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w-b-park-sure-we-doctors-make-a-lot-of-money-but-don-t-forget-we-spend-a-heck-new-yorker-cartoonI just finished reading The Celestial Society, a biography of George Burch written by his daughter Vivian. I knew him as an older attending who seemed oddly out of touch with students. I now know that he was a beaten, sick man at the time I had contact with him. I also found out that he never deviated from his core belief that what medical schools needed to do was train good generalist physicians and develop tools to allow these generalists to become better doctors. He was Chairman of Medicine at Tulane for 30 years, forced out in the 1970s when he opposed the creation of a practice plan to capture faculty patient care revenues. The dean and the chancellor both felt that without the ability to harness this revenue source, Tulane would be forced to shut down.

It is amazing how much medicine changed in the 40 years of Dr Burch’s career. Dr Burch’s entire career was at Tulane and spanned from the 1920s to the mid 1980s. When he started the EKG “machine” was a string galvanometer and was only done on selected patients. He was instrumental in describing variants of EKGs, wrote the first book on interpretation which made the technology available to all clinicians and developed the circuitry which allowed all 12 leads to be measured simultaneously. All the while he was on faculty at Tulane, making very little money when compared to his private practice colleagues and caring for poor patients at Charity Hospital. To him the academic “life of the mind” and the noble activity of caring for the poor sick should have been rewarded by society. The building of a University Hospital with the corresponding contractually obligated faculty sounded the death knell for this type of medical practice.

The conflict at Tulane was the result of Dr Burch’s stature in the world of Cardiology and the perception that his belief regarding cardiac surgery were holding up progress. He believed that outcomes were terrible. His perception was that patients were more likely to die from the surgery than the disease, a belief grounded in observation but since surgeons kept no data not measurable. He believed that surgeons were uneven at best (again, unmeasurable) and in reality it was the post-surgical care that mattered the most. He abhorred the “chance to cut is a chance to cure” mentality and in his clinical experience many people would be better served to have nothing done than to subject themselves to angioplasty or surgery. Tulane wanted him to refer his patients exclusively to Tulane surgeons and likely expected a larger number of patients to be referred, conditions to which he was unwilling to agree. Medicine was moving into an entrepreneurial direction and Dr Burch was being left behind.

Dr Burch died in 1986. Tulane continues to thrive (at least according to the alumni magazine) despite not being in Charity Hospital at all. Many of his beliefs regarding invasive cardiology have been affirmed. Meanwhile, the article on colonoscopy in today’s New York Times, illustrates the cost we have paid for dismissing Dr Burch’s warnings regarding our abandonment of the generalist physician model and embrace of the entrepreneurial model of medicine.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees….

When popularized in the 1980s, outpatient surgical centers were hailed as a cost-saving innovation because they cut down on expensive hospital stays for minor operations likeknee arthroscopy. But the cost savings have been offset as procedures once done in a doctor’s office have filled up the centers, and bills have multiplied.

It is a lucrative migration. The Long Island center was set up with the help of a company based in Pennsylvania called Physicians Endoscopy. On its Web site, the business tells prospective physician partners that they can look forward to “distributions averaging over $1.4 million a year to all owners,” “typically 100 percent return on capital investment within 18 months” and “a return on investment of 500 percent to 2,000 percent over the initial seven years.”

To quote Chairman George, “I’m not antisurgery, I’m pro-patient.”

For those of you that have not been to medical school, the clinical years can be a little stressful. Waking up at 4 am to see patients (and waking them up at 5 am with a cheerful “How are you doing this morning?” only to get a “What time is it???”), spending quality time in an operating room, and learning how to “see patients” through very different eyes all contribute to us becoming “doctors.” My 3rd year was spent predominately at Charity Hospital in New Orleans, where the patient base was mostly poor and African-American, in contrast to the Tulane medical students.

Part of this year was spent with one of the fathers of modern cardiology, Dr George Burch.  Dr Burch, who was in his 80s, would appear twice a week and help the team work through problem patients. He would then take the student part of the team up to his lab, where his lab techs (themselves in their 60s) would serve us tea and cookies as he instructed us on the nuances of medicine. We students couldn’t help but notice the three-dimensional vector EKGs inhabiting the room. These were like minimalist sculptures of hearts, and there were many hundreds lining the walls. Finally one of us got up the courage to ask about them.

“Oh, those,” Dr Burch replied. “I’ve been collecting those for years. When the patient died that I’ve done a vector EKG on  I collect the hearts as well. I have 1500 of them. Some day I am going to dissect the hearts and correlate the anatomy with the physiology.”

He died about 5 years later and I suspect never got around to completing this task. I am afraid that the frozen human hearts did not survive Katrina.

I read the Immortal Life of Henrietta Lacks this weekend. The extremely abridged version of the story is that Ms. Lacks, a poor woman who lived in Baltimore at the time, was going to Johns Hopkins for a complaint related to her “womb.” In the course of the diagnostic and therapeutic interventions, some of her tumor was collected and was the first human cell line to be able to grow independently. The HeLa cell was used to develop and test the polio vaccine,  develop techniques used for IVF and creating other cell lines, used to create the building blocks for the human genome project, and is used to test drugs that affect cell growth to this day. Although Hopkins got no money for developing this directly, their reputation was certainly enhanced greatly (5 Nobel prizes can be directly linked to HeLa). Many companies have made a lot of money using this commercially available descendent of Ms Lacks. The Lacks family, on the other hand, struggled for years with lack of access to basic education and health care as well as being treated as research subjects rather than fellow human beings.

Most medical training in New Orleans in my time was (and likely still is)  accomplished while caring for the poor of New Orleans. My choice of Tulane, in part, was because of a reputation for academic excellence and innovation by such folks as George Burch (founder of American Heart Association), Louis Ignarro (Nobel for work on nitric oxide), Michael deBakey (inventor of heart-lung machine key component), and Andrew Shalley (Nobel for discovery of pituitary hormones). I suspect ALL of these folks would have had much less success without their own Henrietta Lacks at Charity Hospital. I suspect Dr. Burch, for example, did not get solid permission for the donation of the hearts, though I could be wrong.

Modern medicine and modern society have moved beyond (I hope) the concept of poor people existing in the health care world so doctors can practice for their well-heeled private clientele. Much of the Henrietta Lacks story is one of objectification of tissue, families, and the entire African-American culture. The ethics of access to modern medical discoveries are difficult. It is when the very people upon whose backs the discoveries are made seem to be denied access systematically that we need to step in. Although not perfect, the Affordable Care Act is a start, and its promise of access beginning in 2014 is a down payment on correcting these disparities.