Meet , director of the heart failure program at Long Island Jewish Medical Center and a contributing opinion writer for the New York Times. Jauhar's latest book, recounts several prominent moments in cardiovascular medicine's history, while giving readers a look into his personal experiences.
In this exclusive interview, he told 鶹ý that he wants people to understand "that our emotional lives are deeply important and relevant to our biological hearts, that the metaphorical heart and the biological heart intersect." Jauhar also participated in a Facebook Live interview with 鶹ý, which can be or by scrolling to the bottom of this story.
What was the inspiration for your book?
I've always been fascinated by the human heart, and I happen to have a malignant family history of heart disease. My paternal grandfather died suddenly in his early 50s very likely of an arrhythmia that was triggered by a heart attack and that trauma really affected my father deeply throughout his life. And by extension that affected all of us, his children, our family. One of the reasons that it affected him so deeply is that it was so unexpected, and it was a sudden sort of catastrophic event and the heart is fairly unique among organs for its ability to cause a sudden catastrophic death. No other organ can do that. So, when I was growing up, I sort of had this fear of the heart as an executioner, and so I would monitor my own heartbeat and I would worry about my father's heart.
And I knew that we had this family history, and then later my maternal grandfather died suddenly of a sudden arrhythmia that was triggered by a heart attack. But his death occurred when he was 83, and it was a very different outcome. My mother, though she was sad that he died suddenly, she was actually somewhat relieved that he passed away when he was functioning at full force, reading the newspaper, enjoying life. And so that forced me to reconsider what it means to have a sudden death via the heart. The book explores that idea, too.
Can you discuss how you managed writing this book and practicing, and why it's important for doctors to carve out time for endeavors that are meaningful to them?
Writing has always been a way for me to process what I experienced in my professional life and to think about it and to try to understand it; sometimes to reconcile myself to it. So, all those factors come into play to drive me to write. I started writing towards the end of medical school, and I really started becoming productive during my internship at New York Hospital. I was in Manhattan and a lot of what I was doing was thinking about what bothered me in my experience.
For example, I had a patient as an intern who had swallowing difficulties, and so, the plan was to put in a feeding tube, but he didn't want a feeding tube. In fact, he said that one of the great pleasures of his life was tasting food. He even liked hospital food! But the team had decided that he didn't really have the capacity to make the decision not to have a feeding tube. The alternative was trying to eat via his mouth and swallowing and risking developing an aspiration pneumonia, and so that case really bothered me. Why are we doing this, when it's going to interfere with and actually turn his life upside down and compromise what he considers to be a good quality of life? It was that sort of thing that I would think about a lot and then would write about, and so to answer your question, I write about what I experience in my professional life.
I think it's important for doctors, indeed all professionals, to find something that they're passionate about outside of work. Especially medicine today when there's so much burnout. I know of doctors who spend as much or more time in their avocational pursuits than I do in mine. Constructing very intricate models, for example. I have a doctor acquaintance who used to be an architect and is really interested in applying architectural ideas to hospital design. I know physicians who are very interested in writing or in media. There are so many things, and many colleagues who are just as passionate about spending time with their families and with their children, as am I. It's just really important, I think, to find something that allows you to get away from the pressure and the grind that is modern medical practice.
In your research for this book, can you talk about something that surprised you or that might surprise another cardiologist who picks up the book?
I think that one of the ideas that I try to develop in the book is that the heart was always considered the seat of the soul and the source of the emotions. That was a fairly common idea in the ancient world. And then beginning in the late renaissance and going into the modern age, the heart was transformed into a machine that could be manipulated. One of the reasons it took so long, the heart had an almost supernatural quality that creates all these taboos around trying to manipulate or fix it. And now we know that it's fair to say that the heart is a biomechanical pump, but we have to pay attention to our emotional lives in dealing with the health of this pump. We know that fear and distress can cause all sorts of damage to the heart.
We know that, for example, in the broken heart syndrome, grief over anything -- typically a broken romantic relationship -- can cause the heart to acutely weaken and, in some cases, cause death. The emotions that the heart was supposed to contain, in fact deeply influence the machine that it has become, I think this is an important idea that I tried to develop in the book.
So, can you talk about an important moment from your clinical practice that made it into the book?
Well, there are many. The first time I was called to do an echocardiogram on a patient who had developed what's called cardiac tamponade, which is an acute heart failure related to this fluid that builds up in the sac around the heart. That was a seminal moment for me because for most of my life, I thought about the heart and worried about it and worried about what to do, how to grapple with it, deal with it, deal with an emergency related to it. And then here I was as a first-year fellow, I think actually my first call night, getting called to do a stat echo on a patient, and I went in and in fact she had developed cardiac tamponade.
We had to put a needle into her chest and drain the fluid. And all of a sudden we saved her from nearly certain death, but that was a really important moment for me to show me that I could do this, I could handle it. A lot of what I was grappling with when I was in my training as a cardiologist wasn't just learning about the heart but trying to discover what was in my heart. Do I have the courage to do this, to deal with these emergencies and life or death situations? My training was kind of on a parallel track or dual track, learning about the heart, but also learning what was in my metaphorical heart, if you will. So that was one situation; there are many others.
I noticed throughout your work, you tend to incorporate experiences from your life or your clinical practice, and then combine that with topics that are relevant to physicians in general. But I'm wondering, how does this book differ from your previous work? What sets it apart?
Well, I think there's less of the personal and there's more objective history. I tried to intertwine the two, and I very often will use a personal experience as a springboard for talking about the history. But I think that there's more of that sort of objective history as opposed to personal history, although they're both there, it's the history of the human heart, but it's also a personal story. I think unlike "," which was essentially a pure memoir, and "," which was probably a mixed memoir/manifesto, this is more history with memoir intertwined to try to get the reader engaged and make more vivid the issues that doctors and scientists were grappling with.
Your book talks about Daniel Hale Williams, the African American doctor who performed the world's first open-heart surgery. Can you describe this pioneer and society's reaction at the time?
Daniel Hale Williams performed the world's first documented heart surgery, and he's a fascinating story. He was an African American physician who grew up in Baltimore. His father died when he was very young, and he was sent off to live with family. He gradually started doing odd jobs. He was a shoemaker's apprentice, and he worked on a river boat for a while playing guitar, and then he came to become the apprentice for a surgeon. That's how surgeons received their training back in the late 19th century. And then, he eventually ended up going to medical school at what would eventually become Northwestern School of Medicine in Chicago. He practiced in what was Gilded Age Chicago and was successful.
He was the first surgeon to work for the city's railway system, but he really made his mark in the summer of 1893, when a man was brought into the hospital with a stab wound after a saloon scuffle. Williams noticed that the patient was going into cardiac tamponade, blood was filling up in the sac around his heart. So he opened his chest, he cut open the ribs. He opened up the chest to look at the heart, and he saw that blood was spurting from the right ventricle, filling up the chest, and he realized that the only thing to do at the moment was to stitch up the pericardium. The hole in the ventricle closed up, and he didn't have to put a stitch into the muscle. So, he stitched up the pericardium, and the patient survived. This was an incredible achievement. An African American physician in the era of Jim Crow had done what philosophers and scientists and physicians had warned against for millennia: that you can't stitch the heart.
The patient he saved actually outlived Williams. Williams eventually died of a stroke. It's just a fascinating story. The book is really full of these very fascinating, larger-than-life figures who took it upon themselves to do groundbreaking things, to smash taboos that had existed for centuries.
You describe the pacemaker as being discovered almost by accident. Can you tell us that story?
Wilson Greatbatch was an engineer, and he was working up in Ithaca, at a research farm affiliated with Cornell. He was working with the sheep and goats when he came across two surgeons who described the problem of heart block, a disorder where the electrical signal from the upper chambers of the heart don't make it down to the lower chambers because of disease in the wiring system of the heart. Heart block was fatal. Greatbatch had in his mind that there's this big problem in medicine, but he let it go.
Later, when the transistor came out, he hooked up a transistor to other circuit elements in his engineering lab. He created a circuit that essentially produced an electrical pulse, with a period of one second. It would pulse once a second, 60 times a minute. He looked at it and remembered the conversation that he'd had with the surgeons years earlier, and he realized that this transistor circuit essentially mimicked the human heartbeat. So he went to a surgeon and described the circuit and the surgeon said if you can do that, you could save hundreds of thousands of lives. He went back home and essentially took all the money he had out of the bank, and he worked in a barn behind his house and basically fashioned the first pacemaker. And then he did some animal studies with this surgeon in Buffalo, and eventually used some of these first pacemakers on human patients. One of his first patients actually lived until her late 80s.
This was a massive, massive development, both clinically, because so many people had died or were dying of heart block, but also just in terms of smashing taboos -- that a man-made electrical circuit could control the human heartbeat was really a seminal moment in science. And Greatbatch always said that the circuit that he used, that was eventually used in most pacemakers, was developed only because he happened to pick up the wrong resistor. It was just a fortuitous development and, it was entirely by mistake, but Greatbatch had the intuition and the background to realize that what had happened actually had tremendous promise and clinical applicability.
At what moment from your book do you feel was a turning point in treating conditions of the heart? Can you talk about that, maybe a moment that you feel really stood out and shaped cardiology?
One of the main characters in the book is a surgeon named Walt Lillehei, who was a fascinating character. He actually developed a head and neck cancer when he was a resident, and eventually underwent this nearly disfiguring surgery to remove cancer in the lymph nodes from his body. And there was a chance, a strong chance, that he was going to die. And so Lillehei had a kind of foolhardiness about his approach to surgical problems. He had had his own brush with death, and it just gave him that sort of dispassionate view of how to approach other fatal problems, such as heart disease.
One of the big problems in the post-World War II age was dealing with defects inside the heart. Daniel Hale Williams stitched up the pericardium, but that's the membrane surrounding the heart. Fixing problems like holes, for example, between chambers inside the walls of the heart, was impossible because the heart supplies blood to all the major organs. You can't stop it. If you stop it, you develop brain damage within a few minutes. The heart is also filled with blood, so if you cut it open, you'll bleed to death. The heart is also constantly beating, so how do you stitch something that is constantly moving? The only solution was to stop the heart, drain the blood, and then go in and fix the hole, but the problem was that the other organs, like the brain, would develop damage within about 5 minutes. And so how do you do that? How do you do the surgery?
Lillehei had the incredible, almost stupendous idea that the way to do it was to hook up a parent to his or her child and have the parent serve as a human heart-lung machine. The parent's heart would take over the child's circulation, while the child's heart was stopped, cut open, and fixed. Of course, this was hugely controversial because it risked the parent's life as well. People were aghast, saying that this was the first surgery in human history that had the possibility of killing two people!
But Lillehei had tremendous belief in himself and eventually succeeded in using this technique -- which is called cross circulation -- to open up the heart and fix it. While he was doing this, the heart-lung machine (the artificial machine), was being developed by John Gibbon. When that eventually was developed and the technical problems were mitigated, surgeons started to use it after 1954. Lillehei eventually started using it too. But before a heart-lung machine came out, Lillehei was the only surgeon in the world for about 1 year who was doing open-heart surgery. People came from all over to visit his operating room. He had huge audiences, and is generally considered the most innovative surgeon of the 20th century. So I would say that his decision to use cross circulation to actually open up the heart, which preceded the heart-lung machine, was one of the seminal moments in the development of medicine.
Very interesting, so what advancement seems the most promising for the future of cardiology? What sort of thing are you most excited to see going forward?
There are so many. I think it's amazing that we can now replace human heart valves without open-heart surgery. We can do it via catheterization procedures, so we don't have to cut open the heart. I think that this kind of minimally invasive technology will develop even more. Heart surgery still involves a long rehabilitative process, and there are risks to cutting open the chest. If we can do things minimally invasively, that would be amazing. I still am holding out hope for the ability of stem cells to regenerate heart tissue that's been damaged or regenerate tissue inside hearts that had been damaged.
But, as I pointed out in the book, we have come to an inflection point in heart medicine. Mortality from heart disease has dropped. But in recent years there has been a slowing down of the rate of decrease. In fact, autopsy studies have shown that 80% of Americans between the ages of 16 and 64 have the beginnings of coronary artery disease. So I think that even though amazing progress has been made in cardiac technology, we're going to have to come up with a new paradigm to continue to progress the field. And I think that paradigm is going to involve paying more attention to our emotional lives. The so-called metaphorical heart, where emotions were supposed to reside, is deeply relevant to the biological heart.
I think that if we're going to continue to make the kind of progress that we have gotten used to in medicine, we're going to have to start paying more attention to psychosocial factors. We know that depression, fear, and grief can cause heart problems, both acutely as well as chronically. And I talk about that a lot in the book. There've been many studies, like the Whitehall studies in the U.K., that showed that civil servants who feel they have some control over their work lives live longer and have less heart disease than those who feel they have less autonomy or ability to make decisions for themselves. And this is true in so many areas of human life. Feeling like you're in control, feeling loved, feeling secure, these are incredibly important for maintaining heart health.
We see tremendous rates of hypertension and heart disease in poor communities, urban communities in this country, and very often people will point to genetic factors. But, for example, in African American communities, where the rate of hypertension and heart disease are very high, genetics doesn't explain the high rates of hypertension, because the West African predecessors of African Americans didn't have hypertension. Something else is going on, and I and others have argued that psychosocial stress, and factors like racism, income inequality, having less control of your life, and feeling a constant, low-level stress is very damaging to the heart. So I think that one thing I've learned is that one's ability to transcend that distress, and society's obligation to help mitigate it, these things are going to be very important for our heart health in the future.
What are you hoping readers will take away from your book?
I think one of the central messages is that our emotional lives are deeply important and relevant to our biological hearts, that the metaphorical heart and the biological heart intersect. I think that's a key message that I want people to take away. That if you want to live long and live better with your heart, obviously exercise, eat right, don't smoke, but also pay attention to your loved ones, develop good, stable, loving relationships, for these things are very often ignored. They're incredibly important for our heart health.
Do you have any advice for clinicians who are interested in pursuing writing?
Keep a journal, because we experience so many interesting things in our daily practices, and sometimes you won't know what's interesting or could be the basis for an article or story or even a book. But when you reflect on it, you may make connections with other experiences, so I think keeping a journal is very important. In fact, that was the advice I got when I started writing for the New York Times. The Science Editor at the time, Cornelia Dean, said to keep a journal during your residency and see what you might want to write about. And I did that, and I still keep a journal of sorts even now, over 25 years later. A lot of the experiences and stories that I wrote down during my internship made their way into my first book, "."
Are there any last thoughts that you'd like to share with our readers?
I really feel proud of this book. I think it will help readers understand their own hearts and how to live better and, in some cases, longer. Heart disease is the number one killer in the world -- 18 million people die of heart disease every year. It is also the number one killer in the United States and has been since the early 20th century. It still eclipses cancer. There are things that we can do to live longer and better, and I hope I explained some of those things in my book.
Jauhar's Facebook Live interview with 鶹ý can be viewed below: