Health Matters, Part II

GUEST: Dr. Isadore Rosenfeld
VTR: 7/30/1981

I’m Richard Heffner, your host on THE OPEN MIND. Medical matters have loomed large on this program over the past quarter-century, of course. Howard Rusk, Louis Thomas, John Knowles, Benjamin Spock, Nathan Klein, and many other distinguished physicians and medical statesmen have joined me at this table. Always they have illumined their subject and our concerns, yours and mine, with wisdom, patience, and understanding. And none, of course, is better equipped to do so than Dr. Isadore Rosenfeld, the world-famous cardiologist and clinical professor of medicine at the New York Hospital Cornell Medical Center, whose Linden Press book, Second Opinion, has focused Americans’ attention on what he calls our “medical alternatives”. Dr. Rosenfeld was our guest last week, and he’s back with us again today.

So I won’t even say “welcome”. Thanks for staying at the table, Dr. Rosenfeld.

You know, I said at the beginning of the first program that I had this long list of questions. And I don’t think I can check off more than one or two. But I’m going to start somewhere in the middle here, and going back to the book and looking at my own note, you had written…Let’s see. I wrote down page 371. And what I have here, of course, is the notion that you say, “the medical establishment does not speak with one voice on many fundamental medical question. Cholesterol, hysterectomies, coronary bypass surgery, and literally hundreds of other practical matters. Becoming aware of the facts of medicine always means exposure to its controversies, something that patients don’t always appreciate and with which they are not always able to cope”. Now, at the end of our first program, we were talking about being rather straightforward with patients or with their surrogates, as you call them. What about this question of matters with which patients just aren’t able to cope? How do you deal with those?

ROSENFELD: I think every physician who takes the time and gives the thought to this question knows how far he can go, how far and how fast he can go with a patient. Now, I can’t answer this generally. Obviously, if one is dealing with a hysteric or with a patient who has obvious psychiatric problems or is emotionally unstable, the doctor will be challenged in terms of how he can impart certain news that is apt to disrupt that patient’s stability. I refer there to the great sort of middle-America, the great mass of patients, who are normal, like you and me, and who…

HEFFNER: That’s easy for you to say.

ROSENFELD: (Laughter) …who can be given some information. I mean, take an example. Supposing I find a malignant tumor in somebody. It’s a terrible thing for a doctor to find that, and it’s even worse for him to have to communicate that news to a patient. I never use the word “cancer”. I never shut the door on hope, because I’ve been around too long to know that there are errors in diagnosis, that there are people whom you write off in your mind who are there 15 and 20 years later. So nobody has all the answers. I tell such a patient, “Look, we found a growth or we found a tumor. We don’t know what its natural history will be. We have many ways of attacking it. We can attack it surgically, we can attack it medically, we can attack it with immunotherapy, combinations of these. And there is always room for optimism”. And if you educate a patient as to what can be done and focus on the positive, nature itself provides the buttress, the emotional buttress for most people who never believe they’re going to die. You know, I, I think, in one of these two books I tell this story. It’s true. And it’s worth repeating. Some 20 years ago, when I was just starting practice in this city, my wife asked me to see a friend of hers. And she had a lump, a hard lump in her neck, and it was very suspicious for cancer. We had it biopsied, and it turned out to be not only malignant but highly malignant. The cells under the microscope didn’t resemble any cell in the body that we’ve, so that we couldn’t say, “Well, this has spread, this gland has spread from the stomach or the ovary or somewhere else”, you see. We instituted a thorough search of every organ in her body with the diagnostic equipment available at that time, and we could never find the primary or the source which was seeing this malignancy. So we just nicked out this little gland. It was a five-minute procedure, and that’s all. And the question came up: What to do? We had a battery of surgeons around, and they all opted to remove her jaw and dissect out any other little glands that might have the disease. This would have disfigured her permanently and probably not made any difference to her life expectancy. And in consultation with the family, we decided, and the patient, we decided not to do it. Now, that woman is alive today, 23 years later. We never found the primary, we never did anything else. If she had gone to Lourdes or taken laetrile or done any of those things, she’d have been cured by some miracle. There are all kinds of things in medicine that we don’t understand. So I think for a doctor to take a gloomy or nihilistic position on any disease at any time is wrong.

HEFFNER: You know, it’s so interesting to me that you’ve, you use the pronoun “we”, and you’ve made it sound – as you do in your book – that there is a team there, the team initially of the primary physician and the patient. You don’t talk about “I” and you don’t talk about “her”. You’re really talking about two people working together, and that’s a very interesting concept, because I think most of us have been brought up to believe that, “There’s the doctor over there. He’s Mr. Expert. And here am I, the poor patient at the mercy of that expert”. You don’t look at it that way.

ROSENFELD: No. I try also; I try in my one-to-one relationship with patients never to allow anybody to leave my office until I’ve asked them two questions: “Do you understand everything that I’ve told you?” And, “Is there anything else you want to ask me?” Because so often patients leave or feel rushed and they walk out in the waiting room and the door is shut and the next patient is in, and there have been something that they, “Now, what did the doctor mean? What did he mean when he said this?” And then they go and they stew over it and all. So I never let anybody out until I make sure that they understand what I’ve told them.

HEFFNER: You know, too, the question of this team that advised the kind of surgery that would have disfigured this woman you talk about, what really, what chance does a patient have to exercise control over his own destiny in those emergent situations where you are talking about drastic surgery? Here the patient has a doctor who was hopeful and who had a philosophy that led to activities over the following 20 years that didn’t result in death…

ROSENFELD: Well, I didn’t do anything for her. That was just the natural course of the disease.

HEFFNER: No, I didn’t mean that. I meant what you did, I gather, was recommend…

ROSENFELD: That nothing be done.

HEFFNER: …a hopeful approach that nothing at that time be done.

ROSENFELD: Yeah.

HEFFNER: What opportunity do I have? We hear a lot about informed consent. But I’ve also heard a lot from my medical friends that in the final analysis in this day of high technology, the patient on the table really doesn’t have that much of an opportunity.

ROSENFELD: No, he certainly doesn’t have much choice once he’s on the table.

HEFFNER: Well, when you do a biopsy. And I think we’ve heard many, many times of the people who have biopsies performed and then immediate surgery. Who informed…

ROSENFELD: Yeah. I address myself to that problem with respect…

HEFFNER: And you say don’t do it.

ROSENFELD: Yes. With respect to, especially with respect to breast surgery. I don’t think that any woman who is found to have a lump and who is having a biopsy should give carte blanche to the surgeon to do whatever he deems necessary while she is under anesthesia. There’s plenty of time to wake up, discuss it with our family, with your family doctor, and then get a second opinion as to the extent and nature of the surgery. But getting back to your question, I think the key to it is the relationship between the patient and the primary physician. People don’t go to surgeons de novo. I mean, you don’t phone a surgeon and make an appointment with a surgeon, as a rule, unless you’ve, you know, broken your hand or something. If it’s a matter of an operation, whether it’s a coronary bypass or a gallbladder or hysterectomy or what have you, you call your doctor. Your doctor makes the assessment. Your doctor recommends a surgeon. You go to the surgeon. The surgeon talks to the doctor. The doctor talks to you. There is a dialogue, or at least there should be. So it’s not as if the patient finds himself on the, what is it, the treadmill?

HEFFNER: Uh hum.

ROSENFELD: Of medicine, that he can’t get off. If he has the kind of relationship with his doctor which permits him to say, “Look you’ve send me to Dr. Smith about my gallbladder. He says that I should have it out. Now, I want to tell you, my father…” – this is not me talking, this is the patient talking – the patient says, “My father had a gallbladder operation when he was just my age. And you know, he died. And I am convinced that if I have surgery, I’m going to die too. I don’t want to have the operation. What are the alternatives?” Now, if you and your doctor are a team, he will give you those alternatives. I mention some of the alternatives to that particular disorder. That’s why knowing your medical alternatives are very important, and discussing them with your doctor is very important. So that you, there isn’t anything inexorable, there shouldn’t be anything inexorable, as long as the patient can communicate with this primary physician.

HEFFNER: Yeah, for Dr. Rosenfeld, you’re the one who used the word “treadmill”. And I didn’t even dare touch on that. But it is said that when you get into a giant hospital, a teaching hospital, and you get on that treadmill, and there you are, and that in many teaching hospitals the relationship between your primary physician and the patient is minimal. Now, is that a fair statement? Or how fair is it?

ROSENFELD: I work at a teaching hospital.

HEFFNER: I know.

ROSENFELD: My relationship with my patient doesn’t change once he gets, he or she gets into the hospital. I don’t know what you mean. There is a certain amount of impersonal approach when you are having procedures done by people you don’t know.

HEFFNER: I’m not talking about a clinical professor. I’m talking about doctor X, general practitioner Y, internist Z perhaps, who does send his patient on to an expert, perhaps a cardiologist, perhaps in some other field. The patient ends up in the hospital. What then is the relationship between the primary physician and that patient?

ROSENFELD: By “the primary physician”, you mean the…

HEFFNER: I mean the original…

ROSENFELD: You mean if the primary physician doesn’t have privileges or doesn’t work in the hospital?

HEFFNER: Or if he has privileges but he’s not a major personality at this hospital.

ROSENFELD: It doesn’t matter whether he’s a major personality or even if he has no personality. If he is the doctor on record, he is responsible for that patient when that patient is in the hospital. That’s his private patient, and nobody can change that, unless he doesn’t belong to the hospital, and he sends the patient in, and somebody else looks after him. But it doesn’t matter what his rank is in the hospital. He looks after the patient. He’s responsible for him.

HEFFNER: And the resident staff?

ROSENFELD: I know what you’re trying to say. I know what you’re trying to say.

HEFFNER: Say it better than I do, because you can.

ROSENFELD: I know what you’re trying to say. There is a tendency, which I personally deplore, of once a patient is admitted to a hospital that other members of the staff do things and cause things to be done which are not always approved by or ordered by the patient’s primary physician. That happens, but it should not happen. The machinery is there to prevent it from happening. It requires a greater sophistication from, on the part of the patient to say, “Hey, wait a minute. Where are you taking me? You’re taking me down for a cardiac catheterization? You’re taking me down for any intravenous pyelogram? My doctor didn’t say anything to me about that”. And then, “Hold off a minute. I‘m going to call my doctor and see if he ordered it”. Now, that takes a…

HEFFNER: How many patients do you know who would have the temerity to do that?

ROSENFELD: Well…

HEFFNER: Unless they’d been trained by you to do it?

ROSENFELD: Well, you know, many patients. You know, patients are people. There are people who are timid, and there are people who stand up for their rights. I once, some years ago, visited the Soviet Union. And I bought myself one of those fur hats. I was walking around St. Basil’s Square, and I looked, I guess, like Russian. And there was a group of ladies from the United States touring and they came over to me and they said, “Do you speak English?” And I said, “Yes”. They said, “How much do you charge for a tour of St. Basil’s?”

HEFFNER: (Laughter)

ROSENFELD: And I said, “Fifty kopeks”. And all of them took the money and prepared to pay me, you see. Somebody who was less timid might have asked for my credentials. And I think the same thing applies in hospitals. But I know what you’re saying, and I’m not trying to apologize for it. It does happen, and it happens too much. And it shouldn’t. And the only defense, the only defense against it is for patients, people, if we can only reach the number of people who watch this program who are in the hospital and are having things done that they don’t know about or don’t understand or haven’t been communicated to them, they should say, “Say, wait a minute”. I mean, I know patients do it all the time. My patients and other patients do it all the time. They don’t allow blood to be drawn unless they know what it’s for or be sure that their doctors ordered it. There is an awful lot of testing, some of which is not entirely necessary.

HEFFNER: You know, there are those who say that going to a hospital is bad for your health.

ROSENFELD: No, they say a hospital is not for sick people.

HEFFNER and ROSENFELD: (Laughter)

HEFFNER: Or they become…Sure it is. They become sick. But, you know, your suggestion that people not be quite so fearful of the machinery and that they don’t let themselves get on the treadmill is a terribly, particularly important point. And it oozes out of the book. It’s there. You’re talking again about that partnership, and that means an act of participation on the part of the patient. But, going beyond the patient, there is a statement here that you make that I find absolutely fascinating. You started off in the part called “When what you read or hear is wrong”. And you then say at the end of that paragraph, “So the medical profession is in constant competition with Time, Newsweek, The National Enquirer, television, and Walter Cronkite, a contest the doctor doesn’t always win”. What do you mean?

ROSENFELD: What I mean is this: That the amount of knowledge that’s disseminated is enormous. Now, doctors traditionally depend on their educational process, going to meetings, reading journals. And this is the way it always was. But now you have science reporters who may go to a meeting that I…who certainly go to a meeting that I missed, because no doctor can attend every scientific meeting. Now, the science reporter for Time magazine or Newsweek goes to one of these meetings and he hears a presentation in which somebody says that there is a new drug now available for angina or that there is a new drug now available for high blood pressure which will not leave you impotent. And the next day it appears in The New York Times or somewhere. Well, if I haven’t read The New York Times that morning and I haven’t been to the meeting and the report is not yet in the medical literature that I read, I come to my office innocent and full of goodwill, and the patient confronts me and says, “Now, what about this pill that is now available that will not make me impotent and yet lower my blood pressure?” And I say, “Now, what pill are you talking about?” Well, I don’t look very good, you see. And that’s why those are the situations in which the doctor doesn’t always win.

HEFFNER: Yeah, well, that’s instantaneous information.

ROSENFELD: Instantaneous information.

HEFFNER: By the…

ROSENFELD: Patients know about it as quickly as do the doctors.

HEFFNER: All right. You send someone out and you get a hold of Time magazine or The Daily News or The New York Times and you read about it. But what about the scene that is set, the attitudes that are created by the media in reference to the practice of medicine? Whether all doctors are supposed to be Dr. Kildares or Dr. Welbys, or whether the pushing of this medical discovery, not just in terms of the morning paper, but continually, its continuing appearance in the press, does this affect your practice of medicine?

ROSENFELD: Yes, it does.

HEFFNER: Or the demands made upon you?

ROSENFELD: Yes, it does. People have a stereotyped image of the physician prototype. People are more sophisticated. I think it’s all for the good.

HEFFNER: More sophisticated?

ROSENFELD: Yes, people are more sophisticated. Patients know more today about their own individual illnesses. A patient with myasthenia gravis will co me in and say to me, “Now, I’ve heard about removal of the…” People read about it because medicine is no longer a secret. It’s no longer the private playground of the doctor. Medical information is widely available. And if you, and I’m sure if you had some major illness, you would prefer, you would read about it. You would find out who the best people are to treat it. You would look for any breakthroughs. You would do anything to save yourself. And so you should. And I think that the more people…Now, they used to say a little knowledge is a dangerous thing. But I don’t go along with that. I think a little knowledge is better than none. And I think this whole trend to educate people so that they can communicate intelligently with their doctor can only elevate the quality of medical care that people get, and keep the doctor on his toes. You know, the old days of the doctor saying, “Listen, you take this pill and go home and don’t ask me any questions, and call me in a week”; that’s finished. First of all, the bottle in which you put the pill has, by federal law, now got to state all the things that the pill does and doesn’t do, and all the harm that it can cause. You remember, in every medicine there’s a little poison. And that’s a good thing too to have all that information, I think, in the package insert. So that people no longer will accept – and I don’t think they should accept – dogma from on high by the high priest of medicine. The doctor is a dedicated practitioner who has at his command certain facts. He doesn’t have all the facts. And he does the best he can. And if the patient can help him with some new news, that’s fine. I don’t get insulted if a patient tells me that they’ve read something that I don’t know about. Mind you, it happens very infrequently. (Laughter)

HEFFNER: Because you read the paper early in the morning.

The impact of malpractice suits on the conduct of your practice and the practice of most of the people you’ve known, what’s it been?

ROSENFELD: It’s not been good. And I’m not talking about the premiums that doctors have to pay. I believe that anybody who has been harmed by a physician or a surgeon by virtue of negligence should be compensated. I think, however, that the current malpractice situation is a farce. I think that innocent doctors who do their best and who perform procedures which don’t work out because of, you might say, the will of God, are dragged to court and made to pay enormous, inflated sums. Now, the impact that his has had – there have been several – but notably, the first, doctors now practice defensive medicine. People complain about all the tests that they’re doing. The doctors have a tendency now to do every conceivable test for a given symptom so that they will not be dragged into court and say, “Hey, why didn’t you do an x-ray here? Why didn’t you do a blood test? Why didn’t you do a stress test? Why didn’t you do an angio?” So they do everything that could possibly be related so that if anything adverse happens they can’t be accused of having shortchanged the patient. The result is, I think, less time spent with the patient, less of a detailed history, less of a detailed physical exam, more impersonal medicine, more costly medicine, and I think…medicine, and shotgun medicine.

HEFFNER: What do you mean “shotgun medicine”?

ROSENFELD: Well, you know, somebody comes in and you say, “Well, let’s…” He’s got this little ache here. Instead of sitting down and taking the time to find out, maybe it’s digestive, maybe it’s nothing, give him a couple of aspirin and see if it goes away and call him in the morning. The great majority of complaints aren’t serious. But then what doctors will do for this thing, they’ll get a cardiogram, they’ll get blood tests, they’ll get x-rays, they’ll get stress tests, they will think of radionuclear scans. The list is endless. You could walk out with a $3,000 bill for a hiccup.

HEFFNER: Okay, except for my pocketbook, am I better off as a patient, or am I worse off?

ROSENFELD: As far as radiology is concerned, you’re worse off.

HEFFNER: Too many…

ROSENFELD: You’re getting unnecessary radiation. Some of the procedures that are done are not entirely without risk. Risks are not very great in most of the tests we do, but there is some risk. There is some pain in some procedures. There is some discomfort in some procedures. There is loss of time from work. I mean, these are all the things. Now, I’m not deploring the availability of this technology. But what I’m saying is, one has to use it when it’s appropriate and not use it indiscriminately for everybody just to protect yourself. I don’t think it takes a very smart doctor to make a diagnosis who takes every possible test, puts it in the computer, and the computer gives him the answer.

HEFFNER: Yeah, but this isn’t a competition to find out who’s smart and who’s not smart. Talking about the patient, am I better off in 1981?

ROSENFELD: Yes, you are better off in 1981, but only if you are subjected to the tests that you need that are reasonable and that are pertinent to your specific complaint, and which are ordered on the basis of judgment. You know, you can’t ask that question, “Am I better off in 1981 because of all these tests that are done?” because cost of health care delivery is a very real thing. I don’t know the percentages, but thousands of dollars are spent by an average family each year either to pay health premiums or to pay, make up what health premiums don’t cover, what health insurance doesn’t cover. And you are not better off if you are broke or if you are financially threatened or if the health system is going bankrupt because of a lot of unnecessary testing. I’m talking about unnecessary testing.

HEFFNER: Okay. But the answer you gave me first of all – and you were very quick to put it in when I started to ask, “Am I better off?” – is, “Yes”.

ROSENFELD: Yes, health care is better than it ever was before.

HEFFNER: Okay.

ROSENFELD: But that doesn’t mean that we must lose our vigilance and for patients and doctors to continue to tow the line.

HEFFNER: All right, that’s a fairly optimistic note on which to end.

ROSENFELD: Yeah.

HEFFNER: Thanks so much for joining me today on this discussion of Second Opinion, and of medical matters generally, Dr. Isadore Rosenfeld. And I hope you’ll come back when you revise the book and we can go through the newer things that we’ve discovered.

Thanks, too, to you in the audience. I hope that you will join us again here on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night, and good luck”.

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