Doctored (17 page)

Today roughly one out of every six dollars in America is spent on health care. If we do not succeed in controlling these costs, they will gradually crowd out other necessary societal expenditures. Improving health literacy will be critical to these efforts. Without a better understanding of what doctors are actually doing, one may end up like Dr. Oni's patient who had seventeen consultants and twelve procedures and who reinforced a further lesson I have learned many times since entering practice: When doctors are paid piecework for their services, the result too often is waste, disorganization, and overload.

 

SIX

Double Effect

Death is always cheaper.

—Albert L. Waldo, M.D., University Hospitals Case Medical Center

In September 2005 I received a letter from the membership and credentialing committee of the American College of Cardiology informing me that I'd been elected a fellow. The ACC, founded in 1951, is the largest cardiological society in the United States, with nearly forty thousand members, including physicians, scientists, nurse practitioners, and physician's assistants. The convocation was to take place in early March at the college's annual conference in Atlanta. Fellowship in the ACC requires completion of advanced cardiology training, passage of the cardiology boards (which I had successfully completed earlier that year), and letters of sponsorship from other ACC fellows. I viewed it as the final step to admission into an exclusive guild.

I flew to Atlanta a couple of days before the ceremony in the spring. The conference, a colossal affair with roughly five thousand cardiologists in attendance from all over the world, took place at the Georgia World Congress Center near Centennial Olympic Park. There were dozens of talks—mostly standing room only—going on concurrently throughout the ninety-acre complex. PowerPoint slides flashed arcane analyses on subjects ranging from mitral valve repair to the genetics of heart failure to stem cell therapy after myocardial infarctions. I attended one talk on the use of left atrial size as a predictor of heart failure. How to interpret the findings? How do you critically evaluate a study whose methodology (Kolmogorov-Smirnov goodness-of-fit tests, proportional hazard models, propensity scores) you don't understand? I leafed through the four-hundred-page monstrosity that was the conference program book. Here was the academic-industrial complex—publication for publication's sake—in its full glory.

Between sessions I strolled through the convention center. Outside, in the muggy afternoon heat, children were playing in water geysers shooting out of the ground at Centennial Park. I passed through the gargantuan exhibit hall, where companies had set up booths to peddle their wares. At the Merck and Pfizer booths you could check your blood pressure and your serum cholesterol (through a pinprick) and receive a computerized cardiac risk profile. At the Terumo booth you could watch videotaped demonstrations on the use of robotics in the cath lab while enjoying a complimentary fresh fruit smoothie. At nearly every booth there were pretty young saleswomen passing out freebies—pens, penlights, even stethoscopes and portable music players. In one chamber a professional model, her chest covered with a flimsy white sheet, was getting an echocardiogram to demonstrate the resolution of a new ultrasound probe. Nearby, a young blond woman was receiving enhanced external counterpulsation, a noninvasive procedure sometimes performed on patients with heart failure in which pneumatic cuffs on the calves and lower and upper thighs inflate and deflate in synchrony to decrease the workload on the heart. Each compression caused her hard body to thrust suggestively, and a group of cardiologists in rumpled khakis and blazers had gathered to watch.

One session I attended was a panel debate on the safety of the heart failure drug Natrecor, whose manufacturer, Scios, still had me on its speakers' bureau and for which I was still occasionally giving paid talks.
The Journal of the American Medical Association
had just published its paper raising concerns about the drug: Did it cause kidney damage? Did it increase mortality? Sales nationwide of the billion-dollar-a-year medicine had plummeted. The tension in the room was crackling. Two cardiologists got into a shouting match discussing the merits and demerits of the drug. A Scios executive quipped that he'd been sleeping like a baby ever since the
JAMA
paper was published; he'd been waking up every few minutes to cry. It was at the end of the session that I decided the data on Natrecor were too murky to justify my continuing to speak for Scios. Within a few months I'd quit the speakers' bureau, and I never gave another paid talk on Natrecor again.

The convocation took place the following evening in a large auditorium at the Georgia Center. In a small changing room I got dressed in full academic regalia: black gown, hood, cap and tassel. The getup felt heavier than those from my previous commencements. The ceremony opened with a procession of trustees, distinguished guests, officers of the college, and newly inducted fellows. As I marched into the auditorium, I surveyed the proud, smiling faces of family members and loved ones. Old and young, they looked like so many of my patients. These were the people I was going to take care of over the next several decades. I could only hope that I would serve them well. Once we took our seats, there was the laying of a mace, a ceremonial wooden staff with a silver and gold head representing the four chambers of the heart, on a velvet cushion behind the lectern. (The mace, I later learned, is a symbol of the academic quest for truth and wisdom.) Following the presentation of numerous academic awards, the fellows-elect took a pledge to “renew and reaffirm the obligations of the Hippocratic Oath, to practice my art so as to help and to heal, so that the image of the physician will be worthy of the blessings of the afflicted and the sick.”

The president-elect of the college, Dr. Steven Nissen of the Cleveland Clinic, gave the main address. He opened his speech by congratulating us on an important career milestone, “an honor that will bring you respect and admiration from your colleagues, patients, and society.” However, he said, “it is an achievement that brings great responsibility and ethical burdens that will demand constant vigilance.”

It was our obligation, he went on to say, to “remove the biases that stand in the way of good medicine. We need to assure that no consideration of economic self-interest will ever prevent us from giving our patients the safest, most effective, and most economically responsible health care possible.” He decried the proliferation of costly imaging technologies. “The history of medicine is replete with examples of new technologies that have been rushed into practice without the evidence needed to use them wisely.” From what I had seen in my short attending career, his observations were right on target.

He talked about professional integrity. “Trust is priceless,” he said. “It defines the relationship between the doctor and the patient. It can be protected and nurtured and passed on to future generations. Or it can be squandered.”

He said he believed that the medical profession today was too entangled with pharmaceutical companies. “In health care, where so much is at stake, even the appearance of bias can damage trust … Our professional journals rely on advertising to pay the bills, and our national meetings are funded by massive industry exhibitions.” There were slight but clear murmurings through the audience.

He criticized contract research organizations, for-profit companies that ran large clinical trials on behalf of pharmaceutical or device companies and often steered research designs in their favor. He denounced the practice of employing ghostwriters paid by drug companies to prepare clinical trial manuscripts on behalf of academic investigators. And finally, he announced that he had begun to donate all his drug industry consulting fees to a philanthropic charity and encouraged us all to do the same. “You will sleep better at night,” he said.

Listening, I couldn't help but think of my medical school graduation nearly eight years earlier in St Louis. It had fallen on my parents' thirty-third wedding anniversary, an unplanned but perfect gift. They beamed with pride as I strode into the auditorium to the tune of bagpipes. The commencement address that day was delivered by S. Bruce Dowton, a pediatrician and medical school dean, who spoke eloquently about his early dreams of becoming a doctor while growing up in the outback of Australia. “From that limited horizon,” he said, “I knew nothing of the world at large, let alone the world of medicine.” His words resonated with me. Not so long ago, in graduate school at Berkeley, I'd also felt as if I were in a world apart. I'd been desperate to get out of the ivory tower and join the “real world.”

Dr. Dowton offered this piece of advice: “Keep a simple value system. Work out what things in life you care about, the beliefs you hold near and dear, and stick to them. You are about to go through a most tumultuous time. What are you willing to accept? What are you willing to fight for?” I'd written it down in my Palm Pilot: “Figure out a value system.
”
It occurred to me that warm evening in Atlanta, walking out of the Georgia Center in a flowing black gown, that I'd never really done so.

*   *   *

In my first year as a heart failure specialist, I often took care of patients near the end of their lives. I was sometimes asked to predict how long someone was going to live. On rare occasions I was even requested to assist in someone's death. In November of that year I took care of Rose Crespo, an eighty-four-year-old woman with end-stage heart failure who told me she couldn't bear feeling short of breath any longer and pleaded with me to help her die. “Is November fifteenth a good day for you?” she asked, as though she were inviting me to dinner.

Alarmed, her daughter shot out of a chair at her bedside. “Ma, do you understand what you are saying?”

The old lady stared at her and nodded slowly. She had short, curly hair dyed brown and large spaces between her teeth. She spoke with the unvarnished bluntness of someone who has no more energy to waste on being diplomatic. “I can't take it anymore,” she said. “Back and forth, back and forth to the hospital. I'd rather be dead.”

I explained that I could not assist in her suicide, though I could give her morphine to relieve her suffering.

“If you were like me, you'd say the same thing, Doctor,” she said ruefully. “I'm half gone. Nobody wants to bother with you when you're like this.”

Not knowing what to do, I called a representative of the ethics committee, who invited me to a meeting it was having that week. It took place at seven-thirty in the morning in a small room in the basement (not far from where we had cardiology morning report). When I arrived, a dozen participants—doctors, nurses, a psychologist, two social workers, a lawyer, and a rabbi—were gathered around a conference table. They were discussing the protocol for how to rescind do-not-resuscitate orders when patients give consent to be operated on before surgical procedures. Surgeons routinely require such nullification, even for elderly or terminally ill patients who have long-standing DNR status, because of the life-threatening (and often treatable) risks associated with major surgery. “To have this kind of dialogue is difficult,” a psychiatrist was saying. “How do you bring up the issue of cardiac arrest on the operating table? We may have a form for patients and physicians to sign, but let's not delude ourselves about what this form really represents”—namely, protection against medicolegal liability.

A nurse suggested that the form be amended so that along with the attending, whose responsibility this is, residents and physician's assistants could also sign the rescindment. “After all, they, not the attending, are the ones talking to the families.”

“Attending physicians are not talking to the families?” a senior internist asked sharply. His voice took on a pedantic tone. “If a patient is going for a procedure, an attending physician has to sit down and talk about the risks/benefits/alternatives.” (He enumerated the topics quickly, as if they all were one word.) “Are you saying this isn't happening?”

The nurse hesitated. “I'm not saying it isn't happening,” she said carefully, “but attendings are rushed. They show up whenever they want. It isn't really clear what's being discussed.”

“This sort of conversation has to be held with a primary care physician who understands the trajectory of the patient,” a doctor declared.

“The primary care physician isn't the one doing the procedure,” someone else countered.

The head of the committee, a gray-haired fellow named Frank Callahan, put up his hand to interrupt the discussion. He had on wire-rimmed spectacles and possessed the air of an English professor, down to his tweed jacket. “Historically there has been a lot of resentment from surgeons and radiologists, downstream specialists, about being ruled by upstream contracts,” such as a DNR decision made in a primary care physician's office prior to a patient's being referred for a procedure, he said. “It isn't just professional ego. They're saying the guy up there doesn't understand what's going on down here.” The psychiatrist started to respond, but Callahan stopped him and said that time was short and that further discussion would need to be deferred until the following meeting.

The next item on the agenda was whether a patient could refuse care on prejudicial grounds, such as a doctor's race or skin color. The lawyer on the committee argued forcefully that doctors should tell patients that they don't have a choice about who will treat them. “We should say, ‘This is medically mandated, and if you want to go down the street to another facility, well, go right ahead.'” Taking the contrary viewpoint, Callahan responded that he believed that in an emergency, and if an alternative health care provider was available, it was appropriate to honor such requests. “Patient autonomy includes the right to choose who will, or will not, care for us,” he said. “The doctor-patient relationship requires intimacy, and intimacy is a matter of choice.” Even though the hospital would not accept directives that violated its ethical or legal obligations, he said, doctors still had a duty to sacrifice their own interests for the sake of their patients. Though I stayed quiet, I found myself agreeing with him. The bedside is not the place to wage battles for social justice.