One reader challenges Proto’s take on the end of heart surgery.
FIRST, DO NO HARM
As a cardiac surgeon, I appreciate the challenging comments regarding my specialty, and its value or threat to the health of patients (“First, Do No Harm,” Spring 2006). A voice from outside the mainstream is particularly welcome now, as we grapple with the appropriate application of advanced technologies developed—and heavily promoted—by the “medical-industrial complex.” But the article’s not-so-subtle slide from healthy skepticism to nihilistic cynicism deserves comment.
To be sure, improvement in longevity and quality of life must be aims of our activities. What’s more, as the article highlights, the incentives of our health-care system can be perverse: Physicians are largely rewarded for treating, not preventing, disease, and the activities of those whose work is largely procedure-based (such as cardiac surgeons and interventional cardiologists) are reimbursed more richly than those whose practice is non-surgical (such as rheumatologists). Medical (as distinct from surgical) therapy of many conditions—including, quite conspicuously, coronary artery disease—is underappreciated and too little studied. The value of healthy living practices is even more neglected.
But is it fair to argue that surgical procedures today “usually cause more harm than good”? It would surprise no one, orthopedic surgeons included, that most elective orthopedic surgery has no impact on longevity. My own anterior cruciate ligament repair was intended to improve my quality—not quantity—of life, and I am no less grateful for it.
As to the article’s point that “most heart surgery is unnecessary,” the benefits of many procedures are simply beyond question. The impact of aortic valve replacement for symptomatic aortic stenosis or of surgical repair of acute Type A dissection is profound. Matters are less clear for coronary artery disease, although the article fails to acknowledge the demonstrable benefit of surgical revascularization for triple-vessel disease in the presence of left ventricular dysfunction and for two- or three-vessel disease in the presence of large territories of demonstrable ischemia.
Still, I could not agree more that appropriateness of care must be considered as we define quality of care. Are procedures being performed in accordance with accepted guidelines based on objective data? Sadly, many are not. As physicians, we should accept the article’s challenge to correct this failing, which may be the greatest threat to the integrity of our profession. But the answer is not to discard the remarkable progress made during the past 50 years. Complexity theory teaches us that the end result of any of our actions cannot be predicted with certainty and, by inference, that the only way to assure we “do no harm” is to do nothing. But that is not the nature of our calling. Nor, I submit, is it in the best interest of our patients.
Thoralf M. Sundt // Consultant and Professor of Surgery Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
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