A Revival of Paul Dudley White
1999; Lippincott Williams & Wilkins; Volume: 99; Issue: 12 Linguagem: Inglês
10.1161/01.cir.99.12.1525
ISSN1524-4539
Autores Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 99, No. 12A Revival of Paul Dudley White Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBA Revival of Paul Dudley White An Overview of Present Medical Practice and of Our Society René Favaloro René FavaloroRené Favaloro From the Favaloro Foundation, Buenos Aires, Argentina. Originally published30 Mar 1999https://doi.org/10.1161/01.CIR.99.12.1525Circulation. 1999;99:1525–1537Paul D. White was born in Roxbury, Mass, on June 6, 1886. He graduated from Harvard Medical School in 1911 and became a House Officer at the Massachusetts General Hospital (MGH) the same year. An important landmark in his life was his trip to London, where he studied under Sir Thomas Lewis in 1913. He returned to the MGH in 1914. He became an instructor in medicine at Harvard Medical School in 1921. He was a member of the founding group of the American Heart Association and was its president from 1941 to 1943. He was also a founding member of the International Council of Cardiology in 1946 and was its president the same year. He was president of the International Society of Cardiology from 1954 to 1958, and in 1957 he founded the International Society of Cardiology Foundation. (Core biographical information comes from the excellent book Take Heart by Dr Oglesby Paul. He was a resident at Harvard Medical School, which included 2 years of study of heart disease under Paul D. White. I am grateful to my friend Dr Tom Ryan, who wisely gave it to me as a present for the purposes of this lecture.)Dr White wrote 12 books and ≈758 scientific articles. He won hundreds of well-deserved awards. He always kept an open mind for new developments. On his return from England in 1914, he brought with him the exciting new ECG developed by Einthoven in 1903. He was the first to use it in the United States for clinical research.I met him in London during the VIth World Congress of Cardiology. He was present during the discussion I held with Charles Friedberg on the early development of coronary artery bypass graft surgery. After the discussion, I had the chance to speak with him briefly. I also had the pleasure of participating in a symposium in his honor in New York in December 1971. On that occasion, I had the privilege of sitting next to him and exchanging ideas and friendship for more than an hour. He talked about his trip to Latin America and Argentina. At 85 years old, he had a clear mind and looked in good health despite having had a heart attack in 1970. I was impressed by his remarks and judgments but even more so by his humility and modesty.Paul D. White died on October 31, 1973, at the age of 87.If we analyze his life carefully, we will realize that Paul D. White left an important legacy for all of us.The LegacyFirst Message: Clinical History Stands Above Any Technological AdvancesBy 1925, Paul D. White had 2 chief interests: the practice of medicine and clinical research. He truly believed that the clinical record, which starts with the interview, stands above any technological advances. His modest, simply furnished office at the outpatient clinic of the MGH, and later at 264 Beacon Street, witnessed him counseling innumerable patients. (At the national headquarters of the American Heart Association in Dallas, there is a permanent exhibit of his modest Boston office.) He certainly loved his patients as human beings."Listen to what the patient can tell you—it may be more important than anything else you do!"1(p83) he repeatedly emphasized to his students. Besides giving his patients a chance to describe the history of their illness and the symptoms in their own words, he also had the valuable opportunity to observe the psychological implications and the characteristics of each personality, and only then would he perform a careful and detailed clinical examination.Second Message: All Patients Are EqualAmong Paul D. White's patients were many of the great names of the 20th century from America and abroad: presidents, politicians, businessmen, writers, artists, bishops, and prominent physicians and scientists. However, most of his patients were ordinary people.One of his former students, Dr Royal Schaff, watched him "delivering the best care that he could for anybody and everybody, from the President of the United States to the poor little lady coming in from the clinic. Everybody was equally welcome. He treated them all as gentlefolk, not as kings and not as paupers, but with universal humanity that obviously sprang from the heart."1(p85)Third Message: Team EffortIn this era of marked individualism, this is another important legacy that goes beyond medicine. Dr Ernest Craige, who trained with Dr White, emphasized: "I was always struck by his concern for each member of the professional team as well as the other employees—cleaning ladies, dietary, etc. He had some good words for the nurses who worked there and encouraged them to renewed efforts on behalf of the patient."1(p89)Dr Gardner Middlebrook, an intern at the MGH, described how on Christmas morning in 1944, in the midst of World War II, Dr White appeared at the hospital with a bouquet of roses in his arms, proceeded to give a Christmas greeting and several of the flowers to the nurse, and then walked slowly around the wards giving each patient a rose with friendly words. Only a great man with a great soul would do this.Fourth Message: Respect for the Physicians, Particularly for the Referring DoctorsThroughout his life, he related easily and warmly to other doctors. His criticism was always constructive. Because of his experience and knowledge, he was consulted frequently by colleagues. Dr Ernest Craige clearly described Dr White's relation with the referring physician: "Not infrequently the case had been mismanaged or at least drastic alterations in the program were urgently indicated. In his conversation with the referring physician, Dr White would avoid any hint of censure for what had been done to that point. He adroitly guided the analysis of the case such that finally the referring physician would enunciate the correct course to be followed. At this point Dr White would agree enthusiastically with the conclusions reached by this revelation. The referring doctor learned something from the consultation and was grateful for the experience and the manner in which it was handled."1(p89)Fifth Message: Modest FeesPaul D. White was always modest in his fees. His records showed that on December 6, 1943, his charges varied from $15 to $35 (only once did he charge $50). On December 6, 1963, they went from $5 to $25. They were so modest that they upset some of his young assistants. To very wealthy patients, he suggested that a generous check be given to a worthy medical cause. (Several anecdotes in this regard can be found in the book Take Heart by Oglesby Paul, pp 91–94.)Sixth Message: Clinical Teaching and Clinical ResearchPaul D. White's life has always been closely related to his patients. The practice of medicine constituted the prerequisite for his teaching and clinical research. His early obligation with Harvard Medical School at the undergraduate and graduate levels gave him the chance to properly use all the knowledge acquired in his clinical practice.His teaching was done with equal care whether at the bedside of a patient or in the conference room at the basement of the Bulfinch Building of the MGH. At the beginning, only recently graduated American doctors sat in his classes, but as he gained prestige, more and more young physicians came to Boston from all over the world. His teaching also comprises the innumerable lectures he gave in America, mainly through the American Heart Association, and his countless commitments abroad.His books also play a significant role, beginning with Heart Disease, published in 1931. The New England Journal of Medicine commented that it was "the most important practical publication on the subject of heart disease that has appeared in this country during the past decade or two."He devoted a large amount of time to public education and urged widespread support for the American Heart Association's heart disease prevention cause. He was in enormous demand as a speaker. He appeared in different places throughout the country and on the most important American television programs. At the time that Dr White received the Distinguished Volunteer Service Award from Mrs Richard Nixon in 1969, Dr Michael DeBakey wrote him a letter of congratulation: "I know of no one who has worked so tirelessly and fervently to make people conscious of the need to work toward eradicating heart disease."1(p130)Seventh Message: PreventionUndoubtedly, Paul D. White's greatest contribution to mankind was his prescription for a healthy way of life. The central component of his philosophy was its emphasis on the value of regular physical activity.Paul D. White began to speak about the positive benefit of physical exercise in the late 1920s. In 1927, he wrote: "Walking is probably the best exercise because it is easy for anyone to accomplish and easy to grade from the slowest shortest walks to the most rapid and longest."1(p188)The value of bicycling, which was one of his favorite forms of exercise, was mentioned in a 1937 article for Hygeia. He opened many bicycle paths, including a pioneer path in Chicago in 1956. He supported various safe-bicycling associations. He was made Honorary President of the Bicycle Touring League of America.He also encouraged stair-climbing instead of elevators. There are many anecdotes in this regard. Shortly after the Eisenhower heart-attack episode, he addressed the National Press Club in Washington. The club was on the 13th floor of the National Press Building. Griffing Bancroft, a member of the Board of Governors of the National Press Club at that time, wrote: "… a couple of members would meet the guests in the lobby of the building and an elevator was held to whisk them up.Dr White was so met and one of the escorts remarked how nice it was to have an elevator waiting. Dr White spied the stairway and said: 'Why not walk?' With the newsmen staggering in his wake, he strode up the thirteen floors, arriving for the reception as fresh as could be. Our colleagues collapsed into chairs."1(p194)His propensity for walking or bicycling rather than riding in a car and for climbing stairs rather than using the elevator became legendary. He also emphasized the value of physical effort as an antidote to anxiety and emotional stress.If we bear in mind that in his structure for a healthy life he included the control of hypertension and obesity, the opposition to cigarette smoking, and the moderate use of alcohol, we realize that he was a pioneer in the promotion of prevention and rehabilitation of heart patients.Eighth Message: HumanitarianismSir John Parkinson, during the Second World Congress of Cardiology (Washington, DC, 1954), delivered the Laubry lecture "Leadership in Cardiology" and defined Paul D. White as "an ambassador of good will and hope to cardiologists all over the world." His innumerable trips overseas were ostensibly for lectures and teaching. However, his underlying purpose was to promote friendship and understanding between scientists in all parts of the world so as to contribute to a better climate for global progress in medicine as well as for the maintenance of world peace.At the opening session of the First World Congress of Cardiology (Paris 1950), he said: "We who are 'médecins du coeur' would also like to perform the miracle of healing the troubled world of today by a universal bond of spiritual brotherhood and medicine from the heart."1(p214)Consequently, Paul D. White made 6 trips to Russia between 1961 and 1966. In 1964, he attended the Fourth Dartmouth Conference, held in Leningrad. In his talk, he reviewed his own experience in preventive medicine and concluded with a quotation from Sir William Osler from a lecture given in Montreal in 1902: "There is room, plenty of room, for proper pride of land and birth. What I inveigh against is a cursed spirit of intolerance, conceived in distrust and bred in ignorance, that makes the mental attitude perennially antagonistic, even bitterly antagonistic to everything foreign, that subordinates everywhere the race to the nation, forgetting the higher claims of human brotherhood."1(p258)"I truly regard myself as a citizen of the world," he emphasized—and he certainly was. He always supported democracy and freedom, even under difficult circumstances.Ninth Message: Disarmament and PeaceDuring the Cold War, he openly fought for peace and promoted an international scientific brotherhood for this cause: "From the days of the First World War when I personally encountered many of the tragedies and very little of the so-called glories of war, I have been interested in world peace. More recently I have been painfully distressed by the horrors of the Second World War and its aftermath of cold wars and active conflicts all over the world. For many years I have treasured the idea of the possibility that the physicians of all nations, with only the health and happiness of their patients to consider, might bring together not only their colleagues in a united crusade against disease but their multitudes of patients, to promote international friendship, and thereby world peace."2Although he strongly disagreed with the Russians in many aspects, after a number of trips he made they eventually started to trust him. In 1961, he became the first American to be elected to the Academy of Medical Sciences of the Union of Soviet Socialist Republics (USSR). In July 1964, he said in Leningrad: "Why cannot the USSR and the US sign further agreements, as they have already done with at least some success for health and some of the arts and sciences, though often too meagerly and too slowly, against other common enemies in the world which can lead to war which include hunger, poverty, ignorance, and unhappiness without forcing ourselves on peoples who do not need or want help? I believe that if we could do this open-heartedly and adroitly we might very well save the world years and years and years of Cold War and worse, and if it could be done open-heartedly and accepted as such, how really marvelous it would be."1(p257–258)Thus, it should not be a surprise that he attended the World Congress for General Disarmament and Peace in Moscow in the mid-1960s and that he went to China in 1971. Besides fulfilling duties as a physician, Paul D. White devoted his life to dreaming of a world with social justice and solidarity.Tenth Message: OptimismOptimism is part of a positive attitude toward life. In 1951, when talking about the importance of this attribute to medicine, he mentioned: "It is quite certain that biologic effects also result from cheerfulness, optimism, courage, and joy. A chance to counteract the harmful effects of pain, sorrow, and anger is possible through the inculcation of a happy disposition. We know that clinically there are definite effects from the application of this idea. Helpful psychotherapy and the best practice of medicine depend on it in considerable parts."1 (p185–186)The Practice of Medicine in AmericaI will digress for a moment from the life of Paul D. White to address a subject of utmost importance, health care, and see whether Paul D. White's legacy is being followed.In accordance with the principles of American society, medicine in the United States was originally practiced without regulations and with absolute freedom. Patients were able to select their doctors and hospitals, and charges were the consequence of this relationship. "Fee-for-service" established the parameters of health care.Medicine could not avoid the influence of the technological revolution of the past decades. Slowly and steadily, we have benefited from the incorporation of new tools that allow us to improve the diagnosis and treatment of our patients. Indeed, they have had a tremendous impact in the field of cardiology and cardiovascular surgery. The pharmaceutical industry has also contributed enormously to the enlargement of our armamentarium. We have undoubtedly managed to improve the quality of life of our citizens and increase the overall life expectancy to 76 years. But all these advances have been very costly. The use of high-technology medical care, regardless of the benefit obtained, has been cited as a major factor in healthcare cost in the country.3We cannot deny that the fee-for-service method of payment is primarily responsible for the enormous escalation of health expenditure in the United States: from $141 per capita, ie, 5% of gross domestic product (GDP), in 1960 to $3621 per capita, ie, 14% of GDP, in 1995. While the Consumer Price Index for all items rose from 30 in 1960 to 157 in 1996—an increase of 430%—it rose from 22 for all medical care in 1960 to 228 in 1996—an increase of 923%.4After 5 years of near-stability, health spending is expected to rise as a share of GDP beginning in 1998, climbing from 13.6% in 1996 to an estimated 16.6% by 2007.5 By 2010, healthcare expenditures are projected to be 18% of GDP.6 Physicians have been responsible for 75% of all healthcare expenditures.7Fee-for-service encourages physicians to prescribe services that are often unnecessary. This system also increases hospital costs, because many procedures are performed in the hospital. From 1982 to 1987, the physicians' total charges for Medicare patients rose by 76% (from $15 billion to $27 billion). However, the older population did not expand by 76%, nor did old people's demands for care grow by 76%. The cause seems to be the doctors' interest in higher income. In this 5-year period, surgical services increased by 85%, physicians' visits by 52%, consultations by 127%, diagnostic radiographs by 133%, and clinical laboratory services by 84%.4 During my stay in the United States until 1971 and my continuous traveling in subsequent years, I have seen medical practice being highly rewarded. All the fellows we had trained were making large amounts of money even by practicing at the community level.In the 1960s, health care was not called an industry.8 By the mid to late 1980s, it had become the nation's largest industry9 (almost a trillion dollars a year), a growth that brought some deleterious effects:1. The diagnosis is based mainly on the use of sophisticated technology. I agree with Zoneraich and Spodick10 when they say that "many, if not most, cardiological diagnoses could be made by use of patient history and the physical examination, supplemented by simple noninvasive procedures, such as the ECG and chest roentgenogram." However, proficiency in bedside cardiac auscultation has been seriously degraded.11 A nationwide investigation of trainees in internal medicine and cardiology and third-year medical students carried out some years ago demonstrated that programs with structured teaching in auscultation existed in only 27% of medicine and 37% of cardiology programs.12 Contemporary teaching rounds often take place in conference rooms and not at the bedside. Internal medicine topics are also taught during lunch hours in conference rooms.132. The complex relationship between the physician and the pharmaceutical and technological industries, called by Relman14 the "medical industrial complex," leaves aside some ethical concerns.The profuse use of randomized trials supported by the industry with the help of complicated mathematical formulas deserves my frequent criticism. I analyzed these facts in one of my recent publications.15 In the last World Congress of Cardiology recently held in Rio de Janeiro, 39 symposia were organized by pharmaceutical companies. By sheer coincidence, each one of them dealt with subjects related to the pharmaceutical formulas of the organizing company. It is one thing to support a congress, but another matter to organize a symposium!Managed CareManaged care is defined as any system that manages the delivery of health care in such a way that the cost is controlled.16 It is thought to be a relatively recent phenomenon, but it is in fact more than 100 years old. The concept of prepaid care evolved mainly because of the many immigrants that came to the United States in the 1800s.17 As Block18 points out, "the early plans were socialist in their approach, with little, if any, grasp of the potential for profiting from their plans, a marked contrast with many of today's plans. The early managed-care organizations and their physicians were continuously attacked by their mainstream physician colleagues for being socialist incompetents who could not succeed in traditional practices."The percentage of employees enrolled in managed-care plans has increased steadily in the past 10 years: it rose from 25% in 1987 to 75% in 1996.192021 In 1996, 149 million Americans were enrolled in managed-care plans. By 1997, there were 160 million.22Managed care comprises a variety of organizations. The main ones are the Health Maintenance Organization (HMO), the Preferred Provider Organization (PPO), the Point of Service Organization (POS), and the Integrated Delivery System (IDS). PPO and POS plans allow enrollees a wider choice of providers than the "pure" or traditional HMOs do. The growth in the managed-care market is now primarily in these hybrid products.232425It is undeniable that managed care has indeed reduced costs. And it has even produced some salutary effects: patients stay in the hospital far fewer days; many surgical procedures are now safely performed in day surgery; many medical practices (mainly diagnostic tests) have been standardized, thus simplifying their use; and more attention is given to health promotion, disease prevention,26 and the management of chronic diseases.Even though a large portion of the healthcare delivery system is still under nonprofit control, in the fast-growing HMO sector, nearly 70% of HMOs are investor-owned,2728 profit being the most important goal.18 Faceless investors seek return on equity on the basis of the profitable manipulation of the interaction between the healthcare provider and the healthcare consumer. Thus, health care is subjected to the same pressures as faced by any other business.29 The companies compete to report favorable results to shareholders30 with substantial margins (20% to 30% of the total revenue), claiming that those are the amounts that would be expected in any business.31 Thus, a chief executive of a for-profit HMO can be paid as much as $16 million a year in salary and stock options!4 Today, most physicians will agree with Dr Kraus that managed care is money management, and the people who make the money are the ones running the healthcare corporations.24 Profits have been decreasing in the past years. It has been suggested that 1998 could see a return to major rate increases to maintain or enhance profit margins.3233In the managed-care system, patients lose their freedom to choose their doctors. The primary-care physician (or gatekeeper) determines whether the patient will be granted further access to the healthcare system, including referral to specialists and diagnostic tests. To lower costs, patients are kept at the primary level. This results in inappropriate treatment and inadequate diagnosis. Consequently, the doctor-patient relationship, always considered the basis of our profession, is subverted by the demands of managed care.34 When this trusting relationship is not present, something irreplaceable, unique, and always desirable in our daily duties is lost.Each health-insurance plan determines different exclusions and limitations. As we know, incentives that encourage doctors to practice cost-effectively include risk sharing, performance-related payment, and bonuses and withholds.3536 It is necessary to remark that some doctors receive bonuses at the end of the year according to their indication of medical services: the less care they provide, the bigger bonuses they get!The plans often include confidentiality clauses—better known as gag rules or gag clauses—between managed-care organizations and contracting physicians that limit the physician's responsibility to freely communicate with their patients. An AMA study of 200 HMO physician contracts found gag language in almost every one of them.37 Nevertheless, because of public restlessness, some managed-care organizations have dropped several restrictions and gag clauses.In relation to managed care, a physician may experience anger, denial, depression, negotiation, and, finally, resignation. Market-driven health care creates conflicts that threaten our professionalism.38 It will be extremely difficult for a physician who was dismissed from a managed-care organization to be accepted by another one. The incentive to remain employed is so strong that many physicians in a capitated system may not provide all the services they should, may not always be the patient's advocate, and may be reluctant to challenge the rules governing which services are appropriate.39Public concern, discontent, and distrust have grown as enrollees become increasingly aware of the stupendous profit-oriented practice of their managed-care plans and the restrictions that limit their healthcare obligations. The corollary of the public concern is that more than 1000 bills affecting managed-care plans were introduced in state legislatures during the first 6 months of 1996,40 and more legislative interventions can be expected.41 It is hoped that the Congress-sanctioned measures will also improve the quality of health care by the managed regulated system.Several studies have tried to measure the health outcome of patients in managed care against patients in the fee-for-service plans. They have found largely mixed results—virtually any position one would want to take on their attributes can be supported by the current literature.42434445464748495051525354555657585960 The main reason for the discrepancy lies in the difficulty of obtaining an adequate evaluation of quality. The methods we have for measuring service quality are still quite primitive.Even the Health Employer Data and Information Set 3.0, a study supported by the National Committee for Quality Assurance,616263 failed to reach conclusive results.64 Hellinger65 pointed out that relatively few studies compare the effectiveness of care in managed-care plans with that in traditional indemnity plans after 1990. Furthermore, few data are available on newer models of HMOs and on plans that invest heavily in information systems and rely on financial incentives to alter practice patterns. Knowledge about how different types of financial incentives affect quality is a fundamental component for further studies.What will happen in the future? Certainly, we cannot go backward. However, for a system to succeed, it should encourage physicians to function as trustworthy advocates and to avoid being influenced by economic interests without disregarding cost concerns.66667686970 Kassirer firmly believes that to survive, managed-care plans will have to show that they care about more than profits; that they do not skimp on care; that they support their just share of teaching, research, and the care of the poor; that they no longer muzzle physicians; and that they offer something special (including control of costs) by managing care.71Pellegrino remarks that "… for centuries good physicians have treated patients who could not pay, have exposed themselves to contagion or physical harm in responding to the call of the sick, and have sacrificed their leisure and time with their own families—sometimes too liberally—all out of commitment to serve the good of the sick."7The guidelines that distinguish our profession from a business or craft will contribute to the moral foundation of any healthcare system and will prevent us from treating our patients as nonhumans, as statistics, commodities, or exchangeable pieces within a large, profitable structure. The correction of inefficiencies and the elimination of unnecessary expenses (both present in fee-for-services and managed-care modalities) should not be achieved at the expense of the degradation of our profession.As Everett Koop remarks, the greatest challenge is to guarantee access to basic health care for everybody, according to the tenets of the Hippocratic Oath: "I will do no harm to my patients and I will follow that system or regimen which according to my ability and judgment I consider for the benefit of my patients and abstain from whatever is deleterious and mischievous" and to overcome the tenets of the Hypocritical Oath: "I will do no harm to the corporate bottom line and I will follow that system or regimen which according to my ability and judgment I consider for the benefit of my patron!"18As our discussions address the increase in medical costs, we pay little attention to the escalating number of the uninsured: it rose from 37 million in 1994, to 40.3 million in 1996,72 and it may reach 60 million by the year 2000.73 The existence of the uninsured and the underinsured is closely related to poverty.74In 1996, the number of people below the poverty level was 36.5 million. It is important to remark that there was a significant increase in the number of the very poor, ie, those whose total income was <50% of the poverty threshold. In 1996, as many as 14.4 million people were in this category.75 The poor often require more intensive and expensive care than more affluent patients do, and the outcome of their treatments tends to be less certain.7677 The federal funding cuts in health care initiated in 1981 were detrimental to poor patients. Massive cutbacks in social programs to aid high-risk populations, especially poor women and children, ha
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