HEART OF THE MATTER: TREATING THE DISEASE INSTEAD OF THE PERSON

NPR Blog
by Leana Wen
to view in original source visit: http://www.npr.org/blogs/health/2014/06/25/324005981/heart-of-the-matter-treating-the-disease-instead-of-the-person

June 25, 201411:05 AM ET

 

A 56-year-old man is having lunch with his wife at a seafood restaurant just outside Boston when he develops crushing chest pain. He refuses an ambulance, so the man's wife drives him to the ER.
What happens next says a lot about the difference that being a doctor or a patient can make in how one feels about the health care system.

First, how did the patient and his wife see the trip to the hospital?

When the man arrives in the ER, he is told to take off his shirt. He lies in the hallway, in pain, naked from the waist up. Strangers surround him. They don't introduce themselves, and they talk over him, at each other.

Pagers ring and there's a lot of beeping. Someone else must be really sick, he thinks; that must be why no one is paying attention.

After a few minutes, he signs some forms and finds himself being wheeled into an elevator. Masked figures enter. He feels a cool liquid flowing into his veins. The lights go out.

He wakes up hooked up to machines, uncertain what has happened. It takes several hours for the staff to find his wife, who is still waiting in the ER lobby and has no idea why her husband is in intensive care.

They are both surprised when they find out, two days later, that he's had a heart attack. As soon as they get home, they file a complaint with the hospital about their terrible experience.
Now, how did the staff at the hospital see it?

A triage nurse greets the patient immediately upon his arrival and finds out that he has chest pain. Within three minutes, he gets an electrocardiogram that shows he is having a heart attack. The ER doctor activates the special heart attack pager, which immediately summons the emergency cardiology team.

The doctors and nurses arrive and bring the patient up to the catheterization suite. There, the attending cardiologist threads a catheter through an artery in his groin and pushes it all the way to his heart, where the doctor sees on an X-ray machine that a vessel is blocked. She inflates a small balloon in the catheter, opening the artery and restoring the flow of blood to the man's heart.

All told, it took only 22 minutes from the time the man entered the hospital for the cardiology team to clear the blockage. The cardiology team is proud that they beat the national average for what they call door-to-balloon time by 42 minutes. The faster a blockage can be cleared, the better the odds are for a full recovery.

The patient gets well without complications. Two weeks later, he's back at work and exercising again. The ER and cardiology teams consider the man's case a resounding success.

Why then are there such different views of the same ER visit? Who's right? The doctors who believe they delivered exemplary care, or the patient and his wife who feel he was treated badly?

As an emergency physician and advocate for my patients, I frequently hear clashing stories like these. When I review the cases, I find that the doctors and nurses are often surprised by the patient's complaint because they did everything by the book and made no medical mistakes.

Indeed, in this case, every measure of sound medical care was met: prompt diagnosis, speedy and effective treatment and an uneventful, full recovery.

The objective measures that health care workers focus on are necessary, but they're not enough by themselves. Every provider in this man's case had good intentions and was working hard to respond to the medical emergency. But in their rush to open the blocked heart artery, they treated him as a disease to be cured, not a person to be cared for.

Would it have alleviated the patient's anxiety for the doctors and nurses to introduce themselves, and to ask if he wanted his wife by his side? Would it have helped to assure him that all the activity was happening around him because everyone was trying to take care of him?
I think those simple courtesies would have made a difference.

These instructions aren't on typical checklists for treatment of heart attack, yet they are part of caring for people as human beings. In modern medicine, we are fortunate to have incredible high-tech options available, but we must not forget the low-tech approaches that can improve communication and quality of care.

Patients and family members can also speak up when they are confused and scared. It's possible that doctors explained what was happening, but not clearly enough.

What if the patient said he didn't understand what was going on? What problems could have been avoided if the patient and his wife didn't wait until after he was discharged to raise their concerns?
The two viewpoints of this ER visit end with one thing in common. Just as the providers were surprised by the patient's complaint, the patient and his wife were taken aback when the team that I was part of presented them with their doctors' point of view.

"We had no idea they were trying so hard," the man said. "It's too bad we didn't know that at the time."

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine. On Twitter: DrLeanaWen

CNN INTERVIEW WITH DR. DAVID AGUS: A SHORT GUIDE TO A LONG LIFE

Cancer Support Community provides free-of-charge psychosocial support for those affected by cancer.  CSC does not give medical advice; however, it does provide education for its members from experts in the medical and complementary fields. This past Sunday, January 12, 2014 Fareed Zakaria interviewed Dr. David Agus, one of the world's leading cancer specialists.  Dr. Agus discussed prevention.  While CSC membership is composed of those who are already dealing with cancer diagnoses, there is, of course, keen interest in preventing recurrence.  The following is a transcript of this interview.  To see the original source, visit http://cnnpressroom.blogs.cnn.com/2014/01/12/mideast-violence-on-cnns-fareed-zakaria-gps/


ZAKARIA:  The best way to tackle cancer, heart disease, diabetes and all these other diseases that plague the modern world is prevention.  So says my next guest who has a list of ways to ward off these dangerous illnesses.  Perfect for your new year's resolutions.  David Agus is one of the world's leading cancer specialists, he is the author of a new book "A Short Guide to a Long Life."  He was Steve Jobs' doctor, among other things.  David joins me.

DAVID AGUS, PROFESSOR OF MEDICINE, UNIV. OF SOUTHERN CALIFORNIA:  Thank you so much.

ZAKARIA:  So, what struck me about this is you really feel strongly about this whole idea that if you just take some simple preventative tasks, you can reduce the possibility of many of these very bad diseases, heart attacks, even cancer, so give us like your three or four rules for how to reduce your likelihood of getting cancer and a heart attack.

AGUS:  So, first of all, it's not me and my belief.  These are the data.  All I'm doing is trying to put the data in a format that people can understand.

ZAKARIA:  And the data of these are double blind studies.  You're very rigorous about that.  You are not just taking one study.

AGUS:  No, these are the real data that at certain point, it needs to become normative behavior.  Right?  When data hits a critical mass that it's incontrovertible what the conclusion is we need to act on them as a society.  So the first is something very simple.  And it's called movement over time.  In 1953 in the British Transit Authority there were 26,000 workers.  Half were the bus drivers that sat 90 percent of the day and half the ticket takers that walked up and down these double-decker buses.  They weighed the same, smoked the same and lived in the same environment, yet dramatically lower heart disease and cancer in the ticket takers.

ZAKARIA:  The guys who were walking up and down.

AGUS:  Walking up and down.  But we've become a society of bus drivers, of sitters, right?  The more important you are in the company the closer your parking space is to your office.  The richer you are ...

ZAKARIA:  So, I – you know, I know you have these views.  And so, I think to myself, OK, I try to exercise mostly every day, probably about 30 to 40 minutes.  You say that's not enough.  That if you're sitting around the rest of the day it's like you're smoking cigarettes.

AGUS:  Exactly.  Sitting for five hours ...

ZAKARIA:  What are we supposed to do?

AGUS:  Well, you're supposed to get up every half hour and walk for four or five minutes.

ZAKARIA:  Just four or five minutes?

AGUS:  Four or five minutes.  That's it.  Your body was designed to move.  Your lymphatics that control your immune system have no muscle.  So, it's the rhythmic contractions of the muscles in your legs when you walk that actually make your body work.

ZAKARIA:  OK.  Get off your X.

AGUS:  The second preventative strategy is, you know, a very simple one.  Is that 2,000 years ago, Hippocrates said you take the bark of the willow tree, and chew it and pain and fever go away.  And this is a compound that if you take it every day over the age of 40 you reduce the death rate of cancer by 37 percent.  It's called a baby aspirin.  Baby aspirin blocks inflammation.  Inflammation is at the root of cancer, heart disease and neurocognitive decline.  Dramatic data, we as a society don't act on it.  If everybody over the age of 40 took a baby aspirin we've had a dramatic effect on life expectancy in this country, but we don't do anything about it.

ZAKARIA:  You also like statins.

AGUS:  I like statins also, because statins have an anti-cancer effect and they can delay heart attack and stroke, even in people with a normal cholesterol.  So very important that we think in those terms and that we actually think preventatively there.  And I say it out of weakness, not strength.  Now, you alluded to the fact that I was involved in Steve Jobs' care.  I know that most people with advanced cancer will die of the disease and I have to look at someone in the eye a couple of times a week and say I've got no more drugs for your cancer.  I don't want to do that anymore.  So, what we have here is a list of 65 rules of things to do and not to do that can prevent disease that are based on data.

ZAKARIA:  Now, so you've - you say, you know, aspirin, statin, movement, but it's interesting, aspirin and statin are really the only as far as I could tell, medicine-like things that you recommend.  For the most part you look at this whole industry of vitamins and supplements and you think it's all bogus?

AGUS:  I don't think it's all bogus.  I know it's all bogus.  The data have shown and the biggest study came out several weeks ago, the data have shown in now over 65 separate studies there has yet to ever be a benefit in a normal individual with vitamins or supplements.  Ever.  Yet, if a man takes vitamin E, he has a higher rate of prostate cancer.  If smoker or former smokers take beta carotene and vitamin A, the significantly higher rate of lung cancer or death.  If a woman takes high dose of vitamin D increased bone fracture rate.  So I look at those data, significant harm potentially.  No benefit clearly, yet we spend more ...

ZAKARIA:  The kids shouldn't have these gummy bear vitamins?

AGUS:  I've never seen a kid with scurvy or rickets or beriberi.  No, don't take gummy bear vitamins.  Eat real food.  It's the key.

ZAKARIA:  You are against juicing.  Explain why.  This is fascinating because a lot of people think they're being very healthy by having, you know, something in the morning.

AGUS:  But we're a society of shortcuts.  Right, you get a juice, I'm going to get all my vegetables and my nutrients, because it's too hard to eat fruits and vegetables.  So in 1746 James Lennis (ph), head of the British Royal Navy, and he has limes on his ship.  And back then you were at sea for months at a time and you would get scurvy.  They won the battle at Trafalgar.  At the end of it, because his soldiers didn't get scurvy, at the end of it, he said I happened to sell the extracted limes to cure scurvy and it didn't work.

ZAKARIA:  So, they had been eating limes on the ship, but then he sells the juice of the limes and it doesn't work.

AGUS:  Yes, totally different.  As soon as you squeeze it or put it in a blender it oxidizes and degrades right away to byproducts.  And basically, all you're getting is a big bowl of sugar.  You're getting something with very high glycemic index.  Eat the real food.  Fruits and vegetables as good as you can get, juicing no benefit at all.  It's just lots of sugar.

ZAKARIA:  Wow.  When you talked about inflammation, I noticed, this is another piece that you focus on a lot, which is that if the body gets inflammations, if it gets the flu, this is not just - even if you get over the flu, this has a long-term negative effect.

AGUS:  And again, that's one of the things we have to think about in terms of public policies.  That if you got the flu, you skip the flu shot, you would survive most likely, although tens of thousands of people die.  A decade from now because of having the flu and the inflammation your rate of heart disease and cancer are elevated.  And so, we as a society say, you're welcome to get the flu shot or not, you get heart disease and cancer we will pay for it.

ZAKARIA:  What do you think is - you - one of the things we've talked about is, you've said to me that if, you know, you know all these people who are exposed to asbestos are going to get cancer, we could easily - if by putting them on a prevention program, we could actually make sure many of them don't develop cancer.  Have them take aspirin, have them take statins.  Why don't we do that?

AGUS:  Well, I think, you know, there's a liability issue here and whether that the Fukushima in Japan, whether that's the asbestos here in the United States, once you start to say, listen, you have been exposed to something that could cause a problem and I may have exposed you, you put yourself up for liability.  And so we need to change that.

ZAKARIA:  But ironically as a result of that you're not actually giving people the preventive ...
AGUS:  No question about it.  But, you know, the penetrance of getting cancer with asbestos exposure is probably going to be ten, 20 or 30 percent.  So, 70 percent of people you wouldn't have to pay anything. And so, it's a financial game.  And we've got to change that.  We need to change – and for the last decade our country has been about health care finance.  All of the talk in Washington.  We need to change it back to health.

ZAKARIA:  You were advising the Japanese government, including Prime Minister Abe on the Fukushima business.  What's the lesson you drew from that?

AGUS:  Well, I mean the lesson is, we know what happened and that we as a society have to learn from it.  You know, one of the problems is, we don't know who was exposed and to how much.  We don't have a blood test for radiation exposure.  So one of the things we have to start to develop is a triage tool.  We know dirty bombs will happen in the world.  Horrible to say, but it will happen.  And so we need to learn from every experience we have and get better.

ZAKARIA:  So when I listen to all these rules, and we've got how many of them?  60 something of them, the thing, of course, I think to myself is, how many of these do you actually follow?

AGUS:  Well, listen, I do as much as I can.  And the key is moderation.  The good is, I'm in charge of my health, I'm making the conscious decision of what I want to do.  And so, I really believe health will change from each of us, it will change from the ground up, not the top down.  We're in charge of ourselves.

ZAKARIA:  And the key is, do it now, do it regularly, don't wait for something to ...

AGUS:  No question about it.  We're reactive field medicine.  But at the same time, I want people to think about tomorrow, not just today.

ZAKARIA:  David, pleasure to have you on.

AGUS:  Great.  Thank you, Fareed.