COMMENTARY

How a Snakebite and Sudden Death Led to Cardiology and Writing

An Interview With Sandeep Jauhar

Interviewer: Robert A. Harrington, MD; Interviewee: Sandeep Jauhar, MD, PhD

Disclosures

August 12, 2019

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, speaking here on theheart.org | Medscape Cardiology.

Over the past several years, I've had the opportunity to talk with researchers in the field of cardiovascular medicine and science, authors who happen to be cardiologists, and the corollary—cardiologists who happen to be authors. I've had a great deal of fun talking to these colleagues to really explore why it is that they have chosen to write. Sometimes it's fiction, sometimes it's nonfiction. How do they feel that that contributes to the discourse in the medical literature? How do they feel that reaching largely a lay audience contributes to cardiovascular science and knowledge?

Sandeep Jauhar, MD, PhD

I'm really pleased to be joined by Dr Sandeep Jauhar, who is the author of Intern: A Doctor's Initiation and Doctored: The Disillusionment of an American Physician , two books that I enjoyed and had an opportunity to discuss with him previously. We're here today to talk about his latest book, called Heart: A History .

Sandeep, thanks for joining us here on Medscape Cardiology.

Sandeep Jauhar, MD, PhD: Thanks, Bob. It's a pleasure to be with you again.

Becoming a Physician-Writer

Harrington: I had the opportunity over the past week or so to read the book, and I'll say unabashedly that I enjoyed it greatly. I learned a fair bit about the history of how one thinks about the heart. And I really enjoyed the way that you wove history, physiology, science, and your own personal history. It was so well done and it makes for a very compelling read.

Jauhar: Thank you so much.

Harrington: Let's start very broad and then go into some specifics. Why do you write? In addition to writing books, you are also a contributing opinion writer for the New York Times, so a fair bit of your professional activity is devoted to writing. Why do you do it? You sound busy enough as a transplant cardiologist on Long Island.

Jauhar: I've always enjoyed writing, from when I was a schoolchild. I started writing in this latest phase of my career around the time I started my internship, and I wrote about things that puzzled me. Internship is a great time to start writing, because everything is new and in many ways puzzling. A lot of physical stresses and moral stresses come up. Should we really be doing this to this particular patient? Why is the treatment plan this way?

I would think about these things, and it helped me to put down my thoughts on paper to try to figure out what I thought and believed. That impetus has continued into my professional years as a doctor.

Harrington: It's interesting to hear what you say because I also write, but in a very different venue. I write in the scientific literature, so when I am troubled by how we care for a particular type of disease or patient, I'm always trying to figure out how we could study this and what we might do. You have taken a different approach, as have some of your physician colleagues who are authors.

Why do you think you and I go down different paths? Is it just that our brains work differently, or that we're expressing ourselves differently?

Jauhar: It might be. The first question I usually ask myself is, "What do I think about this? How does this fit with my previous experience?" I tend to be very introspective when I'm posed with some sort of challenge or conflict in my professional life, whether it's a moral challenge or an ethical conundrum or something that just bothers me. They are equally valid approaches, and I highly admire the physician-scientists, like you, who can increase the breadth of our knowledge about things.

I think they are complementary roles, and both have equal importance.

Harrington: When I'm writing, Sandeep, I'm thinking mostly about my clinical and scientific colleagues. When you write, I sense that you are thinking much broader than me. You are thinking about the general public, about patients, and about the medical community. Is that a fair thing for me to say?

Jauhar: I've written perspectives in the New England Journal of Medicine that are directed primarily toward my professional colleagues. I've written pieces in the New York Times that go out to a much broader audience. But in both types of writing—and I suspect somewhat in what you do as well—we're trying to get a point across. We're trying to persuade, and we're trying to teach. Trying to get my ideas across and teach new concepts to the public is what gives me a sense of purpose in this sphere of my life.

Health Literacy

Jauhar: It's really important to improve health literacy in this country. There is ample evidence that if patients were more educated about their treatment plans, then we would have probably less unnecessary testing and everyone would be better off. I think this kind of approach has a very broad purpose and can improve things for both patients and their caregivers.

Harrington: One of the things I took away from your latest book, Heart: A History, is that you are trying to increase heart health literacy in a way that is appealing to the public as well as those with a scientific background. You simplify cardiac physiology and biology, but I would not say that you dumb it down. You present some pretty complicated concepts but talk about them in a way that is very approachable. Whether we're talking about the renaissance period of dissection or trying to solve the problem of the heart-lung machine in the mid-part of the 1900s, I thought was a brilliant way to convey these concepts. Bringing out your own family history and adding the narrative to that was very powerful.

Talk about the book. Your previous two books were very different from this one.

Two Fathers, Two Broken Hearts

Jauhar: The primary impetus for the book was my malignant family history. I grew up in a home where my father was still mourning the death of his own father of a sudden heart attack decades after he had died. My grandfather died suddenly while he was having lunch with my father, who was not yet 14 years old.

My grandfather worked in a shop, and one morning he was moving some sacks of grain and was bitten by something. He wasn't sure exactly what it was. They thought it was a snake, but snakebite was very common in those parts of India back then, so he didn't really pay it much mind. While he was having lunch at home, his neighbors, being the good neighbors that they were, brought in a dead cobra and claimed it was the snake that had bitten my grandfather. He took one look at it and went pale and said, "How can I survive this?" Within minutes he had slumped to the floor and went unconscious.

The family summoned an ambulance, and they took my grandfather and the snake to the hospital a couple hours after he had died. My family thought he had died of snakebite, but the doctor said, "No, this was a heart attack. A snakebite would not have killed him so suddenly."

My father, like many who have witnessed the sudden death of a loved one, never got over it. Throughout my childhood, there were moments where the emotion just came out of him, and so I, by extension, also sort of became a little obsessed with the heart. The heart as the executioner of men in the prime of their lives. There was a fear factor. With most diseases there is a prelude, but with the heart, you can die suddenly. You can die even if you are healthy.

My father, like many who have witnessed the sudden death of a loved one, never got over it.

As a child, it seemed like the biggest cheat in the world that my father, who was walking around healthy, doing his job, and loving his children, could just die. And that is really what drove my obsession with the heart. I wrote about this in the book. I used to lie in bed and stare up at the ceiling fan and time my heartbeat with the revolution of the fan's blades.

I was just fascinated by this organ. It is so powerful that it can beat 3 billion times in a typical human lifetime and empty a swimming pool in a week, yet it can stop suddenly. It is so strong yet so vulnerable, and by extension it renders us vulnerable, because everything depends on the circulation of the blood from the heart. That was primarily what drove me and inspired me to go into cardiology.

Self-experimentation

Jauhar: A driver of this book that I really only came to appreciate as I started to research the book is that the history of heart discovery is absolutely fascinating.

There are so many wonderful, amazing stories of self-experimentation. Most people don't realize that the heart had never been operated on until the late 19th century. Every other organ had been operated on, and the reason is pretty clear. The heart is always moving and it's filled with blood—it's very hard to cut into something that is moving and if cut open, you will bleed to death. It was an almost insurmountable technical challenge, and I talk in the book about how that challenge was circumvented. It's just a fascinating story.

Harrington: Many of the stories I had at least a passing familiarity with, and as we got into the more recent stories of, for example, the history of cardiac catherization, I did know many of those stories. But there are people along the way who became obsessed with trying to understand the way the heart worked or the way it might be manipulated. Some people fell into it. One was the African American surgeon who was faced with a patient who had a knife wound to the chest and was bold enough to open the patient up and do an operation. Extraordinary stuff.

Jauhar: No one had operated on the heart, in part because of what I mentioned. The heart is always moving and it's filled with blood, making it exceedingly difficult to manipulate surgically. But also there were cultural prohibitions to manipulating the heart. Throughout history, the heart was considered the locus of our emotions, our souls, and I think those cultural prohibitions did as much to retard progress as the scientific obstacles.

The story of Daniel Hale Williams is a very inspiring story. He was an African American surgeon who grew up in poverty and had apprenticed with a barber and worked as a shoe repairman. Eventually, he became educated in medicine and in 1893 was faced with an extraordinary challenge. A man had been stabbed in a bar scuffle and was bleeding. Daniel Hale Williams opened up the chest, saw that the pericardium was ripped open, and he stitched it closed. That is still considered the first pericardial surgery. As with most things, it's hard to know exactly how the history goes, but there is some evidence that a St Louis surgeon had done something similar a couple of years earlier, but he hadn't published his work and Williams almost certainly didn't know about it.

In any case, it's really fascinating stuff, and the fact that an African American doctor educated during Reconstruction and living in the Jim Crow era was the first to do it is really amazing.

Harrington: He is one of the extraordinary characters who had become fascinated by the heart, its function, and trying to think about ways to manipulate it for the benefit of human health. I think about the stories you told about the development of the heart-lung machine and the group of extraordinary characters who embarked upon that. And then Charlie Dotter, Mason Sones, and Andreas Grüntzig, who were involved with the development of coronary angiography and then ultimately coronary angioplasty. This was, excuse the pun, not for the faint of heart.

Jauhar: Not at all. The heart-lung machine was first conceived by John Gibbon in the late 1920s, but it wasn't built, as you probably know, until the early 1950s. A lot of things were going on; the Depression, World War II, and cultural prohibitions slowed things down.

In the absence of a heart-lung machine, Walt Lillehei, one of the most innovative American surgeons, said, "When a pregnant mother is carrying a fetus, she's exchanging blood with her fetus. She's providing oxygen and clearing out waste. Why can't I hook up a child to a parent with the same blood type, artery to artery, vein to vein, and have the parent serve as a human heart-lung machine?" He did these surgeries. He was really the only person in the world doing open-heart surgery in the early 1950s before the heart-lung machine came into widespread use.

It's almost mind-boggling. People at the time responded very fiercely to Lillehei's suggestion. He ultimately did the experiments, but they said that this is the first surgery in human history that could kill two people. Like with Werner Forssmann and some of the other pioneers, he stood his ground, and he had to have just incredible fortitude to plow ahead.

Harrington: That raises the issues of how we innovate as a field, how we develop new technology. It takes a boldness. It takes a creativity, and sometimes you forget. One of the great triumphs of modern cardiovascular medicine is the repair of congenital heart defects. You forget how life-altering being able to operate on the heart for these congenital defects was, and now we have a whole specialty of adult congenital heart disease that was not a specialty we needed 20 years ago.

Jauhar; Yes, that is right. Congenital heart disease was a major killer of children in the 1940s and 1950s, and what Lillehei and Gibbon and some of these pioneers were able to do saved innumerable lives. It's something to be admired and grateful for.

Heart History in the Making

Harrington: Where is cardiovascular medicine going? You marched us through the technology and through the drugs that changed people's lives, and you point out that many of our drugs have now been used for decades. We've had great success. Many of our technologies, surgeries, and procedures have evolved to the point where they are increasingly common and straightforward.

You end the book talking a lot about prevention. Is this what you see needs to be the major impetus of investigation going forward?

Jauhar: I think one of them. Cardiovascular medicine is one of the great success stories of medicine broadly in the 20th century. Roughly 1 out of 2 Americans was dying of cardiovascular disease in the 1940s after World War II.

There has been a tremendous decrease in mortality for a number of reasons. In part, it was because of public health advances: promoting smoking cessation, statins, ameliorating cardiovascular risk factors. In part, it was the technologies that I've mentioned: coronary angiography, bypass surgery. Whatever it is, the decline has been awe-inspiring. But that rate of decline has slowed in the past 10 or 15 years, so to maintain the kinds of progress that we've gotten used to, we're going to have to look at different things.

It's much easier to lower your blood pressure by taking a pill than it is to lower your emotional stress...

One of the arguments I make in the book is that how we cope with emotional distress is exceedingly important in how and whether we develop heart disease. This is an area that remains relatively unexplored. The American Heart Association (AHA) still does not list emotional stress as a key modifiable risk factor for heart disease. There is a long history behind that. Framingham investigators deliberately avoided looking at psychosocial factors because of various reasons that I explore in the book.

It's much easier to lower your blood pressure by taking a pill than it is to lower your emotional stress, and I think that also, in part, informs the decisions by our large organizations not to face this issue head on. I do think it needs to be addressed, because it is a relatively unexplored frontier.

Harrington: The AHA and our profession are moving more and more toward large-scale policy issues around things that are the social determinants of health and wellness, including cardiovascular health. Having access to sidewalks and being able to exercise, tobacco issues from a policy perspective, and poverty issues weigh heavily in cardiovascular disease. I was pleased to see that you bring that out near the end of the book.

Jauhar: Yes. When we think about stress in cardiovascular disease, one of the things that is very obvious is acute emotional stress resulting in takotsubo cardiomyopathy, for example. That is stress that is just exploding. But there is also chronic stress. Chronic occupational stress or marital stress can promote coronary disease and heart disease. Those are things that we also need to address.

Time for a Break

Harrington: What are you going to do next? I imagine that the emotional toll of writing a book of this magnitude is such that you may need to take a break, but can you can tell our listeners about what is next up for you?

Jauhar: I will definitely let you know once I figure it out. I'm taking an extended break. I very much enjoy writing and I very much appreciate the response to this book I've gotten from readers, and it inspires me to continue writing. We'll see what's up next, but I haven't quite figured that out.

Harrington: Many of us enjoy your writing, so we'll look forward to seeing what you are going to reflect upon next and share with us, whether it's in the New York Times in your role as a contributing opinion writer or as a book author. We look forward to it.

My guest has been Sandeep Jauhar, who is an associate professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. He is an advanced heart failure transplant cardiologist and, as we've been discussing, an accomplished author. Sandeep, thank you for joining us on Medscape Cardiology. I enjoyed your book and, even more so, I enjoyed talking with you about it.

Jauhar: Thank you, Bob. It's always a pleasure.

Heart A History is available in paperback September 2019

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