| Our Readers Respond: Summer 2006 |
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Archive : Summer
2006
First, Do No Harm [Read
the article]
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.
Please note that the opinions selected and posted here do not represent
the official views of proto® magazine or of Massachusetts General
Hospital.
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