling: difficult boss, unfair pay, boredom… All matter, but barely. However, your rank in the civil service is not as determinative of whether you like you station in life as one might think.

This sort of thinking is coming back to the forefront today and should have been there all along. The notion of burnout, for example, comes out of this important part of the history of epidemiology. I have worked on it through the issue of back pain in the workplace. It is very common; but back pain is also common at home, outside of the workplace. It’s also common not to complain about it. What is the difference between the person with a backache and the person with a backache who chooses to be a patient or worker’s compensation or disability claimant? The data reveals much of what Marmot discovered: the difference is “I hate my job.” One problem is that in our society, you can’t say that. It is tantamount to admitting “It’s in my mind,” which in western culture is anathema. However, you can say that the reason you hate your job is that it caused your back pain, as opposed to the reason your back pain is intolerable is that you hate that job. It’s a very culturally-biased response. The message for public health is obvious, but difficult to implement because it requires thoughtful management and a shift in the “common sense.” Both are long overdue and difficult to promulgate. We don’t promote people because they are thoughtful managers, but because they make money for the company.

It is very important for physicians to think along those lines and even more important for patients to do so. We need a different frame of reference to account for predicaments of life that are clinically morbid, such as backaches, feeling blue, knee or shoulder pain, or bowel discomfort. You will always have symptoms, but it’s about the coping. Community-based epidemiology tells us that a lot of us at any given time have or will have symptoms. Usually, we cope effectively and they disappear. The question is to know why sometimes we cannot cope with an episode. The symptoms may reflect some terrible disease, but far more often they reflect a challenge to coping with symptoms that were previously less challenging. That leads to a different patient-physician dialogue. There may not be immediate answers to life’s common predicaments (switch job, change spouse, shape up your kids?). We have a lot of literature on this topic, but it has yet to translate into the common sense or into the patient-doctor relationship. It takes a few seconds for a patient to get a prescription for painkillers, but it will take a minimum of twenty minutes to have a discussion about coping, which involves trust. This all emerges out of the notion that epidemiology is no longer about epidemics, but about how to understand concepts like health and wellbeing. Epidemics still do happen. For example, right now, we have a measles epidemic and children might die. We have AIDS. But the notion of public health has become much broader than just dealing with epidemics.

EuropeNow The American Public Health Association’s website states that “while a doctor treats people who are sick, those of us working in public health try to prevent people from getting sick or injured in the first place.” Is it not what preventative medicine also does, or are we not talking about the same thing? Is it a question of scale?

Nortin Hadler Public health works with populations; medicine works with people, one at a time. The insight from public health may translate differently in different cases. For example, some vaccines are so effective that even though catastrophes are rare, broad vaccination is justifiable. We almost eradicated polio. We got rid of small pox, which had been an awesome determinant of world history. When I was a boy, polio was epidemic, and it was awful. Now it is gone, with a few remaining pockets, which is scary because people are no longer immunized. Measles has an effective vaccine that is well tolerated. For most people getting measles only means missing a few days of school. But there are enough cases of measles-meningitis that vaccination is warranted. Other vaccinations might require a discussion one on one. For example, the vaccination for the elderly against varicella (shingles). We have to vaccinate many people to protect one person from the kind of shingles that we vaccinate for. The discussion with an individual about certain vaccinations must occur one at time. It is informed by the public health literature, but it is not a public health mandate. There should be skepticism about the many things we have done in terms of preventing disease. For example, it’s unsure if any of the influenza vaccine rounds we’ve been doing have been effective at all. The other forms of public health recommendations are to eat correctly, watch our gut-butt ratio, etc. Almost all of those are surrogates for socio-economic variables. It’s not having certain personal resources that mark you for death sooner rather than later. You might say that in the United States, speaking English, when English is a second language, may be better for you than asparagus or free-range anything. That is how you get a job. Having certain personal skill sets means employability and a job that moves you up from entry level to a job with benefits.

EuropeNow We hear a lot about “wellness.” Are health and wellness the same things?

Nortin Hadler I never use the word wellness. I use wellbeing. Wellness is an American marketing tool that goes back to the late nineteenth century when people on both sides on the Atlantic started promoting things that were “good for your health.” Kellogg invented his cereals as a health food. There were clinics all around Europe that catered to people who could afford them, including those targeting young women for peculiar therapeutic regimens. The exercise business is all about socio-economics. The notion that we can purvey healthfulness, longevity, and quality of life is easy to market. Wellness has become a catch phrase that includes many things, like yoga, etc. Whereas wellbeing is wellbeing. You can eat ice cream and have a lot of wellbeing, short of becoming morbidly obese. In my career, I cared for many patients with rheumatoid arthritis and many elderly patients. My job was to help them feel like people again in spite of clinical impairments, to dampen the negative effects on their quality of life and wellbeing. This involves defining self-actualization and seeking pathways to its realization. That pathway always incorporates “community” as a remedy for disaffection. “Community” must be defined by the patient, not by me, or a “guideline,” or marketing schemes.

EuropeNow You have written on “rethinking aging.” What do you think are the main public health challenges of the future as the proportion of older people increases in the population of certain countries? What about the developing interest in the world’s centenarians?

Nortin Hadler The more we work on longevity, the more it appears that there is no fountain of youth. In resource-advantaged countries, we are approaching a life-expectancy of eighty-five, and not much more. Our likelihood of becoming octogenarians is much higher than for the generations that preceded us. However, the likelihood of becoming nonagenarians is not much greater; since there are many more people today, there are more nonagenarians in absolute numbers. This age group faces many issues, such as frailty or dementia. Thinking in terms of saving lives in a population that is living to a ripe-old age of eighty-five is a bit fatuous. Some would say that at the molecular level, the science of aging will give us the secret that Ponce de León was looking for, but don’t hold your breath. At the policy level, what’s important is to keep people feeling competent, capable, and fulfilled. As an octogenarian, everything beyond is a bonus. If you can make it to eighty-five feeling good about yourself, you are basically “off warranty.”

As for the old-old, it’s not clear that their number has dramatically increased. They represent a stable percentage of the population, as opposed to octogenarians who, in 1950, had only marginal longevity. Today, a tremendous number of people reaches eighty, a lesser amount reaches ninety, and of that tail some people get to be one-hundred. Those remain statistical outliers that we don’t completely understand. Though genetic influence matters, studies show it’s minor. Many old-old are frail, bed-ridden, and have neuro-cognitive deficit linking to major inter-personal relationship issues. That’s not wellbeing.

In wealthy countries, we ought to provide people with a comfortable sunset. Dying at a ripe-old age is not a disease. Instead of trying to correct cholesterol in an eighty year-old, we ought to look at quality of life and community issues. Population studies show us that people want to have a community with people to talk to. We ought to focus on providing access to a community, to safe living spaces, to absence of fear. It can be hard for practicing physicians to intuit any of this. To start with, doctors of medicine see a biased population in their practice—those who needed to go there. The perspective of a medical referral center is often different from that of epidemiologists who go into the community.

EuropeNow In one of your books, The Citizen Patient, you not only discuss what reforms could look like in health policy, but also advocate for a changed relationship between individuals and their physicians. Tell us about this relationship.

Nortin Hadler How do we know that what we do is in the best interest of the patient? In the US, Congress passed a statute in 1960 that makes the interest of the patient mandatory in medical decisions relating to prescription drugs. There needs to be evidence that convinces the Food and Drug Administration (FDA) that using the drug would result in more benefit than harm. This is not true for procedures or devices. Almost all we do that requires pharmaceuticals is informed by some science, which varies in quality and quantity. A lot of what we do in terms of devices and surgical procedures is also informed by science, but less stringently so. Very seldom is the science unequivocal or results overwhelming. There are places in medicine where it would be irrational not to intervene, but those are rare. You may not have bacterial meningitis to account for fever, headache and a stiff neck, but we prefer not to find out after the fact. Most circumstances in medicine where intervention is considered are not unequivocal. They require information about the values of the patient with regard to risk and benefit. The risk may include the co-pay, or taking pills/injections, or dying of infection.

What we do for and with patients ought to be collaborative, involving a discussion so the patient and the patient’s caring community have input. As an example, take the notion of a “no code” advance directive (do not resuscitate). Even advance directives are not cast in stone; they are collaborative when initiated and reversible later on (unless you are unable to make decisions). Then they are surrogates. For many cancer therapies, discussion is important. One needs to compare the likelihood of feeling good with or without chemotherapy, particularly if the science suggests that the time of death is the same. One should feel empowered to forego cancer therapy if one feels there is no substantive likelihood of prolonging life. Another example is the many people who take statins. Very few have had that conversation with their physician. Data shows that if you don’t have documented heart disease, statins don’t protect you from dying before your time. A few people will be spared a fatal heart attack. Do you want to take a pill for the rest of your life? It would not be stupid not to take it. The choice should reflect the patient’s aversion to risk. That is the patient’s value. Much of medicine needs this collaborative input and a discussion about risk tolerance, coping, and wellbeing. That discussion often leads from uncertainty to uncertainty. Traditionally, people have asked, “Doctor, what would you do?” I argue that instead the question should be “Doctor, what would you do if you were me?” This would be possible when the doctor-patient relationship is one of trust where the doctor knows the patient, the patient’s risk tolerance and compliance level.

Europenow You’ve also spoken of the Doctor as a “placebo.” Can you explain what you mean? Incidentally, very recently in France, the Health High Authority, supported by the “Fakemed” movement there, has recommended the removal of prescribed homeopathic treatment from state reimbursement, for lack of scientific backing. Can you comment on that?

Nortin Hadler Homeopathy is a fatuous science. It has been debunked. The idea that you leave behind the imprint of an active agent in dilution is absurd and scientifically unsound. However, placebos are not trivial. They generate wellbeing, which is one component of health. Just talking to a patient can decrease the patient’s loneliness and anxiety regardless of the content of the conversation. I’ve had formal debates with leading philosophers about placebos. They have countered many of my arguments (except one). I argued that doctors should not prescribe a placebo if they know it is a placebo. That’s tantamount to lying to the patient. However, these proponents of placebos don’t think that it requires lying. A study was done with people who had abdominal complaints without a demonstrable underlying disorder. It was done by scientists who believe in using placebos with their patients who are willing to think along those lines. Some patients received standard therapy and others a treatment unsupported by scientific evidence. The outcome was interpreted as demonstrating that the placebo worked. But when I looked at the data, it revealed that the standard therapy worked less well than it usually does, thereby inflating the differential favoring the placebo. The same sort of results come out of studies where acupuncture needles are sheathed so you don’t even know if they go in. They concluded that the needle does not have to go in for people to feel better, with about 30 percent of people feeling substantially better. The argument is that such an improvement with minimal toxicity is better than pills. So, how come we don’t cover placebos? If placebos should be covered, then so should religion, which also works a good percentage of the time. All you need is purveyors and believers. It’s a cultural decision. The real cultural question with placebos is deciding whether we want to share the expense with the people taking them.  

EuropeNow You finish your latest book by saying that with proper reforms (in workers’ health policy in the US) “the care of the person will finally become an act of caring for the person.” Could you explain what you mean there? What are the main tenets of the new system you propose?

Nortin Hadler This phrase comes out of a lecture given in 1920 by Francis Weld Peabody at the Harvard Medical School and later published in the Journal of the American Medical Association. It basically means that there is so much to learn, it’s overwhelming. But all through it all you must remember the goal of the learning that the art of patient care is in caring for the patient. What we have created since 1910 with the Flexnerian curriculum is very different from the European curriculum. We were not nurtured by the European tradition. In France, it goes back to Rabelais (1483/94-1553) in Montpellier. In the US, before 1912, there were 121 medical schools, most of them in store fronts. You would buy tickets to attend lectures, and in the end get a degree. Medicine was a guild and its members and practices varied greatly. In Europe, it was more uniform. Following Abraham Flexner’s report, medical schools came to be attached to universities with state-of-the-art science and a minimum four-year curriculum. It has made a great difference and resulted in producing the great clinical scholars and investigators of the twentieth century who dominated modern medicine. Meanwhile medical care fell to other clinicians who became the worker bees. Today, many clinicians are disenfranchised and burn out. They are so pressured that many have been forced to delegate taking a patient’s history to “scribes.” A history is crucial to diagnosis, and therapy, and to establishing a therapeutic relationship. The history has to do with eye contact and other nuances of human interactions. Bedsides clinicians and their artfulness are not valued anymore. Following a business model, they are now called “providers.” And patients are no longer patients, they are “units of care.” How many units of care per provider per period of time can you move through is the mantra of the American healthcare system. This is an industrial engineering model that does not consider human factors. That is why we need to put the patient-physician dialogue at the center. This relationship needs to be nurtured, rewarded, and applauded.

Of all my books, Promoting Worker Health is the one most specifically about US health care. But I have formally studied the health care delivery systems in twelve countries. It’s very difficult because with each new elections, the systems change. Studying the data is not enough; it is necessary to examine where health care plays out, that is in the community. It’s not easy to do in France. It harder to do in Japan. And it is hardest in the US where healthcare is very heterogeneous, thanks to a derailed and ethically bankrupt health care delivery system. Healthcare in the US involves an enormous transfer of wealth, multiples of what any European country spends. Norway and Switzerland come the closest, but still with half the per capita expenditure that we have. While Switzerland does a lot of what we do, Norway spends a lot on caring for the elderly.

EuropeNow Much of your writing has focused on decrying over-medicalization in modern societies. What solutions are to be envisaged?

Nortin Hadler The amount of medical information and misinformation with which Americans live is enormous. People get information from the rumor-mill and marketing, but also from seemingly legitimate institutions, but too much of that is spinned. For example, people are made to believe that a study that might involve mice is directly relevant to their disease. The US is one in only two countries (the other being New Zealand) that has direct-to-consumer advertisement for drugs (for billions of dollars a year). Saying that 20 percent of the US GDP is invested in health care is a gross underestimation. That’s how much spending is reflected in insurance documentation, but it does not include much of what is paid out of pocket (the placebo aisles in supermarkets, physical therapy, etc.). This is also why health journalism is almost extinct. A lot of the support for media, especially TV, comes from the pharmaceutical industry. By commission or not, such outlets are less likely to bite the hands that feed them. The result is a very marketing-oriented discussion and tremendous medicalization. We are the most medicalized country, investing well over $3 trillion in the status quo. That is why it’s impossible to reform.

I started working on an alternative health care delivery system. I love this country and I love practicing medicine. Our biggest resource is the many altruistic and intelligent people who come into American medicine. But in our system, if they practiced according to their conscience, they would starve to death. The system constrains practice. That’s true elsewhere, but our system is ethically bankrupt and it is hard to reform without finger pointing. Since the 1980s, I have been working to create an alternative system. We have written a bill in Arkansas. Why Arkansas? Because of a constitutional peculiarity there that allowed us to do what we needed without the necessity for any constitutional amendment. We have designed a novel employee benefit scheme for large employers, such as states or large companies, to cover all employees wherever they live. It is highly ethical and fiduciary. Everybody is tithed about two percent of income to create a pot of money used to provide rational and ethical health, disability, compensation, and life insurance for the worker. It is an indemnity scheme that affords both management and employees security against the untoward risks we all face. Even part-time employees are covered.

The overall cost is as low as France’s levels. We also pay doctors at France’s level. It is based on trust in the patient-doctor dialogue. The government is out of the examining room. It’s a different approach to providing what is important in health care. It also solves the daunting conundrum of the standard approach to disability insurance. Evidence shows that people involved in contested disability claims never get better and the money never gets to them but to all those embroiled in the contest. The proposed scheme removes the contest; if you can’t work you are provided for automatically for a considerable time period. This system would be totally novel. There is no precedent. That’s one of our problems in the political arena. It’s difficult for politicians to imagine a scheme that monetizes altruism. Auguste Comte is long dead and too often forgotten. Furthermore, it is difficult for modern politicians to imagine a scheme that entails no political risk. It is designed to be totally discretionary: nobody has to offer it and nobody has to take it. We are sure employers will and that employees will be pleased and succored as a result.  

EuropeNow You have received the Prix Prescrire in France in 2012. Do you think the French institutional or intellectual terrain is particularly receptive to your ideas about over-medicalization, in spite of the fact that people in France take more pills than in many other European countries?

Nortin Hadler I don’t know if my ideas resonate in France or simply with the journal Prescrire. In France, some of the same issues we discussed also arise. Do doctors have the time to dialogue with patients and look at data? More than in the US, by far. The Japanese seldom bother and simply take more pills per capita than any other country in the world, though Japan is good at negotiating the price of pills. In the US, on average, we charge fifty to a hundred percent more for pills than any European country for the same pills. In France, many pharmaceuticals are over-the-counter. There is a tug of war whenever the FDA is asked whether something should be over-the-counter. This is also based on marketing. People should be able to negotiate their own health care for quality rather than quantity. That can only happen with a collaborative relationship with doctors.

EuropeNow At UNC, beyond the medical school, “health” is addressed in different departments and programs. Social Medicine, Medical Geography, Medical Anthropology, Epidemiology, Public Health, and even Nutrition—how do all these fields intersect?

Nortin Hadler This cacophony is driven by funding initiatives. There are many joint appointments in the Graduate School, the School of Public Health, and the Medical School. There is considerable overlapping of disciplines and considerable number of collaborations at the level of individual investigators and educators. There are physicians on the medical faculty who go to great lengths to interact with scholars in Medical History or Medical Anthropology, or even in the English department where people work on medicine in literature. But at the institutional level, these are separate entities nurtured by separate funding lines requiring their own people in order to justify the existence of the department and the departmental administration. It’s about turf. Many medical students pursue a Master in Public Health (MPH) from the School of Public Health, but need to take a leave from the Medical School to do so. A number of medical students also pursue a PhD in basic science. In fact, at Duke this option is built into the medical curriculum. Unfortunately, many now pursue an MBA from the Business School, instead. As a doctor, you now would need an MBA to “run your business,” particularly if you want to serve as management in a larger clinic or hospital. But medicine should not be a business, unless the system is broken. And it is broken. Students in medical school take two weeks in ethics on the run. There is not one day in the hospital without an ethical issue. How do we tell a woman that her husband has AIDS? Ethical challenges are part of medicine.

EuropeNow What about fields like “medical humanities?” Is medicine coming to the humanities or are the humanities coming into medical training?

Nortin Hadler My French colleague Professor Michel Revel said it best. When we were growing up, physicians were looked upon as scholarly people. Until well into the twentieth century, medicine revered its polymaths. The Dean of the medical school at Harvard, Oliver Wendell Holmes (whose son went on to be Supreme Court Justice), loved to write poetry. I think that today few medical school administrators read or write poetry. Part of it is the unintended consequences of the Flexnerian revolution. With Flexner, medicine became predominantly a science. Without science, medicine was no longer legitimate. Which is true, but medicine should be seen as a philosophy informed by science. Culture is also relevant. Medicine, like clergy and law, is part of the fabric of society. It is encouraging that today many students enter medical school with considerable life experience under their belts. For example, many were lawyers. But they don’t want to go into the medical law field. They want to be family doctors. They want to be in the community and talk to people.

As part of the alternative system we are proposing, we are also designing a new model for medical school, a novel approach to medical education that produces the kind of physicians at the end of four years that people want to help them go through life. It includes a new way to think about the curriculum that asks of the physicians to be “clinical scholars.” The new medical school would have the patient-doctor relationship built-in from day one. From the time in medical school until retirement from practice, every incentive will be directed at gaining and nurturing the skills and perspectives that advantage doctors’ patients.

Europenow Following up on this thought, in France, there is a critical decline in the number of general practitioners. Is it the same in the US? Would this new approach to medical education help rehabilitate that branch of medicine?

Nortin Hadler I don’t want “family doctors,” I want every doctor to be a resource for any human being who chooses to be a patient. The reason there is a crisis in doctors willing to talk to patients is that we don’t value it. Family medicine is sustained because these practices have physician assistants and scribes employed to move patients through. They are not sustained because they pause to know and care. There is the notion that the very small percentage of doctors who choose to highly specialize and who have to do a lot to maintain their technical skills should be paid more. But they should not be paid more, they should do this because they like it. We should not reward wanting more money but taking care of people. Doctors should be equally valuable in the community of clinical scholars who are doing the best they can by those patients who come to them. France is seeing a shortage of generalists because it made the terrible mistake of following the US and the idea that you have to be on top of your medical school class to specialize. When you start stratifying right away, there is no way back, and it can lead to burnout. I would like medicine to be the land of clinical scholars who are curious to know what may be important in the future. I want to deemphasize the artificial stratifications that don’t benefit the patient and that destroy the relationship between doctors and patients. A small revolution… I try.

Dr. Nortin Hadler (MD, MACP, MACR, FACOEM) is a graduate of Yale College and The Harvard Medical School. He trained at the Massachusetts General Hospital, the National Institutes of Health, and the Clinical Research Centre in London. He was certified a Diplomate of the American Boards of Internal Medicine, Rheumatology, Allergy & Immunology and Geriatrics. He joined the faculty of the University of North Carolina in 1973, was promoted to Professor of Medicine and Microbiology/Immunology in 1985 and transitioned to Emeritus status in 2015. In recognition of his clinical activities, he was elevated to Mastership in both the American College of Physicians and the American College of Rheumatology. He has written over 200 papers and twenty books and been elected to the National Academy of Social Insurance and Fellowship in the American College of Occupational and Environmental Medicine. In the past two decades, he turned his critical razor to much that is considered contemporary medicine at its finest. His assaults on medicalization and overtreatment appear in many commentaries and in seven monographs: The Last Well Person (MQUP 2004) and UNC Press’ Worried Sick (2008), Stabbed in the Back (2009), Rethinking Aging (2011), Citizen Patient (2013), By the Bedside of the Patient (2016) and Promoting Worker Health (2018). Six of his books have been published in French by PUL. He has served visiting professorships at many institutions in North America, Europe and elsewhere, including as Professeur associé à titre étranger, Paris V University, Hôpital Cochin.

Hélène B. Ducros holds a JD (law) and PhD (geography) from the University of North Carolina Chapel Hill. At EuropeNow, she is Chair of Research and Pedagogy.

Published on June 11, 2019.


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