Knocking on Heaven's Door: The Path to a Better Way of Death by Butler Katy

Author:Butler, Katy [Butler, Katy]
Language: eng
Format: mobi, epub
Publisher: Scribner
Published: 2013-09-09T16:00:00+00:00

What if we are fully successful in the purpose of our gathering? Will we devoutly wish for a new risk factor to call into play as we see memory slipping as our dotage arises? Will we avoid physicians and hospitals for routine ailments because we are afraid that unacceptable illnesses will be prolonged interminably?

In the aftermath of the pacemaker scandal, a committee appointed by the American College of Cardiology wrote a set of clinical guidelines in 1984 intended to discourage overtreatment. On a logic that boiled down to “if it ain’t broke, don’t fix it,” the committee advised against implanting the devices in patients with no troubling physical symptoms and no sign of disease beyond slightly irregular cardiograms, slow heartbeats, or vague diagnoses such as sick sinus syndrome. Over the next five years, pacemaker implantations in Medicare patients dropped by 25 percent. But the basic pattern—maximum promotion, the creeping expansion of diagnoses for which pacemakers and other cardiac devices were supposedly warranted, disguised gratuities to cardiologists, and cat-and-mouse games with Medicare—did not end. No matter how Medicare tried to change its rules and tighten the spigot, money continued to flood into the device companies, and like water seeking its own level, some of that money trickled down to cardiologists. By 1987, the median income of cardiovascular surgeons was $271,555, while most primary care doctors earned considerably less than $100,000.

One former Medtronic sales rep told me that in the 1980s he was sent to a three-day course in fine wines, all the better to wine, dine, and knowledgeably converse with the upscale cardiologists who were his sales prospects. In the early 1990s, one of pacemaking’s pioneers, a respected university-based cardiac surgeon, saw how far things had gone wrong when he flew from the east coast to Los Angeles to supervise the placement of a pacemaker in his mother-in-law, who was then in her early nineties. “I went out there on a Saturday to Cedars Sinai, I guess in February,” said the east coast surgeon, who asked to remain anonymous. “It was a very quiet day, and the surgeon and I were sort of waiting around. It turned out we were waiting for the sales rep, and finally he arrived. The doctor put in the pacemaker adequately, and the sales rep handed the surgeon a package and left. The surgeon opened it in front of me, seemingly not at all embarrassed; it was a nice gold wristwatch, as a present.”

Time passed. Things changed. Things stayed the same. The number of transistors in a typical pacemaker grew from only two to more than four million. U.S. health care costs kept rising, to nearly double those in some European countries, without a corresponding gain in health. In 2003, the year my father got his device, when health care was consuming 15.9 percent of GDP and the average American life span had risen to seventy-seven, a Medicare study found that medical device companies were enjoying average net profit margins of nearly 20 percent. It was, the New York Times pointed out, more than twice the average for all other companies in the S&P 500.

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