Doctored

by Sandeep Jauhar

  I couldn’t bring myself to talk to my patient in the cath lab, while everyone was watching, so I decided to wait until he got to the recovery room, where it was more private. I found him there lying on a stretcher. The pain in his chest was gone, he happily informed me. However, the groin where the catheter had been inserted now hurt. “They substituted one pain for another,” he said, laughing.

  I grasped the side rails of the gurney. “I thought you had pericarditis,” I said carefully. I paused. “I was obviously wrong. I’m sorry.”

  He seemed embarrassed. “No, no, please, the past is finished,” he replied. “I am more interested in the future.” He asked me why this had happened; his cholesterol level was normal. I explained that there were many factors besides cholesterol—some we didn’t even know about—that were at play. He inquired about his prognosis. I told him that I thought it was good, though because of the significant damage that had occurred to his heart—damage made worse, no doubt (though I didn’t tell him this), because of my misdiagnosis—he would have to be on medications for the rest of his life. He nodded, looking disappointed.

  A few days later, just before he was to be discharged, I stopped by his room. I asked him with whom he was going to follow up. He told me that he had been given the name of another cardiologist but that he had decided to go with me. “You have been terrific,” he said. “Thank you for everything.”

  I nodded silently, feeling empty. “You are much too generous,” I said.

  FOUR

  Good Intentions

  In nothing do men more nearly approach the gods than in giving health to men.

  —Cicero

  The arguments started soon after Mohan was born, and though they were ostensibly about my job and our lack of disposable income, and not so much about the added responsibilities of a new baby, they were really about our future, what sort of lives we wanted to lead, and so, in fact, they really were about Mohan after all.

  “I don’t think it’s asking a lot for you to think about our future,” Sonia said one evening after I had put Mohan to bed. “Your hours are similar to Rajiv’s, and yet we are struggling financially. That is why I am bringing up private practice.”

  I tried to explain that Rajiv, whose salary was at least double mine, performed invasive procedures, lucratively reimbursed in our current system, but Sonia didn’t want to hear about how the American medical payment model should change.

  “You think this is about jewelry or a four-car garage? Have I asked for those things?”

  She had not, but we couldn’t afford them anyway. The glum reality was that we were cash poor. After we paid rent and student loans, there was very little left over. We had enough money to entertain desires—a car for Sonia to drive to New Jersey to visit her parents, for example—but not nearly enough to realize them.

  “I told you I don’t want to do private practice,” I said firmly. “It has nothing to do with you or how I feel about—”

  “But it does, because we are a family. And we are crammed into a tiny one-bedroom apartment!”

  A force was bearing down on me, pinning me to the headboard of the bed. I wanted to holler, but I didn’t have the energy to deal with the inevitably ugly aftermath. “I can’t do it,” I said, though with less conviction than before.

  “Of course you can! You considered it during your fellowship. Why don’t you talk to my father? He could guide us—”

  “I don’t want to do private practice!” I shouted. “Those guys are a bunch of crooks. I see it every day in the hospital.”

  Sonia’s father, a pulmonologist, had made his money in the era after Medicare was introduced. Like most doctors of that generation, he had learned to play the fee-for-service game, amassing a huge personal fortune—millions—the kind of money that wasn’t available anymore, no matter how hard you worked. He had told me I was living in a fool’s paradise as a salaried physician, where there was little financial incentive to see more patients or order tests. “If you want to get ghee out of a jar, you cannot do it with a straight finger,” he’d said, recounting an old Punjabi proverb. “It has to be bent.” But I didn’t want to do private practice. I didn’t want to give up my job and the academic life, where I could practice the way I wanted, mostly free from the demands of the marketplace; where there was no pressure to overtreat patients; and where I could take pride in teaching the next generation of doctors. Ironically, it’s the people who have money who seem to feel most strongly that you need money to be happy.

  “I’m just asking for a plan for a better financial future,” Sonia pressed on. “I know I need to work, but I can’t do that right now with the baby. I want nice things for us: a home, safe cars, good schools. They may seem trivial to you, but they are not to me.”

  Of course, they weren’t trivial, and in fact I felt sorry for my wife, overwhelmed, physically exhausted, and trapped in a shoebox apartment among piles of laundry with no room to move—and all of it under the shackle of financial dependence on me. But I believed that I couldn’t allow myself to empathize. I was afraid that if I gave credence to her perceptions, I’d have to compromise what I felt at the time were my principles.

  “I like my job,” I said evenly. “I’m not saying that I want to be a hospital employee for the rest of my life or that I would even stay at LIJ, for that matter—”

  “But it isn’t just about you anymore; there is also us to think about. Getting hung up on your title isn’t fair or wise for the future.”

  “Your father—”

  “—is not your enemy. He just wants us to have the best life possible with the least stress.”

  “He doesn’t understand—”

  “What’s to understand? Money is important.”

  “Money doesn’t buy happiness.”

  “Yes, it does!”

  And when things devolved to that degree, I knew it was time to stop, and so did she.

  * * *

  One morning in October 2004, about three months after I’d started my job, a sales representative of the pharmaceutical company Scios came into my office and made me an offer I found hard to refuse. She invited me to join Scios’s speakers’ bureau and start giving paid talks using company slides to promote the drug Natrecor. Scios was marketing Natrecor, a synthetic version of a naturally occurring hormone, for the treatment of acute heart failure. It was a drug I had come to rely on for many of my hospitalized patients, especially the sickest ones in the CCU. A few months earlier, after I’d accepted my position at LIJ but before I’d started working as an attending, a Scios rep had contacted me at NYU, where I was finishing up my cardiology fellowship, and suggested that I consider starting a Natrecor infusion clinic when I arrived at LIJ. Though there was little data recommending the use of the drug in office patients, outpatient infusion clinics for the drug were proliferating across the country because reimbursement was so profitable. The Food and Drug Administration had classified the drug as a protein-based biological agent, so Medicare was paying for its off-label administration on the same generous pay scale as chemotherapy.

  I took a couple of days to think about the sales rep’s speaking offer. Though I had no interest in starting an infusion clinic, especially without more data to support its use, I decided that I didn’t have a problem lecturing about the drug. Though the talks were obviously for marketing purposes, I didn’t think giving them would be sleazy or unethical, especially since Natrecor was a drug I prescribed and believed in. Moreover, and just as important, I needed the money. I asked my department head about it. She replied that she didn’t police her faculty on such matters. So a few days later I called the rep and accepted her invitation.

  This started a series of talks I gave over the next two years. At first I asked to use my own slides to maintain some semblance of objectivity, but the company wouldn’t allow it. I asked if I could modify the standard company slides with some of my own interpretations, but it wouldn’t allow that either. Typically, the talks took place at a fancy resta
urant on Long Island or in Manhattan once or twice every couple of months. I’d get paid a thousand dollars or more for each talk. The extra money really helped. My salary as an academic cardiologist was about a third lower than if I’d been working in private practice, and since I was the sole earner for my family, the talks took some pressure off me financially. The dinners were uniformly excellent, with fine wines flowing freely. Occasionally, if I didn’t feel like driving, I would even get a car service to and from the venue. The drug reps who showed up at my talks were always pretty and flirtatious. They seemed to take a genuine interest in me and my work. So I became addicted to the talks and slyly hinted at more invitations when Scios reps came detailing at my office to promote their drug.

  Of course, I had mixed feelings about the whole thing. Sometimes the promised audience wouldn’t materialize—doctors who were supposed to come would have to stay late in their offices—but I’d get paid anyway. I often wondered what my colleagues in the department—very few of whom had been invited to join a speakers’ bureau—thought of what I was doing.

  In March 2006, about a year and a half after I had started giving these talks, a paper linking Natrecor to increased mortality in acute heart failure patients was published in The Journal of the American Medical Association. It was a flawed study, a retrospective analysis pooling several different trials with diverse patient populations. Still, it caused a major stir. The pharmaceuticals and therapeutics committee at LIJ held an unscheduled meeting to discuss the drug, to which I was invited. At the meeting I reiterated what I believed to be true: that Natrecor was safe and effective in the right patients (those who had adequate blood pressure, no significant kidney dysfunction, etc.). I presented some slides—actually modified company slides—criticizing the paper and pointing out its many flaws. I realized that my presentation was skewed to confer maximal advantage to Scios, and I wondered whether the committee was taking me seriously or viewing me as a company pawn, which is how I was beginning to feel. Afterward the head of the committee pointedly noted that I was in Scios’s speakers’ bureau. Though he didn’t say it explicitly, the clear implication was that my assessment was being influenced by money. In the end, the committee decided to restrict Natrecor use to me (the resident heart failure specialist) and a handful of other cardiologists. By then I’d tapered off the talks anyway, and soon afterward I quit the speakers’ bureau. (A randomized, controlled trial later showed that Natrecor was safe but no more effective than existing, cheaper therapies.)

  During the two years I gave these talks, I often thought of what Jacob Hirsch, a cardiologist at NYU, once told me when we were sitting in the echo reading room during my fellowship. He was eating a sandwich that had been brought in by a drug rep. “It’s not the doctors at the academic centers that they should be policing,” he said. “It’s the docs out in the suburbs, in Long Island and New Jersey. They’re the ones you have to worry about.”

  * * *

  In December 2004, about six months into my first year at LIJ, John and I drove to Columbia-Presbyterian Medical Center in Manhattan to take a daylong course on artificial heart pumps and cardiac transplantation. Artificial hearts had fascinated me ever since I was a boy. I still remember watching news reports about Barney Clark, the retired dentist with end-stage heart failure who received the world’s first permanent artificial heart, a refrigerator-size machine, on December 1, 1982, at the University of Utah Medical Center. I remember eagerly awaiting the latest updates on his condition while my father tsk-tsked about the poor man’s fate. Though he opened his eyes and moved his limbs immediately after the operation, Clark’s postoperative course was rocky. On day 3 his chest had to be reopened because of subcutaneous emphysema, a complication of surgery. On days 4 and 5 he developed progressive kidney failure. On day 6 he had generalized seizures and ended up in a coma for almost two weeks. On day 13 his prosthetic mitral valve malfunctioned and had to be replaced. Other complications followed, including respiratory failure requiring a tracheostomy tube, aspiration pneumonia, pseudomembranous colitis, and sepsis. On day 92, William DeVries, the lead surgeon, spoke with Clark in a videotaped interview. “It’s been hard, hasn’t it, Barney?” DeVries said. “Yes, it’s been hard,” Clark replied, “but the heart itself is pumping right along.” It continued to pump until he finally succumbed to multiorgan failure on day 112.

  Clark’s Jarvik-7 was medicine’s Sputnik; never before had a medical innovation sparked such furious debate, even a kind of national reckoning. Though the experiment was viewed as successful by some (notably Clark himself, who said he believed the operation would be “worth it” if it staved off death), most people were deeply disturbed by what they had witnessed. For some, the human heart has special spiritual and emotional meanings that made it impossible to replace with a man-made device. (Una Loy, Clark’s wife of thirty-nine years, voiced this conviction when she asked, “Will he still be able to love me?”) Others were troubled by the fact that Clark had never left the hospital. He survived for almost four months. But had he really lived?

  Today the outlook for end-stage heart failure patients has changed considerably. The workhorse of mechanical support is the left ventricular assist device, made of plastic and titanium, which piggybacks onto the native heart and pumps blood directly out of the heart and into the aorta, which transports it to the body. LVADs (pronounced “el-vads”) can help bridge patients to a heart transplant (though approximately a hundred thousand Americans could potentially benefit from heart transplantation, only two thousand donor hearts become available every year), as well as serve as a final (or “destination”) therapy in those who are not transplant candidates. The devices can be implanted into a small surgical pocket in the abdomen or even in the sac around the heart, reducing the risk of bleeding and infection. The newest-generation devices can function for several years before failing. Some patients have experienced full cardiac recovery with these devices so that they can be removed, though the mechanisms remain unclear. I wanted to introduce this therapy at LIJ, and John and I had come to the right place to get trained. Columbia-Presbyterian is probably the best heart failure center on the East Coast, if not in the country.

  I had spent several months at Columbia during my final year of fellowship, so I remembered well the mess of traffic and food carts that we encountered in front of the Milstein Pavilion that winter morning. Inside the marble lobby, we were met by Santo Russo, a young Italian cardiologist I had worked with. Santo was a handsome, wiry man who, despite his ill-fitting clothes and unfashionable ties, still managed to maintain a dashing air. Though he had completed his fellowship only a few years earlier, his gentle manner and good European common sense—he was pragmatic, direct, rational—made him someone I looked up to and aspired to emulate. He always had a lot to say about the hospital and American medical education. “Medical school teaches people the bad lesson that in order to succeed, you have to memorize,” he’d once told me. “People go through four years of medical school, three years of residency, three years of subspecialty fellowship, and they are never taught to think. Then all of a sudden at the end of fellowship, they are told to start doing basic or clinical research. ‘What do you mean, you don’t know the relevant research question? We don’t care that for nine years you were taught not to ask questions, to accept the prevailing wisdom. We don’t care about that. We want you to start doing research!’ A better way”—he’d gone on facetiously—“would be to teach medical students for six days of the week and on the seventh day make them forget everything they’ve learned because it will soon be outdated anyway.”

  Santo, John, and I stopped at a small café, where we ordered cappuccinos and chatted about my fledgling heart failure program. Then Santo took us on his rounds. In the cardiothoracic intensive care unit was a patient who had been implanted with an LVAD about a week prior, despite evidence of an overwhelming infection. “He was making almost no urine,” Santo said in his slightly accented English. “Now look.” The urine in his catheter
bag was brown and foamy, like beer. Santo marveled at his patient’s progress. “It really amazes me,” he said as we stood outside the dense semicircle of machines arrayed around the bed. “We can control physiology to such minute detail that even something like sepsis, which we have been taught does not respond to our manipulations, seems to get better.”

  After rounds we joined up with doctors and nurse practitioners from other hospitals and attended a series of lectures. We spent the afternoon in the “cow lab,” a dissection suite, where we watched a surgeon implant an LVAD into the chest of a calf. (A sign read: DON’T TAKE YOUR ORGANS TO HEAVEN … HEAVEN KNOWS WE NEED THEM HERE.) The calf’s thorax was splayed open to reveal a pink beating heart embellished with yellow lines of fat, like a buoy in a red lake. Standing over the animal was a cardiothoracic surgeon, whose gloved fingers were moving purposefully in the chest cavity. The calf had obviously come straight from the farm because there was still mud on its hooves. A dreadlocked anesthetist was adjusting knobs on a baffle delivering intravenous medications. A technician was playing with dials on the heart-lung machine. A nurse instructed us about the various operations of the LVAD, how to change the pumping rate, how to replace the batteries, and so on. When the surgeon relaxed the aortic cross-clamp, inky droplets sprayed onto the brown and white fur. After coring out a thick piece of heart muscle about the size of a quarter, he inserted the inflow port of the LVAD into the apex of the left ventricle and stitched it in to get a blood-tight seal. Then the pump was turned on. Soon it was putting out four liters of blood per minute, enough to sustain life.