Open Heart (41 page)

In one of the books he is working on, he tells the stories of patients whose experiences of, and recoveries from, heart disease cannot
be accounted for by conventional scientific reasoning or observation.

“After a lifetime of caring for sick people, there is no question in my mind that belief is a powerful force for those good, bad, or indifferent things that happen to people, whether in what we call ordinary life, or in things pertaining specifically to health,” he says. “And I think an awful lot of what happens has to do with what has come to be called the mind/body connection.”

When I recount some of what I've been reading about placebos, and the placebo effect, Rich shakes his head sideways, and laments the fact that the word
placebo
has become synonymous with worthless.

“The placebo effect is enormously powerful, and enormously healing,” he says, “and should be mobilized to the max, in addition to whatever else we may bring to bear on a specific condition. But the placebo effect is only valuable to the extent that a patient believes it's valuable.”

What I wonder about, I say, is this: If the doctor-patient relationship continues to be seriously weakened and devalued—if, increasingly, we and our doctors become strangers to one another—what happens to all those conditions that have no apparent organic cause, yet are ameliorated by the simple act of going to a doctor one knows and trusts?

“Well, we know very little about the causes of illnesses that would appear to have obvious chemical, biological, genetic, or environmental origins,” Rich says. “And we know even less about the mysterious interactions between the mind and the body—and these interactions are crucial in enabling the body to heal itself, and to modify the course of illness. Thus the great danger if we lose sight of the doctor's ability to make use of the body's natural power to heal itself.

“But let me be more specific, and talk about something I call paragenetics,” he continues. “Now we know that genes per se are rarely the sole or even decisive cause of most common diseases, but if your father died of a heart attack at age fifty-nine, that festers in your mind, and through the mind/body connection, in your body as
well. You're forty-eight, and then fifty, and then you reach fifty-nine and something starts to happen.

“Now we know that genetics usually confer a propensity—a potential vulnerability. But will the heart attack that got your dad land on the same part of the time clock for you? Of course not. Still, your mind is programming your body in some way to believe that it will, and what I think about more and more is the power of the patient-doctor relationship to
reset
the mind/body clock—something that has largely been lost in the hoopla of technology all around us.

“And there's also this: in the absence of a healthy doctor-patient relationship—when somebody gets an impersonal lab coat doing all the stuff instead of a caring doctor like Phil or Jerry, or gets a different doctor for each visit—then fear kicks in, and becomes an element that itself inhibits the mind/body's ability to heal itself. And we should never underestimate the role fear and apprehension play in a patient's ability to deal with illness, and to recover from illness.

“So what we're really talking about here, I think, are questions of medical responsibility,” he continues. “What I've been teaching for years, for example, is that if you have a patient who is not taking medications, it's
your
responsibility to see that he does. It is because you have not sat down and adequately explained the urgency, or if there are side effects, because you have not given your patient the space—the comfort, the confidence, the necessary trust—to talk with you so that you can look for a suitable alternative. People don't want to talk about the cost of drugs or side effects with a doctor, often, because they're embarrassed, or they're ashamed, and so, here and in myriad other ways, I find that there is tremendous power in the doctor-patient relationship to help in the healing process—but only if we value it, encourage it, and understand its potential both for ill and for good.

“Excellence matters too, of course. Whether it's managing a hotel or a cardiology program, there has to be a commitment to excellence and to care, and that starts at the top, with leadership. In the case of Massachusetts General Hospital, for example, ever since Paul Dudley White, who was Eisenhower's personal physician, was in charge, there has been a standard of excellence there in cardiology
and cardiac care that has been passed down from one generation to the next.

“The way I see it, there is content and there is context. The content is the expertise—how good technically are the surgeons and the angiographers, and how up-to-date are they, and so forth. But then there's the context. And the context is: Does the care work? Because the context, you see, is the caring, the wisdom, and the judgment about employing the knowledge and power we do have—this vast array of medications, treatments, and technologies—to best serve individual patients in the way that we were able to serve you, my friend.”

15

Natural Selection

H
OW
CURIOUS,
AND
HOW
wonderful, I think, that these four friends I have known across a lifetime did not start out wanting to become, or knowing they would become, doctors. I think of various small moments that led them to their choices: Rich hearing about a college named Tufts that was far from Brooklyn; Arthur, disillusioned with law school, remembering a sophomore psychology course he had taken; Jerry discovering that becoming a sociologist was not equivalent to becoming a social activist; Phil, believing (at twelve) that he would never be good enough to play for the Brooklyn Dodgers, deciding (at twenty) that he wasn't smart enough to be a research scientist either—and I think, too, of how other such moments in their lives, as in mine, have made all the difference: Rich deciding to go to the Redondo Beach Library on a day when one of my books happened to be displayed; Jerry, about to examine a woman whose sexual partner was infected with HIV, putting his hands on the woman's neck and feeling huge lymph nodes; and my deciding, just before getting off the phone with Rich, almost as an afterthought, to mention my shortness of breath.

In our conversations, then, I remark on the fact that their delayed discoveries of their vocations, so seemingly serendipitous—yet, looking back, so apparently inevitable: can they imagine
not
having become doctors?—have their parallels in the ways many of the
most beneficial medical innovations of the past century have occurred.

The discoveries of penicillin and the fuller range of antibiotics that can destroy bacteria that cause infectious diseases (of streptomycin, for example, which provides an effective treatment for tuberculosis); of cortisone (steroids), which enhances the body's ability to heal itself; of antipsychotic medications such as chlorpromazine and lithium, which alleviate severe symptoms of some mental illnesses; of the bacterium (
Helicobacter pylori
) that is a cause of peptic ulcers—these discoveries, along with a host of others, have come about
not
because researchers were specifically working to find the causes and remedies they happened upon (cortisone was originally developed for rheumatoid arthritis; chlorpromazine for its analgesic effects in surgery; lithium as a salt substitute for heart disease)—but through chance, accident, and serendipity.

The stories of such discoveries provide a welcome corrective to the generally perceived notion that science proceeds from ignorance to discovery in a logical and linear way. Such a notion—reinforced in my own childhood by the worshipful attitudes that attended the advent of vaccines and cures for polio, smallpox, pneumonia, and other diseases, and encouraged later on by the optimism attending fund-raising campaigns dedicated to finding cures for cancer, muscular dystrophy, multiple sclerosis, cystic fibrosis, diabetes, leukemia, Parkinson's disease, AIDS, and other diseases for which cures continue to remain nonexistent no matter the amounts of money, time, and research expended on them—dies hard.

Witness, this past year, a Christmas letter in my mail from the actor Christopher Reeve, a letter reminiscent of the appeals I was hearing nearly forty years ago when Jerry Lewis, in his annual telethons, began soliciting donations of money to be used to find
the
cure for muscular dystrophy.

“May I introduce myself?” Reeve writes. “My name is Christopher Reeve. Perhaps you remember when I portrayed Superman.

“But after a riding accident in 1995, I've been paralyzed from the neck down, so I'm dictating this letter to you.

“Still I'm alive, and full of enthusiasm, because I believe that a cure for paralysis will be found before long!

“It can happen!

“I believe it because I head up the Christopher Reeve Paralysis Foundation, and I've talked to some of the world's leading specialists in spinal cord injuries.

“Please believe me, they are zeroing in on a cure,” he reports, and in a postscript he asks us to “remember that research costs money and your holiday gift is going to help get people like me up and out of our wheelchairs.” (In a TV ad for his foundation, Reeve is shown getting up and out of his wheelchair and, like Superman, once again flying up and away into the skies.)

How wonderful it would be if the multitude of diseases and ailments that continue to afflict us would be as amenable to reason, research, and the scientific method as, in the first half of the twentieth century, many infectious diseases were. How wonderful it would be if all we needed to find cures for disease would be to identify the problem, raise money, and set researchers to work. Our lack of success in finding cures for diseases we have expended great resources on, however—whether spinal cord injury or muscular dystrophy, breast cancer or influenza—hardly encourages such a hope.

Still, like my friends' discoveries of their vocations, or my discovery of my occluded arteries, the history of medical science and of scientific discovery reassures, and it does so because it turns out to be made up of what any interesting life, or story, is made of: the unpredictable and the unexpected—those small, unanticipated moments that turn out to have large and surprising issue.

And there is this too: because we know so little about the causes of most diseases, how much more wondrous are our triumphs when we
do
discover the cause or causes of a disease, and
do
find treatments that alleviate illness and suffering. That we are able to do so—to have available to us an extraordinary range of medications and treatments which, like antibiotics and bypass surgery, were undreamt of a few generations ago—and that we often discover these marvelous technologies
before
we possess any true understanding of why they are effective (for example, our use of lithium and chlorpromazine for bipolar disorder and schizophrenia before we understood the workings of neurotransmitters)—this heartens because it reminds us that medical science is not separate
from
life, but is
part
of
life, and so it too is informed by mystery, wonder, and chance.

“The main discovery during this [twentieth] century of research and science,” François Jacob, Nobel Prize winner in medicine in 1965 for his work in genetics, writes, “has probably been the depth of our ignorance of nature.”
^*

Thus Selman Waksman, a soil microbiologist who received the Nobel Prize in 1952 for his discovery of streptomycin and its uses in the treatment of tuberculosis, came to revise his initial understanding of the nature of antibiotics. Whereas at the time of his discovery he believed that antibiotics were “chemical weapons” produced by bacteria to maximize their own survival chances against other organisms, he later came to see that because antibiotics were limited to a very few species, they could not play a significant role in the ecology of microbial life generally. Moreover, the ability of microorganisms to produce antibiotics was highly dependent on the quality of the soil in which they lived, and could only be reliably produced in a laboratory. For these and other reasons, Waksman came to the view that antibiotics were “a purely fortuitous phenomenon…there is no purposeness behind them…[and] the only conclusion that can be drawn from these facts is that these microbiological products are accidental.”

But why and how a small group of microorganisms that grow in soil should have the ability to create complex chemicals that can cure infectious diseases—why and how they exist at all!—remains, simply, unknown.

That Alexander Fleming, returning from a holiday in 1928, noticed that a contaminating mold in a Petri dish, one that was sitting in a pile of other Petri dishes and waiting to be washed, had inhibited the growth of a colony of staphylococcal bacteria; that an exceptionally cool nine-day period during his absence had favored the growth of this mold (
Penicillium notatum
), and that a subsequent warmer period had favored the growth of the staphylococcus that the penicillin, due to
its
growth during the nine-day cool period, was now capable of subduing; that Fleming chose not to explore his observation further; that it was not until other scientists (Howard
Florey, an Australian professor of pathology at Oxford, and Ernst Chain, a Jewish refugee biochemist from Nazi Germany), while revisiting Fleming's observations about the ability of lysozymes in tears and nasal mucus to dissolve bacteria, came across Fleming's observations about penicillin, and through a sequence of remarkable and remarkably serendipitous events (at the outset they assumed penicillin would have
no
clinical applications) not only discovered the miraculously beneficial qualities of penicillin (effective against staphylococcus, and also against the pneumococcus, gonococcus, meningococcus, and diphtheria bacillus, along with the bacilli of anthrax, tetanus, and syphilis), but elucidated the principles by which
all
antibiotics were to be discovered—such an unlikely and fortuitous series of events is an unexceptional (if marvelously instructive) example of how scientists have most often arrived at their discoveries and at technologies resulting from their discoveries.
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