For better and for worse

Famed heart surgeon René Prêtre sees the modernisation of medicine as a combination of pros and cons. Technological progress is huge, but limited by available funding. Medical teams give better care, but can be impersonal. Automation is booming, but there is still need for artisanship.

Text: Eric Johnson | Images: Marc Wetli | Magazine: Life & Science – July 2017

Should hospitals and clinics be run as businesses?

No, because we exist to provide a service, not to make a profit. Public hospitals – at least in a country such as Switzerland – are meant to help everyone. At the moment, our society can provide those resources, but I can imagine a day when those resources will be overstretched, simply because the availability of medicine continues to expand rapidly, while at some point, the ability to pay becomes exhausted. Society is not there yet, but at some point it might not allow everyone to have every medical treatment. I have no problem with this limitation, because we already have excellent health care, but the rules of who receives what, which patients have which sorts of treatment, need to be clearly, fairly defined. They should be the same rules for everyone, defined in advance.

“At some point, society will not allow everyone to have every medical treatment.”

So finance is medicine’s greatest challenge?

It certainly is a big challenge. A good example is that of artificial hearts, which are getting better and better all the time. Up until two years ago, artificial hearts were used only as a bridge to transplantation, to keep patients going until a human donor heart becomes available for transplant. Only patients who were eligible for a transplantation, yet who might die before one became available, were given the device. Now, as these mechanical hearts have improved – some patients have lived with them for three or four years on the waiting list – we have opened up their availability to some people, that aren’t eligible for a transplantation. But these machines are very expensive, as are their installation and maintenance. Only in Switzerland we have 1,000 to 1,500 new heart failure patients every year, who will die from their heart condition. Technically, we could give each of them an artificial heart, but where would the money come from? This is just to say that potentially medicine can do so many things, but practically it has financial limits.

How do you choose the patients who receive an artificial heart?

At my hospital, we have decided about a global budget – indirectly about how many devices can be installed – and we have also decided on the selecting criteria. Obviously, transplant patients still have first priority. Age is another important criteria.

After growing up on a farm in what is now Switzerland’s Canton Jura, René Prêtre studied medicine in Geneva, then practiced surgery in the USA, England and France, before serving as Chief of Paediatric Heart Surgery at the University Childrens Hospital of Zurich until 2012. He then moved to Lausanne, where he was named Professor of Surgery at the University and Director of the Cardiac Surgery Service at the University Hospital. In 2006 he founded “Le Petit Coeur”, a charity that regularly sends Prêtre and his team to Mozambique and Cambodia to give heart surgery to underprivileged children and to train local doctors and nurses. Last year, Prêtre published the bestseller “Et au centre bat le coeur” that tells of the technical, financial, emotional and managerial challenges of pediatric cardiac surgery in the developing and developed world. The German-language version was released in April 2017.

Contrast that selection process here in Switzerland with that in the developing world.

In developing countries, the patient selection is a process we encounter every day. Triage is a normal part of our missions. In Mozambique and Cambodia, we have 2,000 to 3,000 children in the waiting room, so to speak, and we can operate on only 30 of them in a two-week visit. So our selection criteria are extremely strict. We take relatively easy cases that won’t take inordinate hours in surgery, and which will be cured with one operation, i.e. they won’t need lifelong special care that, anyway, might not be accessible.

Have you expanded selection over time?

Yes, we have extended it. The local doctors and nurses we’ve trained now operate the easy cases, and I can take children with more difficult heart conditions that earlier I’d have turned down. We started 12 years ago in Mozambique with cases of severity 1 to 2 (out of 5) only; now we are taking those with a severity of 3 and 4. Severity 5 is still too overstretched, because these cases take excessive time and resources, and often call for an enhanced nursing capacity that we don’t have. Intensive care nurses are absolutely critical here: you need somebody to react appropriately in the night when a monitor starts beeping, and with a room full of post-cardiac-op children, there will be a lot of beeping.

“Doctors now are scientists and engineers, not so much the ‘trusted-person’ in their patients’ lives.”

Other than money, what does cardiac medicine in the developing world most need?

Social stability. And education. In this respect, as we locally train people, we have indirectly created a small enterprise. A job has been offered to them, and not just for doctors and nurses, but for support staff from administrators to cooks, to gardeners as well. With steady work and income, they can have stable lives and send their children to school, maybe even university.

Coming back to Switzerland, do patients trust their doctors less than they used to?

Probably, and mostly because practises have changed over time. Years ago, most people saw one general practitioner, whom they knew locally, as both a person and a doctor. Now people go to a hospital, and are seen by ten health professionals – at the end, they hardly know any of them! And we doctors have become principally scientists, who speak in numbers and complicated vo­cabu­lary. Once I heard a father complaining that when his son had a serious fever, the doctor no longer would come to their home at night, but recommended the child be sent to hospital. I realise the house call would have been more personal, but in a hospital you can detect a life-threatening condition more rapidly and start sooner with an efficient treatment. You have access to resources not available at home. In the precise event, sending the child to hospital was in fact the best choice! It’s true, our care has become more impersonal, but at the same time – and many people do not see this – it has improved. Those ten hospital professionals handle many more patients and gain much better results than their predecessors did.

“Automation is increasing in medicine, but in cardiac surgery, we still create things with our hands.”

What changes in medicine have most surprised you?

Some artificial hearts defy the traditional logic of medicine. If you do an electro-cardiogram, you get no signal – just a flat line. With others, the blood pressure does not go up and down with contractions, it remains flat. There is no pulse to take. If you put a stethoscope on the patient’s chest, you won’t hear a heart beating anymore. But in all these cases, the patient lives! The other thing is that technology has opened up a wide range of possible treatments. It used to be that there were one or two possibilities to handle a problem; now there might be a dozen ways.

Technology is just a fact of life, in medicine as in other areas.

There is no way around it, and automation is increasing as well. Particularly in cardiac treatment and surgery, where there is a lucrative industry of supplying devices, like stents and valves to name a few, and all the other materials used for treatment. That said, in my work of cardiac surgery, there is still a strong demand for artisanship – we still create things with our hands. When it comes to repairing, say, a damaged valve, surgeons who are less gifted will just replace it – an easy task – while those with a more artistic trait will reconstruct it. In the short term, there is no difference in results, but longer term the prosthesis will degenerate and will need reoperations. So, surgical artistry and creative thinking still deliver better results. Surgeons have yet, if ever, to reach the standard of “plug-and-play”.

Maputo (Mozambique), May 2015: the last day of the mission with René Prêtre and a happy team. Every operation had been successful.