Open Heart (48 page)

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])

Readers should also see “How Sick Is Modern Medicine?” by Richard Horton,
New York Review of Books
(November 2, 2002), pages 46–50 (especially page 50).

41
   
And the key element:
Jerry has published a number of papers on adherence and antiretroviral therapy, papers demonstrating that adherence is central to successful suppression of HIV, and that trust—the doctor-patient relationship—is central to successful adherence. He has also, in these and many other papers, suggested strategies that make trust—and success—more likely. See, for example: A. Williams and G. H. Friedland, “Adherence, Compliance, and HAART,”
AIDS Clinical Care 9:7
(1997), pages 51–54,58; F. L. Altice and G. H. Friedland, “The Era of Adherence in Antiretroviral Therapy,”
Annals of Internal Medicine
129
(1998), pages 503–505; G. H. Friedland and A. B. Williams, “The Future: Attaining Higher Goals in HIV Treatment: The Central Importance of Adherence,”
AIDS
13, Suppl 1 (1999), pages S61-S72; B. Soloway and G. H. Friedland, “Antiretroviral Failure: A Biopsychosocial Approach,”
AIDS Clinical Care
12:3 (2000), pages 23–25,30; and F. Altice, F. Mostashari, and G. H. Friedland, “Trust and the Acceptance of and Adherence to Antiretroviral Therapy,”
Journal of Acquired Immune Deficiency Syndromes
(2001), pages 47–58.

43
   
Nor, in two-thirds:
Klaidman, page 222, argues that “invasive treatments such as surgery and angioplasty are being used without good evidence that they provide any survival benefit over drugs. Where a benefit is provided, it is in pain relief and exercise tolerance.” See also pages 180–181.

Rates of restenosis—a return of blockages after angioplasty, stenting, or bypass—vary widely. A study in
Circulation
(November 2001) reports as many as 40 percent of patients having a return of blockages and requiring additional treatment; after six months, 607 out of 2,690 patients (reported on in this study) had blockages of 50 percent or more in the arteries where angioplasty had been performed. Early studies of stents coated with an immunosuppressive drug are promising and show restenosis rates below 5 percent. See “Comparison of Angioplasty with Stenting, with or Without Abciximab, in Acute Myocardial Infarction,” by Gregg W. Stone et al., in
NEJM
346:13 (March 28, 2002), pages 957–966; and also “A Randomized Comparison of a Sirolimus-Eluting Stent with a Standard Stent for Coronary Revascularization,” by Marie-Claude Morice et al., in
NEJM
346:23 (June 6, 2002), pages 1773–1780.

When I ask Rich about this, he writes back: “Restenosis: without stent—30–50% after 3–6 months; with stent—20–30% after 3–6 months; with drug coated stent—< 5%. But this is based on VERY preliminary experimentation, and history shows that early enthusiastic reports do NOT hold up. Should be helpful, but how much (in my mind) is an open question.”

44
   
“a significant mental decline”:
As to postsurgical depression, according to the
New York Times
, “there are no conclusive statistics about the incidence of depression after surgery. Estimates vary widely, from fewer than a third of patients to more than three-quarters” (Randi Hutter Epstein, “Facing Up to Depression After a Bypass,”
New York Times
, November 27, 2001). The quotation regarding mental functioning after bypasses is from “Mental Decline Is Linked to Heart Bypass Surgery,” by Denise Grady,
New York Times
, February 8, 2001. See also, for example,
Circulation
105:1176 (2002).

45
   
“the kinds of things”:
Thomas, pages 35–42.

49
   
My journal entry:
I have transcribed my journal entries as in the original, complete with abbreviations, spelling errors, grammatical errors, and gross lapses of judgment.

64
   
“V worried”:
When Rich reads this journal entry, he writes that he is struck by two things: First—your deep premonition and recognition that you had a life-threatening illness, despite what your doctors were telling you. I've long believed that on some level, patients
know
how sick they really are, and how close they are to death, but for whatever reason (overwhelming fear, admission of vulnerability), need to keep it a deep, dark secret within. Second is that the pain was…often too in chest… shit!” You certainly NEVER told me about that, and I doubt you told your docs. I've long suspected that patients often keep crucial tell-tale symptoms from “the doctor,” know that the diagnosis they dread will probably then be made…