Annotations
9.
10.
coronary disease on return to work, Am. J. Cardiol. 41:409, 1978. Logue, R. B., King, S. B., and Douglas, J. S.: A practical approach to coronary artery disease, with special reference to coronary artery bypass surgery, Curr. Probl. Cardiol. 1 :l, 1976. Kushnir, B., Fox, K. M., Tomlinson, I. W., et al.: The influence of psychological factors and an early hospital follow-up on return to work after first myocardial infarction, Stand. J. Rehabil. Med. 7:158, 1975.
What can we learn from debate?
the coronary
The coronary bypass operation is an unprecedentedly successful procedure. True, it is expensive, highly publicized, and this had led to its becoming inevitably controversial.’ There is nothing wrong with controversy when the differences are honest and constructive, but this debate has become polarized to a degree that can only work to the detriment of medical practice. Well-meaning individuals are advocating that this operation and all other expensive treatments be subjected to federal control in much the same way that the Food and Drug Administration controls medication.? ’ This recommendation is an excessive reaction.’ It implies not only that we are incapable, as professionals, of settling our own differences, but that this control is required for retributive reasons as well. It also implies that we can have no faith in our intuitive understanding which derives from clinical experience. There are several reasons why we must avoid a simplistic, legalistic solution to the controversy. First, medicine requires the freedom that allows for the innovations that lead to new treatments. This is as true of medical treatment as it is of surgical procedures. Second, we have a system of checks and balances within the practice of medicine that are very effective in maintaining our professional responsibility for the patient’s welfare. Thirdly, both the intuitive clinical approach and the objective scientific approach are valuable in the assessment of our results, but there are limitations to both and they must be understood.
Innovation Nowhere are the results of freedom which permits innova-~ tive treatment better illustrated than in the treatment of angina pectoris. The use of propranolol for relief of ischemic pain was widely applied before it was officially recognized by the Food and Drug Administration for such use. Coronary bypass also developed because the techniques for cardiopulmonary bypass and microsurgical procedures which were developed in another context were applied to overcome the circulatory deficit that led to the pain of angina. The medical treatment decreases the oxygen requirement and the surgical procedure increases the oxygen supply. Application of these two procedures by their advocates rapidly led to agreement that many cases could be treated medically, but that those which did not respond would be helped by surgery. Neither the medical treatment nor the operation would have developed in a rigidly regulated system,
134
July, 1979, Vol. 98, No. 1
11.
12. 13.
Frank, K. A., Heller, S. S., and Kornfeld, D.: A survey of adjustment to cardiac surgery, Arch. Intern. Med. 130:735, 1972. Braunwald, E.: Coronary artery surgery at the crossroads, N. Engl. J. Med. 297:661, 1977. Effler, D. B.: Myocardial revascularization surgery since 1945, A.D. Its evolution and its impact, J. Thorac. Cardiovasc. Surg. 72:823, 1976.
bypass
but surgery does seem more vulnerable because by its nature it must be done openly. Operative therapy must evolve and the techniques must be refined. To presume that an operation can be tested in its initial stages is naive. At present the coronary bypass operation has been improved to a point where it is no longer reasonable to judge it on the basis of the randomized studies completed to date. It is critical that we rely on something other than simplistic “science” to test our therapies.
Checks
and balances
The checks and balances within the medical referral system are a critical factor which assumes that professional responsibility is met. The adversary role of the cardiologist vis-a-vis the cardiac surgeon is an important example of this mechanism. The relationship is somewhat out of hand when carried to the extremes of the current controversy, but discounting the extremists on both sides, it is clear that the cardiologist and the referring family physician play the important role in deciding whether or not surgery is to be considered. Technical factors relating to operability are the surgeon’s province, but in a typical case the primary physician refers a patient with angina to a cardiologist for diagnostic studies when he has reached a medical impasse. The cardiologist will then either refine the medical treatment, thereby relieving symptoms, or ask for consultation with a surgeon whose work he respects. The surgeon will reevaluate the patient and review the coronary anatomy and cardiac performance, recommending an operation if he feels that it is technically feasible. This progression assures that the patient receives optimal treatment for relief of his pain. This system depends upon competent, responsible individuals for its success. If we don’t have that, then no amount of regulation will solve the problem.
Science Finally, inherent, experience ization of Intuition “come to “Just give subjective
versus
intuition
we have to accept certain limitations which are not only in our own personal evaluation of our with this operation, but also in controlled randommedical versus surgical treatment. is cognitive knowledge, something that we simply know” by virtue of our experience. When we say, me the numbers,” we show our lack of trust in knowledge. But numbers lie too, and blind faith in
0002-8703/79/070134
+ 02$00.20/O
Q 1979 The
C. V. Mosby
Co
Annotations
them is certainly an equal foolishness to the self-seeking gut reaction. We know because the patients tell us that they are benefited by the coronary bypass operation. For the most part, when their grafts are open, they are free of pain. They also know that when the grafts close, the pain returns. Even more important, when the occluded grafts are reoperated, the pain is again relieved. We don’t have to see this too many times to begin to believe that there is a real benefit from the operation. All we have to do is believe the patient.. trust our experience. On the other hand, what rational person would believe the randomized studies which disprove the benefits of surgery? All except one are too deficient in numbers to be valid statistically, and the largest one asks the wrong question by comparing medical treatment with operative results that do not compare with those which currently are acceptable regarding both mortality and graft patency rate. The best that can be said is that we need a valid study of the group to substantiate what we see in individuals. The lessons of the coronary bypass debate are not that we have to impose an external control on our therapeutic innovations, not that
Of senile
we have failed ourselves scientifically, and, above all, not that any one or another faction is culpable. Rather the lessons are that clinical progress results from allowing reasonable creativity, the control of such innovation is built into the referral practice of medicine by the adversary roles of the cardiologist and the cardiac surgeon, and, finally, we must trust both our experience and our research, but that neither is infallible.
E. Lawrence Hanson, M.D. 225 w. 25th St Erie, Pa. 16502 REFERENCES 1. 2.
3.
4.
cardiomyopathy
For some peculiar reason physicians seem to accept the fact that everything ages except the heart. This attitude is diffidult to understand. Surely, the heart and all of its parts must age. Unfortunately, the development of senile cardiomyopathy is difficult to establish by direct scientific observation because, with aging, coronary arteriosclerosis develops and it is impossible to delineate changes due to senescence itself and changes due to &hernia. Nevertheless, no one will deny that all other things on earth age and certainly change with time. Then, why not the heart, too? Furthermore, no physician will deny that skeletal muscle ages. One needs only to see an 80-year-old man attempt to high jump or pole vault or run a 100 meter dash to convince him that skeletal muscles age. These efforts reveal the existence of senile skeletal myopathy. The smooth muscle of a person’s gastrointestinal tract ages. So does his brain. And, so must his heart and his myocardium. To accept as a fact that the myocardium ages and that senescence results in “senile cardiomyopathy” would be good practice and would be especially rewarding in “preventive
0002-8703/79/070135
Hiatt, H. H.: Lessons of the coronary-bypass debate, N. Engl. J. Med. 297:1462, 1977. Preston, T. A.: The hazard of poorly controlled studies in the evaluation of coronary artery surgery, Chest 73:441, 1978. Spodick, D. H.: The surgical mystique and the double standard; controlled trials of medical and surgical therapy for cardiac disease. AM. HEART J. 85:579, 1973. Hanson, E. L.: Lessons of the coronary-bypass debate, N. Engl. J. Med. 298:1030, 1978.
+ 01$00.10/00
1979 The
C. V. Mosby
cardiology.” This practice is particularly important in advising patients concerning strenuous and uninterrupted exertion. Not infrequently one hears about an aged acquaintance or an aged patient who died suddenly during continuous strenuous exercise or shortly after such exercise. The same problem applies to an aged person who loses a portion of his myocardium from infarction and is left with less senile myocardium to carry on the work of the entire heart. All of these situations may be viewed as driving the senile myocardium of an aged person in much the same manner as whipping a dying horse. Managing aged people as though they all have senile cardiomyopathy is a rewarding clinical experience for the physician and his old patient.
George E. Tulane University School and Charity Hospital New
Co.
American
Heart
Burch, M.D. of Medicine of Louisiana Orelans. La.
Journal
135
9.
10.
coronary disease on return to work, Am. J. Cardiol. 41:409, 1978. Logue, R. B., King, S. B., and Douglas, J. S.: A practical approach to coronary artery disease, with special reference to coronary artery bypass surgery, Curr. Probl. Cardiol. 1 :l, 1976. Kushnir, B., Fox, K. M., Tomlinson, I. W., et al.: The influence of psychological factors and an early hospital follow-up on return to work after first myocardial infarction, Stand. J. Rehabil. Med. 7:158, 1975.
What can we learn from debate?
the coronary
The coronary bypass operation is an unprecedentedly successful procedure. True, it is expensive, highly publicized, and this had led to its becoming inevitably controversial.’ There is nothing wrong with controversy when the differences are honest and constructive, but this debate has become polarized to a degree that can only work to the detriment of medical practice. Well-meaning individuals are advocating that this operation and all other expensive treatments be subjected to federal control in much the same way that the Food and Drug Administration controls medication.? ’ This recommendation is an excessive reaction.’ It implies not only that we are incapable, as professionals, of settling our own differences, but that this control is required for retributive reasons as well. It also implies that we can have no faith in our intuitive understanding which derives from clinical experience. There are several reasons why we must avoid a simplistic, legalistic solution to the controversy. First, medicine requires the freedom that allows for the innovations that lead to new treatments. This is as true of medical treatment as it is of surgical procedures. Second, we have a system of checks and balances within the practice of medicine that are very effective in maintaining our professional responsibility for the patient’s welfare. Thirdly, both the intuitive clinical approach and the objective scientific approach are valuable in the assessment of our results, but there are limitations to both and they must be understood.
Innovation Nowhere are the results of freedom which permits innova-~ tive treatment better illustrated than in the treatment of angina pectoris. The use of propranolol for relief of ischemic pain was widely applied before it was officially recognized by the Food and Drug Administration for such use. Coronary bypass also developed because the techniques for cardiopulmonary bypass and microsurgical procedures which were developed in another context were applied to overcome the circulatory deficit that led to the pain of angina. The medical treatment decreases the oxygen requirement and the surgical procedure increases the oxygen supply. Application of these two procedures by their advocates rapidly led to agreement that many cases could be treated medically, but that those which did not respond would be helped by surgery. Neither the medical treatment nor the operation would have developed in a rigidly regulated system,
134
July, 1979, Vol. 98, No. 1
11.
12. 13.
Frank, K. A., Heller, S. S., and Kornfeld, D.: A survey of adjustment to cardiac surgery, Arch. Intern. Med. 130:735, 1972. Braunwald, E.: Coronary artery surgery at the crossroads, N. Engl. J. Med. 297:661, 1977. Effler, D. B.: Myocardial revascularization surgery since 1945, A.D. Its evolution and its impact, J. Thorac. Cardiovasc. Surg. 72:823, 1976.
bypass
but surgery does seem more vulnerable because by its nature it must be done openly. Operative therapy must evolve and the techniques must be refined. To presume that an operation can be tested in its initial stages is naive. At present the coronary bypass operation has been improved to a point where it is no longer reasonable to judge it on the basis of the randomized studies completed to date. It is critical that we rely on something other than simplistic “science” to test our therapies.
Checks
and balances
The checks and balances within the medical referral system are a critical factor which assumes that professional responsibility is met. The adversary role of the cardiologist vis-a-vis the cardiac surgeon is an important example of this mechanism. The relationship is somewhat out of hand when carried to the extremes of the current controversy, but discounting the extremists on both sides, it is clear that the cardiologist and the referring family physician play the important role in deciding whether or not surgery is to be considered. Technical factors relating to operability are the surgeon’s province, but in a typical case the primary physician refers a patient with angina to a cardiologist for diagnostic studies when he has reached a medical impasse. The cardiologist will then either refine the medical treatment, thereby relieving symptoms, or ask for consultation with a surgeon whose work he respects. The surgeon will reevaluate the patient and review the coronary anatomy and cardiac performance, recommending an operation if he feels that it is technically feasible. This progression assures that the patient receives optimal treatment for relief of his pain. This system depends upon competent, responsible individuals for its success. If we don’t have that, then no amount of regulation will solve the problem.
Science Finally, inherent, experience ization of Intuition “come to “Just give subjective
versus
intuition
we have to accept certain limitations which are not only in our own personal evaluation of our with this operation, but also in controlled randommedical versus surgical treatment. is cognitive knowledge, something that we simply know” by virtue of our experience. When we say, me the numbers,” we show our lack of trust in knowledge. But numbers lie too, and blind faith in
0002-8703/79/070134
+ 02$00.20/O
Q 1979 The
C. V. Mosby
Co
Annotations
them is certainly an equal foolishness to the self-seeking gut reaction. We know because the patients tell us that they are benefited by the coronary bypass operation. For the most part, when their grafts are open, they are free of pain. They also know that when the grafts close, the pain returns. Even more important, when the occluded grafts are reoperated, the pain is again relieved. We don’t have to see this too many times to begin to believe that there is a real benefit from the operation. All we have to do is believe the patient.. trust our experience. On the other hand, what rational person would believe the randomized studies which disprove the benefits of surgery? All except one are too deficient in numbers to be valid statistically, and the largest one asks the wrong question by comparing medical treatment with operative results that do not compare with those which currently are acceptable regarding both mortality and graft patency rate. The best that can be said is that we need a valid study of the group to substantiate what we see in individuals. The lessons of the coronary bypass debate are not that we have to impose an external control on our therapeutic innovations, not that
Of senile
we have failed ourselves scientifically, and, above all, not that any one or another faction is culpable. Rather the lessons are that clinical progress results from allowing reasonable creativity, the control of such innovation is built into the referral practice of medicine by the adversary roles of the cardiologist and the cardiac surgeon, and, finally, we must trust both our experience and our research, but that neither is infallible.
E. Lawrence Hanson, M.D. 225 w. 25th St Erie, Pa. 16502 REFERENCES 1. 2.
3.
4.
cardiomyopathy
For some peculiar reason physicians seem to accept the fact that everything ages except the heart. This attitude is diffidult to understand. Surely, the heart and all of its parts must age. Unfortunately, the development of senile cardiomyopathy is difficult to establish by direct scientific observation because, with aging, coronary arteriosclerosis develops and it is impossible to delineate changes due to senescence itself and changes due to &hernia. Nevertheless, no one will deny that all other things on earth age and certainly change with time. Then, why not the heart, too? Furthermore, no physician will deny that skeletal muscle ages. One needs only to see an 80-year-old man attempt to high jump or pole vault or run a 100 meter dash to convince him that skeletal muscles age. These efforts reveal the existence of senile skeletal myopathy. The smooth muscle of a person’s gastrointestinal tract ages. So does his brain. And, so must his heart and his myocardium. To accept as a fact that the myocardium ages and that senescence results in “senile cardiomyopathy” would be good practice and would be especially rewarding in “preventive
0002-8703/79/070135
Hiatt, H. H.: Lessons of the coronary-bypass debate, N. Engl. J. Med. 297:1462, 1977. Preston, T. A.: The hazard of poorly controlled studies in the evaluation of coronary artery surgery, Chest 73:441, 1978. Spodick, D. H.: The surgical mystique and the double standard; controlled trials of medical and surgical therapy for cardiac disease. AM. HEART J. 85:579, 1973. Hanson, E. L.: Lessons of the coronary-bypass debate, N. Engl. J. Med. 298:1030, 1978.
+ 01$00.10/00
1979 The
C. V. Mosby
cardiology.” This practice is particularly important in advising patients concerning strenuous and uninterrupted exertion. Not infrequently one hears about an aged acquaintance or an aged patient who died suddenly during continuous strenuous exercise or shortly after such exercise. The same problem applies to an aged person who loses a portion of his myocardium from infarction and is left with less senile myocardium to carry on the work of the entire heart. All of these situations may be viewed as driving the senile myocardium of an aged person in much the same manner as whipping a dying horse. Managing aged people as though they all have senile cardiomyopathy is a rewarding clinical experience for the physician and his old patient.
George E. Tulane University School and Charity Hospital New
Co.
American
Heart
Burch, M.D. of Medicine of Louisiana Orelans. La.
Journal
135
