I BECAME INTERESTED IN WRITING ABOUT HEARTS after running across a snippet of data showing that the United States now spends more on treating and repairing hearts than on new passenger cars—a straw in the wind, it seemed, that warranted further exploration.
I’d been intermittently involved in health care businesses and have occasionally written on health care policy issues, but I had no preconceived idea for a book, except that I wanted to learn as much as I could about the “heart industry.”
In the course of talking to people in the field, a lawyer friend, Joe Bartlett, who has been deeply involved in medical issues, offered to introduce me to Craig Smith, the chief of the heart and lung surgery division at Columbia-Presbyterian hospital in New York City. It is a premier cardiac surgery center, and the country’s largest heart transplant center by a substantial margin.
After several discussions with Smith, he agreed that I could “embed” within the division an extended period in order to get a ground-level view of its operation. I wanted to learn how doctors think about their profession and their business, the pressures they work under, how they make decisions, how they choose their colleagues, how they get paid. I was also curious about the play of outside forces—regulators, pharmaceutical and equipment companies, accrediting agencies, patients—on what the doctors do and how they do it. But I decided to drop any preconceptions for a book, immerse myself in the division, and let the book come to me.
Smith stipulated that there would necessarily be meetings I would be barred from attending, and topics that might be off-limits, which seemed reasonable enough. As a practical matter, once I had been with the division for several weeks, I became part of the wallpaper and could attend virtually any meeting at all and ask about anything, subject only to legal restrictions on patient privacy. I observed all or part of about two dozen operations and met a fairly large cross-section of patients. (I was always introduced to patients as a writer, but no one ever objected to my presence. That surprised me at first, but, on reflection, don’t we all like to talk about our illnesses?) Smith himself proved an ideal interlocutor—available, open, straightforward, nondefensive, and self-critical.
There were many surprises. I had never understood how many details of an operation are decided only after the chest is open and the surgeon can see and touch the diseases he will be working on. Despite all the scientific understanding of the heart, the critical decisions always come down to what will work with this patient, this set of coronary arteries, this misshapen mitral valve. The image that kept springing to mind was that of the Renaissance violin maker—the combination of lore, empirical understanding, and the insight of genius that no machine or computer program has ever replicated.
Nor had I appreciated the speed with which technology is moving, or how fast the field is changing. I had never imagined that a heart center could routinely transplant two hearts a week, or how astonishingly high transplant survival rates are—or how close we are getting to the ideal of workable, relatively inexpensive artificial hearts. And I have a much better idea of why health care spending is growing so fast and why it will almost certainly continue to do so.
Everything I learned at Columbia-Presbyterian, however, came from watching stories unfold—a difficult operation, a resident’s progress, a wrenching life-or-death decision. This book is a compilation of those stories.