Thursday, March 24, 2005

Second Opinion
Second Opinion
by Howard Markel

Last Thursday, Bill Frist took to the Senate floor to offer a diagnosis of Terri Schiavo's condition. His conclusions were based not upon the time-honored technique of examining the patient in question but rather on watching "an hour or so" of video footage of Schiavo.

As a physician, I was astounded. Long-distance doctoring is problematic on many levels but especially for a doctor who has not practiced much medicine for more than a decade. Plus, there is the fact that even when Frist did see patients on a daily basis, he practiced as a heart transplant surgeon. Which means that most of his clinical work was done with anesthetized patients on an operating table. To be sure, no one has ever questioned his credentials as a transplant surgeon. But in the real world of medicine, his opinions on persistent vegetative state, especially those supported only by videotapes from Schiavo's parents, simply don't carry much clinical weight.

Given Frist's propensity to play doctor from the floor of the U.S. Senate, I thought it might be equally appropriate for me to play medical school professor--a role I play in real life--and evaluate his medical decision-making process, much as I do for medical students. Below are excerpts from Frist's statements to the Senate last Thursday, interspersed with my comments.

Mr. President, in closing tonight, I want to take a few final moments to speak on an issue that I opened with earlier this evening, and it has to do with the Terri Schiavo case in Florida. I'd like to close this evening speaking more as a physician than as a United States Senator and really speak to my involvement as a physician--and as a Senator and as leader in the United States Senate which has been a fascinating course of events for us over the last forty-eight hours.

It is vital for a physician to identify himself clearly and definitively. If you are the physician actually treating the patient or are involved in his or her treatment as a consultant, then say so. If not, identify that fact clearly and quickly to avoid misleading others who depend on your objectivity. This is especially important when you have not been involved in the patient's care or if you have some other agenda--in this case, political--at stake in the case.

I was interested in it in part because it is a very difficult diagnosis to make, and I've been in a situation such as this many, many times before as a transplant surgeon.

You may have encountered such situations "many, many times," but there's a big difference between encountering such situations and being an expert on them. And there's little reason to believe you are the latter. When, after all, would a transplant surgeon ever be called in to make a diagnosis of persistent vegetative state in a patient? Generally, other physicians--typically neurologists--make that decision long before the organ donor (either dead or clinically brain dead) is wheeled into your operating room. This is critical because these other physicians have no conflict of interest in the outcome; as the surgeon who has a relationship with the patient awaiting an organ, you do.

I have talked with her family and had the opportunity to meet her son, and her son told me that she is responsive. She has a severe disability; a lot of people with cerebral palsy and disabilities have severe disabilities.

Doctor, please be more precise in your medical terminology. Cerebral palsy is a neurological condition likely related to traumatic births that typically impairs one's ability to use muscles that affect walking, moving one's arms and hands, or even speaking. But cerebral palsy patients typically do not have cognitive deficits; Schiavo clearly does. No first-year medical student would link these very different neurological problems in the same sentence.

Persistent vegetative state, which is what the court has ruled--I question it. I question it based on a review of the video footage, which I have spent an hour or so looking at last night in my office.

Just a moment ago you correctly asserted that persistent vegetative state, or PVS, is a "very difficult diagnosis to make." But now, based on your brief review of a home video, you are willing to question the diagnosis of many other doctors who have actually examined Schiavo?

One of the classic textbooks that we use in medicine is called Harrison's Principles of Internal Medicine. In the sixteenth edition, which was published just this year in 2005, on page 1625, it reads, "the vegetative state signifies an awake but unresponsive state. These patients have emerged from coma after a period of days or weeks to an unresponsive state in which the eyelids are open, giving the appearance of wakefulness."

While I am certainly glad you can quote Harrison's, it is not exactly the text of choice for this argument. That's because the book is basically an encyclopedia of just about every malady known to humankind. Each topic is covered in a few pages, which serve as only a quick introduction to the more in-depth searches every physician needs to perform--especially when entertaining diagnoses they do not typically see in their daily practices. Tell me, Doctor, did you check more comprehensive books or treatises on neurology and, more specifically, the vast medical literature on PVS produced in the past ten years?

I would simply ask, maybe she is not in this vegetative state, and maybe she's in this minimally conscious state. In which case the diagnosis upon which this whole case has been based would be incorrect. Fifteen neurologists have signed affidavits that Terri should have additional testing by unbiased, independent neurologists.

You cite these 15 neurologists who filed affidavits on behalf of Schiavo's parents. What about the dozens of presumably unbiased and independent experts appointed by the court who examined Schiavo numerous times over the past 15 years? All these doctors concluded that she was suffering from PVS and that there have been no significant signs of improvement. In fact, it has only been the physicians hired by Schiavo's family who have disagreed. Why do you discount the court-ordered doctors as well as those hired by her husband--but not those hired by her parents?

Time and again, Doctor, you have waved your stethoscope in the political arena. But physicians are expected to treat illness and not to let ideology get in the way of their medical judgments, especially when it comes to controversial issues such as end-of-life decisions, reproductive choices, or the prevention of sexually transmitted diseases. Our patients deserve and rely upon us for such objectivity; our professional ethics demand it. Perhaps you need to be shown to the Senate Cloak Room. It contains plenty of hooks where you might hang up your white coat before entering the Senate chambers.

Howard Markel is professor of pediatrics and the history of medicine at the University of Michigan. He is the author of When Germs Travel, due out in paperback from Vintage/Random House in May.

Originally published 03.23.05