The Art and Science of Medicine

GUEST: Richard P. Cohen, M.D.
VTR: 1/29/04

I’m Richard Heffner, your host on The Open Mind. And I must say that it’s been my own very great good fortune over the years generally to have enjoyed absolutely splendid medical care at the hands of truly fine, thoughtful and expert physicians … men and women … who have combined great technical skills with a warm and comforting manner.

Of course, as one medical guest said to me … there’s room for both of those. At the same time, he added, if given the choice, I would rather be saved impersonally and technically than go to my death very comforted.

Anyway, I don’t have to worry about that for my guest today, my own physician, does combine both qualities even as we may have some faintly etched friendly differences of opinion as we discovered recently when talking about just how tough and direct and particularly immediate a physician needs or ought to be in laying out all the bad news there is for his patient to confront.

Dr. Richard P. Cohen, Clinical Professor of Medicine at Cornell Medical School and Attending Physician at the New York Presbyterian Hospital is really a physician’s physician. And I want to begin our program today by asking my guest just how much up front a physician ought to be in telling us, right off the bat, what we obviously aren’t going to want to hear. Does the doctor necessarily know best at this point? That’s a real question.

COHEN: Well, Richard, I think that the difference between when you see me and you call me for results or I call you with results, is that you’re … you’re going to talk to me and I won’t post your results on a web page for you to go look at, “this is your cholesterol, this is the result of your x-ray.” And so I, or any practitioner has to be aware when we’re giving you results, that we’re putting some of our self into the way we present those results.

Now we … you and I have discussed the issue of if something is abnormal, say in a blood test that I do on you and I think that that’s a lab error and I want you to come back to repeat that and then I don’t think that I do you any good by saying to you, “Your potassium is 7.5, if that’s real, you could be dead in 20 minutes”, which is in theory … true … when I really believe that that’s a lab error. As long as I know that you’re going to come back and repeat that test. So, we don’t like … there’s a … the literature talks about a term called “truth dumping”. And we just throw out …

HEFFNER: Truth dumping?

COHEN: Truth dumping. Just dump the truth on the patient … say, “I got your blood tests back, your potassium is 7.5, that could be life threatening, please come right over to have it repeated.” If you’re going to come right over … telling you that that’s life threatening doesn’t make your day better or doesn’t promote my ability to care or heal you.

HEFFNER: But suppose there’s been no error. And I want that time, even the time it takes to get to your office to think about who I am and where I am and what’s going to happen.

COHEN: That’s a bit far-fetched for me to try to, you know, to try to really fathom that. If, if, God forbid I make a diagnosis of cancer of pancreas on you and you come in my office …you know I’m going to sit with you and I’m going to explain to you the reality of that diagnosis statistically … the likelihood that I’m not going to be able to help you. So that you can, you can begin to make preparation in such for what would be your demise, and put your affairs in order. And for me to help you palliate to make your death easy and better.

But … the paradigm I use with the medical students in teaching is … I’m sitting …you’re sitting in the office on a Friday afternoon and you get back an equivocal mammogram on somebody. And that patient has no idea that that result is going to come to you that Friday; they think it’s probably … do you really have to call … the question we ask is “Do you have to call that patient and tell them, ‘I just want to let you know I got your mammogram, there may be a problem, I’ll talk to you next week about sorting this out’.” When there’s nothing that you can imagine … any good from that. I … I’m not sure … I’m not sure that when we’ve discussed this in the office that that kind of stuff really does people any good.

HEFFNER: Of course, when you say “I’m not sure … I, Richard Cohen, am not sure that that’s going to do you, Richard Heffner, any good” … in another area of disease … you are saying “doctor knows best”.

COHEN: The doctor … no, the doctor has the scientific knowledge. The patient has the biggest stake in what’s going on. But the truth telling in certain senses can really be mean and counter-therapeutic. There’s no upside to being mean to people. There’s just not … it doesn’t serve any purpose.

HEFFNER: Well tell me about truth telling and being mean. What do …

COHEN: Well, often …

HEFFNER: … you mean.

COHEN: … often the truth can be mean. Because if … if you see patients and somebody has megadisagnosis … somebody they have a disease and you think their disease is very innocent, benign such, and you sit with them and you talk to them and you go through all that. And then you find out they went to the Internet that night and they, without the filtering of understanding the realities and the settings in which things have gone on, they’re getting all the facts, but without real understanding. That’s, that’s mean. And that’s … that’s what I’m kinda trying to get at.

HEFFNER: Well my understanding is … and I wouldn’t guess this from my association with you, or, since I’ve been lucky, with other physicians … that there is less and less time in the doctor’s office and more and more time on the Internet doing just exactly what you say. Is that true?

COHEN: I think … yeah … sure … around the country with, with physicians feeling constrained with time and it’s easy … it’s very easy for me to say to you, “Rich, I got your potassium … 7.6 … come on in now, we’ll repeat it … go up on the Internet and check out hypercalemia understand what its implications are. That’s, that’s not what … that’s not why I went to school; that’s not what my mother would want me to do in terms of my interaction with you.

HEFFNER: that’s not what you went to school for; it’s not what your mother wanted you to do; but I gather, it is what willy-nilly so many physicians do. Now you a moment ago said, “around the country”. Are you implying that doctors in New York have more time; can spend more time; do spend more time with their patients?

COHEN: I think that …I would be naïve to think that the kind of practice that I’ve been blessed and the word is “blessed” to have … an Upper East Side Manhattan practice where I have not had to get involved with managed care and insurance care. It’s a throwback to the old days. I’m very blessed to be able to be on the Upper East Side of Manhattan where … the way I practice medicine today, which is, which is different, okay… is not really much different than I did 20 years ago, in terms of the time I spend and the way the mechanics of the office work. That’s not the way it is around the rest of the world, or surely around the rest of the country.

HEFFNER: Well I want everybody who’s watching to know that I don’t come from the Upper East Side; I come from the Upper West Side …

COHEN: [Laughter]

HEFFNER: … but I hear …

COHEN: [Laughter] I won’t hold that against you.

HEFFNER: … I, I hear what you’re saying and that’s a very interesting comment to make. It’s puts you in a much smaller setting with a much smaller group.

COHEN: Oh, sure. And when, when you say to your audience that you’ve been very blessed, you know, you’ve always gone to physicians who … when you call, you get a call back within an hour or a half hour. When you need an appointment you don’t wait more than a day or so. When you have an X-ray, you get a call from the physician within two hours about what it showed. We’re realistic, that’s not the way things necessarily go on around the country. Or even in large parts of the city. There’s a, there are … I’m aware that there are … and everyone is reasonably aware that there are different ways that care is given, there are different classes of care.

And I happen to be in a position with that class that’s very personal and very quick and very responsive to, to patients. And I enjoy doing that.

HEFFNER: So, we’re talking about economics. Not medicine, but economics.

COHEN: Well it’s probably economically driven, surely. My fees are not limited and I’m not forced to … I don’t have to watch the clock that I want to turn people through because I can only charge so much for every patient.

HEFFNER: And yet I’m … been fascinated by the fact, I probably shouldn’t say it because it will change …that your fees are low; not high.

COHEN: I’m … I make a nice living and I’m very comfortable with my fees and I, you know, [laughter] I think my charge … thank you …

HEFFNER: You’re an old fashioned guy, I guess. That’s the point. What, then, is happening to medicine on the primary physician level around the country.

COHEN: Well, you know, I’m not saying something that other people haven’t said before … the primary …

HEFFNER: Nobody says anything at this table that other people haven’t said before.

COHEN: Fair enough.

HEFFNER: Believe me.

COHEN: Well, you know, most … most primary care providers, which I am for you … I am the first call for you, I’m the one who everything gets coordinated through and I really enjoy doing that. Most people … what I do has now become triage work. You come in and they send you to the specialist or they decide which tests you want. It’s not the same kind of somebody to coordinate; somebody to watch. Care in this country has become very much provided by some specialist. And that’s, you know, it’s okay … but as far as getting back to our original discussion … it’ doesn’t really foster communication because there isn’t anybody to put everything together and that’s why patients are unhappy.

HEFFNER: What’s going to happen? What could happen that’s better? Nothing.

COHEN: Oh, what should be done to make things different?

HEFFNER: Yeah.

COHEN: Well, one would like to think that what patients really want and what makes me successful is that patients want the doctor to be available; patients want the doctor to be able to take time to be able to talk to them, to go over things, to explain things. For a patient to come in and feel that the doctor really heard what I had to say. When you come to see me, you sit down in the consultation room and we talk and then we go into the examining room and then we come talk again. Most people don’t have the time to do that. And that … that’s what … you know, I think that’s what patients really like about our care.

HEFFNER: Well, I understand then what you mean you are a throwback to an earlier time because that’s what I’ve been accustomed to and that’s why I feel so much at home. I remember when … I guess it was the first time I saw you and I came into your office, and you said, “Welcome home.” And that meant a great deal to me. But let’s go back now … if, if, if you don’t mind to this question of informing me and I wouldn’t put it … make it me … because I’m so healthy that nothing could be wrong that you’d have to tell me about.

COHEN: [Laugther)

HEFFNER: But, you’ve talked about … over the weekend why let somebody know on a Friday … that there is some equivocal material here, when nothing can be done in the meantime. How far are you going to carry that?

COHEN: Well, there’s no specific answer to that. I think that if somebody …if I get a result on somebody that requires immediate action, I’m obviously going to call them right away. If I have someone who’s anxious to find out what their scan showed, and they know I’m going to get the result; even if I have bad news for them on a Friday, you know, you really have an obligation in terms of the doctor-patient relationship to, to call them. But I’m not a computer that when something comes to me that I’m just going to shoot it out. I think about what I say to people in any … a good physician … talking to patients is a skill and interacting with people is part of the healing … part of the caring.

HEFFNER: Are you suggesting that two people … two different individuals, patients could have the same … be in the same situation … a Friday … a report … and your knowledge … your medical knowledge …your human personal knowledge of these two people might lead you to take a different tack.

COHEN: Absolutely. Absolutely. That’s a …

HEFFNER: And …

COHEN: … and it depends which test it is, you know, and what the result is. And that’s what’s fun and that’s what caring and that’s what we try to teach … that’s what empathy is. I remember … it’s a story that I teach my students … I had a mentor who was a brilliant, famous physician in New York and he became …I actually practiced with him for a number of years. And still a very important in my upbringing, my professionalism. He was a very paternalistic doctor, from the old school. If a patient said to him, “Doc, what’s my cholesterol?” He would answer with, “I’ll tell you what you need to know, where’d you go to medical school?”

He got very seriously ill, obviously before he died, and one day I went to visit him in the hospital and I walked on to the floor … this is a New York hospital, and the nurse said to me, “He’s very, very angry. He’s very, very angry. He’s very angry at the house staff.”

I’ve been in the business long enough that I knew he was angry at me, because he would be afraid to be angry at me, so he’d get angry at the house staff. And I walked into his room and his eyes were bulging out of his head with anger. And I said, “Aaron, what’s the matter?” And he said, “They’re not keeping me informed.” He said, “They’re not giving me the information I need to know to make decisions here.”

And I sat down and I … I can see it now … I sat down at his bedside and I held his hand and I got real close to him and I said, “Aaron, we’re getting lots of bad news.” I said, “Every day we’re getting bad news.” I said, “I’ve got to decide the pace at which we keep you informed.” I said, “We can’t really keep you informed. It’s mean” I said, “You’ve got to trust me to keep you informed at a reasonable pace.”

And he started to cry and I shed a tear and that day he became a patient. And it made it a lot easier, but it wasn’t fair for him to know each result as it came in because all it was going to do was upset him; because there was nothing to do. And that was good medicine, all right. And this was a man who was a brilliant physician. And that day he became a doctor …

HEFFNER: A patient.

COHEN: … he became a patient … thank you. That’s an important story for the students to understand.

HEFFNER: Do they?

COHEN: Oh, absolutely.

HEFFNER: Your students? The new …

COHEN: Oh, absolutely and we make a real effort, even in the first weeks to, to bring these points. I’ve been honored by the Dean for a number of years now; I give an opening lecture during orientation about caring for patients and right the first day, the first day they get this right in their face.

HEFFNER: See, that … you know that’s hard for me to deal with because when you say … if you said, “When did you go to medical school?”, I’d probably try to think of an answer, because I, I want to know.

COHEN: No, No. And that was wrong, that was wrong … that way of practice, paternalistic practice is, is wrong. Is wrong. Is wrong.

HEFFNER: Now, wait a minute, what are you saying “It’s Right or Wrong?”

COHEN: Well, you’re …it’s, it’s not as black and white as you’re saying. In the old days, in 1960 … 90% of patients in this country who had cancer were not told they had cancer.

HEFFNER: Seriously?

COHEN: Oh, absolutely. Good study … Journal of the American Medical Association … 90% were not told they had cancer. When I was a kid, Katherine around the corner had breast cancer, metastases to her spine … you know she had “arthritis”, the “arthritis” hurt. When she developed hepatitis, we thought it was “hepatitis”, it wasn’t; she had metastases to the liver.

You know I understand the case now in retrospect. But she was, you know, she was never told. That’s considered wrong now. I was wrong. When I was an Intern at Memorial Hospital, I remember patients in the Intensive Care Unit; there was a blind woman there, who didn’t know she had cancer. She thought she was in New York Hospital, not Memorial. And you weren’t allowed to tell her. So I’m, I’m not advocating that. But the point I want to make to you is that the notion that everything just needs to be thrown in the patient’s face, and that the patient needs to know everything … that’s, that’s, that’s not necessarily fair or good.

Somebody comes in with lung cancer and you think their prognosis is really yucky, okay? Do you want to just tell them, “Oh, you’ve got a four percent chance of being alive in five years.” You know, and if they don’t specifically ask you that question, no, you tell them “We’re going to make a real effort”, we point out the positive side, etc., etc., etc.

If they say to you specifically, “Do I … should I take a new job … I’m thinking of buying …” “Well, no” you can answer specifically. But to do what the Internet does is very different than what I do.

HEFFNER: Well, when, when I knew that I had cancer and went to Memorial and all of that, I went on the Internet and it scared the bejesus out of me.

COHEN: I rest my case. That’s not my goal. I mean I don’t think that that’s what a physician ought to do to his patient. I don’t think that somebody walking out of my office in tears because I scared the bejesus out of them is what I went to school to do.

HEFFNER: But it gave me questions to ask at Memorial. It did. And that was important.

COHEN: That can be done without scaring the bejesus out of you. That’s, that’s my point. And you agree with that.

HEFFNER: Yeah. I, I … you know what? I agree with it for the next guy. I’m not so sure … now I don’t want to be proven wrong with the situation in which you tell me the truth and it’s bad, bad, bad and I can’t do anything about it and that’s an untimely point and its cruel. I don’t want to be faced by that. But I must say that … maybe the problem is, Dr. Cohen, my age because I’m so much older than you that I go back to the paternalistic medicine and I remember that time and I’m still suspicious of medicine being practiced that way.

COHEN: And I’m aware of that with you. And that, that’s good. That’s good. And I can understand that because you saw people, you remember those stories of the patients who had cancer who were told they had arthritis …

HEFFNER: Yeah, but I’m still shocked when you say “1960”; I think of everything happening in 1925 … the year I was born.

COHEN: This is a young business. This is a young business. Modern medical ethics really only begin at the Nuremberg trials, I mean before that there were no … who thought that physicians could do harm? When you were a kid, what harm could a physician do? What’d he do, what’d he do, he didn’t do anything wrong?

Then we found out that there were Nazi doctors who were doing terrible things. So all of a sudden we were saying, “Oh, we’ve got to have medical ethics”. So medical ethics develops appropriately. The patient’s right to know; the patient’s right; the patient’s right. That’s where everything … you had the right to know; you had the right to refuse; you have the right to decide; you have a right to participate. The doctor doesn’t have the right to withhold. That’s where ethics went.

And then, of course, we screwed it up because then we said, “Yeah, you also have the right to have a doctor kill you if you want him to take you down”. Oh, wait a minute, that’s not where we want to go, you know; that’s where the break comes in all of this. Or with Dolly … everybody should be allowed to be cloned. Well, well, hold on … why shouldn’t you have the right to be cloned? Well, wait a minute. Maybe that’s not right. You know, so it’s … all of this is very young.

HEFFNER: What do you … what do you find in your patients about interest in these things? Are people talking about these issues? The ethical issues?

COHEN: I think my patients are tuned in and I’m a … and I like most of my patients to have a, a Living Will and I want patients to have Advanced Directives. I think they’re very important; that’s where you basically tell me today that if, god forbid, you have a stroke and you can’t eat on your own you don’t want to be fed artificially, you don’t want to be put on a ventilator. I have those conversations … not all the time … because, fortunately, in my practice, not that much. But my patients who have serious terminal illnesses, we talk about how far we want to go, what … at which point we’re not going to go back to the hospital; at which point we’re not going to give you medicine; we have those conversations all the time.

Yeah, I think the patients are tuned into that; they are sophisticated and patients … the kind of people that I see …

HEFFNER: Is the law sufficiently tuned into that?

COHEN: The law …the law … I think the law is really concerned, appropriately, that the patient be …his rights be protected and that the decisions that are made are made because of good and valid reasons and not because of economics or ethnicity. When, when I was an Intern, a Resident at Memorial Hospital, we used to have a … and this is well known, I mean I’m not telling anything out of school … the names of all the patients on the floor would be on a bulletin board and next to it would be a letter … a, b, c, or d … determining how much care we thought that patient should get. An “a” was somebody who, you know, everything ought to be done and a “d” was someone for whom only measures to maintain comfort should be made.

And those decisions were made by the doctors based on how things were. Well, the state legislature found out about this and the country found out about this, and said … “no, no, that’s wrong, that’s wrong; the patient should decide. You should ask the patient how much they want done. It should not be decided by the doctors.” And that’s when the DNR laws come in … those laws are good because the potential for us to make those … or for someone to make those decisions based on ethnicity, or income, and such were really dangerous. And so the state said to itself, “No, no. We’d better protect and we’re going to have very formal rules.”

HEFFNER: But then you’re leaving the patient at the mercy of the rules.

COHEN: The rules work pretty well.

HEFFNER: They do?

COHEN: Yeah. The rules work pretty well. Because one of the things that …you, you won’t understand this …that we still have all the cards and a good empathetic doctor …

HEFFNER: You mean “a”, “b”, “c” and “d”.

COHEN: No, no. I meant in like a poker game. Like a poker game. Because the way I say to you and the tone of voice and one needs to be aware of this; the way I present a piece of data to you will influence the way you’re going to do things. And, and that’s very important for me to be cognitive of. If I say to you … if I say to a patient who’s going into the Intensive Care Unit, who is seriously ill with pneumonia …but they’re at the end stage of life … and you say, “well we can move you to the Intensive Care Unit, but I gotta let you know, if you go to the intensive care unit, they’re going to put this tube in your throat and then they’re going to have to sedate you, and you periodically may wake up and it’ll be very uncomfortable; and you may feel like you’re underwater and you won’t be able to talk and you’re only forty …

HEFFNER: [Laughter] Thanks, but no thanks.

COHEN: But that’s the way … but you can present that way. As opposed to “I’m very optimistic and it maybe somewhat uncomfortable and such … so we have all the cards, in all of these interactions and so …but that’s, that’s why you train the good people and have teams of people looking and making sure everybody’s playing fair.

HEFFNER: Now, are you convinced that medical students are being trained well enough now to do that; to play the cards right?

COHEN: Yeah. Yeah. I think we make a real effort … I know the Cornell curriculum and it mirrors curriculums at other good schools around the country. All the schools are good, really. You know, you start with … there’s a lot of teaching this … we have a course in ethics, we have a course in the doctor-patient relationship; we have, you know, stuff on talking to patients; that students get into the doctor’s offices, even in the first weeks of medical school. Largely to look at those kinds of issues; they don’t really know how to listen to heart sounds, but they know how to talk to people. And those are skills that they have. And we might want to nurture those skills. And the other thing to do in a good medical and in a good medical education is, is that the people who are not really interested in being willing to step up on that … they shouldn’t do what I do. They should be pathologists; they can be radiologists and they do make major contributions to medical care … but they aren’t necessarily the ones who are talking to patients.

HEFFNER: Are there more good talkers than others?

COHEN: I think … I … it’s not that hard. I don’t …

HEFFNER: It’s easy for you to say that.

COHEN: No. I don’t think we have … medical school class is very different than it was when I was in medical school. But they’re, they’re very good. You know I don’t think there’s really a problem.

HEFFNER: So you’d say, knowing the medical student of today, “we’re not in trouble”.

COHEN: Not at all. No. No, we’re not. Not at all. But the big difference between the medical student of today and the medical student when I was in medical school is what …

HEFFNER: They’re women.

COHEN: They’re women. That’s absolutely … we’ve had this discussion. Yeah, they’re women and they’re terrific. They’re terrific.

HEFFNER: And that’s the best possible, positive note to end the program on.

COHEN: [Laughter]

HEFFNER: And thank you very much for joining me today, Dr. Cohen.

COHEN: [Laughter] Stay well.

HEFFNER: Get well!
And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.