Open Heart (6 page)

“With respect to cardiology,” Rich explains, “the problem goes something like this: the more likely the test is to be abnormal—treadmill ECT [electrocardiogram tracing] testing, nuclear cardiology, echocardiography, cardiac MRI, et cetera—and therefore suggest the presence of heart disease, the more likely it is that the result will be a ‘false positive'—meaning that the test is abnormal, but the patient is normal. In addition, these tests and scans all miss a certain percentage—ballpark, 15 percent—of abnormal patients. In these cases the test is normal, but the patient is not.”

Clinical trials and outcome studies that evaluate various ways of treating heart disease are, it turns out, remarkably inconclusive: whether a doctor recommends angioplasty, bypass surgery, drug therapy, or beating-heart surgery (bypass surgery performed without using a heart-lung machine, and sometimes without cracking open the chest), chances are patients will end up about the same. Even if one receives treatment considered optimal, there appears to be less than a 50 percent chance it will improve the likelihood that one will live longer than one would have lived
without
the treatment.
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Such studies and statistics, moreover, are themselves highly misleading, for the truth, as with me, is that some treatments are better for some people than they are for others. Not only is each of us different and unique, but each person's
disease
is also unique, and this is what a skilled cardiologist takes into account when diagnosing a condition and when prescribing treatment. Then, too, statistics themselves represent, at best, an
approximation
of reality.

Stephen Klaidman, in
Saving the Heart: The Battle to Conquer Coronary Disease
, summarizes much of what I hear from my friends: “Clinical judgment is not an exact science, which is where the art comes in,” he writes.
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Each person “is a distinct entity, anatomically, physiologically, and psychologically, and the clinician must take account of the differences. Each person's disease is also distinct, and that, too, must be taken into account. Furthermore, since randomized clinical-trial results as reported in the medical
journals provide only generalizations, there is no way of being absolutely sure, except in some relatively small number of clear-cut cases, that for patient X angioplasty is a better choice than drugs or surgery.”

“I have always been plagued by our ignorance when confronted by an individual patient,” Rich says, “and the problem we have in cardiology is that while tests can reveal the status of the disease, their prognostic accuracy is far worse than their diagnostic accuracy.

“Having atherosclerosis ain't so bad if you know you'll live happily with it for the next thirty years—as compared to the next thirty hours. Lowering cholesterol levels, controlling blood pressure and diet, quitting smoking, and the rest are surely important, but in each
individual
case, sad to say, the situation is neither so clear nor so rosy.”

But why not?

The answer, as I begin to understand it, is that it takes more than tests and screenings, scientifically true as they may seem, to deal with the complexities of each disease as it makes its home in each one of us. Klaidman makes the essential point: “The cardiologists who diagnose with subtlety and accuracy, and who best understand the idiosyncrasies of each individual patient and his or her disease…may be the most valuable clinicians because they do better than others in guiding their patients toward treatment choices that are most appropriate for them.
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Their special gifts, which are becoming rarer all the time, are clinical judgment and clinical skills—that is to say, using the most basic methods to figure out what is wrong with a patient and the best way to fix it.”

“The great secret, known to internists…but still hidden from the general public, is that most things get better by themselves,” Lewis Thomas writes.
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“Most things, in fact, are better by morning.” And one of the essential ingredients in the healing process is the belief the patient has in the person doing the healing.

What happens, then, I wonder, if the thoughtful and well-trained doctor we see one time may not be the doctor we see the next time—and if, because of such experiences, trust and faith in the doctor,
or in any provider of health care, begins to erode?
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What happens when, under policies initiated by managed-care companies, people not only don't have access to doctors who know them, and whom they know and trust, but see a series of doctors whose clinical skills and judgment are compromised by guidelines (guidelines monitored, generally, by people who have no medical expertise themselves) as to how much time they can allow for seeing, talking with, and examining each patient?

The answer, according to my friends, and according to preliminary outcome studies such as those sponsored by the Robert Wood Johnson Foundation and the Rutgers University Institute for Health, Health Care Policy and Aging Research, is that we are courting disaster. These studies point out that patients' trust generally depends upon the perception that their doctors are free to act in their best interests. But how believe this when the utilization review boards and structural arrangements that govern managed care restrict choice, contradict medical decisions and control, and limit (and sometimes obstruct) doctors' communication with patients? These studies also show that policies such as “gatekeeping” (whereby primary care providers must
approve
the use of specialists), along with incentives to limit care, further erode our trust as well as the independence and ability of our doctors to act freely on our behalf.
^*

John Kirklin, a cardiac surgeon at the Mayo Clinic in Rochester, Minnesota, asserts that “the perpetually increasing demands on surgeons, pediatric cardiologists and adult cardiologists, and their responses to these demands, have resulted in their being, as a group, less contemplative, less able to understand intimately the special circumstances of each of their patients, and perhaps less fit to help patients with heart disease make the many complex decisions required.”
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A 1997 study of 453 recent medical school graduates—residents in internal medicine and family practice—illustrates such concerns. In this study, the 453 doctors could not correctly identify the distinctive sounds of
common
heart abnormalities with a stethoscope 80 percent of the time. “While directors of internal medicine programs consider [cardiac auscultation] to be an essential skill for every
practicing physician and would like more time to be devoted to its teaching, fewer than one third of all internal medicine programs offer any structured teaching of cardiac auscultation,” the study notes, and points out that “an even worse situation exists for lung auscultation.”
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Although a human being using a stethoscope may not be the only or best way to detect heart or lung abnormalities, it remains a most reliable and accurate way of doing so. “We chose cardiac auscultation,” the authors conclude, “because there is evidence that this skill, competently performed, is a sensitive, highly specific, and cost-effective method of detecting valvular heart disease in asymptomatic subjects. In a larger sense, however, we chose cardiac auscultation as a paradigm for all bedside diagnostic skills. Thus, deficiencies similar to those we found for cardiac auscultation might exist in other important areas and deserve further exploration.”

The danger implicit in such a deterioration of clinical skills came home to me when my son Aaron went for a routine physical and our family practitioner, David Katz, listening to Aaron's heart with a stethoscope, heard something he thought abnormal. Dr. Katz sent Aaron to a cardiologist. The cardiologist heard the same sound, did an echocardiogram, and confirmed Dr. Katz's suspicion—that Aaron had a leaking aortic valve. Because blood normally flowing directly from the left ventricular chamber into the aorta was backwashing into the heart through the leaking valve (aortic insufficiency), the left ventricular chamber of Aaron's heart was slightly enlarged. In addition, because the aortic valve did not fully close, pathogens could adhere to the rough surface of the valve, thus making it prone to infection (endocarditis).

Had Dr. Katz not recognized the tell-tale sound, and had Aaron not, since that time, had regular exams and echocardiograms to monitor his condition (a condition that requires no restriction of activity), and taken medications (antibiotics for dental work or any so-called dirty surgery, and a blood pressure medication to reduce the pressure on the enlarged ventricle), the consequences for him might have been grave indeed.

(William Osler, the famed Johns Hopkins physician, according to his biographer Michael Bliss, would tell his students that “if they did
not do their business properly, when they got to heaven they would be met by large numbers of little children, shaking their fingers and saying, ‘You sent us here.'”)
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There are also, my friends report, tangible costs that arise from our infatuation with technology, including the tendency for doctors to perform needless and costly interventions (screenings, angioplasties, bypasses), as well as interventions at which they are less than competent. Rich is incensed, for example, by the numbers of useless and often failed bypasses and angioplasties he has witnessed, and by the conflicts of interest that too often determine the kind and quality of treatment patients receive. His indignation and his fears are confirmed by others. Dr. Stephen Oesterle, director of interventional cardiology at Massachusetts General Hospital, for example, believes that “50 percent of the angioplasty that goes on is unnecessary”—a figure that translates to more than one hundred thousand unnecessary procedures a year in the United States alone.
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In addition, many cardiologists and cardiac surgeons have financial interests in the companies whose products—stents, medications, catheters, surgical instruments—they use; many are investigators in clinical trials in whose outcomes they have a financial stake; and many go on the road as paid speakers to medical conventions and hospitals, promoting new drugs or devices in whose sale and use they have financial interests.
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Generally, too, patients will be totally unaware of these interests and conflicts of interest, or of the degree to which these interests influence diagnosis and treatment.

Technology companies survive and grow by innovating, a by-product of which is the continuing obsolescence of their products as they are replaced by newer ones, and so they inundate practicing physicians with new technologies, many of which have not been adequately tested. Before a complicated new system for opening arteries is in place, for example, a new one may arrive on the market to replace it. And while this, as Stephen Klaidman explains, “might be fine for cutting-edge cardiologists and cardiac surgeons who thrive on such challenges…it is not the best thing for average practitioners with average skills operating in small, understaffed community hospitals, or for their patients.”

But patients rarely know that their local cardiologist, who may do only a few dozen balloon angioplasties a year, should not be doing complicated stent placements without proper training. “All they know,” Klaidman writes, “is that they've seen an (often hyped-up) version of the new device or procedure in the news media or maybe even on the Internet, they want it, and they tell the local cardiologist, in effect, ‘If you can't or won't do it, I'll find somebody else who will.'
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This creates pressure to use the latest technology, whatever it is…”

In
The Lost Art of Healing
, Nobel Prize-winning physician Bernard Lown, no stranger to the benefits of technology—Lown is the inventor of the defibrillator and of cardioversion for cardiac resuscitation, and is also responsible for many elements of the modern cardiac care unit—emphasizes the priority of listening to the patient and of taking a careful history. “The time invested in obtaining a meticulous history is never ill spent,” he asserts.
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“Careful history-taking actually saves time. The history provides the road map; without it the journey is merely a shopping around at numerous garages for technological fixes.”

“I am convinced,” he writes, “that listening beyond the chief complaint is the most effective, quickest, and least costly way to get to the bottom of most medical problems. A British study showed that 75 percent of the information leading to a correct diagnosis comes from a detailed history, 10 percent from the physical examination, 5 percent from simple routine tests, 5 percent from all the costly invasive tests; [while] in 5 percent, no answer is forthcoming.”

It does not seem at all nostalgic, then, to hear my friends quote the familiar saying that the secret of the care of the patient is in caring for the patient. “The good physician knows his patients through and through,” Dr. Francis Peabody wrote in 1927, “and his knowledge is bought deeply.
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Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

In the weeks and months following surgery, I reflect, also, on elements of my experience that
are
truly anomalous but that have little
to do with biology or technology: if I had not had the kind of excellent health insurance I had (a kind that allows me to use any doctor or hospital anywhere) and the job that allowed me this health insurance; and if I had not been as well connected as I was with doctors who knew me and listened to me; and if I had not received the prompt and expert medical care I received in an excellent hospital because of my insurance and my friendships; and if I had not had the self-confidence to persist in trying to discover why I was experiencing seemingly unexceptional symptoms; and if I had not had the education and the will (are there genetic markers for will, self-confidence, or persistence—medications that can bring them into being or correct their absence?) that enabled me to be in otherwise good health; and if I had not had the good health that allowed me to survive coronary artery disease and surgery without harmful or permanent side effects, would I be here to tell my tale?