The Cutting Edge or the Cliff: on Which Do You Stand?

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By Kristin Story Held, M.D.

View PDF of Article: https://jpands.org/vol25no1/held.pdf

“I worked from the day I could stand… well, that’s enough about me…,” a humble man uttered reticently as we broke bread over the house wine in the back booth of  a  South  Texas cafe. Not a patron there would have guessed that this ordinary octogenarian in jeans was a visionary from a lineage of cutting-edge, patient-serving, problem-solving surgeons who revolutionized medicine in the 1960s.

One of my favorite books is King of Hearts: The True Story   of the  Maverick  Who  Pioneered  Open  Heart Surgery, [1] the biography of C. Walton Lillehei, M.D., a man considered by many to be the father of open-heart surgery. The Journal of Thoracic and  Cardiovascular  Surgery [2] eulogized Dr.  Lillehei, describing him as a “surgical giant” of the 20th century, saying, “Worldwide, millions of patients with implantable pacemakers and prosthetic valves owe their lives to him. But his greatest legacy may be the generations of surgeons he educated, inspired, and encouraged, who will advance the surgical treatment of heart disease into the next millennium.”

Dr. Lillehei trained 134 cardiothoracic surgeons at the University of Minnesota Hospital and an additional 20 surgeons at Cornell University Medical Center. Prospective trainees, including Norman Shumway, Christiaan Barnard, Herbert Warden, Morley Cohen, and Richard DeWall, came from all areas of the world. Twenty-three of his 154 trainees became program directors of cardiothoracic programs; they in turn trained 477 surgeons. By 1988, at least 820 cardiothoracic surgeons in 36 countries could trace their preceptorial heritage back to Dr. Lillehei, and by now the number must be much greater.

Dr. Lillehei completed his surgical  training  under  Dr. Owen H. Wangensteen at the University of Minnesota. Dr. Wangensteen was Chairman of the Department of General Surgery at the University of Minnesota from 1931-1967, and aspiring surgeons flocked to his program for world-class training. One of them, Dr. Christiaan Barnard, performed the first heart transplant in 1967. Reading this, I smiled in knowing that my unpretentious dinner date had shared countless dinners, enjoyed Dixieland jazz, and worked in the lab with  Dr. Barnard himself at the University of Minnesota during his internship in general surgery with Dr. Wangensteen and his residency in neurosurgery with Dr. William Peyton (Story JL, personal communication, Jan 27, 2020).

In 1967, Dr. Wangensteen sent a few brave, pioneering young surgeons south, giving birth to the Department of Surgery at the new University of Texas Medical School at San Antonio. The new founding program director  and  chairman of neurosurgery was 35 years old.  A  self-described teacher, he went on to chair the program for 30 years, trained nearly two dozen neurosurgery residents, and influenced thousands of medical students and scientists with his contributions to teaching and research.

I was introduced to King of Hearts by that same unassuming octogenarian surgeon with whom I broke bread. He had also acquainted me with William Peyton, William Osler, Harvey William Cushing, William  Shakespeare,  Hippocrates,  and God. From my first formed memories, I recall wanting to be a physician—in the tradition of Osler, Cushing, Hippocrates, and Luke. I learned this would be a long road traversed by few, a rite of passage accomplished by fewer. Intelligence, ingenuity, work ethic, perseverance, virtue, moral compass, character, compassion, creativity, courage, sacrifice, appreciation of individual worth, and respect for the sanctity of life were the requisite traits, I was told by that humble surgeon. Born Jul 30, 1931, in a small wooden house with no electricity or plumbing, in a South Texas dust bowl during the Great Depression, he possessed nothing but those requisite traits and the willpower to use them.

The New Medical Revolution

Ironically, Jul 30 marks the day another South Texan would revolutionize the medical world. On Jul 30, 1965, President Lyndon B. Johnson signed Medicare and Medicaid, Titles 18 and 19 of the Social Security Act, into law. The Act’s prohibition clause3 promised that government would never interfere  in the practice of medicine. Government broke that promise.

Medical practice commenced a cataclysmic collapse under the weight of government, hospitals, insurance corporations, pharmaceutical companies, group purchasing organizations, pharmaceutical benefits managers, private equity groups, data brokers, information technology vendors, auditors, graders, politicians, bureaucrats, administrators, and a never- ending cascade of third-party intruders into the patient- physician relationship.

Their tactics include lobbying, politicking, belittling physicians, mischaracterizing our motives, demonizing our intentions and integrity, and trivializing our training and worth, all to create an alleged need to control us. This corporatization of medicine—replacement of physicians by lesser-trained corporate employees, growing ranks of powerful middlemen, ever-rising medical costs, exorbitant drug prices, drug shortages, stifled innovation—all are features of government’s third-party collaborations.

This results in moral injury to physicians and physical injury to patients. While the interlopers boast unprecedented earnings on Wall Street, most physicians now discourage their family and friends from going into medicine and are leaving medicine early in spite of a growing physician  shortage.  Urged by socialist politicians, many Americans  now  clamor for “Medicare For All,” for government to take over and run medicine, which is the precise opposite of the necessary prescription.

In the 1960s, as bold surgeons were breaking scientific boundaries and politicians were breaking promises to the American people, a courageous pastor and civil rights activist was breaking societal barriers. His life of wise words and valiant deeds raised the bar on human interaction and serves as a well of wisdom for those who seek to quench a thirst for strength, inspiration, love, nonviolent protest, and peace.

In 1964, the Rev. Martin Luther King, Jr., a Baptist minister from Georgia, and ultimately Alabama, became the youngest man to receive the Nobel Peace Prize; he was 35. In 1968, he traveled to Memphis for a march in peaceful protest to help striking sanitation workers; he was assassinated.

In his “Tough Mind and a Tender Heart Sermon,” on Aug 30, 1959, Rev. King profoundly observed: “Science investigates; religion interprets. Science gives man knowledge, which is power; religion gives man wisdom, which is control. Science deals mainly with facts; religion deals mainly with values. The two are not rivals.” [4]

At a time when scientific advances are poised to launch, our values are more important than ever. As we unleash previously unimaginable powers, where will we aim, and where will we land? As a profession and as a people, we must confront the philosophical divide in American medicine 2020. Medical schools are teaching population-based medicine and a team approach. Work hours are limited, and time spent entering data into the electronic medical record (EMR) supplants time spent on rounds, in the operating room, and in direct contact with patients. The American College of Physicians recently came out in support of  government  takeover  of  medicine. [5]  In these transformational changes, is there the inherent risk that no one actually ever enters into a patient-physician relationship and that no one actually ever takes individual responsibility for the patient?

Dr. Ezekiel “Zeke” Emanuel, Affordable Care Act (ACA) architect, who chairs the Department of Medical Ethics and Health Policy at the University of Pennsylvania, is often cited for his article“Why I hope to die at 75: An argument that society and families—and you—will be better off if nature takes its course swiftly and promptly,” published in The Atlantic. [6]

Dr. Emanuel was President Obama’s key health adviser on ACA. He lamented that doctors take the Oath of Hippocrates too seriously, “as an imperative to do everything for the patient regardless of the cost or effects on others.”7   His idea    is that as long as doctors are in charge, cost control will not  be possible. He believes that true reform includes redefining doctors’ ethical obligations, and medical students should be trained “to provide socially sustainable, cost-effective care” instead of thinking only about their own patient’s needs.

Dr. Donald Berwick, former head of the Centers for Medicare and Medicaid Services (CMS), opined that the federal government must step in between doctors and patients to curb and redistribute the use of medical resources, with allocation based on “important subgroups.” He said that “groups,” not the “individual patient in the doctor’s office,” should be the “unit of concern.” [7]

The Department of Health and Human Services and CMS recently appointed Brad Smith as director of the Center for Medicare & Medicaid Innovation (CMMI) and senior adviser on “value-based transformation” to HHS Secretary Alex M. Azar II.8 Is  Smith  a  scientist?  A  physician?  Did  he  develop a cure for cancer? Cure AIDS? Invent an artificial heart,  blood, or retina? No. According to the HHS press release, “Smith most recently served as the Chief Operating Officer  of Anthem’s Diversified Business Group and was previously co-founder and CEO of Aspire Health, a healthcare company focused on providing home-based palliative  care  services to patients facing serious illnesses.”8 What does this tell us about our values when the federal government’s director of innovation is a businessman who has proven himself worthy by making the field of home end-of-life care profitable?

As far back as 1947, in “The Purpose of Education” from the Morehouse College student newspaper, the student Martin Luther King, Jr., warned us: “If we are not careful, our colleges will produce a group of close-minded, unscientific, illogical propagandists, consumed with immoral acts. Be careful, ‘brethren!’ Be careful, teachers!” [4]

Would those heroic surgeons of the 1960s be able to do what they did in today’s environment? Do physicians now  exist who are free to serve the sick and advance the field in the tradition of our visionaries, from the perspectives of intellect, curiosity, and a deep-seated desire to find a solution for each individual patient and problem? Or will a team of population- focused, algorithm-following, shift-working  “midlevels,”  led by businessmen who profit from home death care, and ethics professors who hope to die at 75, command us to shut up, clock out, and send everyone to CVS with prescriptions for secobarbital or DDMP2, popular aid-in-dying drugs? [9]

Physicians must not let this happen. We must honor our tradition, preserve and advance our noble calling. We must contribute our time and talents. After residency, I worked in the ophthalmology department at our medical school for five years. I enjoyed clinical research, training residents, and particularly enjoyed operating. Ophthalmology operated in OR 1, which shared a scrub sink with OR 5, neurosurgery’s operating room. During this period, we cultivated collaborative relationships among neurosurgeons, ophthalmologists, electrophysiologists, and imaging specialists, sharing interesting cases and intellectual dialog.  We  encountered  a  series  of  patients  with ocular ischemic syndrome, evaluated their blood flow with color flow Doppler, and treated them with innovative procedures. We demonstrated post-operative improvement in blood flow to their eyes and brains. We reported our work in Surgical Neurology. [10]

Recently, I encountered a similar patient in my practice. She had already lost vision in one eye from ocular ischemia and carotid vascular disease. She is my exact age. I tried to contact her vascular surgeon, but he had left medicine, and a new surgeon had taken over her care. I inquired about studies of her intracranial blood flow such as MRI angiography. Her new surgeon paused, and replied with a sigh, “I’ll see if I can get her insurance company to approve any studies.”

Is this what it has come to—waiting to see what insurance companies will let us do, instead of expediently doing what’s best for our patients? Are we beaten down? Are we giving up?

What Must We Do?

On Oct 1, 2015, I opted out of all third-party transactions. including Medicare, because I found it morally untenable to stay in the current system.

On Oct 17, 2015, my worst fears were realized.  My precious 22-year-old daughter was involved in a devastating utility-terrain vehicle accident, sustaining a ruptured spleen, lacerated liver and kidney, broken bones, and severe de- gloving injury of her face and eyelids. She was rushed to the trauma center at our University of Texas Medical School at San Antonio, which was developed by my former medical school classmate and friend, Dr. Ronnie Stewart, now chairman of the general surgery department.

When Dr. Stewart and I were  training,  my  daughter would have had emergent diagnostic peritoneal lavage and splenectomy at a minimum. While the week in the center’s intensive care unit (ICU) was trying, it was also inspiring. You see, Dr. Stewart was trained by those Wangensteen visionaries who started the general surgery program in San Antonio back in those revolutionary 1960s. Not  only  had  he  developed  the trauma service and built a  world-class  trauma  ICU,  but he had innovated. Under his direction, the splenic  rupture  and pseudoaneurysm were embolized through a small groin incision in a state-of-the-art interventional radiology suite.  The severe facial and orbital injuries were repaired beautifully by my former resident, oculoplastic surgeon Dr. Connie Fry, who also trained at our university.

Let us not forget God. When my daughter was crying out for help, writhing in pain, as  her  spleen  was  infarcting  and no medications would ease her misery, we gathered around her hospital bed, laid hands on her, and prayed to God for a miracle, for the waves of pain to subside and part like the Red Sea, so she could rest and heal. We surrendered it all to Him. At that moment, the door opened and in walked our new nurse, who grabbed a marker, flashed a smile, and introduced himself to us as he wrote his name on the board: MOSES. Yes, God has a sense of humor at times of crisis when we need it most. Shortly after nurse Moses entered, the pain remitted, and healing began.

I am forever indebted to the amazing physicians and surgeons in my life, who have lived so much of their lives for others. I pray for them. I am proud of them and all they do. And I cling to the thought that I too might in some small way be linked to that incredible lineage. You see, my visionary dinner date, who taught me about ocular ischemic syndrome, the King of Hearts, Osler, Cushing, Hippocrates, and God, is the man I call Dad. I’m a physician because I was raised by this man of great character, courage, and all the requisite traits he had the willpower to use.

Rev. King wisely counseled: “There comes a time when  one must take a position that is neither safe nor politic nor popular, but he must take it because his conscience tells him  it is right.” [11] As politics of medicine descend upon us, let’s work in community with one another to keep a lane of freedom open for cutting-edge, personalized patient  care,  centered  on the patient-physician relationship, guided by fundamental Hippocratic values, and delivered by physicians who love and serve humanity.

When many are discouraged with medicine, let’s find hope. Two of my four daughters are now physicians, one on faculty at our medical school. As immense pressure descends upon them, I pray they have discernment to do what is best for their patients. I pray courage displaces discouragement. When we as physicians feel like we’ve been driven to the edge of the cliff with nowhere else to go, I pray we can back up and forge a better way together. Rev. King warned us, “We may be able to use our minds to probe into the storehouse of nature. We may know all about the science of genetics and psycho-physical changes within human nature. All these are fine, but if we do not place righteousness first these very things which are capable of being used constructively will be used destructively.” [12] If you stand at that cliff, I urge you to step out of the current system; together we will widen our lane of freedom. AAPS can guide you, support you, and fight alongside you. The 2020s are in desperate need of a revolution.

Kristin S. Held, M.D., practices ophthalmology in San Antonio, Texas, and serves as president of AAPS.

REFERENCES

  1. Miller GW. King of Hearts: the True Story of the Maverick Who Pioneered Open Heart Surgery. Crown; 2000.
  2. Gott VL. C. Walton Lillehei (1918-1999). J Thorac Cardiovasc Surg 1999;118:774-775. Available at: https://www.jtcvs.org/article/S0022- 5223(99)70043-7/pdf. Accessed Feb 8, 2010.
  3. 42 U.S.C. §1395. Prohibition against any Federal interference. Available at: https://www.law.cornell.edu/uscode/text/42/1395. Accessed Feb 8, 2020.
  4. Bio Staff. 17 Inspiring Quotes by Martin Luther King Jr. Biography.com. Available at: https://www.biography.com/news/martin-luther-king- famous-quotes. Accessed Feb 8, 2020.
  5. Doherty R, Cooney TG, Mire RD, et al. for the Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med 2020, 172 (2_Supplement): S3-S6. doi: 10.7326/M19-2411.
  6. Emanuel E. Why I hope to die at 75: an argument that society and families—and you—will be better off if nature takes its course swiftly and promptly. Atlantic, October 2014. Available at: https://www.theatlantic. com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/. Accessed Feb 8, 2020.
  7. McCaughey B. ObamaCare’s latest whopper J. NY Post, Jan 1, 2014. Available     at:                    https://nypost.com/2014/01/01/obamacares-latest- whopper/?utm_source=email_sitebuttons&utm_medium=site%20 buttons&utm_campaign=site%20buttons. Accessed Feb 8, 2020.
  8. HHS Press Office. HHS and CMS announce Brad Smith as CMMI director, senior advisor for value-based transformation. Press Release; Jan  6, 2020. Available at: https://www.hhs.gov/about/news/2020/01/06/hhs- cms-announce-brad-smith-cmmi-director-senior-advisor-value-based- transformation.html. Accessed Feb 8, 2020.
  9. Dear J. The doctors who invented a new way to  help  people  die. Atlantic, Jan 22, 2019. Available at: https://www.theatlantic.com/health/ archive/2019/01/medical-aid-in-dying-medications/580591/. Accessed Feb 8, 2020.
  10. Story JL, Held  KS,  Harrison  JM,  et  al.  The  ocular  ischemic  syndrome in carotid artery occlusive disease: ophthalmic color Doppler flow velocity and electroretinographic changes following carotid artery reconstruction. Surg Neurol 1995;44:534-535. doi: 10.1016/0090- 3019(95)00368-1.
  11. King ML Jr. Remaining awake through a great revolution. The Martin Luther King, Jr. Research and Education Institute. Available at: https:// kinginstitute.stanford.edu/. Accessed Feb 9, 2020.
  12. King ML Jr. First things first. Sermon. Atlanta, Georgia; Aug 2, 1953. The Martin Luther King, Jr. Research and Education Institute. Available at: https://kinginstitute.stanford.edu/. Accessed Feb 9, 2020.