Open Heart

by Jay Neugeboren

  When Rich returns the postoperative reports to me, he adds a note: “FYI. Looks great—you’re going to outlive all your EHHS buddies! Love, Rich.”

  3. The Consolation of Diagnosis

  25 Celebrating: Compare the chimera of total body transplants to this—sixty-five years ago—from “Lindbergh, Carrel & Pump: They Are Looking for the Fountain of Age,” in the June 13, 1938, issue of Time:

  From this moment [we are] opening to experimental investigation a forbidden field: the living human body [Dr. Carrel says]…organs removed from the human body, in the course of an operation or soon after death, could be revived in the [Charles] Lindbergh pump, and made to function again when perfused with an artificial fluid… When larger apparatus are built, entire human organs, such as pancreas, suprarenal, thyroid, and other glands…would manufacture in vitro the substances supplied today to patients by horses or rabbits.

  “In effect,” Time declares, “Dr. Carrel, with the Lindbergh pump, is looking for the fountain of abundant, replaceable age.”

  “It makes an arresting picture,” Time concludes, “one that French, Roman Catholic Dr. Carrel is romantic and mystic enough to appreciate—two men, one an ageless seer, the other a young and devoted inventor, sitting on two rocks in the middle of a sea, talking, planning ways to prolong the life and end the ills of mankind.”

  Compare also (this time, thirty-eight years ago) a September 24, 1965, Life magazine feature, “Control of Life: Part 3, Manmade and Transplanted Organs Usher In an Era of Rebuilt People,” in which we find the following statement: “So confident are medical researchers in the feasibility of heart replacement that the U.S. government has launched a crash program to subsidize the development by industry of an implantable heart that could be put into human patients within five years.”

  For a sane, fascinating history of the hopes and disasters that accompanied the attempt to build and implant these artificial hearts, see Renée C. Fox and Judith P. Swazey, Spare Parts: Organ Replacement in American Society. More often than not, sad to say, the people in whom these experimental machines were placed seemed to be kept alive mainly to keep the machines going.

  For an excellent overview of the ethical issues involved, see Stanley J. Reiser’s essay, “The Machine as Means and End: The Clinical Introduction of the Artificial Heart,” in After Barney Clark: Reflections on the Utah Artificial Heart Program, pages 169–175. “Machines,” Reiser writes, “also can become key agents of a view developed through the Scientific Revolution that nature should be mastered, not lived with. What greater act of domination could we as humans devise than to substitute a machine for the most conspicuous agent of life, the heart?” Reiser alerts us to the dangers of our infatuation with technology: “The ideal of a value-free science and a compelling desire to apply rapidly what we can produce make for a powerful combination in a modern world in which the capacity to produce innovations may outstrip our capability to wisely integrate them into the fabric of personal life and societal objectives. The creating of technologic means simply comes easier to us than the development of rational and humane ends to apply them” (pages 174–175).

  26 Consider, though: The data concerning drug-resistant organisms in hospitals are from Laurie Garrett’s Betrayal of Trust: The Collapse of Global Public Trust, page 278. Jane E. Brody, in a New York Times article, “A World of Food Choices, and a World of Infectious Organisms” (January 30, 2001), states that “the potential for widespread disaster has definitely expanded.” She cites a study from the Centers for Disease Control and Prevention, which found that “food-borne illness accounts for a staggering 76 million illnesses, 323,914 hospitalizations and 5,194 deaths each year in the United States.” In addition, “The disease-control centers estimate that E. coli O157:H7, which was unknown as a cause of food poisoning before 1980, now infects as many as 20,000 Americans a year and kills up to 500.”

  27 In our time: The quotation regarding the downgrading of the interaction between patient and doctor is from James LeFanu, The Rise and Fall of Modern Medicine, page 223.

  27 Or consider: The 15 to 75 percent figure regarding the disparity between television resuscitations and actual resuscitations comes from Dr. Richard Horton, “In the Danger Zone,” New York Review of Books (August 10,2000), pages 30–34 [30].

  28 And though nearly 40 percent: The figures regarding the percentage of women who fear dying from breast cancer come from “Fearing One Fate, Women Ignore a Killer,” by Benjamin J. Ansell (New York Times, January 9, 2001). Readers should also see “Lessons of the Heart: A Devastating Lack of Awareness,” by Denise Grady (New York Times, June 24, 2001).

  28 Despite our sophisticated testing: For the difficulty of diagnosing heart disease, see especially Chapter 11 of Richard H. Helfant’s The Women’s Guide to Fighting Heart Disease.

  28 The American Heart Association reports: AHA 2002 Heart and Stroke Statistical Update, page 11.

  29 But we now learn: Stephen Klaidman discusses the absence of ruptured plaque in people who experience heart attacks in Saving the Heart: The Battle to Conquer Coronary Disease, page 214.

  29 In addition, studies: For basics concerning statins and their relation to heart disease, see the New York Times, January 24, 2001, “Heart Study Affirms Value of Statin Drugs.” See also “U.S. Panel Backs Broader Steps to Reduce Risk of Heart Attacks,” May 16, 2001, by Gina Kolata; and “Cholesterol Fighters Lower Heart Attack Risk, Study Finds,” November 14, 2001, by Lawrence K. Altman. See also “Early Statin Treatment Following Acute Myocardial Infarction and 1-Year Survival,” by Ulf Stenestrand and Lars Wallentin, in the Journal of the American Medical Association (JAMA) 285:4 (January 24–31, 2001), pages 430–436; and “Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III),” in JAMA 285:19 (May 16, 2001), pages 2486–2497.

  Concerning statins as the best-selling drugs, IMS Health’s “Drug Monitor” states, “Top 5 best selling drugs for the 12 months ending March 2002 was [sic] again Lipitor, Losec, Zocor, Ogastro, and Norvasc. Lipitor continued to show the highest growth in the top five at 29% at constant exchange” (emphasis theirs).

  30 But the paradoxical finding: Louise Russell discusses the correlation (and lack of same) between cholesterol and heart disease in Educated Guesses: Making Policy About Medical Screening Tests, pages 45–74.

  30 Furthermore, these risk factors: For an analysis of the “alternative explanation,” see Joseph B. Muhlestein, “Chronic Infection and Coronary Artery Disease,” in Medical Clinics of North America 84:1 (January 2000), pages 123–148. Readers should also consult P. W. Wilson et al., “Prediction of Coronary Heart Disease Using Risk Factor Categories,” Circulation 97 (1998), pages 1837–1847.

  In an article entitied “C-Reactive Protein, Inflammation, and Coronary Risk,” we find the following: “Despite progress in the prevention of cardiovascular disease, a significant proportion of first cardiovascular events occurs among individuals without traditional risk factors” (David A. Morrow and Paul M. Ridker, Medical Clinics of North America 84:1 [January 2000]). See also Paul W. Ewald, Plague Time: How Stealth Infections Cause Cancers, Heart Disease, and Other Deadly Ailments (page 117): “If all the noninfectious risk factors are combined, they explain only about half the risk of acquiring atherosclerosis. In other words, about half of the people with atherosclerosis acquire it even though they do not have elevated risk factors for the disease. Something big is missing from the picture.”

  30 In addition, some researchers: David Weatherall discusses the correlation between low birth weight and the risk of heart disease in Science and the Quiet Art: The Role of Medical Research in Health Care, pages 173–174. See also a study by D. J. P. Barker et al, “Fetal Nutrition and Cardiovascular Disease in Adult Life,” Lancet 341 (1993), pages 938–941. “in both healthy subjects”: Information regarding the predictive power of established risk factors ver
sus exercise capacity comes from Jonathan Myers and Manish Prakash et al., “Exercise Capacity and Mortality Among Men Referred for Exercise Testing,” NEJM 346:11 (March 13, 2002), pages 793–801.

  31 But they are: Klaidman discusses the unreliability of using diagnostic tests such as angiography as treatment guides: “In recent years, however, it has become clear that angiography is not good enough. It does not spot all blockages in the coronary arteries, and more importantly, many of the ones it misses, either because they are relatively small or not in the biggest arterial channels, are more likely to cause heart attacks than most of the ones it identifies” (page 206).

  31 “Put a patient”: When, in the spring of 2002, my doctors in New York City—my general practitioner and cardiologist—suggest I go on a low dose of beta-blockers, since statistical studies indicate that they prevent heart attacks in people who have already suffered from heart disease, Rich disagrees. My resting heartbeat is now about 48 to 50 (my blood pressure steady at about 115/75; my cholesterol 148; HDL 43; LDL 75), and the beta-blockers would lower my heart rate even further. Rich sees no need for it: the possible gains are not worth what he sees as the probable risks associated with the long-term use and side effects of any medication. When I call Martin Baskin, my family doctor (an internist), and tell him what Rich has said, he laughs. “Well,” he says, “that’s why medicine is an art, and not a science.”

  Compare the clinical judgment of a doctor, and its relation to a doctor’s training and clinical experience, to the following, from an interview with Lincoln Quappe, a firefighter who died in the World Trade Center on 9/11:

  When you’re in a fire, things are running through your brain a million times a minute, and you’re just trying to do your job. In those situations you look back at your experience. You think, I got burnt the last time I stayed around in this situation. I won’t let that happen to me again. You go by all the telltale signs and from what other firemen have told you. Guys say, Listen, we saw this happen. We talk about fires all the time. We’re constantly learning, learning every day, and even in a mundane fire you learn something, and you’re like, Oh, man, I didn’t know that. Or I forgot about that, but now it’s reinforced in my mind. I’ve been burnt before so I have an idea of how much heat I can take…

  It’s hard to say which fires are most dangerous. Each is completely different. Some fires that seem small can be the most horrific with firemen dying. Even a silly little fire can get a guy killed. It all comes down to fate. But there are signs that you can pick up on at a fire when it’s getting bad. I don’t have all the answers but I have an idea when it’s time to go. I use other guys in my company as barometers. I’ll be in contact with my guys. I know what they look like as far as body features. I hear them on the radio. If Bobby says it’s time to get out, I’m going. I use him as my guardian angel, because I know he’s seen a lot of things in the past. The captain too. If the captain says, We’re getting out of here, I’m going. I don’t want to die here.

  (New York Times, “A Voice from the Rubble,” interview by Tom Downey, September 23, 2001)

  31 “In fact”: See Russell, for example, pages 58–60, for a discussion of the variability and unreliability of laboratory test results.

  Lab tests for cholesterol are not alone in being unreliable. When a federal environmental initiative designed to cut down on the use of mercury, which can pollute air and water if not disposed of properly, led hospitals and doctors to switch from mercury-based blood pressure cuffs to electronic cuffs, leading medical experts, joined by the American Heart Association and the National Heart, Lung, and Blood Institute, questioned the reliability of the electronic blood pressure cuffs. Many critics claimed they are often dangerously flawed and give readings that can be in error by 30, 40, or even 50 points. See the front page article by Gina Kolata, “Risk Seen in Move to Replace Gauge of Blood Pressure,” New York Times, June 16, 2002.

  32 By contrast: LeFanu discusses this paradox (“the more tests a doctor performs…”), and Medawar’s views on the “art and science” of medicine, on page 222.

  32 “would go further”: Sherwin Nuland, “Whoops!”(a review of Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science), New York Review of Books (July 18, 2002), pages 10–13 [11]

  32 Thus, for example: Both LeFanu (page 222) and Russell (pages 10–11) provide clear, informative discussions of the significance of false positives and unnecessary treatments.

  33 Even if one receives: Klaidman, page 173, cites the low effectiveness of socalled optimal treatments.

  33 “Clinical judgment”: Ibid., page 174.

  34 “The cardiologists”: Ibid., pages 173–174.

  34 “The great secret”: Lewis Thomas, The Lives of a Cell: Notes of a Biology Watcher, page 100.

  34 What happens: “Contrary to expectations,” David Mechanic writes in NEJM 344:3 (January 18, 2001), page 198, “the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians’ availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix… The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998.” Still, partly because, as Mechanic notes, “physicians are expected to do more now than they were in the past during each visit with a patient” (page 202), both patients and physicians—everyone I talk with—continue to believe that office visits are, or seem to be, shorter.

  35 These studies also show: Concerning gatekeeping and patient trust, Mechanic writes, “Aware that their physicians are uncomfortable with some issues, patients must either directly broach the issue, which may undermine their close relationship, or keep their problems to themselves and thus forgo treatment that would be covered by their insurance. Either way, trust in the physician is strained.” JAMA 275:21 (June 5, 1996), page 1695.

  35 “the perpetually increasing”: John Kirklin’s comment is from Klaidman, page 173.

  35 “While directors”: Salvatore Mangione and Linda Z. Nieman, “Cardiac Auscultatory Skills of Internal Medicine and Family Practice Trainees: A Comparison of Diagnostic Proficiency,” JAMA 278:9 (September 3, 1997), pages 717–722.

  36 “if they did not”: Osler’s adjuration to his medical students is from Michael Bliss’s marvelous biography, William Osler: A Life in Medicine, page 270. In addition to being an excellent biography of Osler, Bliss’s book gives us a rich, fascinating, well-informed history of medicine and medical practice during the years of Osler’s life, 1849 to 1919.

  37 “50 percent”: On the basis of an interview with Stephen Oesterle, Klaidman (page 192) cites the figure of 50 percent for unnecessary angioplasty. See also “Study Finds Inefficiency in Health Care; Employers Are Said to Pay $390 Billion a Year in Unneeded Costs,” by Milt Freuden-heim, New York Times, June 11, 2002.

  37 In addition, many cardiologists: Klaidman calls our attention to such conflicts of interest on page 192 ff; readers should also see a series of articles entitled “Medicine’s Middlemen,” in the New York Times: “Medicine’s Middlemen: Questions Raised of Conflicts at 2 Hospital Buying Groups” (March 4,2002), by Walt Bogdanich; “When a Buyer for Hospitals Has a Stake in Drugs It Buys” (March 26,2002), by Mary Williams Walsh; and “Hospital Group’s Link to Company Is Criticized” (April 27, 2002), also by Walsh. (Other articles in this series appeared on April 23, April 30, and June 7, 2002.) See also Melody Petersen, “Methods Used for Marketing Arthritis Drug Are Under Fire” (April 11, 2002) and “Suit Says Company Promoted Drug in Exam Rooms” (May 15, 2002), both in the New York Times. For a recent view of what might be done to prevent or manage conflicts of interest, see “Managing Conflicts of Interest in the Conduct of Clinical Trials,” JAMA 287:1 (January 2, 2002).

  38 “All they know”
: Klaidman, page 223.

  38 “The time invested”: Bernard Lown, The Lost Art of Healing, page 16.

  38 “The good physician”: Francis Peabody’s speech, “The Care of the Patient,” is reprinted in The Caring Physician: The Life of Dr. Francis W. Peabody, by Paul Oglesby, pages 155–174.

  39 In all significant categories: A. K. Jha, M. G. Shlikpak, W. Hosmer, C. D. Frances, and W. S. Browner, “Racial Differences in Mortality Among Men Hospitalized in the Veterans Affairs Health Care System,” JAMA 285:3 (January 17, 2001), pages 297–303. For information on the gap in health care for blacks, see Sheryl Gay Stolberg, “Race Gap Seen in Health Care of Equally Insured Patients,” New York Times, March 21, 2002.

  40 “some patients”: The quotations from Hippocrates and Plato are from Stanley Jackson’s Care of the Psyche: A History of Psychological Healing, page 40.

  40 For the two million people: Concerning the condition of people living in poor nations, Helen Epstein and Lincoln Chen write,

  Indignation over the high cost of AIDS drugs has helped focus international attention on the global AIDS epidemic and by the end of 2001, an antiretroviral drug cocktail could be obtained in some developing countries for $300 to $500 per year, many times less than the price in the West. However, for a variety of reasons, including the sluggishness of government bureaucracies, the stinginess of drug companies, and the fact that even at these low prices the drugs are still too expensive and difficult to distribute, few AIDS patients in developing countries are actually receiving these drugs or, for that matter, any modern medications at all beyond the cheapest antibiotics. (“Can AIDS Be Stopped?” New York Review of Books (March 14, 2002), pages 29–31 [30])