By NORTIN HADLER, MD

To live a year without a backache is abnormal.

Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly. 

Almost all of the people we will be talking about in this book were afflicted with regional backache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.¹ Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.

While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. 

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By RICHARD GUNDERMAN, MD

Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.”  To a large degree, technology has taken over medicine.  I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices.  In such cases, the technology remains largely a tool, and the wielder remains basically in charge.  I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.

Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper.  Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources.  Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes.  What happened?  DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.

At stake is what we mean by knowledge.  Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient?  Or do we instead rely on what is represented on a computer screen?  Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us? 

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