Rx: An Ounce of Prevention

GUEST: DR. ISADORE ROSENFELD
VTR: 6/21/1986

HEFFNER: I’m Richard Heffner, your host on THE OPEN MIND. And like everyone, I guess, I feel a heck of a lot safer if not necessarily better when there’s a doctor in the house. Even when my wife earned her doctorate a few weeks ago, surely when my guest on THE OPEN MIND is once again Dr. Isadore Rosenfeld, Clinical Professor of Medicine at New York Hospital, Cornell Medical Center. A distinguished cardiologist, President of the County Medical Society, and one of the best raconteurs I know. Dr. Rosenfeld’s new Simon & Schuster book is entitled, MODERN PREVENTION: THE NEW MEDICINE. And I want to begin our program by asking him just what’s so new about an ounce of prevention being worth a pound of cure, his profession’s stock and trade. Dr. Rosenfeld?

ROSENFELD: That’s a very good question. You know, Richard, you mention the word prevention, and most people say, oh well, it’s the same old stuff about smoking and weight and watch your diet. As a matter of fact, there are thousands of useful, new facts that have become available which I think can make a difference not only in the prevention of the major killers like cancer and heart disease, but things like kidney stones, gall stones, sea sickness, mountain sickness, snoring, all kinds of things that interfere not only with the duration of life but with its quality. For example, let me give you one example that I think is quite useful. Patients who smoke, cigarette smokers, are the bane of a doctor’s life. If somebody comes into the doctor who has heart disease and so on, the patient doesn’t…and generally the doctor will say to him, look, go somewhere else. If you can’t stop smoking, I won’t have anything to do with you.

HEFFNER: Now, have you said that to anyone?

ROSENFELD: I don’t say it.

HEFFNER: Okay.

ROSENFELD: Because those people really need more help. And there’s no use sending them away. But there’s a lot of suggestive evidence that beta carotene, which is a precursor, a forerunner of Vitamin A, not Vitamin A but a forerunner of it, may be preventative of lung cancer. So instead of chasing these people away, I still insist that they stop smoking to the best of their ability and mine and give them beta carotene. And there are a lot of things that are not way out that we used to think were the province of the food faddists and health faddists. Supplements. Traditionally the medical profession has been against vitamins and supplements and…you know, you go to a traditional doctor, and I am a traditional doctor, and you say shall I take vitamins? And what’s the stock answer? You know it. You have a balanced diet? You eating everything? And you say, yes. You don’t need vitamins. Well, I’m not sure that’s true. I’m not sure, for example, that some Vitamin C and some Vitamin E and some Selenium don’t act as anti-oxidants and help prevent. I may be wrong, but I think in those amounts they’re harmless and they may be good. That is what I’ve tried to put in this book. The things that are reasonable that may make an impact on prevention in addition to sort of the usual thing.

HEFFNER: But you know I have something of a larger question to ask you. I’m fascinated by modern prevention. I’m fascinated by the ability to thumb through the book and find out all of the things you mentioned. Obviously one looks in terms of one’s own immediate concern. But you started off the program by saying there are so many new things that we know. You said that, and I had been planning to read from the book where you say just precisely that. Wonderful new things that we know. Just amazing numbers of them. But if that’s the case, doesn’t that put the whole idea of our being more involved, ourselves, the general public, in our own care? Doesn’t that put that somewhere behind the eight ball? That argument, how do we keep up with, how do we know about these things? Isn’t this an indication all the more that we do need to come and ring your bell?

ROSENFELD: Yes. I’m not writing this book in order for you not to ring my bell.

HEFFNER: Yeah, but you’re talking about our obligation. The things we need to do.

ROSENFELD: Yes. Let me put it this way. I think that there is a problem in education and in communication of medical facts to the lay public. This is not because doctors don’t want to communicate as I’ve indicated in the book, or don’t know how to communicate, or that patients are not interested. There’s a tremendous interest in medicine. The fact is that in the real world you go to a doctor when you’re sick. And the doctor will address himself to your problem. Doctors are really too busy to sit down and tell people what they have to do. To tell them about beta carotene. To tell them about a lot of these other things that I talk about there. And as a result there’s an information vacuum and people go to all kinds of gurus and to all kinds of magazines and all kinds of resources some of which or many of which are of questionable validity.

HEFFNER: Then what do you do? How does a lay person distinguish between quackery and the real information that isn’t going to come from the too-busy physician?

ROSENFELD: Well that’s a…One of the things is to read the book.

HEFFNER: I’ll buy the book.

ROSENFELD: But I think that…We’ve discussed this before in one of the wonderful interviews we’ve had a year or so ago. I think that it’s an obligation of the media to see that in their talk shows and in the distribution of information the kind of information that’s given is done by qualified people.

HEFFNER: Yes, but come on now. The media are business enterprises. They’re designed to appeal to as many people at any one moment as possible. It’s not their business to be in the health business. Now is there…

ROSENFELD: If it’s not their business to be in the health business, they shouldn’t capitalize on people’s interest in health, and present as experts individuals who are not.

HEFFNER: Now wait a minute. What about the medical profession doing something more to help solve this problem? You’re talking about the traditional organization of medicine. The too-busy physician. Is there some other way in which the general public can get the kind of talk you talk about? You say it’s not that doctors don’t want to talk, but that they’re sick-caring people. They care for the sick. And they don’t want to spend their time on the well.

ROSENFELD: They can’t spend their time.

HEFFNER: They can’t do it. Well, then how about organizing the organization of medicine in a way that provides for it rather than against it?

ROSENFELD: Well, you can’t organize it, I don’t think, in a doctor’s office. And as things are going now, as things are shaping up in the delivery of health care, with less and less of the traditional doctor/patient relationship active in the future, what we’re going to be seeing is the delivery of health care by corporations which will then make this kind of communication even more difficult. And less common. But I think that what you say is being done. For example, on Sundays on cable television they have this Lifeline and that’s really directed toward doctors but there’s an awful lot of useful information on that. The problem is it costs a lot of money. I was until recently, as you pointed out, president of the New York County Medical Society, and we looked into a way of disseminating information. Not only disseminating it in a positive way, but analyzing many of the things that are being presented to people in books and in products in the health food stores that are quackery. The B-15 kind of thing that was the rage so many years ago. And it’s again largely a matter of funding.

HEFFNER: What did you do?

ROSENFELD: We didn’t do anything. We didn’t do anything. I mean it’s in committee. Now perhaps my successor will do something. But we’re aware of it. And there are…the means do not exist in commercial media to do it. Perhaps public television would be interested.

HEFFNER: Yes. But your specialty is such that I imagine that…I imagine…(clears throat) Excuse me. What are you doing about losing one’s voice? I mean, I didn’t even see that in the book. You’re a cardiologist. There is specialized…

ROSENFELD: You go back to silent film.

HEFFNER: You mean I should talk for a minute. I’ll try again, Dr. Rosenfeld, seriously. In terms of your expertise, it takes you to communicate it. There are few people who know as much about cardiology as you do. Therefore, you’re a very busy person. How do I avail myself except through this book of the expert information that you know? Where do I get it?

ROSENFELD: Well, I’m not the only person who writes books. There are doctors, good doctors, who write books on a variety of subjects. I think one has to be discriminating. What I’m saying is that one has got to find, people have got to find reputable sources of information. They exist. But I think one has to be careful. One has to screen them. The various books, I think the HARVARD NEWSLETTER, for example, is very good.

HEFFNER: Read by how many people?

ROSENFELD: I don’t know. Well, that’s…I mean it’s there. It’s there. And people should know about it. And I’m telling them about it now.

HEFFNER: Yes. But I’m really asking the question, you say modern prevention, the new medicine. And I’m asking you whether it is a realistic statement to indicate that prevention is so very much coming into its own at this time. This is modern medicine.

ROSENFELD: Yes. I think it is. And I’ll tell you why I think it is. People have traditionally considered medicine, considered medicine in the sense of you know, you wait until you’re sick, and then you go to the doctor. There is a whole thrust now not only in this book but among people, even the interest in health food stores and so on, looking for prevention. I say that prevention is here. And I indicate to what extent it is here in this book. And that in my judgment is the new medicine.

HEFFNER: Dr. Rosenfeld, I think if I may be so bold as to say, you say here that modern prevention, prevention medicine can be here, could by here. And you demonstrate that in your excellent book. But to say it is here, and then go on to indicate the many different instances in which doctors…

ROSENFELD: Can be here. The extent to which it is here depends on individuals’ gumption and determination to utilize the facts that are available. It is here if you seek it out and apply it. You don’t get it by osmosis. It is here, yes. It is available, but you’ve got to look for it and you’ve got to act upon it. The other thing is you know that many people know some of the facts that are in this book and don’t apply them.

HEFFNER: Why?

ROSENFELD: A) It’s boring. B) It can’t happen to me. This is especially young people. People look for a quick fix. You know, I think that 35% of the cancers could be eliminated by diet. And I spell out the kinds of diets for the particular types of cancer. I mean cancer of the stomach would have a different diet than let’s say cancer of the bowel. A different one for cancer of the breast. And there are specific diets which we think may reduce the likelihood of specific cancers. You don’t find people paying attention to that information. We could reduce the number of heart attacks. We have already substantially. We could reduce them even more by control of certain risk factors. And not only control of risk factors but also the administration of certain medications that people won’t take.

HEFFNER: Let me ask you a question.

ROSENFELD: Let alone cigarette smoking.

HEFFNER: All right. Let alone cigarette smoking. You know how many doctors who smoke cigarettes?

ROSENFELD: Not many, quite frankly.

HEFFNER: I do.

ROSENFELD: Well, I don’t.

HEFFNER: And maybe some of our friends in common. Do you know any doctors who smoke cigarettes?

ROSENFELD: I would have to think. I really would have to think. I was at a doctors’ convention the other day. I can’t remember. I can’t remember more than one or two. I think the facts are that doctors have stopped smoking, 70 or 80%…I really don’t know many doctors who smoke.

HEFFNER: I remember when Norman Cousins sat at this table shortly after, and this is many, many years ago I’ll admit, shortly after he had done an editorial in the SATURDAY REVIEW in which he talked about his doctor friends who have preformed operations, have seen what a lung of a smoker looks like, and they go on taking their drags on the cigarettes. But the point I really wanted to raise…

ROSENFELD: I think that’s changed, Dick.

HEFFNER: Well, I hope so.

ROSENFELD: I really think that’s changed.

HEFFNER: but the point I, the question I really wanted to raise was whether among those who are able in terms of their information to exercise the preventative arts, do they do so? Or are we spitting against the wind?

ROSENFELD: You’re talking about…(inaudible)…

HEFFNER: No. I’m talking about your own profession.

ROSENFELD: And what is the question? I’m sorry.

HEFFNER: Do they make use of the information that they have that you would put into the category of preventative medicine?

ROSENFELD: In their own lives?

HEFFNER: In their own lives.

ROSENFELD: I think most of them do, yeah.

HEFFNER: So, you’re…

ROSENFELD: I really think most of them do.

HEFFNER: So you are saying that it is possible for us to turn from people who have been indifferent, haven’t been willing to give the time, haven’t been concerned enough about what we do into a race of people who will make use of this knowledge?

ROSENFELD: I think it’s absolutely true. As a matter of fact, talking about doctors and smoking, the data from England indicates that those, this is some years ago, a 50% reduction in smoking among doctors and a corresponding reduction in the incidence of heart attacks.

HEFFNER: Among doctors.

ROSENFELD: Among doctors. And medical students, for example, have much better health statistics than law students. Because I don’t know if I said it in this book or another book that I have written, but the fact remains that medical students really now do invoke many of the things that I talk about here. And their morbidity, their illness is less, their respiratory diseases are less, their blood pressures are lower, they get more exercise than their counterparts in other graduate faculties. That is true.

HEFFNER: So what you’re saying that the obligation is to get the information to people and if we get the information to people, they’ll use it.

ROSENFELD: Yeah, I think so. They may not all use it, but if some use it, that’s very important.

HEFFNER: And the need for the physician to talk, which you describe so eloquently here and the unwillingness in the present situation…

ROSENFELD: Well, it’s not unwillingness. It’s inability.

HEFFNER: Inability.

ROSENFELD: You call your…if you’ve got a good doctor who’s busy he’s working you know twelve, thirteen hours a day seeing patients. He’s harassed. I mean every minute counts. This is the real life of medicine. You call his secretary, ask for an appointment and then say, look I’m feeling perfectly well, see, but I want about a half hour of the doctor’s time. I want to sit back and I want to talk with the doctor about what I can do to keep well. Well, you know she’ll give you an appointment six months down the line. And she’ll run in to tell the doctor there’s something wrong with this fellow.

HEFFNER: Why is this?

ROSENFELD: Because he has no time. Because he’s looking after the heart attack, because…

HEFFNER: Wait a minute. Wait a minute. What do you mean he has no time? He has twenty-four hours a day. Correct?

ROSENFELD: Yes.

HEFFNER: What is he doing with it?

ROSENFELD: The phone rings. It’s Mr. Jones with chest pain or Mr. So-and-So with a cough. Mrs. So-and-So with a urinary problem. Someone with a weight loss problem. Someone with a rash. I mean doctors are busy answering the phone, taking care of people who are sick.

HEFFNER: Is this because there are not enough physicians?

ROSENFELD: There are enough physicians.

HEFFNER: Then explain that to me.

ROSENFELD: First of all, it depends upon the community in which you live. There are enough physicians, but you know we’re a society that really depends on physicians. We don’t take care of ourselves. I think many of the calls that come into doctors…

HEFFNER: Now, wait, wait, wait a minute. You’re, if you say on the one hand that we have enough physicians, you must mean that we have enough physicians to enable a physician to respond to the kinds of needs you are describing with talk, where talk is necessary. With explanation. Why doesn’t it work out?

ROSENFELD: Well, I don’t think that the statistics for the needs for physicians really take into account, that’s a very good point you make, take into account putting aside a specific amount of time just sitting and talking to patients. Not only…

HEFFNER: Are you talking about the economics of medicine?

ROSENFELD: The economics of medicine. You know most people are covered by insurance for their visits and for hospitalization and so on. Insurance will not pay for a check-up. Insurance will not pay for an educational lecture. Patients also do not want to go to a doctor, even if he had the time, to spend the money to ask him questions because they will not get reimbursed. You can only get reimbursed currently on the basis of treatment or diagnosis or management of a disease. Not of health.

HEFFNER: So we’re talking about economics of the system.

ROSENFELD: The economics of it is important.

HEFFNER: We’re talking about the attitude of the patient. What about the attitude of the doctor?

ROSENFELD: I think that it’s a conditioned reflex. I think that most doctors are so accustomed to dealing with problems, with disease, with pain, with what have you, with operating, that they themselves are not geared to…I mean they would be very surprised if they got any number of calls saying listen doctor could I have a half an hour of your time to talk about some of these things? And then when you go through this…you see prevention isn’t prevention of one thing. Prevention is a total life style. And the supplements, the vitamins, the diet that you would invoke to prevent one condition might not apply to another. Well, now what is a doctor going to do? Is he going to sit down and in half an hour tell you the contents of a book that involves every system of the body? Can’t do it.

HEFFNER: Look, you’re then saying that it’s impossible, and you have already said that it’s possible. It’s not only possible, it’s really here. I’m asking you as I asked you at the beginning of the program what restructuring of medicine is needed to provide that time? If the oath says, do no harm, couldn’t it as easily say, talk?

ROSENFELD: Well, I think it’s a very noble motive. I think we’re years away from being able to achieve it. I think it may involve, for example, the structuring of paramedical information sources, trained nurses, public health individuals, and not physicians. I don’t think you are going to see in our lifetime a situation in which there are enough physicians with enough time who can sit down and spell out in detail for the whole thing, the whole area of prevention.

HEFFNER: But you have said there are enough physicians.

ROSENFELD: There are enough physicians. There are enough physicians to do this.

HEFFNER: To do this right?

ROSENFELD: To take care of sick people.

HEFFNER: But not to take care of well people.

ROSENFELD: That’s right. Not to take care of well people.

HEFFNER: Then we have to have this paramedic group.

ROSENFELD: Perhaps, perhaps. There are not enough physicians to take care of well people and educate them in the course of a twenty-four hour day. That’s the reality.

HEFFNER: All right.

ROSENFELD: And look at your own experience with your own doctor in terms of getting an appointment with a busy doctor.

HEFFNER: Okay. Fair enough. That’s why I asked whether the title of your book, which is so excellent, is so real. MODERN PREVENTION: THE NEW MEDICINE. Whether you like the title or not…

ROSENFELD: I don’t happen to like the title…

HEFFNER: I know.

ROSENFELD: I told you that before the program.

HEFFNER: But it’s saying something. It’s saying there is a new kind of medicine. And the medicine is preventative medicine. And now you’re saying, in fact, unless we read an awful lot, the profession isn’t going to provide it.

ROSENFELD: What I mean to say is not…what I mean to say is that prevention is really where it’s at. This is or should be the new medicine.

HEFFNER: Okay.

ROSENFELD: That it is available. The extent to whether it is or should be is an individual thing. It depends on the extent to which the lay person is able and willing to find out the facts and apply them.

HEFFNER: And the extent to which the medical person is willing to provide those facts.

ROSENFELD: Well, if you will.

HEFFNER: Well, why do you say if you will? Is there any question about that?

ROSENFELD: Yes, because I don’t think that this is a, that this is an attempt by doctors to withhold the facts.

HEFFNER: I didn’t mean that.

ROSENFELD: I mean I think it’s a matter of most doctors who I know, including myself you know, work eighteen hour days and our phones ring day and night dealing with emergency situation, people who are actively sick. The way medicine is now structured, the doctor’s role is to take care of sick people. It is not currently structured so that the doctor has the luxury and the time to sit down with a well person. It should be. In the ideal world it should be. It isn’t. And we’re going to have to realize that. We can have, I think…You see, Richard the reality of life now is that, again I keep talking about reality, the economics is that in our current administration, in the current priorities, the health, the health establishment is in fact being cut back. There’s fewer dollars for research. I think the DRGs which we could sometime talk about on anther program, the way that elderly patients are being treated in the hospital…I think the emphasis on group medicine, the HMOs where the one-to-one relationship is disappearing is all for cost effectiveness. Immediate cost effectiveness. I don’t believe that there is a concern among the authorities to maintain and deliver the kind of quality health care that you are interested in. And I think that the next five or ten years are going to see a dramatic decrease in the quality of care in this country. So to talk about a system in which not only is the care of the sick maintained, but educating well people is also an objective, I think is an illusion.

HEFFNER: To what extent is prevention medicine taught in medical schools?

ROSENFELD: To some extent. Probably not enough. For example, nutrition. Nutrition used…was never taught at all. Now it’s beginning to be taught. I don’t think medical students get enough training in nutrition.

HEFFNER: Suppose that the doctor who is so busy for eighteen hours a day, and there’s no question but that she and he that they are, suppose such a doctor saw fewer people, charged fewer fees, and spent more time, believe it or not, talking, as you believe doctors should talk? Would the medical profession collapse? Would it go broke?

ROSENFELD: No. I think it would be an economic hardship on doctors.

HEFFNER: Doctors who are the highest paid people…

ROSENFELD: No.

HEFFNER: No? Medicine is not the highest paid profession?

ROSENFELD: I don’t think so. I think we work the hardest. I don’t know, you know, what other professions make. I can tell you this, again without going into detail, that fees have been frozen since 1984 for all patients over 65. And that is in a setting of rising costs, rising rents, rising salaries, and so on. And the government has frozen Medicare fees. There’s also talk of reducing medical fees. Rents in this city of New York, as you know, for commercial enterprises have skyrocketed. So that I think the doctors are now, whether you think, of course doctors make a very nice living. No doctor pleads poverty. I think he earns what he…he earns what he…he deserves what he earns in terms of his energies. But I don’t think…I don’t think the answer lies in having doctors charge fewer fees and spending more time.

HEFFNER: Why not?

ROSENFELD: I think one of the answers lies in the third party payers assessing the importance to what we call cognitive services. If you go to a doctor and he takes something out of your eye or takes an electrocardiogram, he gets a substantial compensation. The people who set the scale for what is worth reimbursement do not consider that a doctor talking to a patient is worth any compensation at all. So you can have your appendix removed and the doctor will make several hundred dollars or have a baby or lance a boil. But if he takes that same amount of time and educates you, which in my judgment is extremely important, he gets paid, he has no compensation either from the third party carriers or in fact the patients.

HEFFNER: We have some areas of disagreement here as to where we need to begin. And our time is up. But I really do thank you, Dr. Rosenfeld, for joining me again on THE OPEN MIND.

ROSENFELD: Thank you. I enjoyed it.

HEFFNER: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, please do write to THE OPEN MIND in care of this station. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Richard Lounsbery Foundation; The M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; Mr. and Mrs. Lawrence A. Wien; Pfizer Inc., and THE NEW YORK TIMES Company Foundation.