Until I read Stabbed in the Back: Confronting Back Pain in an Overtreated Society, I didn’t realize that it was possible to write a book about back pain that was thoughtful and full of interesting tidbits, and yet had nothing useful to say to patients.
The premise behind the book was promising: An experienced medical researcher exposes the scandalous shortcomings of the back pain treatment industry, and offers a path forward.
It was also referenced in Crooked, a book which I found tremendously useful, if not faultless.
I put it on my list.
Who Can Resist a Canny Curmudgeon?
Dr. Hadler was trained as a rheumatologist, and worked in both a hospital and a research lab at the University of North Carolina, Chapel Hill. He specialized in microbiology and immunology, until he turned his attention to the mess at the intersection of politics, sociology, and medicine.
Since the mid-2000s, he’s published eight books on overtreatment and reform. This is a remarkable output, especially since he continued researching and seeing his patients all the while. He has since started tiptoeing toward retirement. In 2015, he transitioned to Emeritus Professor of Medicine and Microbiology/Immunology.
As an author, Hadler has his adherents. It’s easy to see why. His tone is intellectual, yet gruff. He’s not afraid to ruffle feathers, break a few eggs, rock the boat, or engage in other feisty metaphors. Who can resist a canny curmudgeon?
Hadler is happy to adopt this persona. In the introduction, he writes, “No reader will find all of the chapters that follow resting easily within his or her preconceptions. Many will find some of the information presented here to be counterintuitive, some of it infuriating.”
I was all set to have the status quo overturned. I wanted to nod along with him, and scribble notes all over the margins that said THIS!!! But when Hadler started outlining his most basic assumptions, I found myself scribbling other things.
Back Pain as an Object Lesson
Why, exactly, did a rheumatologist decide to write a book on back pain?
A glance through Hadler’s academic publication history shows he has never restricted himself to rheumatology. He’s written papers on conditions like lupus, gout, fibromyalgia, and arm pain. He’s currently on the editorial board of the journal Spine, and he’s published several papers on diagnosing and treating back pain.
Yet, once I started reading Stabbed in the Back, I noticed that Hadler was barely interested in back pain, let alone the patients who suffer from it. He refers to back pain as an object lesson, and that is a good signifier of his perspective.
The key point, to Hadler, is that back pain treatment reflects systematic flaws in the medical system. He will happily change the subject and discuss other conditions if they better illustrate those flaws. The number of lines devoted to arm pain, PTSD, whiplash, and fibromyalgia was higher than I expected.
Dr. Hadler is a voracious researcher and powerful intellectual, and these qualities are responsible for the best parts of the book. Stabbed in the Back is a wealth of odd historical trivia.
For example, did you know that the ancient Egyptian physician Imhotep mentioned a sprained vertebra in a medical text? Or that, according to the Code of Hammurabi, incompetent surgeons would have their hands cut off?
These tidbits were fascinating. If I didn’t have back pain, and was merely looking for an interesting book on the subject, I would have been satisfied.
I learned that in the 1860s, public consternation about “Railway Spine” broke out. I learned that Franz Kafka worked for the old Bohemian equivalent of a workers’ comp agency, and that Jack London went undercover to investigate life among London’s poor.
Craving Some Measure of Empathy
And yet, despite the intellectual rigor Hadler brought to the subject, I found myself craving some measure of empathy. Although Hadler readily reviews secondhand, historical accounts of illness and poverty, he seems unwilling to consider firsthand testimonies of present-day patients.
We do get one glimpse of a back pain patient, the first Hadler ever treated:
Off I went to my first rheumatology clinic, proudly displaying a name tag that read “Assistant Professor of Medicine” and confident I knew all that was known about rheumatoid arthritis, lupus, scleroderma, and the other systemic diseases that are the purview of the academic rheumatologist. My first patient was a well-muscled man of forty, who appeared anxious and in some discomfort.
“Doc,” he said, “I injured my back and I don’t know if I can go to work.”
If the complaint was, “My back has been getting stiffer and stiffer since I was a teenager,” I would have been able to help him with his ankylosing spondylitis. But I had no experience or body of information to draw upon to help him with any component of his complaint—the pain in his back, the notion that his back was injured even though he couldn’t point to a particular event or accident that had caused the injury, or the perception that he was too incapacitated as a result of his back pain to continue pursuing gainful employment. I examined him, reassured him that he had suffered no major structural catastrophe, and admitted that I knew not what else to do or say. I suggested that since he had been coping for a couple of months already, he should continue to do so, and I would see him in two weeks, prepared to offer him wiser counsel.
That is the last we hear of this man, or any individual patient. I don’t know what Dr. Hadler told the man at the next appointment, and I don’t know whether his back pain ever did get better.
For Hadler, the individual’s experience seems to be an unimportant point. He’s interested in studies, and statistics, and aggregate numbers. This attitude has its merits, since making health claims based on anecdotal evidence is its own sort of shortcoming.
Still, Hadler takes a detached view of actual people who are suffering from back pain. They float somewhere in the background as a vague, depersonalized mass.
Other than organizing the occasional survey, Hadler makes no effort to talk to patients, or understand what their lives are like outside the clinic or the courtroom. They may as well be lab rats, for all the individual differences he notes among them.
Were You Aware That Back Pain Doesn’t Exist?
Hadler specifies that his book is about regional backache. Perhaps you haven’t heard that specific term. Hadler coined it himself, before claiming it doesn’t exist. He goes on to say that scientists still have no idea what causes back pain.
According to Hadler, Mixter and Barr “invented” the ruptured disc in 1934. The “invention” spread because labor leaders and workers comp lawyers were keen to believe in it.
Hadler never seriously considers whether herniated discs (or any other specific spine problem) can indeed cause back pain. He seems annoyed that anyone is still trying to figure this out. In his opinion, people who look for a specific cause are chasing a chimera.
He isn’t interested in reviewing the origins or (effective) treatment of back pain. No, the story he has to tell is about an invented disease that is allowed to live on because patients have poor coping skills, and are incentivized to act sick. Unscrupulous surgeons can make a lot of money by exploiting this weakness.
Surgeons are indeed the targets of most of Hadler’s barbs about back pain treatments, though he does take a few jabs at osteopaths and chiropractors.
One of the strongest parts of the book was Hadler’s history of surgical treatment options, which was both frightening and disconcerting. I was horrified to learn that doctors have tried to chemically dissolve, or burn away, the disc’s nucleus.
So, if surgery isn’t the answer, what is? In Hadler’s world, the proper prescription for backache is big ol’ dose of Suck It Up and Deal.
Some key excepts:
- “Degenerative disease of the spine is a genetically driven concomitant of aging, like graying or balding. We need to ‘get over it.’”
- “[P]sychosocial confounders to coping are as important in rendering the back pain persistent as they are in rendering the pain reportable in the first place.”
- “’My back hurts’ is likely to mean, ‘My back hurts but I’m really here because I can’t cope with this episode right now.’”
- “Individuals with regional backache might fare less poorly by managing as best they can, perhaps with some lay advice, than by choosing to become patients. If the statement ‘I can’t cope with this backache’ were the customary complaint when patients sought care, perhaps they would fare better.”
- “If demeanor and conviction can conspire to palliate back pain or arm pain, the inescapable conclusion is that the pain is ‘in your mind.’ And so it is, at least in part.”
Fibromyalgia Doesn’t Exist Either
I’ve lived with sciatica for four years. In that time, I’ve concluded that it is not a mental problem, or a sign of poor coping skills. Although our current medical system sucks at treating back pain, it belong in the category of medical condition, not psychological shortcoming. It deserves to be investigated and treated in a medical setting.
Yet, I was able to shake off Hadler’s claims about back pain, with only minor residual annoyance. I knew that back pain had mechanical causes. I knew patients were right to expect medical treatment. Hadler’s refusal to consider biomechanical evidence was irritated, but not the craziest thing I’ve heard from a doctor.
No, the parts that got me truly worked up were Hadler’s claims about fibromyalgia. The chapter on fibromyalgia (which he considers similar to back pain in many ways) contains subheadings like, “The Social Construction of Fibromyalgia,” “The Sick Role,” and “Hypochondria,” which gives you a pretty good idea of how seriously Hadler takes the diagnosis.
He insists that, “Fibromyalgia is a learned illness,” and that, “The patient is prepared to be medicalized and not to hear that the symptoms are ‘in the mind’ and therefore either evidence of a mental illness or a form of confabulation.”
The solution, he believes, is to teach better coping skills. “The challenge is to breach the dominant construction of pain as disease. Then the therapeutic issue becomes the social and psychological factors that compromise coping to the degree that the symptoms are rendered insufferable.”
Hadler even objects to the term “fibromyalgia,” and again prefers to use his own label, “chronic widespread pain.” It seems Hadler only insists on naming conditions he doesn’t believe in.
I’ve known several people with fibromyalgia. While they each have distinct personalities, strengths, and weaknesses, I have never met one and thought, this person would be fine if they had a better attitude.
On the contrary, the people I know with fibromyalgia do a remarkable job coping with constant pain. They hold down jobs and maintain close relationships, and nurture interests that have nothing to do with illness. Sure, some people with fibromyalgia struggle with mental illness, but so do many people who don’t develop chronic pain.
I don’t see how anyone could interact with large numbers fibromyalgia patients, and conclude that their problems are purely psychological.
What to Do?
It should be clear by now that Hadler is not so much interested in curing back pain, as he is in attacking the system that allows it to proliferate. He criticized the legal system, workers’ comp insurance companies, and health care policies that encourage workers to act sicker than they are, and that incentivize them to accept treatment they may not want.
He does make some good points, although his assaults on the legal and insurance systems are clearly not waged on his home turf. His arguments might have been more effective had he teamed up with a lawyer.
In the last chapter, he offered an abridged plan for improving the health insurance, disability, and workers’ comp systems. But by then, I had long since stopped believing that patient welfare was his number one concern. I couldn’t muster up real enthusiasm for his proposals, even if the logic was sound.
I found myself longing for a Marty Makary, who could offer a sharp and persuasive critique of the status quo, and who could back up their claims with both data and patient stories. I wanted someone who left the office once in a while, and actually talked to people.
Instead, I felt…Stabbed in the Back.
