Customer Reviews

The Surgeons: Life and Death in a Top Heart Center

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The Surgeons is an intriguing glimpse into the lives and work of the heart surgeons at New York's Columbia-Presbyterian Hospital, one of the world's top cardiac surgery centers.

Author Charles Morris provides an intimate look at the work of these virtuosos who hold lives in their hands every day. We get to know such artisans as Craig Smith, head of cardiothoracic surgery, who is well-known for doing the quadruple bypass on former President Bill Clinton; Eric Rose, a cardiothoracic surgeon and chairman of the Department of Surgery; Mehmet Oz, senior adult cardiac surgeon, well-known author of three New York Times best-sellers, and regular contributor on Oprah; and many others, whose names will be better known as a result of this book.

From his unparalleled access to attend surgeries and meetings, Morris gives us an incredibly insightful view into how these surgeons think. It's a real-world, insider's look at the people, problems, and politics in a major hospital. As an example, he explores the politics between the surgeons and the interventional cardiologists, and talks about how their disciplines are converging.

The book tackles a variety of topics, from how the heart works and the history of heart surgery to health care policy and directions for high tech medicine. It even explores the innovative new business models pursued by Columbia-Presbyterian. An intriguing bit of trivia that Morris reveals is that Thomas J. Watson, former chairman of IBM, made a personal project of financing and developing the heart-lung bypass machine, which is still used today in many open-heart surgeries.

Morris excels at sharing the stories of surgeries and the patients benefiting from them. We get an intimate look at patients that made it and those that didn't. We experience the heart-rending story of four-year old Erika Maynard and her family, a story sure to tear at your heart strings. We get to go with him on a heart transplant run to secure a heart, and then see it transplanted. Morris' writing is so visual, and the stories so real and vivid, that you actually see and feel them.

The Surgeons is a fascinating read!

Mellanie True Hills
American Foundation for Women's Health and www.StopAfib.org
Author, A Woman's Guide to Saving Her Own Life

Author Charles Morris offers insightful profiles of top cardiac surgeons at a New York area medical center. One gets a sense of the incredible training and sacrifice that goes into being one of these medical virtuosos, who literally hold the lives of patients in their skilled hands.

Morris also provides an interesting discussion of health care economics, making predictions on how America may attempt to address the healthcare crisis what with the aging of the Baby Boomer generation.

Morris' admiration for the surgeons profiled often leaves him awestruck, with a tendency to deify these practitioners. Rolled out as the proverbial whipping boys are the Bad Guys of Big Pharma and Medical Device Companies. The critique tends to obscure the fact that doctors are somewhat willing participants in the promotional schemes used by such firms, but they escape much of the venom that Morris reserves for health care businesses.

"The Surgeons" is an enlightening and thought-provoking book on specialists that you hope you'll never have to see. Take care of your ticker!!

With amazing detail, "The Surgeons: Life and Death in a Top Heart Center" provides a view of many behind-the-scene challenges of modern cardiac surgery. I spent four days as a patient in the cardiac unit at New York's Columbia-Presbyterian Hospital while author Charles Morris shadowed surgeons "unrestricted" in the same unit for an entire year.

It is quite fascinating to read what doctors are thinking, feeling and doing while life is literally in their hands. Cardiac surgery is one of the few procedures in which, at every moment, "the patient is at risk of sudden death." As a result of many long years of medical training and incredible sacrifice, cardiothoracic surgeons provide their patients the gift we all crave, longevity and quality of life.

Charles Morris writes a fascinating description of what happens once a heart patient is anesthetized on the operating table. Prep work takes about an hour. The patient is "shaved, and painted almost head to toe with bright red antiseptic; various monitoring leads and hookups are affixed around the body, breathing and imaging tubes pushed down the throat, a flow monitoring catheter is threaded through the jugular vein" into the heart, and a urinary catheter into the bladder. The patient is wrapped with yards and yards of sterile tape and gauze and "eyes are taped shut."

When Columbia-Presbyterian heart surgeon Craig Smith, MD recently opened my chest, the mitral and aortic valves were beyond repair with healed endocarditis and a worn out aortic root. In 8.5 hours of surgery, Dr. Smith skillfully removed scar tissue and replaced both valves with bovine (cow) tissue and the aorta with a 28mm graft.

Although many of the more difficult cases are sent to Columbia-Presbyterian, heart valve surgery is considered "relatively routine." Craig Smith performs about 350 heart operations a year and heads up the largest heart transplant center in the country.

Congratulations to Charles Morris for his eloquence, as he provides heart patients and the public a greater understanding and cardiothoracic surgeons and the medical community a voice.

This book can very easily be divided into two halves. The first half concerns the success and failure of various heart surgeries (the best part of the book if you are really interesting in understanding what takes place during surgery). The second half delves into health care industry problems. Both halves are well written and insightful. When I bought the book I would looking for discussion and depiction in line with the first half. The second part, prescriptions for an ailing US health care industry, seems to be out of place in this book and I wish there was more dedication to stories of surgery and patient and doctor followup (admittedly there is a good portion of this in the first part of the book). I think the big change of topic occurs right after discussing Morbidity and Mortality meetings (M&Ms). Still the second half is not a total loss as the author prognosticates about the future of cardiothoracic surgery in light of less invasive options. Although the discussions of the influence of RCTs (Randomized Clinical Trials) is interesting, it goes too far off topic. If you are interesting in understanding what a surgical career might be like, read this book.

This is a fascinating book, whether one is a heart patient oneself or not. The hospital in discussion is Columbia-Presbyterian in New York. Morris "embedded" himself there, staying in the cardiac area, attending surgeries sitting in the back near the nurses, attended staff meetings, all that stuff. He opens with a little history of heart surgery and an typical patient. Incidentally, although this is written for a popular audience, he does assume some slight knowledge on the part of the reader - for example, he doesn't stop to define "comorbidity" as in "Like many heart patients, Goldfarb suffers from a variety of comorbidities..." He describes how doctors and nurses "suit up" and create a "sterile field" around the patients, and then pretty much cut-for-cut describes Mr. Goldfarb's heart valve replacement.

He describes the different specializations within cardio-thoracic surgery: it's not just "heart surgeons" in general. There's the bypass specialists, the anesthesiologists, the pacemaker-and-defibrillator surgeons (he doesn't mention it, but in my experience they are usually called electrophysiologists, or EPs), the pediatric specialists.

Of particular interest: the difference between those surgeries in which the patient is put on a heart pump, and "off-pump" surgeries. The various range of outcomes of transplants. He describes a failed pediatric transplant - the patient dies. No avoiding the tough issues. The whole way the transplant process works - he goes along with a "harvest" team to get the heart from a donor, and talks about teams from other hospitals there to harvest other organs from the same donor, and what it's like to have several different teams working on one body.

Of interest to heart failure patients (of which, I am one) would be the discussion of the LVAD, and also the chapter on the development of "cath labs" used by cardiologists, which is something different from cardiac surgeons (if you've had an angiogram, you've been in a "cath lab.")

And there's a big section on "The Problem With Drug Companies" and another on how to determine "best practices" as well as some controversial issues about evaluating different studies on various practices and on rating the hospitals. If you are interested in how statistics are used, and how meta-studies that evaluate the combined results of numerous previous studies can be "gamed" to produce varying results, you'll find this section as interesting as I did. Research studies play a huge part in how the patients get treated, and it's quite useful to know that there are studies, and then there are *studies*.

It's a fascinating book - this barely begins to describe it. He's a good writer, and the book moves right along; we get to know the doctors and nurses as people. He has editorial comment as well as just description of what's going on, and it's useful input for anyone who is following the US's continuing struggle over how we provide health care and to whom.

Interestingly, I also happened, quite accidentally, to recently re-read Lewis Thomas' "The Youngest Science: Notes of a Medicine-Watcher" - which was written about 25 years ago - and it was interesting to compare his descriptions of medical practices and hospital routines from the 1930's and 1950's to Morris's of half a century later. You might find the same pairing of readings equally interesting.

I happen to be interested in surgery but I think Charles Morris could write a book about basket weaving and it would be interesting.

This book provides a multifacted and engrossing window into the world of cardiac surgery, focusing on Columbia-Presbyterian as a (perhaps atypical) case study. Overall, I think Morris did a very good job, and I consequently learned a lot from this book. Here are some of the main lessons I extracted:

1. Cardiac surgery is much more challenging than general surgery, partly because the work needs to be very meticulous, and partly because some mistakes can often quickly be lethal (the rate of mortality or serious complications is roughly 5%). As a result, surgeons who have completed their general surgery residency and enter a cardiac surgery residency still have a lot to learn, and typically have a tough time in the earlier months.

2. Cardiac surgeons need to have extensive technical knowledge, manual dexterity involving both precision and strength, intense concentration, a cool head under pressure, intuition, creativity, and enormous physical stamina.

3. The atmosphere in the cardiac OR is usually quiet, serious, and focused.

4. Even among experienced attending cardiac surgeons, there's considerable variation in their skill level, with corresponding variation in their ability to handle challenging cases and their success rates. It's therefore important to do your research and find the best cardiac surgeon you can. Related to this, cardiac surgeons tend to sub-specialize in particular areas, so try to find a surgeon whose specialties match your particular problem(s).

5. The details of surgical repair need to be individualized to each patient, and surgeons need to have the knowledge and judgment to make such decisions during the course of surgery, when they have access to see things directly.

6. Operating on patients is more challenging when they have comorbidities and when they've had prior cardiac surgeries.

7. Speed is always preferable for a cardiac surgeon, provided that it doesn't come at the expense of higher error rate. The shorter the time a patient is anesthetized, on the heart-lung bypass machine, has the heart stopped, etc., the better for the patient.

8. Success rates for cardiac surgery also depend on the whole team (anesthesiologists, perfusionists, nurses, etc.), not just the surgeon. Morris gives an example where a nurse messed up the dosing for a post-op medication, and the patient thereafter went downhill and eventually died (this doesn't prove causality, but one can't rule it out either, and the case is suggestive).

9. Cardiac surgery centers with larger patient volumes usually have greater expertise and better success rates.

10. Academic teaching hospitals are where cardiac surgery residents are trained. Attending surgeons usually do a good job of deciding how much responsibility and hands-on "practice" to give to residents, thus avoiding excessive risk to patients. But still keep this factor in mind when deciding whether to go to a teaching hospital.

11. Use of the heart-lung bypass machine is associated with cardiovascular and neurocognitive complications, and is thus not an entirely benign procedure. For this reason, "off-pump" surgery without the bypass machine is sometimes preferred.

12. The latest developments in cardiac surgery and interventional cardiology can improve patient outcomes, but unanticipated problems can also become evident after longer observation periods and larger numbers of cases. Therefore, consider staying away from cutting-edge approaches unless more established approaches are clearly ruled out.

13. Minimally invasive procedures have benefits such as better cosmetics and reduced recovery time, but they also tend to make the surgeon's job more difficult and can sometimes lead to poorer outcomes than full open-chest surgery.

14. Cardiac surgeons tend to be competitive and some are even arrogant, but the best ones usually seem to maintain humility. They're also very well paid, with most of them earning several hundred thousand dollars per year, and the elite ones earning well over $1 million per year (arguably too much?).

15. Big pharma, medical device companies, and other financial interests have substantial adverse influences on cardiac surgery, as is unfortunately the case with the rest of medicine. We need major reform, and we need it now!

Surprisingly, a key area where I found the book a bit lacking was in the detailed descriptions of cardiac surgery procedures themselves. I would have preferred more specific step-by-step information, but I may not be a typical reader in that regard.

I also found Morris' ideas on health care policy in the last chapter to be often misinformed and misguided, and even naive in some respects. For example, he's sadly mistaken in his belief that great progress has been made in cancer treatment, and thus doesn't appear to have done his homework here. More generally, this chapter is tangential to the subject of the book and the book would have been better without it.

The above issues lower my rating to 4 stars, but I still certainly recommend the book to anyone wanting to learn about the world of cardiac surgery. If anyone knows of other good books specifically on cardiac surgery, please post a comment accordingly.

"The Surgeons" is an interesting read for the ER-Grey's Anatomy drama crowd, but its real value is in the clearheaded analysis of the business model of surgery, drugs, and product placement. A star off for Morris' incomplete but interesting examination of reforming health care economics leaves this at 4 stars.

As one of the few financial writers with a finance background, reformed investment banker-turned-writer Charles R. Morris tends to "get it" in fundamentally understanding both classic liberal economic history and theory - think writing like the Economist, but more in-depth and with a better grasp of both the bigger picture, microeconomics, and especially history. Having previously defended growth in the health care system as fundamentally acceptable, Morris put his money where his mouth was and spent a year shadowing surgeons in cardiac care, not coincidentally one of the highest growth sectors within the industry.

Morris spends the first half of the book largely explaining what the superstars of the "business" actually do, and the cases are gripping enough to satisfy those who want medical drama. These are extraordinarily well-compensated but extraordinarily talented artists whose skills are essentially irreplaceable. More valuable but less entertaining is his business analysis.

The run-of-the-mill heart surgeon is in the process of having his bread and butter procedure be replaced by stents (delivered by interventional cardiologists), and the industry is starting to really focus on the highest margin product rather than the best return on investment. More widely, while out-of-control spending for new procedures and new drugs careen is a major problem, the defacto solution of the insurance companies deciding which ones get adopted isn't good for any of the stakeholders, including the insurers themselves. Finally, while Morris goes after big pharma and device companies for their role in this, he balances it out with a fascinating behind the scenes look at a drug that got a lot of negative press - but that doctors still wanted to use.

A star off, however, as Morris' chapter on what could be done on health care economics on a macro level is quite disappointing given his solid look at the drivers of them; he provides some bullet point solutions but doesn't explain why they'd work. Still, very much worth a read. 4 stars.