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« Back to Healing the Heart main page    Transcript for: Healing the HeartTHINK TANKSATURDAY, MAY 20, 2000 ANNOUNCER: Funding for Think Tank is provided by the John M. Olin Foundation, the Lynde and Harry Bradley Foundation, and the Smith Richardson Foundation. (Musical break.) MR. WATTENBERG: Hello, I'm Ben Wattenberg. Forty years ago doctors performed the first coronary bypass surgery on the human heart, a major event in medical history that's saved millions of lives. Now, how far have we come in treating heart disease since then? How far do we have left to go, and are the new remedies being applied wisely, or sometimes simply for profit. To find out Think Tank is joined by Stephen Klaidman, senior research fellow at the Kennedy Institute of Ethics at Georgetown University and author of Saving The Heart, The Battle To Conquer Coronary Disease; Dr. Stuart Seides, the vice chairman of cardiology at the Washington Hospital Center; and Edward Hudgins, director of regulatory studies at the Cato Institute in Washington, D.C. The topic before the house, healing the heart, this week on Think Tank. (Musical break.) MR. WATTENBERG: By the estimate of the American Heart Association, coronary heart disease affects some 12 million people in the United States. Although the rate is down by about 25 percent in the last 10 years, still more than 450,000 Americans died of the disease in 1997. That's one of every five deaths. For a long time pain reducing drugs, and open chest bypass surgery were a heart patient's only options. Now, doctors can choose from a variety of new procedures, including angioplasty, coronary stents, and minimally invasive bypass surgery. These discoveries have helped prolong lives. The life expectancy for man at age 65 has risen by more than 20 percent in the last 3 decades. At the center of this remarkable explosion in technology is the close and sometimes controversial relationship between the medical profession and the manufacturer of the drugs and devices used to treat heart disease. For the most part the devices have been invented by doctors, doctors who aimed to do good and wound up doing very well. Does this yield some potential for overuse of the new procedures, are there issues of medical ethics involved? And even so, might not any attempt to change the current system of rewards hamper the development of new and better treatments? Gentlemen, thank you for joining us. Let me begin with you, Steve Klaidman, what do we know now about heart disease that we didn't know until recently? MR. KLAIDMAN: Most of all, we know how to fix some of the plumbing we couldn't fix before. But, we're beginning to learn a lot about the causes of the disease, what actually causes the build up of atherosclerotic plaque in the arteries. MR. WATTENBERG: Atherosclerosis is what is normally called hardening of the arteries? MR. KLAIDMAN: Exactly. MR. WATTENBERG: I did my research, right? MR. KLAIDMAN: Yes. We know more now about what causes most heart attacks. That's something that was speculated about for most of the century and pretty well nailed down in the last ten years or so. And as we move into the next decade we may learn some of the molecular level events that actually cause the plaque to develop. MR. WATTENBERG: Dr. Seides, on a practical level, how has your practice at the Washington Hospital Center changed in the last 10 or 15 years, what are you doing now that you didn't used to do? DR. SEIDES: Well, I think, as I characterize my own career, I graduated from medical school in 1970. So this is my 30th anniversary. And I would say a couple of things. One, the most skilled cardiologist in 1970 would be bewildered by what he or she saw today. The world is entirely different. We've gone from an observational, and really minimal treatment approach in 1970 through an era of surgery, angioplasty, fixing arteries from the inside with balloons. MR. WATTENBERG: Angioplasty is when you shove one of those tubes up a vein and get into the heart and jiggle it around? DR. SEIDES: We don't like to say shove. It's when we carefully place a tube through an artery into one of the coronary vessels and expand or displace the plaque material, the block material, either with a balloon, or remove it with a cutting device, or place a stent, which is a metallic scaffold in the artery to keep it propped open. So we have developed those kinds of techniques, and where we are here in the year 2000, I think, we've learned a number of things. One, we can do the plumbing, as Steve has implied, and do it successfully. We've also learned that fixing the plumbing isn't the entire answer to treating heart disease. You don't really know whether that's true until you can fix the plumbing, and we have fixed the plumbing. MR. WATTENBERG: You said, we have developed. Who is the we? DR. SEIDES: Well, the we, you know, we always stand on the shoulders of giants. And I think one can go back very, very far in terms of saying why or how are we at the place that we are today. But, to address what we are talking about today, in terms of instrumentation, a lot of that instrumentation has been driven by individual entrepreneurship, and inventorship, frequently on the part of physicians, and then developed, cultivated, marketed by commercial enterprises, companies out there. MR. KLAIDMAN: I think probably if you want to talk about devices, I mean, you really want to begin with the Mason Sones (sp) in the late '50s at the Cleveland clinic who invented angiography, and gave us the ability to look at the insides of the coronary arteries and see where the blockages were. Without that development none of the devices that came afterwards would have been possible. MR. WATTENBERG: When you gently place that tube up the artery is there a viewing scope that you can see what's in there, is that the way that works? DR. SEIDES: Yes, there's an imaging chain that these days consists of a standard x-ray tube, and then amplification using a television chain. In the old days, when this was first developed, as Steve was saying, back in the late '50s and early '60s one viewed the fluoroscopic image directly, and so a much higher intensity of radiation exposure occurred to both the patient and the operator. These days we use much less radiation and amplify the image using television technology. But, I think to some extent when one looks at this it is the difference between science and engineering. I think there's science and then there's engineering. And a lot of what we have done is really based on engineering, which is the application of science to practical problems. And cardiology, interventional cardiology has taken advantage of the science and created engineering. And that engineering has been promulgated in an entrepreneurial way to create devices. MR. WATTENBERG: Ed, now it's time to bring you into this discussion. Dr. Seides has already mentioned several times, Steve mentioned it, the role of the entrepreneur in this whole situation. Medicine, at least until recently, was not regarded as a realm of the entrepreneur. It surely is now. What do you make of that? MR. HUDGINS: First of all, I think it's a good thing, because if you look at industries that are market driven they tend to be the ones that do the best. Whether it was the automobile industry at the beginning of the century, so now everyone can have an automobile, now we have traffic jams, but Henry Ford did his part, or whether it's computers or computer software, when you have market driven technologies they usually tend to be good technologies, they usually tend to get the price down, and because you have competition of different technologies you tend to get the best for the public. So in general, I think it's a good development. MR. WATTENBERG: Adam Smith lives? MR. HUDGINS: Very much so. MR. WATTENBERG: Okay. Now, your book toward the end, Steve, says two things, Adam Smith lives and that's fine, and then it also says Adam Smith lives and that's not so fine. Now, why don't you give us the not so fine. You've heard the case that markets work and they create new technologies and they're good for the public, but I know you have a problem. MR. KLAIDMAN: To begin with, healthcare is not an industry like all others. Doctors take a Hippocratic oath. Their duty is to the patient, absolutely. Secondly, and this is on the Adam Smith lives side, this system is like democracy in a way. It's the worst form of government, except for all the others. And so what we need to do here is to keep a sharp eye on the effects of entrepreneurialism in medicine. And I don't know a better way to go about doing this, but I do think that patient's interests can be compromised when physicians have financial interests. MR. WATTENBERG: You have a number of examples in the book, give us some examples where patients' welfare is being compromised. MR. KLAIDMAN: The sort of thing I have in mind, and Stu I'm sure will want to comment on this as well, is when you have, for example, an interventional cardiologist, such as Stuart is, who diagnoses patients and recommends treatment. There are many treatment options, and there are gray areas about treatment. That is to say, one patient might be a candidate for more than one kind of treatment. There is, it seems to me, a considerable likelihood that a physician is going to be influenced or biased toward making a treatment recommendation that he or his group do. MR. WATTENBERG: I believe you quote someone in the book, approvingly as I recall, saying that 50 percent of the angioplasties performed are unnecessary. MR. KLAIDMAN: It's not approving or disapproving, it's simply to provide the only kind of evidence there is, which is anecdotal. I interviewed probably 100 or 120 cardiologists and cardiac surgeons for the book. I asked virtually all of them whether they thought these procedures were used too frequently. The answer in virtually every case was yes, the numbers ranged from somewhere between 20 and 25 percent to a high of 50 percent. MR. WATTENBERG: Okay. Now, Doctor, Steve is saying that 25 to 50 percent of angioplasties are unnecessary. Do you do any of them? DR. SEIDES: I would like to think not, but certainly I would be I think it would be - MR. WATTENBERG: He's saying somebody does it, I mean, Dr. X, Dr. Y, or Dr. Z. DR. SEIDES: I would like to think not. But, what I would say to you is that we have an evolving understanding of the role of angioplasty and bypass surgery in the treatment of patients with coronary heart disease. And the patients in whom I would recommend one or both or either of those procedures today are somewhat different than the patients I might have recommended it to years ago. MR. WATTENBERG: Angioplasty being an invasive procedure has some life and death risks to it, not enormous but there is some. DR. SEIDES: There is some risk, yes. And I think like any other MR. WATTENBERG: Have you had any patients die on your during a procedure? DR. SEIDES: Certainly, yes, I have. Not many, but the few that have are memorable, and certainly is reminds me and should remind any physician who does any procedure that it's incumbent upon them to balance the risks and the benefits of that procedure before recommending it to a patient. I think one needs to distinguish, though, between let's say procedures that are done in excess because of a financial driver versus those that may be done in excess because of either a less than ideal understanding of the disease process, or even at times a degree of enthusiasm about doing versus non-doing. And I think that's where physicians themselves may vary greatly. MR. WATTENBERG: Ed, there's an old statement in the advertising business quite similar to this, 50 percent of advertising is wasted, but we just don't know which 50 percent it is. How do you come out on this? MR. HUDGINS: It's interesting, because I think you gentlemen would agree that a diagnosis by definition is a prediction, you're not quite sure. Then after the fact you might say, well, maybe an angioplasty was the best thing, on the other hand maybe it wasn't. So there's always uncertainty involved, and what we're talking about here is the gray areas. But, I think what's even more interesting that's coming out of this discussion is that we're not only talking about a market for devices, medical devices and so forth, but a market for information. One of the problems with the current regime is that the food and drug administration very much controls what can be said about medical devices, pharmaceutical products, et cetera. But, the Internet is changing all of that. People feel much more empowered now. When someone gets an illness the first thing they do when they come home is they go on different web sites, they talk to other patients online, et cetera, et cetera. I think what you're going to see in the future is more of a market for information, not only about products, but about doctors, about procedures. MR. WATTENBERG: Buy stock in hypochondria? MR. HUDGINS: Yes, but the point is, I would rather have a full open market rather than a market where the government more and more controls the flow of information, because that's part of the problem with the current system. MR. KLAIDMAN: What's your level of concern about bad information and the ability of people to interpret it, it can be complex and difficult and misleading? MR. HUDGINS: That's true. But, you see, I believe that one of the problems is that people want to take their healthcare more into their own hands. The problem is in the past they haven't been able to, because it was something for the most part you had to be a medical doctor. Even if you wanted to look up information about a disease or something, it was very tough to do. Now it's not. But, what that means is that patients have to become more sophisticated. MR. WATTENBERG: I want to talk to our viewers. We at Think Tank depend on your feedback to make our show better. Please email us at thinktank@pbs.org. Steve, let me just go back to something. You said that 25 to 50 percent of angioplasties are unnecessary. MR. KLAIDMAN: That's not quite what I said. What I said is something on the order of 100 cardiologists and cardiac surgeons told me that. MR. WATTENBERG: Okay. DR. SEIDES: But, if you asked each of them MR. WATTENBERG: That's my point. Now, here's one of them and he says MR. KLAIDMAN: Here's an honest man who says he would like to think that he hasn't done any of them. MR. WATTENBERG: Right. So the question is, are you saying that some of the cardiologists who perform these 25 to 50 percent 'unnecessary angioplasties' know that they are unnecessary? I mean, aren't you charging in that case sort of functional malpractice? MR. KLAIDMAN: No, I'm making a subtler point, I think. What I'm saying is that within these gray areas, where there are more than one treatment possibility they're picking the one that they do. It's a way to treat the disease. It may be a perfectly sensible way to treat the disease. It may not be the optimal way to treat the disease. They may not see it that way. To them it may look like the optimal way to treat the disease. MR. WATTENBERG: If someone comes into your office and it's borderline between prescribing some cardiac medication or doing something interventional, which is what you do, do you think unconsciously, as Steve seems to indicate, you or people like you kind of inevitably lean toward what you do, and say, hey, I know I can get up there with a stent or something, and to hell with those drugs? DR. SEIDES: I would like to think, again, I'm going to phrase it that way, that I would not be driven by the economics. I think there is also, I think, among physicians and many other people, a desire to use the skills that you've trained and honed over a period of time. After all, anybody can write a prescription MR. WATTENBERG: I can't. DR. SEIDES: Any doctor can write a prescription, but only someone with a certain skill set can do angioplasty, can do a bypass operation. So there is, I think, some subtle driver to do that which you are trained to do. I think those of us who hold ourselves to a high standard would, again, like to believe that we are driven neither by personal gain, nor by ego, and make a recommendation that we honestly believe has the most favorable risk-cost/benefit potential. MR. WATTENBERG: Ed you'd better say that the market sorts this out, is that what you were going to say? MR. HUDGINS: Well, I was going to say that the market sorts this out. And what is happening now is, of course, the medical profession, which you're right, has not been thought of as a market area for so long, is becoming one. What I'm arguing for is more markets. That is, for example, unfortunately right now because of some of the medical monopolies exercised by medical boards and so forth, it's hard to get information about doctors who may be involved in a lot of malpractice suits. And I agree, a lot of them are nuisance suits. But, for example, to what extent can a patient go online, or go to some central place, and say I want to look up the reputation of my doctor, I want to see if for every single case they prescribe an angioplasty, versus this guy does angioplasties, but I actually see that sometimes they'll prescribe medication indicating this is a more honest doctor. In other words, I'm saying that more information is better, it makes a more sophisticated customer. And that's the direction we're moving, and I think it's a good direction. MR. KLAIDMAN: I think more high quality information surely is better. And you've got very few examples. There's New York State and Pennsylvania, which publish ratings for hospitals and heart surgeons, just cardiac surgery. Arizona and California there's a private group that's trying to put out some of the same information. But, that too is fraught with problems, because they rely heavily on mortality figures. Those mortality figures are not always easy to interpret. DR. SEIDES: I would, in general, be personally favorably disposed to a free market economy. I think if you talk to doctors among the things they like least are the fact that there are insurance companies that are interposed between the patient and themselves. So that the doctor-patient relationship, at least on an economic basis, is entirely distorted. I think part of the problem with free market or free flow of information, which is not free market, I think part of the problem with information though is that it is very difficult in a complex environment to contextualize information. I mean, if you look at the way, for example, the media will treat a medical discovery, you know, it gets front page in the newspaper, and patients call us up and say, gee, I heard there's a new cure for heart disease. It's not contextualized, it's not put into the mosaic of what we already understand and know about the particular illness. MR. WATTENBERG: I want to ask you a question. In terms of any disease that you consider yourself an expert on, would you think that any patient of yours who starts truly investigating it on the net or elsewhere is going to learn anything that you don't already know? DR. SEIDES: I think it would be arrogant for me to say no, I don't think they could possibly learn anything I don't know. But, I can tell you from experience, and from practicing here in downtown Washington, where I have a lot of people who come in with handfuls of Internet information, that they seldom will come up with something that can be contextualized into their particular treatment that we haven't already considered. MR. KLAIDMAN: But, I would like to come back to the question of conflict of interest and cardiologists and devices. And a quote from the book, an entrepreneur, also a surgeon named Wes Sterman (sp), said a disease is a business opportunity. And this is really the focal point for me. The concern then becomes, if you treat a disease as a business opportunity, you then develop a device and the goal is to have a successful business, to sell as many of these devices as you possibly can. You've got people who are testing your device at hospitals around the country, once you get it through the FDA, or even before at the testing stage. And you're getting more and more people who become wedded to this device, and wedded to its market potential. And that, it seems to me, does become a financial driver for using something that maybe doesn't need to be used. MR. WATTENBERG: We have to get out, and I do want to ask you one more question. I will give you Ed's answer to that, which is it is in the patient's best interest that a disease, indeed, be regarded as a business opportunity, because when it is all the competitive juices flow in a variety of different ways, to help the patient, because if you don't help the patient sooner or later the market will see to it that you don't make any money. Is that your point, I assume? MR. HUDGINS: I think that would be a good point. MR. WATTENBERG: Now, where do we go from here? MR. KLAIDMAN: In terms of the science, I think Stuart and I are probably going to agree. Where we go from here is an attack on the disease itself. Everything up until now has been palliative. We fix people for a while and then the disease recurs. Now, people are looking at what causes the disease, and how to prevent it. MR. WATTENBERG: And that gets into biogenetics and that kind of stuff? DR. SEIDES: Yes, then I think looking at things on a cellular and mechanistic level that will allow us to treat this disease in a way that is more biologically than mechanically based. MR. WATTENBERG: What's the time frame for this next revolution in learning and curing the disease? Are we talking a couple of years, or a couple of decades, or more? DR. SEIDES: I think it's going to be soon, in plenty of time for you and me. MR. WATTENBERG: From your mouth to God's ear. Yes, sir, what comes next, but we have to be quick. DR. SEIDES: Okay. Thirty years ago I think you said you graduated in medicine. Thirty years ago my uncle, who was very close to my own age, Robert Hudgins, died from a heart problem. He had two operations, and the technology at the time couldn't save him. Today he would be alive. So I can only celebrate the kinds of developments that we have seen in the last 30 years. But, I think in order for these to continue, what we need to understand is that the market does best. There are indeed, conflict of interest issues, but that's where the market and a sophisticated consumer are going to do the best job, not more government mandates and more regulations. And I think that's the direction we're going on. MR. WATTENBERG: Okay. Thank you Ed Hudgins, Steve Klaidman, Stu Seides, and thank you. We at Think Tank encourage feedback from our viewers via email. For Think Tank, I'm Ben Wattenberg. ANNOUNCER: We at Think Tank depend on your views to make our show better. Please send your questions and comments to New River Media, 1219 Connecticut Avenue, Northwest, Washington, D.C. 20036, or email us at thinktank@pbs.org. To learn more about Think Tank, visit PBS Online at pbs.org. And please let us know where you watch Think Tank. This has been a production of BJW, Incorporated, in association with New River Media, which are solely responsible for its content. Additional funding is provided by the John M. Olin Foundation, the Lynde and Harry Bradley Foundation, and the Smith Richardson Foundation. (End of program.) Back to top  Think Tank is made possible by generous support from the Smith Richardson Foundation, the Bernard and Irene Schwartz Foundation, the Lynde and Harry Bradley Foundation, the John M. Olin Foundation, the Donner Canadian Foundation, the Dodge Jones Foundation, and Pfizer, Inc. ©Copyright Think Tank. All rights reserved. 
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