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A New Dimension for Cardiac Care
From: Columbia University
| By:
Mehmet Oz |
EDITOR'S INTRODUCTION |
Cardiothoracic surgery is often touted as one of the crowning achievements of modern medical care--relying on the dazzling technical skills and advanced medical understanding of its practitioners. Yet for one leading American heart surgeon, Mehmet Oz, associate professor of surgery at Columbia-Presbyterian Medical Center, cardiac care too often lacks an equally critical component: healing. As part of his effort to introduce healing into cardiac medicine, Oz co-founded the Complementary Care Center, which studies the effect of complementary and alternative techniques on heart patients. His research has led him to confront challenging questions--including whether psychological or physiological metrics are more important in measuring patient recovery, and whether prayer can transcend both distance and time to improve health. |
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| Oz consults with a patient. | |
 y interest in complementary and alternative medicine has familial origins. First, my upbringing in Turkey forced me to look at the world from a different perspective. That viewpoint comes in handy while practicing clinical medicine in the West, where a strong bias exists toward a pure scientific approach. |
The second, and probably more important, reason was my father-in-law's interest in complementary medicine. My wife's family is from Huntington Valley, Pennsylvania, just outside of Philadelphia. The religious community in that region has created a wonderfully healthy environment. The healing of individuals largely remains the responsibility of the individual and the family. They place a lot of emphasis on self-reliance and spiritual health as a predictor and maintainer of physical health. You go see a doctor if you have appendicitis, but you manage the majority of your ailments using alternative therapies. |
In the West, particularly in the hustle and bustle of an urban environment like New York City, we have lost that sense of individual responsibility for health. Although people seek spiritual health, the challenges to finding it are greater and the guideposts are less obvious and secure. We end up caring for a lot of our societal ills within hospitals, which have their own limitations. |
Mechanical hearts
A third precipitating factor was my involvement in the mechanical heart program. In the early 1990s, mechanical hearts, or left ventricular assist devices (LVADs), were only a dream for the cardiac care field. We became used to watching our patients die because their hearts were failing. If we only had a device to keep them alive, they would be healed. With the development of the LVAD, we finally got that device. We performed our first LVAD operation in 1991, none in 1992, and then 5, 10, 15, 20 operations a year. Today we perform about 40 LVAD cases a year at Columbia-Presbyterian Medical Center. Yet when I began to put these devices into patients and to theoretically "heal" them, some individuals remained unwell. They felt depressed and weren't happy be alive. That observation awakened me to the reality that we need to play a larger role in the healing process for our patients. |
The final reason why I wanted to offer complementary and alternative care is that I use these therapies; I practice yoga. |
Complementary care center
The Complementary Care Center was the brainchild of myself and Gerald Whitworth, a perfusionist who runs our heart-lung machines. We founded the center in 1994 to provide patients with complementary and alternative therapies to help them heal. There was quite a bit of politics involved with opening the center. In particular, we ran into headwind with credentialing complementary and alternative practitioners to treat patients in the hospital. |
The first prerequisite to starting the center was my success in my day job as a cardiac surgeon; the hospital was more inclined to give me a little extra slack. The second was the proud tradition of innovative research at Columbia-Presbyterian Medical Center. LVAD surgery was controversial when we introduced it a decade ago, but we have demonstrated its role in maintaining health. Likewise, complementary medicine, although currently controversial, may have kernels of truth that prove valuable for the health of patients. |
After three years under the administration of the department of surgery, we moved the center under the hospital's purview in an attempt to deliver hospital-wide services. As the center became stronger, our opponents became more vociferous and we found it increasingly complex to get things done. In July 2000 we moved the center back into the "safe harbor" of the surgery department. Our department chairman, Eric Rose, is a very strong supporter and a close friend. |
Research focus
Moving from the hospital to the surgery department also returned us to the control of the university, a more natural place for studies of complementary medicine. If you're primarily patient-focused, you should be part of the hospital; if you're primarily research-focused, you should be university-based. The university has a credo to maintain an open mind; it's part of the academic challenge. Hospitals have no such obligations. While we offer services to patients, the center's focus remains research-oriented--studying whether complementary therapies benefit patients. |
While the center does not make money, it sustains a reasonable loss per year. In the future we're planning on raising additional money for the center through philanthropic venues. Well-to-do patients who use complementary therapies have also been very willing to help support us. Our areas of research and services range from hypnosis, prayer and guided imagery to massage, yoga and herbal medicine. |
Return to early medicine
Researching complementary medicine is particularly challenging because there is no pre-existing foundation of knowledge. In traditional Western scientific research, I can build on the shoulders of previous researchers. I can look up an article detailing previous findings and conduct the next stage of inquiry. In complementary medicine, you don't have that luxury. You're building on sand and you're forced to do the hard, time-consuming work of driving in the pilings. I find conducting research in complementary medicine much more difficult than traditional scientific research--figuring out whether a given LVAD device works well, for example. |
In essence, I want to repeat with complementary medicine the initial steps of early Western medicine--making judgments based on experiential data sets. For example, it was only in the last century that the role of microbes in causing illness was discovered. Ignaz Semmelweis, a Viennese physician in the mid 1800s, noticed that the midwifery school across from his hospital had one-tenth the hospital's postpartum morality rate. He realized that the reduced mortality might be related to the thorough hand-washing techniques taught to the midwives. It forced him to re-evaluate and to start considering crazy ideas, like the presence of invisible bacteria on your hands. Even though he couldn't see these microbes, he could conceive of them and try to prove their existence. |
The mantra study
The center conducts research on a range of different complementary therapies. Currently, one of our biggest research projects is the mantra study, examining the impact of guided imagery, music, healing touch and prayer. I find the prayer arm of this study the most interesting. Patients who choose to participate are randomized into the prayer or the control cohort. They do not know which group they are assigned to. Those patients placed into the prayer cohort are prayed for by a dozen different off-site prayer centers, located around the world and representing different religions--from Buddhist monks in Nepal to Baptists in North Carolina. A pilot study conducted at Duke University a few years ago showed such intriguing differences between the prayer and control cohorts that we decided to conduct more thorough research, and in collaboration with Duke researchers we ultimately plan to enroll around 1,500 patients. |
Prayer transcending space and time
The prayer study is particularly intriguing because it raises the question of whether prayer can transcend distance and time. How can prayer in Tibet have an impact in New York? Can prayer transcend time? For example, a patient arrives at the hospital for heart catheterization and agrees to take part in the study. He is randomized to the Tibetan prayer group and goes in for his operation. It's 8 a.m. in New York City but 8 p.m. in Tibet. By the time the Tibetan prayer group receives the message that the patient needs to be prayed for, his operation is over. Despite similar jumps in distance and time, the Duke study's findings suggested a positive impact associated with prayer. |
Envisioning the fourth dimension
I've always been fascinated by the idea that New Age physics may have a much better understanding of the realities of our existence than biomedicine. In biomedicine, we're forced to reduce to actual practice what the physicists can keep theoretical on paper. Physicists can talk about the fourth dimension (time) because they don't actually have to envision or work with it. As you know, a table is not actually solid. It is made up of very small amounts of mass, held together by forces between particles. Physicists can accurately talk about the table as consisting of X, Y and Z elements, and they can describe mathematically a fourth dimension by integration or differentiation. Physicians have to instead say, "Mr. Jones, lie on this table." |
If asked, you would probably say the image at right shows two separate circles. You'd be wrong. You're looking at the image as a two dimensional structure. In fact, it shows a donut that I've sliced, coming vertically out of the paper. You looked at a three-dimensional structure, but you only saw two dimensions of it. |
What's the fourth dimension of a donut? Since we've never seen the fourth dimension, we can't envision it. Yet donuts do change in appearance over time, becoming part of a continuum that we are uncomfortable evaluating. The fourth dimension forces us to challenge our definition of reality. I would argue that until we gain the ability to build a model of the fourth dimension, we won't have the ability to make real judgments about whether prayer can transcend time or space. |
Guided imagery
One of the center's earlier studies focused on the use of guided imagery by heart failure patients awaiting transplants. We assigned 10 patients to the control group and 10 to the group using guided imagery. We set both subjective and physiological end points: "How do you feel?" and "How long can you walk on the treadmill?" Our findings were very interesting. Patients in the guided imagery group felt better than those in the control group, but there was no physiologic difference in their performance. |
You might think that these people were being fooled, because their physiologic condition did not improve. I would argue that, if they feel better, it might not really matter whether or not they can walk farther. It all depends on the end point you choose. If I am dying of heart failure, am I better off if I feel better, or am I better off if I can walk farther? |
The physiology of subjective end points
In fact, feeling better has huge implications for how the patients care for themselves. The more we understand the human immune system, the more we appreciate the impact the mind has on that pathway. Depression impacts the T-helper cell function so that when you're psychologically depressed your immune system also becomes depressed. |
Physicians regularly categorize patients after heart surgery as depressed or non-depressed. The depressed group has a much higher chance of postoperative infection and an even higher risk of death. The most important risk factor after a heart attack is the amount of damage that has been done to your heart. The second most important risk factor is depression. It's more important than 15 other medical variables that we track. |
In a sense, it's a classic "chicken or egg" story. Did you have the heart attack because you're depressed, or are you depressed because you had the heart attack? A lot of times, it's the former: You became depressed and therefore you had a heart attack. It's very common among my patients. Take Joan, a patient I saw today whose husband died a few months ago. Since his death, she's been very despondent. She started having angina about two months ago and now she's having heart surgery. |
Changing patient population
Since we started the center, in 1994, the kind of patient who comes to us has changed slightly. We tend to attract patients who know we offer these therapies and want them; they are more inquisitive and more proactive in their care. We also have more female than male patients, since women are typically much more interested in healing. |
Another important step is that the center now also offers therapies for a patient's spouse. Often spouses are the ones who suffer the most, and you need to have a strong caregiver in order to have a healthy caregiving relationship. Similarly, we give free massages to all our health care providers--nurses, physician assistants, perfusionists and everyone else who takes care of our patients. The best way to convince a staff member to advocate for complementary therapies is to personally expose them to the benefits of those therapies. |
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