Medical Care: Risks and Benefits

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Eugene Robin
Title: Medical Care: Risks and Benefits
VTR: 10/16/85

I’m Richard Heffner, your host on The Open Mind. Let me read some headlines: “Is There A Doctor In The House? Throw Him Out.” “Sometimes Say ‘No’ To Your Doctor.” ”Why Doctors Can Be Hazardous To Your Health.” Now what these rather unnerving headlines have in common is that they all have to do with a little book entitled Matters of Life and Death: Risks Versus Benefits of Medical Care, and its author, Dr. Eugene D. Robin, Professor of Medicine and Physiology at the Stanford University School of Medicine, is one of the many good reasons for recording several Open Mind episodes here at KQED, the San Francisco Bay area’s prime public television station. Now, Dr. Robin tells us right up front that along with the enormous benefits modern medicine brings mankind, it puts us at great risk too, harming us far more often that we or our doctors like to admit. His prescription: that we each make a very careful risk/benefit analysis of our situation each time we make ready to call a physician or enter a hospital. And I want to ask Dr. Robin right up front it that doesn’t come awfully close to recommending that you and I practice medicine without a license. Dr. Robin?

ROBIN: That’s a very good question. I don’t know how you define practicing medicine. I think a more accurate summary of my feelings would be that you and I, meaning everybody, know a substantial amount about the health care system, know specifically about what’s being proposed for us, and take an active role in the decision making process. Also that we not be satisfied with superficial answers or with adulation of a given doctor, but make an earnest effort to find out and try to get the best advice and have the best done for us.

HEFFNER: But that’s common sense, isn’t it?

ROBIN: Yes, but of course common sense is often not very commonly practiced.

HEFFNER: but you know, that’s just the point. If it isn’t, and if it hasn’t been, it hasn’t been for good reason. Obviously we civilians are afraid to do that.

ROBIN: Yes, to some extent afraid, and to some extent, I have to say, uninformed. The tradition has been to put doctors on a pedestal, to regard them as gods or demigods, and to feel that, A) they should not be challenged, because they are the god and the expert, and B) that it’s dangerous to do so. You know, if you flount (sic) the gods, you have to expect punishment. Someone has said, with very good sense behind it, that medical care will improve spectacularly if doctors get off their pedestal and patients get off their knees. I think doctors are probably in the process of getting off their pedestal, or often being nudged off their pedestal. It’s also important for people to know that they can understand the elements of medical care. They can learn and should take the responsibility for a surprising number of things that go on with them medially, and they should be active and not passive about their medical care.

HEFFNER: But that’s, those are a lot of “shoulds”. And I guess the question that I really want to ask you is whether we can, whether we’re really capable. I know what you want us to do as laypeople. But do you really think that we can, in a period in particular when there is more and more technical information, when there are more of those tests that you have some real concern about, how can we dare to get off our knees?

ROBIN: By taking a direct involvement in finding out exactly what is being proposed and what its consequences are. We use highly technological equipment, for example, VCRs and television and so on, and we have to know enough to push the buttons off and on and to have some general idea of how they work. What you ask is particularly interesting because the proliferation of technology and science poses not only a possibility of spectacular benefit to patients, but also spectacular degrees of harm. The problem is that despite the fact that there is new technology and new science and medicine, they way that it’s evaluated and the way it’s determined whether on balance it produces more benefits or risks is an antiquated system. It’s totally inappropriate and unacceptable. And therefore, it’s often the case that not only does the patient find it difficult to evaluate what’s taking place in them, but the doctor himself is not in a good position to evaluate. So by getting together and sharing inadequacies and so on, the hope would be, and I think it’s a realistic one, that the quality of care that would be delivered would be more appropriate. That is to say that things would turn out better for patients.

HEFFNER: Dr. Robin, as I read Matters of Life and Death, and it is a fascinating book, I couldn’t help think of an assignment that I give my students each year, and that is to read The Grand Inquisitor, that Dostoyevsky selection. And I wanted to ask you the same sort of question that the grand inquisitor put to Christ as to whether you aren’t mean to us, whether you don’t make demands upon us, the civilian population, that we’re not able, ready to meet.

ROBIN: I think if you posed it as an absolute, you know, that either you can meet them or you can’t meet them, then the answer would be, sure, it’s very difficult for a mother with a sick child to go to her pediatrician and he says, ”I think Johnny should have a tonsillectomy,” and say, for the mother to take the responsibility for refusing the pediatrician. But she can take the responsibility for saying, “I value your advice, but I think I better ask one or two more pediatricians, because Johnny is my child.” And that degree of courage I don’t think is unusual. Another example: In the State of California, you’re entitled to your medical records if you ask them from the doctor. I think it’s a very good idea, A) to get your medical records, B) not to get them for the sake of putting them up on the wall or starting a collection, but to read through them, and C) to ask your doctor to help translate what’s in your medical records, or if he’s reluctant or she’s reluctant, to get another doctor to do it. You then have a fix on your medical care which is not antagonistic towards your doctor, but puts you in a position to decide to what extent are the recommendations A) valid scientifically, B) valid medically, and most importantly, how do they fit your own needs and desires and lifestyle?

HEFFNER: Of course it seems to me that what we will get to will be a dichotomization, a further dichotomization between rich and poor. Not just rich in resources, but rich in the kind of training that enables us to do this, enables to avail ourselves of the records and understand them. A good system for those who are very well educated; not such a good system for those who aren’t.

ROBIN: Well, I think that, forgive me, but I think that makes a static presumption. I could easily visualize a circumstance where courses which deal with the medical care system will be provided, say, at a high school level or even a grammar school, and whereby removing the mystique and the glamour from medicine, that rich and poor will at least have a more solid understanding of what takes place in the doctor/patient relationship.

HEFFNER: Is the medical establishment pushing for this kind of orientation? I ask innocently.

ROBIN: Yes, I’ll answer guiltily. I doubt that they are consciously pushing for, but I must say a very pleasant surprise to me has been the substantial number of doctors at various levels who’ve expressed support for the ideas in the book, sometimes with reservations, sometimes without. One of the things that may interest you most of all is that an ex-president of the AMA reviewed the book highly favorably, and his conclusion was that the statement of the book was incorrect. It’s not only that the book should be read by patients, it should be read by doctors. There are, of course, physicians who feel quite strongly that the content of the book is wrong, or more particularly, that its tone is too strident and too polemical, and that perhaps it’s a little undignified. If I could tell you when, what my response is to that kind of criticism, whether it’s accurate or not, it satisfies me. When I’m accused of stridency, etcetera, I say, “If you walk into a room and everyone is whispering, and you speak in a normal tone of voice, everybody looks up and says, “Gee, that’s a loud fellow. And then I ask them why they are whispering. Because whether my solutions are correct or not, the idea of more informed involvement in medical care by patients, the idea of risk/benefit analysis, and the idea of a more human direct relationship with doctors are obviously sound ideas.

HEFFNER: Are the doctors likely to talk in anything above a whisper when it comes to talking about what the other fellow isn’t doing right enough?

ROBIN: Very often, I think, it’s a popular misconception that doctors are out to protect each other and therefore that it’s difficult in terms of individual doctors to find physicians who will criticize constructively or otherwise. In a malpractice suit you always find a plethora of experts who are willing to testify of the plaintiff, and a plethora of experts who are willing to testify for the defendant. I think the more difficult area for doctors to criticize is where there are systematic errors in medicine, where all of medicine has been wrong to the detriment of large numbers of people.

HEFFNER: What are those areas?

ROBIN: Well, there are literally hundreds, but I can give you some current examples. One example is in coronary bypass. There are two very good, convincing studies which indicate that only certain classes of patients who have disease of their coronary arteries will benefit from surgery. There is every indication that 50 percent of patients who undergo coronary artery surgery don’t belong to those classes. And if you consider that the overall death rate from coronary artery surgery is about two percent for the country, and that last year there were 200,000 coronary bypasses performed in the United States, then the death rate is really very considerable.

HEFFNER: Let me stop you right at that point. If you know that, and now I somewhat know that, and our viewers do, why does it happen?

ROBIN: It happens for a substantial number of reasons, one of which is that items like that don’t come stamped with a seal of approval, of whoever it is decides that things are absolutely right or wrong. So surgeons who do those procedures inadvertently or unnecessarily say it’s a controversial area. Secondly, there is no firmly established structure within the government or anywhere else which sets out to protect patients by informing them of that kind of fact. And as a matter of fact, one of the reasons for taking an active role in your own care is that if you don’t protect yourself, there really isn’t, it isn’t very likely that someone else is going to protect you.

HEFFNER: In this free enterprise system of medicine, is it that aspect of the profession that contributes significantly to the risks and diminishes the benefits?

ROBIN: To some extent. But I think it’s an error to regard economic factors, for example, as the dominant one, which leads to systematic errors. Systematic errors were with us long before he economics became so favorable to the medical care system, and they flourish in England, for example, where there’s not a fee-for-service system and where doctors, to put it bluntly, make less money.

HEFFNER: Then where do we look? To ignorance? To malfeasance? If not to greed?

ROBIN: We look to ignorance and apathy and the heavy hand of tradition and history, so that it hasn’t been conventional for people to get heavily involved in their own care, or for doctors to speak out.

HEFFNER: Well, again, that was the question that I asked about. How much do you find it, of the speaking out? This is such a heavy, heavy, heavy area we’re talking about, my life and death and that of the people who are watching this program. You know, it’s scary not to be a doctor. I don’t know if you are fully aware of that, because you are an MD. You have a kind of mantle that protects you that the rest of us don’t have.

ROBIN: It’s scary to be a doctor when you’re a patient. And it’s interesting that doctors as patients are substantially, in the average, in my opinion, more insecure than patients because they know our inadequacies and the kind of things that take place. If I could give you an example which is crying out to be described, in my opinion, of how bad things can be, and yet the story hasn’t come out, perhaps that would be a service for your viewers. Is that all right?

HEFFNER: Please, go ahead.

ROBIN: Because I’m squeezing it in, but…

HEFFNER: No, go ahead.

ROBIN: …it’s close to the top of my consciousness.

HEFFNER: If it’s not too bloody, go ahead.

ROBIN: It’s hardly bloody. It concerns a surgical procedure which is called radial keratotomy, RK. And if you watch television or read newspapers or you get friendly magazines, it’s being very heavily advertised. The surgery is done for…

HEFFNER: You said, “Advertised”…

ROBIN: Yes. Yes.

HEFFNER: Okay.

ROBIN: The word is used advisedly. That’s the specific word.

HEFFNER: Okay.

ROBIN: And hyped. So that there is no mistake about the promotion that goes into the surgery. The surgery is done for nearsightedness, myopia. And it consists of a 15-minute surgical procedure in which eight or 16 small incisions are made in the cornea of the eye. The purpose of the incisions is, as they heal, they scar, and they make the eye more flat, and therefore the person is less nearsighted. So the benefit of the surgery, the exclusive benefit is that if it’s successful, you won’t have to wear spectacles or you won’t have to wear contact lenses. It can be said it’s cosmetic, cosmetic or vanity surgery. Now, what are the risks? Well, the risks go approximately as follows: About 20 percent of the patients who have it have unsatisfactory results. They still need glasses or they have glare or difficulties with intermediate vision or difficulties with night vision. One third of the patients or near as we know, as a result of the operation develop farsightedness. And it’s rapidly progressing farsightedness. So it’s almost certain that people who are so affected will have to have changes of their lenses frequently. Not only that, as all of us get older, we develop something called presbyopia, which means difficulty to accommodate, as you get older. And that, if you couple that with hyperopia, in the old they’ll get even worse. There have been infections reported with the surgery, and a small number of patients have actually lost an eye as a consequence of the infection for this surgical procedure. And most terrifying of all, at least to me, is that when an operation like this was done by a Japanese surgeon called Situ about 15 years ago, all of his patients in 10 or 15 years went blind. The cornea is a very fragile structure. And even though that may not be a major concern, it’s certainly some concern that there may be irreversible changes in vision.

HEFFNER: Dr. Robin, would I be able to find an ophthalmologist, a surgeon who would sit across from me and say, “Well, Robin knows what he’s talking about, but not in this field, and let me tell you this, that, and the other thing,” and confront what you’ve just told me with what would seem to the layperson sufficiently adequate response?

ROBIN: As far as I know, the American Academy of Ophthalmology, which is the professional organization of ophthalmologists in this country – as a matter of fact, they recently had a meeting in San Francisco – have labeled the procedure experimental. Now, I don’t really know what that means. Experimental means that you get someone to pay $1,500 or $3,000 so that you can be experimented on. But much of the leadership of the American Academy of Ophthalmology has a position which is not as sharply formulated as mine, but is the same. At the recent meeting here, there were major doubts raised about the surgery. Not perhaps, as sharp as mine, but close. At the same time, the American Academy of Ophthalmology had models so that doctors, ophthalmologists, could come in and practice the surgery. It’s simply, I think, that, if it is simple, that doctors are not used to confronting issues like this even when they have extraordinarily strong opinions in a given area.

HEFFNER: Well, it does strike me that you sort of did but you sort of didn’t answer the question about someone else sitting here with credentials and with charm and with the capacity to be convincing and saying just the opposite. But let me ask you…

ROBIN: I can’t answer that fully, but I can answer this: that when I discussed it with leaders of ophthalmology, I did it in San Francisco not so long ago, the very eminent ophthalmologist said, “Of course, I couldn’t look myself in the mirror if I did this surgery.” And then I said to him, which was the obvious question, “Why don’t you say that in public?” And as I recall, he shook his head.

HEFFNER: Tell me whether there is a downside to the chamber of horrors, part of which you’ve just given expression to, much of which you go into in your book. Would you consider there to be a downside to what you are doing?

ROBIN: Yes. Very clearly, if what I say is interpreted as doctor-bashing, that would be wrong, because I’m not doctor-bashing. Secondly, if it prevented people from getting care that they needed, that would be wrong. Thirdly, if what I propose for more careful validation of things that are applied to masses of patients has the downside in that it will take a longer time for worthwhile things to be implemented and get into medical practice. My impression, and I think the impression of a number of people, is that we’re going too quickly, that we’re using a technology and science which is unchecked, and some slowing up is appropriate at this point. But there is no question that if, for example, it was required to do clinical trials on everything that’s present in medicine, some very good things would be slowed up.

HEFFNER: And how would you feel about that?

ROBIN: I would feel, as I said before, that the balance is so obvious that we’re misusing science for patient benefit, that that’s a worthwhile thing to do is to slow it up. And even if I’m wrong, the thing that I’m absolutely certain of is that the patients and the public have to know that what’s being done is not validated and may have dangers, and then they’re entitled to make their choices. But to do this through uninformed consent, the worst kind of uninformed consent, because even the doctors themselves may not visualize the risks, I think is terribly incorrect.

HEFFNER: To what degree are these problems, this kind of ethical and scientific dilemma, to what degree are they considered in medical school curricula?

ROBIN: To a very minor degree. Thank you for asking that. Because I’m teaching, as far as I know, the first course which is entitled, a two-quarter course for undergraduate medical students at Stanford, which is called “The Limitations of Medicine”, in which many of these matters are taken up. I think it’s a severe criticism of our medical school curricula that this is, that courses like this or this subject matter is not taken up. The students are impressed with the fact that there is so much to learn in the way of doing and practical things that these issues, to put it mildly, have not been highlighted.

HEFFNER: You know, I can’t help but wonder whether, if your book had been written, if the counterpart of the ideas that you are expressing had been as well expressed as you express them 30, 40 years ago, if we had been on our guard, as you want us to be now, do you think we would have made the same degree of medical progress that we have made? Now, I know that’s a tough question, but it’s a serious one.

ROBIN: That’s a very difficult question to answer. And the obvious thing that I would say, if I wanted to defend my book is no, I mean, would say yes, of course, we could easily pick out what’s good and throw out what’s bad.

HEFFNER: But I know you have too open a mind to be that cavalier.

ROBIN: But that’s not true. As I think about it, I think we can say at this period of time the advances of technology and medicine are so poorly coupled to patient welfare that it’s needed now. That’s also a saving grace for me, because 30 or 40 years ago, 30 years ago anyhow, I was teaching the same thing to medical students, and I was convinced that I was doing nothing but good and that I was teaching my students to go out and save mankind.

HEFFNER: Are you talking then largely in terms of the impact of technology?

ROBIN: Well, no. It would have been a good idea to have a better way of sorting out risks from benefits 30 or 40 years ago, but it wasn’t as acute a problem, nor did we have a media and a public who hung on it for every tiny change in medicine up or down whether it represents truly progress or whether it represents a potential threat.

HEFFNER: And you would repeat, I gather, the point that you don’t think this is a function of economics to any great extent?

ROBIN: No, I’m sorry that I gave the wrong impression. Yes, I think economics figures in very substantially and in a growing way. But I don’t think it’s the decisive factor. And if tomorrow you took the profit out of medicine and you had a completely rational economic system, I don’t think you would stamp out this disregard of risks and this pushing of benefits and hype in an unrealistic way.

HEFFNER: But, question: Would you take the profit out of medicine?

ROBIN: I don’t mean to be reluctant, because you have heard that I’m not a very reluctant person.

HEFFNER: Right. And I’m not going to let you be.

ROBIN: Okay. I think, given a society in which there is profit for X and Y and Z, that there should be profit in medicine. But I think medicine is a very delicate area. And therefore that it should take a hind seat to the questions of good patient care and providing the best we can for our patients. In order to do that, several things would have to be done. One is that medicine would have to become cheaper, substantially cheaper. And secondly, we would have to quit doing a lot of things in which the profit element pushes us to do…independent of patient welfare.

HEFFNER: Do I detect hidden in the answer a yes to my question as to whether you believe that it would be better, it would be well for us to take the profit out of medicine?

ROBIN: No. I guess what I was trying to do was to be humble and say that I would think it would be worth trying the experiment.

HEFFNER: And you feel that that experiment can work if we get down to an, or up to an educational level that counts?

ROBIN: Yes. I think there is no question that patients and the general public are consumers of medicine in the same way that they’re consumers of cars and services and so on. And I think that if they took an intelligent involvement in medicine it would inevitably involve economic factors as well.

HEFFNER: The head of this station, Mr. Tiano, and the head of Channel 13 in New York, Jay Iselin, have been talking about how much better, wiser, quality-concerned consumers we’ve become. Do you think that is becoming the case in terms of medicine too?

ROBIN: I hope so. I don’t really have a broad enough acquaintanceship. There are so many variable streams of voices which are saying, “Ours is the proper way to practice medicine, and ours is the proper way to criticize it, and so on”, that I think that’s a very difficult question to answer.

HEFFNER: Dr. Robin, that’s the point at which we end our program. And I want to thank you for discussing Matters of Life and Death, and I think your book on the risks versus the benefits of medical care are extremely important for all of us. Thank you for joining me today.

ROBIN: Thank you for having me.

HEFFNER: and thanks, too, to you in the audience. I hope you will join us again next time here on The Open Mind.