Timehost says, "Hello everyone, and welcome this evening to the Time Forum.Tonight, we are going to be talking about issues -- and people -- in medicine.Time has just come out with a special issue, called Heroes of
Medicine. It puts human faces to some of the medical advances of our time. We're joined now by the editor of the issue, Time's Barrett Seaman and by Dr. Sherwin Nuland, the author of "How We Die" and the author of an introductory essay
in the issue."
Barett_seaman says, "Pleasure to be here."
Sherwin_nuland says, "A pleasure for me, too. I'm glad to be included."
Timehost says, "Dr. Nuland's newest book is called "The Wisdom of the Body." Thanks to both of you for joining us. Before we take some questions from people on line perhaps you'd like to tell us a little about "Heroes of Medicine" for those who have not seen it.What was the genesis and purpose of the issue? Perhaps you'd like to start, Barry."
Barrett_seaman says, "Last year, again with a strong contribution from Dr. Nuland, we did an issue called Frontiers of Medicine.In it, we looked at the extraordinary advances in medical science over the past decade according to disease category, by and large.We had stories on cancer research, on hearts, on the contributions of technology and genetic research.This year, we looked at the same broad subject, but through the prism of the people who made those advances."
Barrett_seaman says, "And if not the people who made the most recent advances, at least those who are emblematic of the vast array of medical scientisits - doctors, researchers, nurses, and even patients, who contribute."
Timehost says, "Dr. Nuland, you looked at the topic of medical advances from an historical perspective..."
Sherwin_nuland says, "Yes, I did."
Timehost says, "Are we living in an extraordinary age as far as medical advances are concerned?"
Sherwin_nuland says, "We're living in an extraordinary age in the sense that we are no longer moving in a linear way, but in an exponential way. It has been said that there are more bioscientists alive today than the entire total since the beginning of time.Not only that, but there are massive infusions of money going into biomedical research, not only from the governments of various Western countries, but from the gigantic coffers of the major drug companies. Universities are contributing manpower and training so that there has never been a time in medical history comparable to the last 25 to 30 years."
Timehost presents question #394 from Woods_time:
Has medical research become essentially a team endeavour in the 1990s?
Barrett_seaman says, "My answer to that is yes, but with a strong caveat, which I think Dr. Nuland will endorse, that we would be nowhere without the curiosity and perserverence of individuals."
Sherwin_nuland says, "Well, there isn't much question that because of the complex nature of medical research, it has become a team endeavor, but just as we say that there appears on the scene an individual like Dr. Marshall who has discovered and proved that it's not acid that causes ulcer, but bacteria.This is also true of someone like Dr. Batista who, working singlehandedly, identified a method of heart surgery for failure of the heart muscle that has already saved a significant number of lives when used in his hands and may save even more when teams start to work on the techniques and methods for the operation."
"One more thing..You must remember that any team is composed of individuals and that it is the combination of individual brilliance and performance that makes the ultimate effort more successful than might be carried out by just one person."
Timehost presents question #390 from Highroad:
If you could discover the answer to one medical question -- any medical question -- tomorrow morning, what would it be?
Sherwin_nuland says, "There's not much question what I would want to find out and that is the relationship between the brain and the mind.The last seven or eight years have witnessed enormous strides in our understanding; primarily due to the use of new technologies like PET scans, for example, and similar devices.But we have a very long way to go.One of the beauties of the scientific endeavor which is difficult for most people to appreciate is that science is a matter of curiousity, more than a matter of practical results. The practical results would be almost immediate in the treatment of mental diseases and in understanding the influence of medical processes on physical diseases."
Barrett_seaman says, "Ooh! That's a good question! I guess I would add a query about what role, if any, spirituality plays in the physical."
Sherwin_nuland says, "Interestingly, we are finally getting around, and scientists are too, to the realization of the importance of spirituality in the way illness plays out its course. There has been a lot written of late about statistical evidence that people with faith in God have better results. As we begin to delve into these matters, we seem at the beginning to be focusing on issues about the end of life, but the application will come in understanding the way a disease manifests itself differently in different individuals.One's spiritual life, of course, cannot be separated from one's physical life and we already have evidence that emotions are reflected in activities in the brain stem, which, in turn, affect hormone output and the immune system."
Barrett_seaman says, "I'd be curious as to who out there has read our issue."
Timehost says, "We'll see...and by the way, for anyone who hasn't seen it, it's available online. Just go to the Time home page...or to special reports...and you can look at it there.Let's take another question..."
Timehost presents question #396 from Soosh:
What about research into alternative therapies, i.e. acupuncture in the treatment of diseases in conjunction with Western traditional medicine? Has there been any effort made to include this in the research process?
Sherwin_nuland says, "The National Institutes of Health established about 10 years ago an offiice of alternative medicine. Unfortunately, they underfunded it and left it subservient to the will of certain congressmen with their pet projects. This has made a mockery of what should have been a very substantial effort of understanding the basis upon which certain traditional methods are effective, and upon which other methods are ineffective, even though they have existed and been used for centuries.A deliberate effort was made in this issue of TIme to discuss the search for medications that come from plants, and I think it's important that this was done because we have traditionally thought of herbal medicine as part of the traditional armaments. Nevertheless, we should remember that the vast majority of the pharmalogical agents that are being used to treat all diseases come initially from plants."
"This is perhaps the most striking example of the crossing over between traditional and orthodox medical practices, but there are many others. As for acupuncture, I have witnessed on various visits to Chinese medical schools how well acupuncture works when used accurately and I am convinced that we have already lost many years in not carrying out studies of acupuncture using our finest scientific methods. Perhaps we will now correct that."
Barrett_seaman says, "We had a piece in the issue about Paul Alan Cox, the ethno-botantist who spends a lot of time in places like Samoa finding out what traditional medical people have done about various diseases and then applies it to modern science."
Timehost presents question #387 from Greenacres:
As the earth's biodiversity is threatened, are we losing the answers to many medical questions, and cures?
Sherwin_nuland says, "Well, of course, there's no way to answer that because when plant possibilities disappear, we can't backtrack and discover what has been lost.But the answer would seem obvious - yes.As we lose large sections of rainforest, there is no question that we are also being deprived of vast possibilities of discoveries from herbal therapies."
Barrett_seaman says, "Maybe so. I think Dr. Cox would agree that the destruction of rain forests, for example, threatens to extinguish promising natural medicines."
Timehost presents question #389 from Highroad:
We spend so much money and energy fighting "difficult" diseases. At the same time, we know all sorts of things that we should do as individuals or as a society to help promote health and welfare. Yet we dont do them. Is it just because drug companies can make heaps of money off of patents, while other health approaches with proven success don't appear to make money?
Sherwin_nuland says, "I don't think that it has anything to do with the drug companies.It really has to do with the excitement of cutting-edge science as compared with the relative boredom of prevention and early diagnosis.In fact, our entire biomedical effort, as some people see it, is misdirected.Daniel Callohan of the Hastings Institute, America's premier bioethical thinktank,will be publishing a book within the next six months that says exactly that, namely, that we should be expending most of our resources on the treatment of chronic diseases and the prevention of diseases like cardiac and neurological and malignant diseases. He makes a strong argument, with which our correspondent would probably agree, that the exciting stuff actually saves far fewer lives than the methods that would seem more pedestrian and, therefore, less likely to attract government funding."
"Remember that what has increased life expectancy in the life 100 years is not the effects of acute care improvements, but such things as purefying the water supply, vaccinating against disease, and other major public health measures. A good illustration of the disparity between pedestrian and cutting-edge medical research is that lack of funding that goes to diabetes, as compared with AIDS and cancer research.There has only been a very small drop in cancer mortality in spite of all the money that has been spent on treatment and research. The answer to cancer mortality is in such notions like closing down every cigarette company, making sure that every woman over the age of 40 gets mammograms at appropriate intervals and similar measures of this sort."
Timehost presents question #404 from Interested:
Are our ethics, and our ability to offer compassionate medical treatment, keeping up with our scientific discoveries?
Sherwin_nuland says, "What a wonderful question. There has been an enormous flurry of activity since the late 1960s, when the field of medical ethics was founded, to introduce ethical, moral and even certain religious principles into medical practice.The result has not been generalized until the last three or four years, but during that time, many medical schools have begun to offer courses for students and many medical training programs have added an emphasis at the bedside on ethical issues of which many young doctors in the hurly-burly of clinical care may not have paid sufficient attention to.The movement to increase the presence of medical ethics at the bedside is rapidly expanding and already exhibiting significant effects. Virtually every American hospital has had a bioethics committee for anywhere from five to 15 years."
Barrett_seaman says, "It has certainly become more complicated, as our story about Dr. Jason Brandt of Johns Hopkins, who specializes in the psychiatric treatment of people who are at risk of carrying the gene for Huntington's Disease, shows. If they have it, they will get it and die from it. How many people want to know that? Should know it? Can deal with the consequences?"
Sherwin_nuland says, "We have finally reached a point, not only in medical science, but in all science, where the implications of further discovery are so great for the general society that perhaps we should begin to consider the possibilities that scientists should no longer be permitted to determine the directions of research on their own, and uninfluenced by the general population who will be affected."
Timehost presents question #405 from Stamm_time:
How successful can Dr Wintemute of UC-Davis be in his crusade to treat gun violence as a public-health issue? The gun lobby really attacked him and trashed federal gun study money.
Sherwin_nuland says, "I believe the real importance in what Dr. Wintemute is doing is that he is focusing a great deal of national attention on the problem and he is providing statistics that are so frightening to people who were earlier complacent that he will be enlisting significant numbers of participants in the cause. He is, to me, an example of how a single voice, seemingly shouting in the wilderness, can make an enourmous difference. I will predict that the presence of the article in this magazine will itself change the thinking of many thousands of Americans."
Barrett_seaman says, "All by himself, Dr. Wintemute will probably not be very successful, What he brings to the debate, however, are some credible statistics about the use of guns in violent acts. As the rest of us digest that, it becomes an issue in the debate over whether guns kill people or people kill people."
Timehost says, "But yet it is the kind of approach, something that doctors are talking about that perhaps we might not have thought of as a medical issue?"
Sherwin_nuland says, "Well, this is an interesting point that's being made. Because one of the phenomena of late 20th century medicine is a widening of the frontiers of those areas that are of medical concerns. What I mean is, more and more of the problems of society are being, in a sense, medicalized.For example, 60 years ago, almost no one would have thought that his unhappiness over a bump in his nose would be a problem he should bring to his doctor.Twenty years ago, the ability to achieve an erection for a 60 year old man was not a medical problem. Ten years ago, Dr. Wintemute's crusade would not have been considered a medical problem, but the arena of medicine is rapidly widening.Remember that in 1985 a group started by physicians won the Nobel Peace Prize for its Ban the Bomb activities. This would have been unheard of as recently as ten years before that."
Barrett_seaman says, "True, it is not medicine per se. But if doctors are interested in the root cuases of the pathologies they treat, they're going to find themselves going back to things like gun control."
Sherwin_nuland says, "The real function of medicine is to relieve human suffering.Physicians have always turned their attention to problems like this,but never as much as they do today.There's a great deal of division within the medical community about this. And many physicians have been very vocal in proclaiming that the only function of a physician is to treat disease in the sense of pathological, organic changes within their patients.The sicknesses of society, in this view, should not be part of a physician's concerns."
Timehost says, "Despite that trend, one of our questioners says our health care system appears to prevent doctors from caring..."
Timehost presents question #398 from Interested:
Given the high cost of health care, and all the bureaucracy surrounding it, it's kind of hard to see any doctors as heroes. What steps can be taken to help doctors best help to heal the sick?
Sherwin_nuland says, "Well, it's hard for me to answer a question I don't agree with.For me, as a physician of nearly 40 years, I think nearly every doctor is a hero. This is an extraordinarily dedicated profession with a very high profile in the community, taking a great deal of risk and doing a great deal of good and sacrificing a great deal to accomplish those good ends.No doubt, many doctors forget their humanity, and no doubt doctors are very well accomplished for what they do, but what they do is more valuable to society than virtually anything that other professions provide.If that be treason, make the most of it."
Barrett_seaman says, "That's a tough political question. I, too, disagree with the premise, but I understand the sentiment behind it -that people feel increasingly removed from the "hands" of their physicians. Specialization is largely respnsible for that, but managed care exacerbates it. I suspect a new breed of general practitioners will emerge to fill the void."
Sherwin_nuland says, "Barry, let's hope so."
Timehost presents question #406 from Stamm_time:
The increased use of non-MDs like nurse practioners in rural areas may be all to the good, as TIME notes, but having a doctor write prescriptions for patients he does not see sounds like a very dangerous precedent. What do you think?
Sherwin_nuland says, "I agree absolutely.Unfortunately, in the areas served by the nurse practioners, there seems to be no choice, but the general notion on which this health care delivery is based is a little worrisome to me and the prescriptions are a significant part of that concern."
Barrett_seaman says, "Technology allows doctors to "see" more than they ever have before, don't you think? The more information at hand, even if only digitally at hand, the easier it is to get it right -especially if there's no alternative."
Sherwin_nuland says, "But only if there is no alternative."
Barrett_seaman says, "Granted."
Sherwin_nuland says, "There is no substitute for the direct sight, the direct touch and the direct conversation with a patient because, after all, medicine is not a matter so much of science as it is a matter of judgement."
Barrett_seaman says, "True enough. But if I'm on a space shuttle with what appears to be a major medical problem, I'd rather have a doctor on the other end of a computer with a read-out than I would just telling him how I feel over the radio. That's my only point."
Timehostpresents question #407 from Interested:
You've singled out heroes of medicine...are there villains of medicine?
Sherwin_nuland says, "There are unfortunately villains of medicine just as there are villains in every profession and occupation. There's a very prominent villain these days who goes around killing people on request, protected by a loudmouthed lawyer. I should say, by a loudmouthed and publicity-seeking lawyer."
Barrett_seaman says, "I'd add to the villains list the MBAs and CPAs in charge of cost-cutting for the HMOs."
Timehost says, "Well, we're going to have to wrap things up...I know Dr. Nuland that you've got to leave, so thanks for joining us.
Sherwin_nuland says, "Thank you very much for having me. It was a fantastic first-time chat.Good-night."
Timehost says,"Barry, any final thoughts?"
Barrett_seaman says, "Of course: go out and buy the issue. You'll learn a lot! Goodnight."
Timehost says, "Thanks, or as we said, you can take a look at it here on-line! Thanks, Barry, for joining us."
Barrett_seaman says, "You're most welcome."
Timehost says, "And a short program announcement: because next Wednesday is the day before Thanksgiving, we're not going to have a Forum next Wednesday.But we'll be back two weeks from tonight.So we hope to see you then.Goodnight."
