Health Matters, Part I
VTR Date: July 30, 1981
Dr. Isadore Rosenfeld discusses medicine and medical options.
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GUEST: Dr. Isadore Rosenfeld
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 is my guest today.
Thanks for joining me today, Dr. Rosenfeld. I made up a long list of questions. And as I came over to the studio I was thinking, “What manner of man am I really going to deal with here? Should I consider him first an artist? Should I consider him first a scientist?” Of course, the best thing to do is to ask you the question.
ROSENFELD: Well, I consider myself first a doctor, and all these other things that I do, like appearing occasionally on television interview programs or writing books, is simply an extension of that occupation, that life’s work.
HEFFNER: All right, now, is the doctor an artist? Is he a scientist?
ROSENFELD: The good doctor is both. Now, I know that sounds like, that sounds platitudinous. I think part of the problem that we’re facing today is that we have such a preoccupation with technology, which has its place, and for which I think God, and which saves lives, and without which we would be where we were in the eighteenth century vis-à-vis disease. Despite all that, I think today’s problem is preoccupation with technology at the expense of some humanity. I think there has been and there is a dehumanizing element to the practice of medicine. You see, we’re told every day, we’re told marvelous statistics. How many people die of infection anymore? How many people are in iron lungs? Look at all the patients whom we cure cancer. Look at the life expectancy today. Things have never been better on paper. Yet it’s a curious paradox that if you ask people about their perception of medicine as it is practiced toady vis-à-vis their interpersonal relationship with their doctor, some of them find it difficult to establish a relationship with him that is based on his being as healer, a counselor, and confidante. Many people, unfortunately, view their doctor as a technician.
HEFFNER: Well, you say, now…I’m interested. You say many people view their doctors as technicians. And I thought at first you were talking about the doctors viewing themselves in a sense as technicians rather than healers, having been so overwhelmed – maybe “overwhelmed” is the wrong word – so beset by the need to master so many technologies.
ROSENFELD: No, I think it’s more, I think it goes deeper than that. Of course, today’s doctor, when you compare him with the doctor in the good old days and the horse-and-buggy medicine, in the old days, everybody loved the doctor in the old days. And curiously enough, the doctor could do very little for you then. He was an observer of disease. The textbooks of those days showed the graphs of how fevers develop in the course of an illness. Nobody could cure pneumonia. There were no antibiotics. There was very little surgery except amputation. Yet, despite the fact that he was limited in what he could do, the doctor was universally loved and respected. And that was because he comforted, he communicated, and he consoled. Whether or not he treated was beside the point, because patients in those days were very fatalistic and very nihilistic. If you lived or died was the will of God. Today, the doctor knows that he’s more than a hand-holder; he’s a doer. And he is so preoccupied with working you up and getting you cured that he doesn’t feel he had time for either niceties which patients traditionally still expect. Now, the great pity as far as I’m concerned is that the doctor or some doctors don’t feel they can do both. I think they can, and they should. I think there’s room for both. I think they can, and they should. I think there’s room for both. And I think, if given the choice, of course, I would rather be cured impersonally and technically than go to my death in a very comforted way.
HEFFNER: With your hand being held.
ROSENFELD: With my hand being held. But the point is one shouldn’t have this kind of extreme choice. The options should not be so polarized.
HEFFNER: You say, “The options shouldn’t be so polarized”. But as we develop more and more information, more and more technical knowledge, isn’t it likely that there is no other way to go but that the options will be so polarized that the need to know more and more that our medical schools will put, despite what is said, will put less and less emphasis upon doctoring, and more and more emphasis upon science? Isn’t it inevitable?
ROSENFELD: Well, you’ve got several questions wrapped up in that very profound statement. I don’t think that the fault lies with the machine; I think the fault lies with the man. I don’t know, I don’t think that a busy schedule, that a tight schedule, or knowing when or how to use sophisticated tests to arrive at a diagnosis or implement treatment, I don’t know that those make a warm and compassionate and caring approach impossible or difficult. Some of the busiest and most harried doctors I know always leave you – and the best – always leave you with the impression that the time you spend with them, however brief, is yours, and that nothing else matters but you to them. I also know other doctors, who, if you had all day to spend with one patient, could never convey that. Now that is not, in my judgment, a matter of education or a matter of machines or technology; it’s a matter of character and temperament. And I think what you said in the latter part of your question, that if we select people who are properly suited, innately properly suited to be real doctors, then all the technology in the world is not going to corrupt them or dehumanize them.
ROSENFELD: And I think the problem lies with our educational system. And the educators are aware of this. We select students now, the current crop of doctors, we select them on technical ability and marks.
ROSENFELD: Because we don’t know a better way to do it. The admissions committees in every medical school in the country are swamped by thousands of applications for maybe a hundred seats. Now, they haven’t got the time to interview all these people, so they use computers. They plug a kid in and then they take out the top 200. That’s the only way they can do it. They have tried psychological screening, and that doesn’t work either. And this is a real dilemma.
HEFFNER: How about spending the time that you feel a true physician can and will spend on an individual patient? How about in terms of the ripple effect of how much good you do when you pick for medical school the right kind of candidate? How about spending that kind of time instead of just going by the numbers, by the computer?
ROSENFELD: Well, it’s technically very difficult to do. This is a plea that I have made and I feel very strongly about. You see, it’s true that we need brilliant scientists. I think that some of the young men and women in medical school today will turn out to be, to move the frontiers of medicine. They will get the Nobel Prize and so on. We need them. But we also need people to look after the sick. And I think there are many of these young men and women who should be in Ph.D. programs and scientific research careers who get thrown into the MD route and who, if for one reason they’re forced to practice because government or other support agencies have cut off their research grants, they have their MD, they go into practice and they’re not temperamentally suited to do it. And I think there are more and more of these people going into practice.
HEFFNER: But Dr. Rosenfeld, look what you’ve said. You’ve said, “Heffner, it’s not the machine; it’s the man”. Okay. Then you say, “The machine can’t work when the machine is medical school admissions. The machine really can’t work in terms of…”
ROSENFELD: No, I didn’t mean machine in…By “machine”, I didn’t mean “establishment”. By “machine”, I meant the technology to which you were referring.
HEFFNER: No, no. I understand that. But then you describe a process of admission…
HEFFNER: …to medical school that almost seems to preclude – “preclude” is too strong a word – seems to emphasize the kind of person who becomes technological…
ROSENFELD: No, you don’t get the right…I don’t think we’re getting the right mix of people.
HEFFNER: Then what is the hope for the future? Goodwill on our part…
ROSENFELD: I’m not sure. I’m not sure that I know the answer to that. And I don’t think medical school educators know the answer to that, either. As a matter of fact, this emphasis on marks has much more effect than just in selecting students for medical school. For instance, the kids in undergraduate college are so competitive it’s dog eat dog. They have been known to disrupt the laboratory results of somebody whom they view as a competitor so that they would be one leap ahead. They cheat, some of them. These are documented things. Now somebody who cheats in pre-med cheats in med and cheats as a doctor. One of the possible ways – I was discussing this with the dean at the Cornell medical School the other day – one of the possible ways of solving the problem is this: when a young man or woman is in undergraduate school, they have a counselor, an advisor, a premed advisor. They can be watched during that four years, independent of their grades, as to how they interact with their peers, how they interact with their teachers, how they interact in their social environment. And I think that if one were to place emphasis on such a counselor’s analysis, based on a four-year observation, which would then be presented to the medical school with the application and given weight, that may be one way to do it.
HEFFNER: Well, I hope there is at least that way. But look, I want to get on to this question of Second Opinion, a fascinating new book. And I was reading your Complete Medical Exam. I get nervous reading some of the questions you are asking, thinking about the answers I would have to give if my physician were to ask me. But one question that occurred to me…As you press this matter of the patient’s right and need and responsibility to participate with this physician in seeking, where appropriate, a second opinion, I wondered, and I wrote this question about because I wanted to use the words that I want to mean what they mean: How can you reconcile what I think is the obvious need of every patient for seeing in his physician a source of strength and of real help with this need for a second opinion, for second-guessing that doctor? Not one who can do no wrong, who we’ll all accept the notion, forgive me, that doctors aren’t gods…But I’ve got to believe in you, and I’ve got to believe in what you say because part of your relationship with me and mine with you had to do with my faith and trust in you. How does that correspond with this notion of look for a second opinion?
ROSENFELD: I don’t mean to suggest either now or in the book that every medical situation warrants a second opinion. I think there are certain well-defined circumstances whoever under which one is well advised to get it regardless of whatever threat it might constitute to the doctor-patient relationship. First of all, I think that where a good relationship exists in the first place, the doctor should initiate that procedure of the second opinion. I know in my own practice…
HEFFNER: Then we don’t worry about it.
ROSENFELD: Yes. But I know that in my own practice when I make a major, a decision for a major recommendation in which I have complete confidence in my own judgment, I nevertheless offer the patient a second opinion. Because I think in the back of everyone’s mind, if you give them a dire prognosis or a diagnosis, you tell somebody they have, or you imply to somebody that they have a cancer or tell somebody they have a bad heart or need cardiac surgery and so on, I think that it’s only human in the back of every patient’s mind to hope that perhaps you’re wrong. So I think that, in the first place, in such major situations, doctors should take the initiative. Where the doctor doesn’t take the initiative, however, I think that it is important for us to change the kind of psyche that you describe now because nobody has a monopoly on wisdom and on judgment and on information. And there isn’t a doctor practicing today who has not at some time or other, and more than once, made an error in a major recommendation to a patient. So I think that the situations in which a second opinion become warranted really, in the circumstances, become quite clear. In the interpersonal relationship, in the, how the news is broken, how it’s received, I think it’s almost a self-determining situation. The sensitive doctor will know when the patient is worried or insecure, and should initiate it. And if he doesn’t, the patient who is worried and insecure should be able to say to his doctor, “Look, I have great love and confidence in you. We’ve had a great relationship. This is a very terrible thing you’re telling me”.
HEFFNER: It’s interesting to me that in the people, with the people I’ve discussed your book and the question of second opinions, usually the focus comes almost immediately on surgery. They think one is talking about surgery. But I gather from your book you’re talking about a much wider field of medical alternatives than surgery.
ROSENFELD: Yes, yes. Surgery, as a matter of fact, if you stop to think of it, surgical operations happen very rarely in the course of one’s lifetime, if at all. I can name many people, including myself, who have never had an operation, but who have had illnesses. You know, there’s acne, there is diverticulitis, there is peptic ulcer, there is heart trouble, there is stroke. There is a whole variety of serious, disabling or life-threatening diseases in which the therapy, the treatment can very, and in which differing degrees of expertise by a practitioner can make a great deal of difference. I think one of the saddest things to observe in the practice of medicine is to see people suffer unnecessarily. To suffer because they are following the recommended advice, the recommended regimen of their doctor, following it to a T and not getting any better. And so wrapped up with this attitude that they don’[t want to hurt the doctor, and he’s after all a doctor and he must know what’s right, that they go on and they suffer unnecessarily. Whereas it may be that some other physician is working at a new approach, has had a new approach. You know, we often get set in our ways of doing things, doctors, that is. I know some doctors use digoxin, that’s the kind of digitalis preparation they use. It has certain characteristics. Others use digitoxin because that’s what they’ve been accustomed to. Now, that works differently from digoxin. And the digoxin doctor doesn’t use digitoxin because he’s never, he has no experience with it. Now, it’s the same thing in the management of whether it’s chronic arthritis or a bowel problem or a cardiac problem. Doctors get in to a treatment by rote, and by habit do things in a certain way. It may be that in some cases that aren’t responding to a different approach would be preferable and more effective.
HEFFNER: So Doctor A has this approach…
ROSENFELD: Which may work in 90 percent of his patients, and he’s very satisfied with that approach. But if you are in the ten percent that doesn’t work, he may not opt to send you somewhere else.
ROSENFELD: He may hope that ultimately you will fall into the 90-percent bracket.
HEFFNER: Okay, but you, the patient, opt to ask for the second opinion.
HEFFNER: You have concluded this is a good guy, and whether he is or isn’t, whether his feelings will be hurt or not, you owe your first allegiance to you, the patient. And you opt for a second opinion, and long comes Doctor B from School B rather than from School A.
HEFFNER: And he suggests the other mode of treatment, the other drug. What do you do? Go for the best two out of three?
ROSENFELD: No, you read this book. (Laughter) I’m serious.
HEFFNER: That’s easier.
ROSENFELD: I’m serious. You know, I’m not plugging it. But the reason that I wrote the book was not to spend 400 pages on telling people to get a second opinion. You can say that in a couple of paragraphs or in a discussion like we’re having now. But it becomes very important to know what your options are. And in this book, for example…And there may be others. I don’t know. I haven’t found them, but there may be others. But what I try to do in this book is take all the major diseases, if you look through the index, and indicate the various approaches, surgical and nonsurgical, for the treatment of a disease. For example, in hypertension, I mention all the dugs now available, because some patients react adversely to some drugs. In angina pectoris, which is pain in the chest due to coronary disease s a rule, there is a host of drugs that we can use that your doctor may not be using. Some of them are new; some of them are old. There is more than one way to skin a cat. And most patients I know are treated successfully by their doctors. I’m addressing myself to those patients who aren’t responding. They should not hesitate to ask for second opinion. And this is especially true in the cancer field.
HEFFNER: But you’re not addressing yourself only to those who aren’t responding, because you’re talking about, with great humanity and great feeling, those who aren’t responding in terms of the quality of their lives, those who aren’t responding in terms of the speed with which a cure can be effected or relief can obtained.
HEFFNER: Now, what happens? I read and I reread Second Opinion, and I did because I found myself the victim of all the symptoms that you could possibly shake a stick at or write about. When was this book written?
ROSENFELD: This year, 1981.
HEFFNER: All right. This is 1981. Maybe this program will be repeated at the end of 1981, or in 1982.
ROSENFELD: Well, let me say immediately…
HEFFNER: Get the new edition?
ROSENFELD: (Laughter) There will be a new edition, we hope, every year and a half. I’m working on the new edition, which will appear in paperback in April of ’82. So I plan really to devote the rest of my life, to the extent that I’m able, to updating this book and making it an available reference for those who are interested in the treatment of all the major diseases.
HEFFNER: Seriously, you are going to update…
ROSENFELD: Yes, April ’82. And Bantam Books has agreed to publish that. So…
HEFFNER: See, that makes, to me, a very great deal of sense, because I wondered here, as I read, “Well, now, how many weeks or months does it take to set this up and type, and how many new drugs for doctor group C rather than A or B have been developed?” But it is an attitude that you’re talking about, and the…
ROSENFELD: Well, it is an attitude, but there are also facts, and there will be changes. I think that as of today the book remains up to date. But it will be even more so in April of ’82.
HEFFNER: I have to say that we’re taping this on the last day of, or next to the last day of July 1981. So that if there’s a new drug on the market today, people will know. You know, you start off the book, you say, “Your doctor usually has several alternatives at his disposal to treat most conditions. One may be better, more convenient, or more appropriate for you than another. You should know or be made aware of all these options when you are sick, and you should be able to discuss them freely with your physician. Unfortunately, either because they are too busy or don’t believe that it’s really any of your business, some doctors don’t tell you that you have any choice at all or what it is. That attitude is not in your best interest, nor is it likely to result in optimal medical care for you”. Are there any things that you wouldn’t think, when you came to the program today, are there things that you set aside? “Well, I’m not going to talk about those. Those, in a sense, are none of their business or too difficult for them to cope with”.
ROSENFELD: Did I think…
HEFFNER: Do you censor what it is you are willing to share with your patients?
ROSENFELD: No, just… (Laughter) No.
ROSENFELD: No. No, truly no. And I’ll tell you why. Of course, it depends on the patient, and it depends not so much on what you say as how you say it. I think there are doctors who can give you the worst news in the world, and have such a way of presenting it that you actually feel good when you hear it. I think that if one is dealing with a competent, responsible individual, it is your duty, it is my duty, as I see it, to inform that patient of the facts that I have accumulated about him in order for him to be able to comply with my recommendations. It is too much for me to expect somebody who doesn’t understand what they have or doesn’t understand the risk of the illness that they have, for them to comply by buying expensive medication or submitting to painful or expensive procedures if they don’t know what they have. Now, I don’t know if I’m responding to your question, but, and I don’t, I gather what you mean is: Do you tell somebody they have cancer? Is that basically what it is?
HEFFNER: Well, I wondered just where you draw the line. And since you’ve said, because of the modifiers, you’ve talked about the responsible patient, the person…
HEFFNER: You talked about an intelligent…
HEFFNER: And when that isn’t the kind of person before you?
ROSENFELD: Then you have to speak to this surrogate. You have to speak to somebody who is responsible for that patient.
HEFFNER: Always laying it on the line?
ROSENFELD: Laying it on the line, but laying it on the line with a humanity. For example, the question that you ask most particularly pertains to how you communicate the news about cancer. You can tell a patient that he has anything, he or she has anything. I mean, if I say to somebody, “Look, you know, you’ve got an ulcer”, or “You know, you’ve got gout”, or “You know, you have hemorrhoids”, they’re not going to fall apart. And our society is geared to accept that. But when a doctor says to a patient, “You have cancer”, even if it’s a benign skin cancer that once removed will never cause the patient any trouble, but the use of the word “cancer” is devastating. Now, how a doctor communicates to a patient the news that they have a potentially or usually lethal disease is an art.
HEFFNER: You know, that’s where we began the program. Is it art? Is medicine an art, or is it a science? Are doctors artists or scientists? It’s a good place to end. But I insist that you stay there. We’ll end this program and being again anew so that those who are watching us now can watch next week too. Thanks so much, Dr. Isadore Rosenfeld.
And 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”.