"For extreme diseases, extreme methods of cure," Hippocrates said in the fourth century B.C. Hippocrates, of course, was wrong. What he surely meant to say was: "Extreme diseases require congressional hearings, slanted witness lists and misleading reporting." In 1977 this is considerably closer to the mark than his old-fashioned prattling about "extreme methods of cure."
By now I suspect that Daniel Greenberg regrets using the word "quackery" in direct reference to surgery for coronary-artery disease. Greenberg is a fine reporter and, in addition, has had some very interesting comments on "The Press and Health Care" (more about this later).But he did use the word (The Post, Aug. 2) and the word cropped up again in the headline. This is distressing for two reasons: It is totally incorrect and a disservice to cardiac patients, and it represents a currently fashionable - but also totally incorrect - way of looking at the entire issue of medical treatment.
Greenberg's denunciation of by-pass surgery for coronary disease was based on recent testimony by Dr. Richard Ross before a Senate subcommittee. According to The Post, Dr. Ross told the interested senators that although the operation has been successful in relieving the pain of angina pectoris, "there is no evidence that the operation prevents sudden death or makes patients with coronary-artery disease live longer." Picking up on this testimony, Greenberg wrote, "Its only verifiable value, [Ross] emphasized, is for relieving the painful condition - angina pectoris - that sometimes accompanies artery obstructions and that can often be successfully treated with drugs."
Now I may not be a genius and my colleagues may not all be Sir William Oslers, but I suspect that even Dr. Ross would consider us smart enough to first try drug therapy on our patients with angina (now that the FDA has finally made a betablocker drug available in this country). Simply put, the patients who go to surgery have not responded to medical treatment. In the past there was no alternative if drug therapy failed. Today there is.
There is an additional secret, however. Cardiac surgeons cannot - much as they might like to - sweep suffering coronary patients off the street and operate on them; nor can they (yet) advertise their services. They get their patients by referral, and most of those referrals come from physicians like me - non-surgical internists, cardiologists and family doctors, many of whom have a barely disguised terror of surgery, for both themselves and their patients.
Therefore, non-surgeon physicians have been dubious about surgery for coronary-artery disease. Unlike Greenberg, we have lived through the era of the Beck procedure and the time of the Vineberg operation and microsurgery and the Takaro graft. We have seen a dozen enthusiastic surgical assaults on the coronary arteries, and we have seen them fail. We have learned to be skeptical. When Rene Favalora reported his first cases in 1969, we remained skeptical. There is something different about his operation, however.
It doesn't work for every case of coronary disease, and it doesn't work every time that it's supposed to. Still, even the notoriously unenthusiastic Dr. Ross concedes that the operation is "unquestionably useful for relieving the severe pain" of angina. That's quackery?
Furthermore, there is accumulating evidence that successful surgery does prolong life in certain subsets of patients with coronary disease, particularly those with what is termed "left main" obstruction. It is simply too early to tell what the eventual effect of surgery will be on life expectancy.
It is the essence of medical practice to live with uncertainty and to be forced to make decisions on the basis of incomplete knowledge. Practicing physicians are trained to do this, but senators and regulators apparently are not. They now insist on "proof" that medical procedures are "effective" or "cost-effective." That proof is often long in coming. We began to treat high blood pressure in this country in the late 1950s. "Proof" that this was effective wasn't forthcoming until 1972. Banting and Best isolated insulin for injection in 1921 - and scientific debate still rages as to whether it has any effect on the complications of diabetes. Would Congress have us abandon these treatments until all the sainted double-blind studies were complete?
In his recent article "The Press and Health Care," Greenberg pointed out that, "with rare exception, the press is a sucker for out-of-the-ordinary pronouncements from major institutions or people holding official rank." Furthermore, in the health area "in most cases the press accepts the spoonfeeding [from official sources] without quibble." Since officialdom concentrates on what's bad in American medicine, press clippings have piled up on such subject as "CAT scanners, the alleged surplus of hospital beds, fraudulent use of government health-insurance programs and a rash of findings on the risk and benefits of this or that drug or clinical procedure." Officialdom, Greenberg went on to say, "is currently obsessed with cost containment and the inequities, inefficiencies and dangers of modern medical practice. And it puts its money into studies designed to substantiate its preconceptions."
These are brilliant, bitter words. Too bad they appeared only in The New England Journal of Medicine, whose physician readers are already mordantly aware that they can expect a fair deal from neither the press nor the government. And too bad that Greenberg didn't reflect on them when he started to write about the Senate health subcommittee and coronary surgery.