New England Journal of Medicine – Vol 330: 440-441, 1994.
The Last Well Person
Clifton K. Meador, M.D.
Vanderbilt University
Nashville, TN 37205
"A well person is a patient who has not been completely worked up." -- a resident's
answer to the question, "What is a well person?" (Freymann J: personal communication).
"There must be something the matter with someone who goes to see a doctor when there
is nothing the matter"1.
Well people are disappearing. I should have known it was coming when the invalids
became extinct. (Invalids disappeared shortly after the advent of Medicare, which
demanded specific diagnostic labels even though none applied2.) However, I began to
realize what was happening only a year ago, at a dinner party. Everyone there had
something. Several had high cholesterol levels. One had "borderline anemia." Another
had a suspicious Pap smear. Two others had abnormal treadmill-test results, and several
were concerned about codependency. There were no well people. After that, I began to
look more carefully. I have not met a completely well person in months. At this rate, well
people will vanish. As with the extinction of any species, there will be one last survivor.
My guess is that the extinction will occur sometime in late 1998. Before we can speculate
about the last well person, we need to understand what is happening. Why are they
vanishing?
The demands of the public for definitive wellness are colliding with the public's belief in
a diagnostic system that can find only disease. A public in dogged pursuit of the
unobtainable, combined with clinicians whose tools are powerful enough to find very
small lesions, is a setup for diagnostic excess2. And false positives are the arithmetically
certain result of applying a disease-defining system to a population that is mostly well.
What is paradoxical about our awesome diagnostic power is that we do not have a test to
distinguish a well person from a sick one. Wellness cannot be screened for. There is no
substance in blood or urine whose level is reliably high or low in well people. No
radiologic shadows or images indicate wellness. There is no tissue that can undergo
biopsy to prove a person is well. Wellness cannot be measured, yet we seek it with
analytic methods.
In the final definition, wellness can be distinguished from sickness only by the person
involved, sometimes with the help of another person who cares and listens. About all any
of us can expect is to know that if we feel good, stay active, and are comfortable, then we
are probably well -- at least for the time being. Clinical medicine can only say, "With the
methods we used, we found none of the diseases we looked for." No one can measure the
absence of all disease.
1
If the behavior of doctors and the public continues unabated, eventually every well person
will be labeled sick. Like the invalids, we will all be assigned to one diagnosis-related
group or another. How long will it take to find every single lesion in every person? Who
will be the last well person? How will that person avoid diagnostic labels? From my
experience with those who pursue wellness compulsively, I imagine that the last well
person will be something like this:
A Composite Case Presentation
Time: Late 1998. Place: A shopping mall near Kansas.
Occasion: The Mid-America Health Fair, offering screening for all known human
diseases.
The last well person is a 53-year-old professor of freshman algebra at a small college in a
fictitious town. Once a successful stockbroker, he quit that job after attending a weekend
workshop on stress reduction and codependency conducted by a local church. He
mistakenly thought he was sexually addicted. He has taken countless aptitude tests. By
combining his Myers-Briggs profile with his scores on the Minnesota Multiphasic
Personality Inventory, he found that his level of stress would be reduced if he taught
introductory mathematics at a small coeducational college. He chose one in a temperate
location with a median yearly temperature of about 15 °C. After checking into the
average pollen count and the mean wind-chill factor in January, he selected the college.
The new occupation gave him the free time he needed to devote to staying healthy -about 7 hours and 13 minutes a day.
Along with annual diagnostic workups, the man regularly has himself tested for a variety
of conditions at assorted health fairs in the area. These screening tests include
determinations of blood sugar, cholesterol (high-density and low-density lipoprotein),
hematocrit, serum ferritin, carcinoembryonic antigen, and prostate-specific antigen and an
occasional stool test for parasites after he visits relatives in Florida. All the tests to date
have been negative. After undergoing two unnecessary colonoscopies because of false
positive tests for blood in his stool, he now tests his own stool monthly for blood.
Naturally, he abstains from meat for a full week beforehand.
The patient regularly watches the health reports on morning television, simultaneously
videotaping those on all three major channels for delayed viewing. With each report of a
new potential toxin or food additive or any of the myriad newly discovered health
hazards, he narrows his diet, adjusts the humidity in his home, adds extra filters to his
heating system, or makes yet another change in his lifestyle. On one occasion he tore out
the floor of his basement to install a radon shield. He subscribes to several magazines
offering tips on wellness and health, attaching the latest advice to his bathroom mirror to
review while he shaves with his well-grounded electric razor. Of course, he has smoke
detectors in every room and a rope ladder from his upstairs study. He installed an
elaborate reverse-osmosis water-filtering system that also checks the fluoride level.
2
According to his best calculation, he consumes 15 percent of his calories as fat, with the
remainder split between protein and carbohydrate ("complex carbos," he calls them). He
completely avoids saturated fat, salt, sugar, red meat, and all but trace amounts of
vegetable oil, which he uses in his wok when he stir-fries his vegetables. He fortifies the
vegetable fat with n-3 fatty acids. He initially discovered that animal crackers were the
only commercially available bread low enough in fat to permit him to eat bread and
remain on his fat-restricted diet. He was ecstatic when low-fat bread appeared on the
market. However, the additives began to worry him. Therefore, he still limits himself to
animal crackers.
He was a regular eater of tofu until he heard Garrison Keillor say on the radio that tofu
did not extend one's useful life, but only the last few weeks of one's terminal coma. He
saw no point in continuing anything that foolish. He does not smoke or chew tobacco, of
course, or drink tea, coffee, or anything alcoholic. Recently he abandoned decaffeinated
coffee because of reports about its harmfulness.
Every day he takes vitamins C, E, B6, and small amounts of D; several doses of kelp; and
a concoction of dried seaweed mixed with desalinated sea water, along with a baby
aspirin. He takes three doses of bulk laxatives, eats a bowl of bran, and drinks eight
glasses of water daily after having heard of "occasional irregularity" on television.
He is an aerobic wonder. He can run just about forever without getting winded. He rides
his bike every weekend and uses his rowing machine on rainy days. He has installed a
pulse-rate analyzer, a blood-pressure monitor, and an ear oximeter on his stationary bike
and rowing machine. Both have alarms set at the prescribed maximal levels, which he
readjusts every birthday.
He sees his dentist twice a year, flosses three times a day after brushing, and paints his
teeth with a specially mixed solution of fluoride and calcium with a trace of vitamin D.
He gargles with a weak solution of hydrogen peroxide and plaque remover before bed. He
has learned to examine his own vocal cords with a hand-held mirror.
He wears a prescription wavelength-adjusted set of dark glasses whenever he goes
outside. The wavelength is calculated precisely to filter out those ultraviolet waves of the
sun known to cause cataracts (I forget the wavelengths, but I am sure the glasses are
available at any local House of Eyes and Glasses). If he is in the sun more than five
minutes, he applies number 15 sunscreen. There is a space marked out on his den wall so
that he can check his visual fields monthly and simultaneously calculate his visual acuity.
Every year he and his significant other stand naked in front of a full-length mirror. They
record all nevi and measure each one with a millimeter ruler. If any look suspicious, they
photograph them with a Polaroid camera. The significant other is needed to help in
examining those areas of the body inaccessible to ordinary viewing. To date the man has
found 113 nevi, and biopsies have been performed on 9 of them. All have been benign.
3
The patient has made many efforts to be screened for every known psychopathological
disorder. Because there are many psychological schools of thought, this pursuit has
consumed a large amount of time. The patient even spent several months of his quest for
psychological health in southern California, the bastion of new schools of psychology. He
tried Rolfing, client-centered therapy, transactional analysis, primal-scream therapy,
gestalt therapy, and neurolinguistic reprogramming -- all with no success. Each school
rejected him as utterly normal.
On two occasions he was asked to leave a group -- once an encounter group and the other
time an experiential-learning group -- after making his first utterances. Finally, to his
embarrassment, he was thrown out of a psychic-channeling session at a New Age
harmonic conversion in the Mojave Desert. He had failed to channel anything except
vague memories of his high-school janitor.
In summary, all extant psychiatric and psychological schools of clinical thought have
rejected him. From the patient's experience, it is fair to say that all psychiatric and
psychological diseases defined by these schools have been ruled out.
(Editorial note: In earlier times the man would have been considered to have an
obsessive-compulsive neurosis, but that diagnosis has had to be dropped. Obsession is no
longer a disease, but an essential attribute of staying healthy).
His medical workups are lengthy. Every orifice has been subjected to endoscopy at least
once, and most of them annually. He has had countless computed tomographic scans,
magnetic resonance imaging scans, and one scan by positron-emission tomography -- all
of which were normal. He has had one biopsy of his thyroid and two of his prostate. He
regularly gets profiles of his blood and urine chemistry. At no time has any test or
procedure yielded a positive or abnormal result that remained abnormal when the test was
repeated.
That is how I suppose the last well person might appear. It is miraculous that he escaped
being labeled with a disease for so long, and incredible that he missed being given a false
diagnosis. In my imagined meeting with the last well person I can hear myself saying,
"Doing all those boring things you do to stay healthy may or may not make you live
longer. However, I am sure of one thing; it will make your life seem longer."
The last well person would not smile. Escaping disease in the 1990s is very serious
business.
References
1. Barsky AJ. Worried sick: our troubled quest for wellness. Boston: Little, Brown,
1988.
2. Meador CK. A lament for invalids. JAMA 1991;265:13741375.[CrossRef][Medline]
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