A heart attack can have salutary effects. In some instances, it helps us to reexamine our lives and reorder our priorities. The same is true for medicine.Petr Josek Snr/Reuters
One of medicine's greatest challenges is heart failure. Nearly all of the human body's tens of trillions of cells depend on a constant supply of blood, and failure of the heart to meet this demand represents one of the gravest threats to health and life. It is estimated that heart failure afflicts over 5 million Americans, and it represents the most common reason for hospital admission in patients over 65 years of age.
We can live without a hand, an eye, or even a kidney or lung, but the heart is absolutely indispensable. It reliably contracts 100,000 times each day, for a total of 2.5 billion beats over the course of a life time. It pumps blood through a network of vessels that, if each were stretched out and laid end to end, would measure over 60,000 miles in length. Cessation of cardiac function remains one of the most important indicators that life has ended.
The scientific and rhetorical proof of the heart's role in circulating the blood constituted one of the greatest triumphs in the history of medicine. William Harvey (1578-1657), perhaps the greatest English-speaking physician who ever lived, was not the first to suspect that the blood moves in a circuit, but he was the first to provide rigorous experimental proof. Yet even Harvey's demonstration had holes. Lacking a microscope, he could not explain how the blood finds its way from the arteries to the veins.
Physicians are not immune from heart failure. Like our patients, we too develop coronary artery disease and hypertension, two of its principal causes. Over time, these conditions can force the heart to work too hard or deprive it of too much blood flow, causing it to wear out. Inspecting an electrocardiogram, a chest radiograph, or a heart muscle biopsy specimen, we can determine if the heart is diseased, but we cannot tell whether or not the patient from whom it was taken happens to be a physician.
There are, however, other forms of heart failure that pose a special threat to physicians. These ailments lie completely beyond the reach of our high-technology diagnostic tests and therapies. A physician might receive a completely clean bill of health from a colleague in cardiology yet still suffer from a profound sickness of the heart. The heart is not only the pump that circulates the blood but also the foundation of our life and practice. To forget this elemental truth is to lose heart.
One such form of heart failure is exemplified by a physician who has provided his office staff with clear instructions: "If I am in the room with a patient for longer than two minutes, come and get me." This colleague suffers from cardiosclerosis, hardening of the heart. In his practice, attention and compassion have given way to throughput and revenue. He provides health care as a means of making money, but he no longer cares for his patients.
Another such disorder is microcardia. I encountered a case of this disorder in a colleague who had a bad habit of taking phone calls from his business partners during patient rounds. His phone would ring. With the patient in mid sentence, he would answer and engage in a lengthy business-related conversation. Then, without skipping a beat, he would return to the patient as though nothing had happened. The stunned and disappointed look in his patients' eyes left no doubt that something had.
An especially prevalent form of heart failure is corporate cardiopathy. Physicians today feel heartsick about the de-professionalization of medical practice. Hospitals increasingly resemble luxury hotels, physicians are told by non-health professionals how to care for their patients, and the quest for higher scores and rankings supplants quality relationships and access to care. Management has superseded medicine, or as one colleague put it, "Medicine is being run by guys in suits."
The heart is more than a pump. It is the center and source of our being, our locus of ultimate concern. The way we relate to patients, colleagues, and students is symptomatic of our deeper loyalties and commitments. Where our hearts are, so will our practices be. One approach to medicine is to ask, "Are we making money?" Another is to ask, "How many of our patients, colleagues, and students would stand up and say, 'I trust and admire this human being?'"
A heart attack is a serious threat to life. For some patients, the first sign of heart disease is sudden death. Yet a heart attack can have salutary effects. In some instances, it helps us to reexamine our lives and reorder our priorities. The same is true for medicine. Many physicians are discouraged and burned out. Yet every threat to excellence in medicine is also an opportunity for physicians to get clear on what being a physician is really all about.
Rudolf Virchow, the greatest pathologist in history, famously argued that medicine should be regarded less as a biological science than a social science. In saying so, he meant to draw our attention to the organizational, social, and cultural contexts in which health, disease, and medical professionalism are always embedded. Physicians may master the science and technology, but if we neglect the knowledge and skills necessary to lead health care, we and our patients will surely suffer.
Yet merely putting physicians in charge will not solve the problem. Receiving an M.D. does not inoculate human beings against the seductions of wealth, power, and fame. To lead medicine in the appropriate direction, we must first recognize that the most real thing happening in health care is taking place not in the halls of government or the boardrooms of corporations, but in classrooms, laboratories, and at the bedside. To find heart, medicine must have its heart in the right place.