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DOUG MUZZIO: Hello, I'm Doug Muzzio, this is City Talk.
They are Fred and Martha Cooper, Mr. Taska, Mr. Mukazh,
Mr. Radkins, Mr. Princhipow, Patricia and Philip Reilly. It
is a disaster. Fragmented, depersonalized, and business
driven. A brave, new, post-Hippocratic world where
medicine's venerable first principle has become an empty
shibboleth, where caring is hard to find. He's been called
remarkable. One of the nation's most respected leaders
of academic medicine, an expert story-teller and a
unique voice in American Medicine.
♪ [Theme Music] ♪
He is Dr. Brendan Reilly.
Brendan is Executive Vice Chair of Medicine at
New York Presbyterian Hospital and the Gladys and Roland
Harriman Professor of Medicine at Weill Cornell Medical
College. He's served as chair of medicine at Chicago's Cook
County Hospital. When that hospital was the inspiration
and setting for the iconic television series, ER.
Before that, he was a small town doctor in rural New Hampshire,
and before that, he was my college roommate. They are
among the patients in his remarkable memoir, One Doctor--
Close Calls, Cold Cases, and the Mysteries of Medicine.
It is the American Healthcare non-system.
Welcome Brendan.
BRENDAN REILLY: Thanks, great to be here.
DOUG MUZZIO: Long time.
BRENDAN REILLY, MD: Yes.
DOUG MUZZIO: Great reviews, great book. I think it's an
important book, a book that really lays out in very human
terms what medicine is. But more than that, is a really
damming indictment of the current state of American
medicine. So personally, I thank you.
BRENDAN REILLY, MD: Well, can I say something about that?
DOUG MUZZIO: Sure.
BRENDAN REILLY, MD: Because it's not intended to be a
damming indictment.
DOUG MUZZIO: Well, I read it as such, I'm sorry.
BRENDAN REILLY, MD: Well, the tricky part about medicine is,
and this, I think, resonates throughout the book,
is that there's lots of good, and there's lots of bad.
DOUG MUZZIO: Right.
BRENDAN REILLY, MD: And one of the amazing things about
medicine that I've seen, just during my own professional
lifetime is what medicine can do today, compared to what it
could do 30 or 40 years ago is unbelievably fantastic.
DOUG MUZZIO: But --
BRENDAN REILLY, MD: Well, but before you get to the but,
it means that an awful lot of people have done tremendous
work to advance the science of medicine and then to bring
that to patients. The but is that even though the science
has advanced tremendously and has the potential to help lots
more people, how we actually provide the care, how we
deliver it, and I think, most importantly, the
personal relationship between the doctors and the patients
are what are getting short shrift today. And this book
is a lot about what it is like to be a doctor, both from
a patient's point of view, but I think almost uniquely, compared
to other books, this is a book about what it's like
to be a doctor from the doctor's point of view.
DOUG MUZZIO: And then that gets to the title of the book,
One Doctor and it really has two meanings. One is that the
one doctor is you and that you provide a first person memoir
of a variety of cases that in some ways are as dramatic
as anything on ER or Grey's Anatomy and you know, could
be a television series in itself. But the One Doctor
means something else as well. What does that other
One Doctor mean?
BRENDAN REILLY, MD: It gets to this personal relationship
business. My opinion is that every person in the
United States should have at least one doctor who
really knows them well. This is probably less important when
you're young and healthy, but believe me, it gets real
important as we get a little bit older or being to encounter
our own healthcare troubles, because there's just no
substitute for having a doctor how knows you well, and equally
important, a doctor who feels like he or she is a partner
with you. There's all kinds of tricky decisions that patients
have to make, especially as they get older, and as will
happen to all of us eventually get sick, and there's this idea
out there that medicine is all science, you know?
If you have X diagnosis, you do A, if you have Y
diagnosis, you do B. The fact is that there's lots of judgments
that have to be made and those judgments cannot be
made by the doctor alone. They have to be made
together with the patient. And unless there's some
kind of relationship between those two people, especially
over a long period of time, often the wrong decisions
are made. So One Doctor is all about how everybody
needs to have one doctor.
DOUG MUZZIO: Okay. You open the book with a quote from
Sr. William Osler, from 1904, and let me just read the quote:
"Life a simple and temperate life, that you may give all
your powers to your profession. Medicine is a jealous mistress.
She will be satisfied with no less." This mistress has taken
you many places. I mean, urban/rural, public/private,
big/small, affluent/poor, and Ivy League and slums.
Still your muse?
BRENDAN REILLY, MD: Oh sure. You know, I'm sure you've
thought and heard this many times yourself. People whose
job, whose work is something that they passionately love
are very lucky people.
DOUG MUZZIO: Yep.
BRENDAN REILLY, MD: I am a very lucky people.
DOUG MUZZIO: I, me too.
BRENDAN REILLY, MD: And I have been for a long time.
And so that is still true today. In fact, the working title
of this book, before the publishers, who are a lot
smarter than I am about this, picked One Doctor.
The working title was, The Dinosaur's Mistress.
The dinosaur, me, and mistress, this medicine
that I've been having this affair with for 40 years.
DOUG MUZZIO: And are continuing having that affair.
BRENDAN REILLY, MD: Yes I am, yeah.
DOUG MUZZIO: You call yourself a dinosaur. And I've heard
you compare yourself to NPR's resident car diagnosticians
at Click and Clack at Car Talk. How are you a dinosaur?
BRENDAN REILLY, MD: I'm a dinosaur because even in
my own professional lifetime-- There was a large number of
doctors like me, whose job was to do what we talked about
before, which is to take care of the whole patient. That means
that if you're my patient and something is wrong with your
eye or your toe, or your heart, you come to me first.
And most of the time, I can help you. I don't automatically have
to send you to the eye guy or the toe guy or the heart guy.
I can help you. And out of that comes that relationship
I was talking about, which over time then allows me to
help you but it also allows you to know that when I say,
"You know, what's wrong with your toe, Doug?" is not
something I can handle. I need to send you to the toe
guy. You have every reason to believe that I'm doing it for
the right reasons, that I'm not just churning patients so lots
more doctors can see more patients and make money.
This relationship has a lot to do not just with making
patients comfortable, but it actually has to do with
equality of care. So in the old days, there were lots of
people like me. Today, there are many, many fewer,
and unless important changes happen in the healthcare
system, people like me literally will go away. That's why I am
a dinosaur. I'm literally on the verge of extinction.
DOUG MUZZIO: What's replacing the dinosaur?
BRENDAN REILLY, MD: A very fragmented, disconnected
system, where, for example -- and let's be careful here,
right? We're making generalizations.
DOUG MUZZIO: Absolutely.
BRENDAN REILLY, MD: Medicine is a huge thing, so there are
always exceptions to these generalizations. But more and
more primary care doctors are becoming people who kind
of do very simple, preventative medicine kinds of things;
which frankly you don't need a doctor to do. Lots of other
healthcare providers can take your blood pressure and give
you shots and stuff like that. But more and more primary
care doctors are becoming people who refill prescriptions and
give you appointments to go see somebody else. That is not
what primary care medicine used to be about or should be about.
And that is the kind of medicine that I used to do, and still to
some extent do do, and yet, unfortunately, there's a whole
younger generation today who will look at me cross-eyed
when I talk about this stuff, because they don't
know what I'm talking about.
DOUG MUZZIO: So not only are you old, but you speak
a different language?
BRENDAN REILLY, MD: Yes, although I tried to redress that
a little bit by writing a book.
DOUG MUZZIO: That's right. Okay. You've described your
role and other's roles as sort of a medical maestro,
and you're the conductor of a symphony and you call them
the "ologists". What, what is the symphony doctor do?
More than what you've already described? Keep going.
BRENDAN REILLY, MD: Well, so for example, this book actually,
most of it is set in the hospital here in New York,
in present time.
DOUG MUZZIO: Two weeks in winter of 2010.
BRENDAN REILLY, MD: That's right. And it describes me,
as you said, in first person, taking care of a bunch of very
sick, complicated patients at a famous teaching hospital
here in New York. And what you see there is that many
of these patients -- very sick, very complicated, they do
require lots of these ologists, for sure, because they're sick,
some of them are dying, and even though I'm a good doctor,
there's all kinds of stuff that the ologists are better
at than I am. The maestro is required, though, because
when you're a sick person in the hospital, and you've
had to see eight different ologists, because you're
sick with things that are wrong with your heart and your
kidneys and your brain and maybe you need surgery and
maybe you don't, and you need to have fancy tests and all
that stuff -- There does have to be a person who's overseeing
the care for you. Who's totally focused on the whole patient.
That's not to say that great specialists don't care about
people. They do. But their job is to focus on the piece
of the person that they are expert at. That's why people
like me ask the ologists to see the patients. But someone has
to then put it together. Someone has to make sure that from
the patient's point of view, the care that is being suggested
and provided by all these different ologists comes
together and makes sense and results in a good outcome.
DOUG MUZZIO: So not only do we read about -- And really enter
the lives of some of the people that I mentioned up top --
Mr. Taska, Mr. Mukazh, Mr. Radkins and Fred and
Martha Cooper, during this same period, you had a personal
medical emergency or two sets of emergencies.
Can you describe that as well?
BRENDAN REILLY, MD: Sure, I think it's actually the reason
I decided to write the book. The book is written in three parts.
The first part is that long Saturday that we
talked about before.
DOUG MUZZIO: Sure.
BRENDAN REILLY, MD: The middle part is a flash back to a
long time ago that we haven't talked about.
But the third part is back in the hospital in New York,
taking care of these six folks in the hospital.
What's different about the third part is during that
very same few days, when I'm taking care of these
sick folks in the hospital, I'm also having
to deal with life-threatening emergencies of both of
my parents. Both, at the same time. Both of whom --
DOUG MUZZIO: Who I met 45 years ago. Go ahead.
BRENDAN REILLY, MD: That's right. Both of whom are in
their 90's. My father has metastatic bladder cancer,
my mother has had cognitive decline with dementia and
is also having trouble with her heart. And what was
remarkable about that time was that I had a patient in
the hospital during those very same days -- this is the
Mr. Mukazh you're talking about, who had metastatic
bladder cancer involving his hip. That's exactly what
was wrong with my father. Mr. Mukazh, the patient in the
hospital, had opted to do everything. Surgery, radiation
therapy, chemotherapy, even though he knew it was not going
to cure him. His decision was that was the way he wanted
to go. My father, on the other hand, was cognitively intact
and a retired physician. So, a knowledgeable person,
had decided not to do any of that. And so during those
few days, every time I would see my patient in the hospital,
I would wonder if we're doing the right thing for him, and I
would think about my father and every time I would see
my father, I would wonder exactly the same things
about him. So it put me in a position where I was not only
just the doctor and seeing the doctor side of the
doctor/patient relationship, I was also in a sense,
the patient too. Because I was trying to help my father and
my mother, as best I could. So I was actually on both
sides of this doctor/patient equation and that was very
interesting experience for me and in looking back, after
the events described in the book, I said, "Hmm, you know,
that might be an interesting thing to write about."
DOUG MUZZIO: Sort of a digression away from the book
a little bit, but those two cases, your dad and Mr. Mukazh,
and several of the incidents and stories that you write about
deal with the end of life and how modern medicine treats
end of life and how folks treat end of life. And that--
talk about that from both sort of a doctor's perspective,
and sort of the son's perspective.
BRENDAN REILLY, MD: Well, one of the great thing's that's
happened recently in American medicine is that palliative
care specialists have gained some ascendance in the
healthcare system. And palliative care folks are
people whose job is to try to help make patients feel better.
They're not necessarily people who can cure their
diseases, their job is to make people feel better,
which in the old days is what doctoring always was about,
that's the whole idea. There's a quote from Atul Gawande,
for example, that says, something to the effect of,
you know, medicine's ultimate job is to fight death.
But you know, in the long run, death's gonna win.
DOUG MUZZIO: Yeah.
BRENDAN REILLY, MD: So there is some wisdom required in
figuring out how hard and how long do you fight and when do
you say, you know, "I think my time has come."?
And, "What's most important now, is how I feel. And am
I able to reduce my suffering, am I able to interact with
my friends and my family during whatever time I have
left?" Many Americans haven't thought about this stuff.
We tend to think about it when we have to, you know?
I mean really, who wants to think about this stuff if
you don't have to?
DOUG MUZZIO: Right.
BRENDAN REILLY, MD: But unfortunately, lots of times
when you get really sick, you don't have much warning
about it, you're suddenly thrust into a situation in a hospital
where you're having to make these life and death decisions
and you haven't really thought carefully about what you
personally want when your time comes. And so for example,
in the case of the Mr. Mukazh we're talking about, he's
saying, "I know I'm gonna die of bladder cancer, but I'm
choosing all of these options to try to help prolong my life
as much as I can." My father, on the other hand, knew exactly
the same things, and made the decision, "No, what's more
important to me is the quality of my life. I don't wanna go
through the harms that are going to accrue to me by having
operations and radiation therapy and chemotherapy."
Medicine is always this balance between harm and good.
And for every patient, it's a different kind of decision.
Which is again, why more and more it's so unfortunate
that many patients are very alone in this process.
Which is why this business about a relationship with the
doctor is so important. If there is a doctor you know,
whom you trust, and you can bounce ideas off, you're more
likely to make smarter decisions-- not medically or not
in the doctor's opinion, but what's smart for you and your
family and your loved ones?
DOUG MUZZIO: Advice to folks, particularly those of us
who are in the Medicare ages in terms of what they might do
to make this transition easier? Also, legally, what
might they do as well?
BRENDAN REILLY, MD: So as you know, there are instruments
available to folks to clarify what they would want were
they to become ill in certain ways. They are called advance
directives. And maybe people think of them as living wills.
Living wills in general don't accomplish this goal.
Living wills tend to say things like, "If I'm in a desperate
situation, I don't want to have 'heroic care'."
Well, what's that? Right?
DOUG MUZZIO: Right, and what's that -- right.
BRENDAN REILLY, MD: Exactly. And so what's more important
is that preferably together with a person you know well,
a family member, a friend, whoever, you and that other
person meet not once, but many times with, again, your doctor.
If you're lucky enough to have one doctor, which most people
don't anymore. But if you are, and begin a conversation about
what I may or may not want under certain conditions. Folks in
our age group, well, are lucky, in a sense, because we're at
least having to begin to think about this, and many of us have
had to confront these situations with either our parents,
other loved ones, and so there's a little context there that
allows you to think more clearly about this. Legally, crazily
enough, every state is completely different.
DOUG MUZZIO: I know.
BRENDAN REILLY, MD: In how it allows people to do this,
but that said, you have to look at the bright side. Compared to
20 years ago, things are better than they used to be,
people are beginning to pay more attention to this.
Most Americans still haven't executed any kind of advanced
directive, but many more have than used to. Unfortunately,
and this is the last thing I'd say about this, is just having
this piece of paper, you know, with a notary public
saying something about it, really doesn't do you any
good unless you also have this doctor who's gonna help you
implement your will. Because if you're unlucky enough to
wind up in an emergency room deathly ill, and your doctor
is nowhere to be found, well, the way American medicine
works is that they do everything they can do to save your
life, which is fine, but if you're 100 years old and have
metastatic cancer, that may not necessarily be what you want.
And so a lot of this has to do with communicating what you
want and trying to make sure that it actually happens.
DOUG MUZZIO: Okay, so the first section of the book and
the third section of the book are, in a sense,
medicine as it is now --
BRENDAN REILLY, MD: In the hospital.
DOUG MUZZIO: In the hospital. But the middle, the flashback
to rural New Hampshire 25 years earlier where you're a primary
care physician, you're in a small town, sort of medicine as
it used to be. Sort of the medicine of house calls and
then we come to your cold case, the case that's sort of still in
you and almost will never leave. It's one of those viruses
that you can't expunge, and you wouldn't want to, exactly.
Talk about that time and that cold case and
what it meant to you.
BRENDAN REILLY, MD: So at the time I was a primary care
doctor in a small town, but the small town was a small,
New England college town. I worked at Dartmouth Medical
School. And part of my job was to be the small town doctor.
And by far, the best medical experiences of my life --
Involved making house calls. Going to folks' homes where
doctors learn so much more about their patient than just seeing
them once in a while in the office. But the cold case was
actually the case of an elderly couple, people I knew well
and actually people I loved. They were wonderful, wonderful
people. And to make a long story short, both of them got
very sick and one of them I was able to help a lot, and one of
them I wasn't able to help, and his outcome was tragic.
Part of it was my fault. Part of it was the "system's" fault,
and memories of that case have never left me because it
actually made me who I am in some ways. The lessons
that I learned there, I've kept with me and those lessons
have informed what I've tried to do in the years that
followed. And one of the cool things about that cold
case was that that patient himself had his own cold case
and his own cold case was Amelia Earhart; because this patient
was a famous engineer who had actually designed the
navigation system for Amelia Earhart's airplane on her trip
to travel around the world. Ultimately her fatal trip,
to travel around the world. And he had been guilty for
years, because his navigation system, which was far better
than the old ones, had been removed from her airplane
just before she took off for all the wrong reasons.
Again, a series of complicated errors that he felt responsible
for, which in many ways is exactly what happened to me
with him. I felt responsible for some of the errors that
wound up taking his life. And so there's this very unusual
mirror image between my cold case and his own cold
case. And as you know, they're still looking for
Amelia Earhart and so Fred, the name of the patient,
if he were alive today, would still be frustrated because his
cold case hasn't been solved. But in many ways, my cold
case was solved. I think I did eventually find out why
Fred died and what my role in it was.
DOUG MUZZIO: And you've got to read the book.
BRENDAN REILLY, MD: And I learned a lot from it.
DOUG MUZZIO: Okay. Let's go to the modern medicine, or what
you call the non-system of healthcare in the
United States. What are the perversities, the problems,
with current, modern American medicine?
BRENDAN REILLY, MD: Boy, how much time you got?
DOUG MUZZIO: Uh, maybe we could do another show.
BRENDAN REILLY, MD: Yeah.
DOUG MUZZIO: In fact, I'm serious.
BRENDAN REILLY, MD: But again, let me be clear about this.
You know, I'm not the Che Guevara of American Medicine.
DOUG MUZZIO: We understand.
BRENDAN REILLY, MD: I am establishment medicine.
And there's an awful lot that's great about American medicine.
But the perversities you know, maybe even better than I
know, they occur at the economic, political and social
levels as well as the medical level. The biggest underlying
problem is that it isn't really a system at all. It's a
disconnected series of interests, each of which has
its own set of incentives. Whether you're talking about
insurance companies, drug companies, hospitals, doctor's
groups, individual doctors, nursing homes. And these are
pieced together in almost serendipitous ways which vary
in different parts of the country and in no sense is it
a health care system like many advanced Western countries
have. And that, you know, whatever people's politics are,
that is why the Affordable Care Act is so important.
I think even President Obama would say, it's not gonna solve
all the problems, but it is the beginning of a change
to at least begin to create a system. And the main change
is to try to get all Americans into healthcare.
DOUG MUZZIO: That seems to be the sine qua non.
BRENDAN REILLY, MD: Most Americans don't get it when
they hear that the United States, on many measures,
ranks dead last among industrialized nations in
various healthcare metrics. And yet, at the same time,
for example, in a city like this, you walk down the street
and you see these magnificent Taj Mahals of medicine
where it is true, you can get the best care anywhere
and "miracles", quote, unquote, are actually happening in
these places every day. How can that be true and at the same
time the United States ranks last? Well, if you're the
president of the United States, your answer to that is,
"Well, it's always going to rank last until we get everybody
into the system." Because the folks who are out of the
system are most of the people who are suffering terrible
outcomes and they're suffering bad outcomes because they
can't get the medical care that they need. And so his first
priority has been to bring the disenfranchised and the
underserved Americans into some form of healthcare,
to begin to address this problem of how the nation as a whole,
all of them, need to do better than we're doing now.
DOUG MUZZIO: Whew. In your intro you talk about the book
you want- as Hamlet did- catch the conscience of the king.
Who's the king in this situation?
BRENDAN REILLY, MD: Yeah, that's a good question. You know,
I mean I'm old enough to remember when people asked
questions like that, and the answer would be, "Well, I want
the public, I want readers to know more about what's
going on." And well, okay, then what do you do? Well, in the
old days the answer to that was you call your congressman.
That's what they got elected to help fix, right? Well, today,
I'm not so sure that's gonna do it. So who the king is today,
I'm not sure. What I hope happens is that real people read
the book, realize that there are challenges out there, realize
what's happening today is not necessarily what's best for
them. And then what happens after that, I'm not sure.
I just hope more people begin talking about this fragmented,
disconnected thing we've got going here. And while
the current "thing", "the system" can be very good for
lots of the vested interests in the system, in general,
it is not very good for patients. How we get from
here to there, I'm not sure.
DOUG MUZZIO: And I don't think anybody else is either, but
thank you Brendan, this is an important book. It's really
odd here, interviewing you 45 years later, I must say.
But my thanks to my friend, Dr. Brendan Reilly for being
on the show. For sharing his experiences and analysis
of modern medicine; and for his extraordinary memoir,
One Doctor -- Close Calls, Cold Cases and the Mysteries
of Modern Medicine. See you next week, here, on CUNY TV.
♪ [Theme Music] ♪
DOUG MUZZIO: Hello, I'm Doug Muzzio. Let us know what you
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