Tag Archives: surgery

What Is A Cardiologist?

The skeptical cardiologist recently received a cease and desist letter from a lawyer representing Dr. Steven Gundry who felt I was defaming the goop doctor and supplement peddler by saying he was not a cardiologist.

The lawyer’s letter reminded me that many patients do not understand exactly what a cardiologist is and mistake us for cardiothoracic surgeons.

Here’s how the American College of Cardiology defines a cardiologist:

A cardiologist is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels.

And here is part of my response to the lawyer which further clarifies the differences:

I understand your confusion with respect to the terminology of cardiologist versus cardiac or cardiothoracic surgeon. A surprising number of patients and readers think that I as a cardiologist perform “heart surgery.” Of course, actual surgery on the heart requiring “cracking open the chest” (which is what most laypeople consider “open heart surgery”) is always done by a cardiac surgeon not a cardiologist.

Like all other board-certified cardiologists I have gone through accredited training programs in internal medicine followed by a formal cardiology training program. There is no evidence that Dr. Gundry has done this.

Cardiologists, being extremely bright, entrepreneurial  and energetic, have expanded the toolkit they have for diagnosing and treating heart disease without having to engage in surgery. Thus,
cardiologists can insert  stents to open blocked coronary arteries, implant pacemakers and even replace valves all by accessing the cardiovascular system via its arteries and veins.

We don’t call this surgery because we aren’t surgeons and didn’t go through surgical training. We call these procedures. These are invasive procedures, to be fair, as we have invaded the vasculature and the interior of the heart and from these arterial and venous incursions complications may ensue.

A typical invasive procedure that cardiologists do looks like this:

This is a cardiologist  gaining access to the arterial system by inserting a catheter into the radial artery.

 

 

A typical open heart surgery performed by a cardiothoracic surgeon requires large incisions with direct visualization of the heart and looks like this:

 

 

 

 

 

Cardiologists And Cardiac Surgeons Undergo Totally Different Training

I began my response to Gundry’s lawyer by indicating my surprise that the lawyer felt Gundry was a cardiologist:

This comes as quite a surprise to me as my detailed research into Dr. Gundry’s background, training and credentials revealed absolutely no evidence that he is or ever was a cardiologist as we in the medical community define cardiologist. In fact, as you can see in his listing on CTSnet (which is a network of cardiothoracic surgeons) his post medical school training consisted of the following

University of Michigan Hospitals Surgery Internship (1977-78)
National Institutes of Health, Clinical Associate in Cardiac Surgery (1978-80)
University of Michigan Hospitals Surgery Residency (1980-83)
University of Michigan Hospitals Cardiothoracic Surgery Residency (1983-85)

He is trained as a cardiothoracic surgeon. Cardiothoracic surgeons go through surgical training programs which are completely different from the medical training programs that cardiologists like myself go through.

My description of him in this regards reads as follows:

“He is also widely described as a cardiologist but he is not, He is (or was) a cardiac surgeon (like, strangely enough, the celebrity prince of quackery, Dr. Oz)”

As you can see, my statement is perfectly accurate.

As far as him being a being elected a “Fellow of the American College of Cardiology” I can find no documentation of this and he is not currently listed as a member of the American College of Cardiology. But even if he was this does not make him a cardiologist because many cardiothoracic surgeons are members of the ACC.

Might I suggest you ask Dr. Gundry if he thinks he is a cardiologist. I’m pretty sure he would answer no.

What Is A Quack?

The lawyer then went on to accuse me of suggesting that Gundry is a quack because:

A “quack” is defined in common parlance as a lay person pretending to be a licensed physician. In other words, a fake doctor. The term “quack” connotes dishonesty, deception, fraudulent behavior, etc. Dr. Gundry has been a licensed physician and surgeon since at least 1989 (see Exhibit B attached), performed thousands of heart surgeries, and developed patented, life- saving medical technology. Your statements are not only factually incorrect, but are also irresponsible and intentionally misleading, resulting in harm to Dr. Gundry’s reputation and income.

To which I responded:

There seems to be an attempt here to suggest that by saying he is not a cardiologist I am calling him a quack. But as my previous information should have convinced you he is not a cardiologist but a cardiothoracic surgeon. He has done very good work as a cardiothoracic surgeon and I am happy to attest to that. I will be happy to add that information to his description in my up and coming posts on him.

At no point do I call him a quack in my posts. Clearly if I’m calling him a cardiothoracic surgeon I am acknowledging that he is a licensed physician and not, clearly, a fake doctor.

I have to admit my definition of quack has not been the common dictionary definition of “fake medical doctor.”  I have always considered those who engage in quackery to be quacks.

Quackery is defined at Quackwatch (the definitive website on the topic) as the promotion of unsubstantiated methods that lack a scientifically plausible rationale. 

And one can have a perfectly legitimate training as a medical doctor and engage in what most would consider quackery.

Even board-certified cardiologists like myself can engage in quackery.

Clearly there is a disconnect between the common definition of quack and that of quackery and in a  subsequent post I will delve further into the miasma of quackery, quacks and quacking,

Anatinely Yours,

-ACP

N.B. While researching this post I came across a fantastic article on Gwyneth Paltrow’s goop Doctors from David Gorski at Science-Based medicine. I highly recommend reading the entire piece (gwyneth-paltrow-and-goop-another-triumph-of-celebrity-pseudoscience-and-quackery) for your edification and pleasure.

Gorski’s paragraph on Gundry begins

  • Dr. Steven Gundry, a cardiothoracic surgeon very much like Dr. Mehmet Oz who, as he took incredible pains to lecture Dr. Gunter in his section of Goop’s hit piece on her, who once was a very respectable academic surgeon and, even better than Dr. Oz, served as Chairman of Cardiothoracic Surgery at Loma Linda University for a number of years, before leaving academia to undertake his private practice. (No wonder he and Dr. Oz seem to have an affinity for each other!) These days, he devotes his time to his practice, writing books, giving talks, and selling expensive supplements like Vital Reds (a bargain at $69.95 for per jar, discounted to $377.73 if you buy six jars) and Lectin Shield (a slightly more expensive bargain at $79.95 a jar, $419.70 for six), while bragging (as he did in his response to Dr. Gunter) about how so very, very hard he works and even—gasp!—accepts Medicare and Medicaid patients. His most recent book is The Plant Paradox: The Hidden Dangers in “Healthy Foods” That Cause Disease and Weight Gain. (Spoiler: That “hidden danger” is lectins.)

 

Featured image Photo by Ravi Singh on Unsplash

Happy Birthday, Nonagenarians!: Thoughts On Surgery In The Very Old

On February 26, my dad became a nonagenarian.

IMG_6325
My dad, tripping the light fantastic with grand-daughter-in-law Kelly.

My sister and I, and our offspring, had a brilliant celebratory gathering in Tulsa, Oklahoma for my father’s 90th birthday which included playing “The Priest in the Parish has lost his Considering Cap,” taking photos with queen Elizabeth, dancing to music by Glen Miller and The Beastie Boys, singing karaoke, enchilada and beer consumption, and a Powerpoint presentation on his life.

Nonagenarians, individuals aged 90 to 99 years, are the fastest growing age group in the world: nearly doubling from 6.7 million people in 1995, to 12.2 million people in 2010. Projections suggest that by 2050, there will be 71 million people aged 90 years or older.

Increase In Surgeries In The Very Old

Concomitant with the rise in nonagenarian numbers, we are seeing increasing procedures and surgeries performed on the very old.

My father has had 22 surgeries (itemized in detail in the appendix to Book 2 of his memoirs) including four spinal operations, four hip operations and one total knee replacement at the age of 87.

Obviously, he survived them all, but after one spinal operation, while recuperating at my home in Louisville, he awoke in the middle of the night with severe back pain and the inability to move his legs. He had developed an abscess at the wound site which caused overwhelming sepsis and he spent several weeks in an ICU recuperating from this life-threatening complication.

Is there an age at which individuals should not get elective surgery? Or is it the mileage that counts, not the model year?

Complications of surgery definitely go up with age, but we have all seen 90 year olds like my father who are functioning better mentally  and physically than individuals 20 years younger.

According to the Social Security online calculator, the average man his age can expect to live on average 4.3 more years longer.

A more sophisticated tool is the “Living to 100 Life Expectancy Calculator” which asks 40 questions about your health and family history. When my dad entered his information, it gave him a life expectancy of 98 years (I can expect to live to 99).

If we could be sure that he would continue to have a good quality of life after elective surgery for 4 to 8 years it might makes sense to consider elective procedures and operations that improve mobility and lessen pain.

However, I see a lot of deterioration in the quality of my patients’ lives between the age of 85 and 90, and even more between the age of 90 and 95.

By 95, those who have survived are living a fairly limited life; very few are independent and active, mentally and physically.

Excess and Rationing Of Surgery In The Very Old

drdebakey02
Dr. Michael E. DeBakey, shown with his surgical team in the mid-1960s, has operated on more than 60,000 patients, including Russian President Boris Yeltsin, who called him a “magician of the heart.”

Michael Debakey, the legendary cardiothoracic surgeon (read about his amazing medical contributions in this NYT obit here)  developed a tear in his aorta at the age of 97. He requested that the life-saving, but extremely high risk surgery for the disease (a procedure he had developed 50 years earlier), not be performed on him.

drdebakey01When he lapsed into unconsciousness, his wife insisted on the operation being performed. Dr. Debakey survived the 7  hour surgery but spent 8 months in the hospital recuperating at a cost of over a million dollars. He died two years later at the age of 99.

It’s hard to know what his quality of life was after the operation. The obituary and other reports say that he “returned to his office and an active schedule,” but the skeptic in me suspects that he was wheeled into his office in a wheelchair where he met with admirers as his strength allowed.

Alternatively, you can find cases exmplified by this headline: “Sentenced to death for being old: The NHS denies life-saving treatment to the elderly, as one man’s chilling story reveals.”  The     N HS or British National Health Service is a single payor system, about which concerns have often been raised regarding rationing surgery to the elderly.

In 2010 the anti-health reform group 60 Plus engaged former Surgeon General C.. Everett Koop to appear in a  video which suggests that Democrats were meeting in secret to craft “death panel” legislation that would ration certain surgical procedures.

Factcheck.org, however, debunks Dr. Koop’s claims:

Former U.S. Surgeon General C. Everett Koop claims that the United Kingdom’s health care system would consider seniors “too old” to qualify for the artificial joints, heart pacemakers and coronary stent that he’s received in the U.S.

U.K. guidelines make clear that patients of “any age” may receive pacemakers, for example. And in fact, official statistics show 47 patients aged 100 or older got new or replacement pacemakers in a single recent year.

My dad now tells me he is pondering replacement of his other knee..

Like most treatment decisions doctors make with patients, computers can aid in providing statistics about average complication rates, longevity, and recovery time but ultimately the recommendations for each individual should be based on their unique, often unmeasurable physical, mental and emotional characteristics.

Age alone should never determine our treatment approach.

I  have a feeling my dad will be tripping the light fantastic with his great grandchildren on two artificial knees when we celebrate with profound joy his 95th birthday.

-May you all become  happy centenarians!

-ACP

To learn the answer to questions like, “Why is the actual heart beat so old-fashioned, you know, boom-boom, boom-boom?” watch this Ali G interview of Dr. Koop: