Ask the Expert: Questions for J. Willis Hurst, MD

You have had a wonderful career, with many highlights. Where is it that you feel you have been able to be most influential? Well, I hope I’ve been able to help a few patients along the way, because that is a doctor’s first love. I have also been committed to teaching medical students, house officers and cardiology fellows. I have been fortunate to have been associated with a very large number of such trainees. I adore working with them and hope that I have positively influenced them. Many of them now work in academic medicine or have other prominent positions, but I am equally proud of those who have gone into practice and are doing an excellent job all accross this country and in many other countries. I think my greatest influence has been in the realm of teaching so many trainees. My teaching has been greatly influenced by the legendary Dr. Eugene Stead, who was the first full-time chairman of medicine at Emory. I believe that a true teacher urges trainees to ask themselves questions about each patient they see and to exercise the self-discipline needed to seek the answers. The true teacher facilitates this approach. Equally important, a true teacher guides trainees to think. Information is important, but it is equally important for the trainee to learn to use the information in a thought process. I spend most of my teaching time doing just that, and eliminate all of the lectures I can. I tell the house officers to jump at the chance to give a lecture, because a lot can be learned while preparing for it, but I don’t attend very many. In brief, I teach self-learning, for that is what trainees must do when they leave the warm arms of teaching institutions such as medical schools or hospitals. I also try to show by example and discuss the humanitarian aspects of doctoring. I agree with Frances Peabody who said, The secret to caring for the patient is to care for the patient. I treasure a note I received from a former house officer who wrote, Last night I thought about taking a short-cut on a patient and not do something I was trained to do, but I felt your hand on my shoulder, and did it right. How did you choose cardiology as your field of specialization? I chose cardiology because a professor in my medical school was very interested in the field and was a superb teacher. During the time I was a medical resident, Dr. Paul White visited our school and, influenced by the same teacher, offered me a position as cardiology fellow at Massachusetts General Hospital, which I later completed after I served in the armed forces. So that’s another reason, but I always liked cardiology because it’s the only specialty I know in which the organ moves, makes noises and generates electricity, all of which are analyzable. It makes for an extremely interesting examination. What are your feelings about teaching and its importance? If one goes into academic medicine and works at a medical school, the word school certainly implies teaching. I’ve always felt that students, interns, residents and fellows will choose to go to an institution where the teaching is excellent. I, and many of my colleagues, have emphasized teaching as a major effort for medical school faculty. Of course, the research must be there, but the teaching cannot be neglected. After so many years of teaching, does any one student bring back feelings of it was all worth it? I would not be willing to say that one trainee stands out more than another. That said, I would add that I am proud of all of them many have risen to the top in academic medicine and practice, and many others do a superb job. I would not want to name any single person whom I could say made it all worthwhile. Overall, the ability to influence a large group of students has made me very happy. When you first decided to write your famous book, The Heart (later named Hurst’s The Heart) did you have any inkling that it would become such a classic? In the early 1960s, there were three books on the subject of the heart. One was Dr. Paul White’s book, my former teacher who taught me cardiology, then Dr. Paul Wood’s book which was very popular at the time, and Dr. Friedburg’s book. It turned out that Dr. White said he was not planning to pursue a revision of his book. Then, Paul Wood died about two weeks after he visited me here at Emory. During his visit here, Dr. Wood indicated that while working on the new edition of his book, he discovered that by the time he got to the end of the book, what he had written in the first part was already out of date. He could not see how a single author could possibly write a book. That was the stimulus right there for me. I began to think in terms of collecting a group of people who had made their name and pioneered in certain areas, and with whom I agreed. As a result, my partner, Dr. Bruce Logue, and I wrote the book entitled The Heart as a multi-authored book. Dr. Friedburg regrettably died in an automobile accident some time after our book was released. Our book was then the only text of its kind for many years. I’m happy that Hurst’s The Heart has continued to be successful (first known as The Heart, the publishing company, McGraw Hill, added Hurst in honor of my creation of the book). It has been published in five languages and continues to be a highly respected book. How was President Lyndon Johnson as a patient? I first saw President Johnson when he was majority leader. I was chief of cardiology at the U.S. Naval Hospital in Washington, D.C. Mr. Johnson had his first heart attack during that time. We became friends, and from that point on, I took care of the cardiovascular aspects of his health problems for the next eighteen years. He soon became Vice President, and we traveled together to some fourteen countries. I saw him frequently, although he had no cardiovascular trouble at all. When he became President, I saw him frequently at the White House, and over the years, I visited him many times at his ranch. He and I and the family became rather close, and I enjoyed him enormously. There was no official White House cardiologist I served simply as his private consultant and saw him frequently, and we enjoyed a good relationship. Dr. George Berkeley was the White House physician during those years, but I served as Johnson’s private consulting cardiologist. He taught me a lot. He was a brilliant person, an extremely interesting person. One useful thing he taught me which I applied in my later work when I became chairman of the department of medicine at Emory was that a good idea will not work if it is not implemented at the appropriate time. The art of choosing the right time is almost as important as the innovation itself. What led you into fiction writing, and co-authoring a novel with your son? I began to write fiction with my son Phil, who is a psychologist. The books Prescription for Greed and Tarnished are about the healthcare system. The current system is making it difficult for good doctors to work. The system includes the doctors themselves, lawyers, industry including pharmaceutical houses and politicians. All of these are linked, and I’m not sure that the public understands this complex system that encompasses all of these elements. I wanted to write the novels in an attempt to point out to the public at large where some of the problems lie, hoping that perhaps with greater public recognition of the problems, we could begin to clean up the mess American medicine has become. What are some of the most important issues or challenges to you today in cardiology? I have been greatly concerned about certain issues since 1970, when I began to see things change. One of the biggest problems lies in the fact that many people are attempting to turn medicine into a business. Medicine is not a business. For example, if you need a new suit of clothes, go to a department store and tell the sales associate, I need a new suit of clothes, but I don’t have any money; chances are, you won’t get a new suit. On the other hand, if you’re sick and you go to a hospital or to a doctor, by and large, you will receive care regardless of whether you are able to pay. Thus, a vast difference exists between medicine and business, and the more people try to make it a business, the worse medical care becomes. Another issue involves the many wonderful technologies that are available today. Diagnoses can now be made that could not be made in the past. New technologies are indispensable on the one hand, but on the other hand, they are often overused. How to appropriately use technology, but not overuse it, remains a challenge. In addition, there is a prevailing sense that the consistent use of high technology (which is necessary) occupies doctors’ time to the extent that they do not have the time to take care of the patient in a more holistic fashion. Doctors tend to take care of a part of the body, but not the entire body. It’s acceptable to have a certain number of doctors who fit this mold, but we wouldn’t want everybody in the profession to just treat a body part, because is would seriously blunt the humanitarian aspect of medicine. What contributed to your success as a physician, teacher and author? I adore and enjoy medicine. I enjoy all aspects of it. I enjoy patient care, I enjoy teaching, I enjoy clinical research, I enjoy writing every aspect of it appeals to me. Now that doesn’t mean that I’m superior, or that I’m necessarily different from anybody else. The only quality I can claim to have is persistence. I have learned that a good idea requires persistence and proper timing to implement it. You've seen cardiology go from treating a heart patient with an oxygen tent and sedation to biventricular pacers and coated stents. What do you foresee for the future? I think the future will bring more high-tech medical care. Much of what we do now will eventually vanish and be replaced by newer, high-tech techniques. I’m sure the new technology will carry a high price with it as well. I do hope that all this new technology will not cause doctors to forget the humanitarian responsibilities they have in regard to their patients. What do you think was cardiology’s greatest achievement in the last 50 years? The greatest achievement in cardiology, in my view, has been the worldwide use of coronary arteriography. Of course, cardiac catheterization had been used for years to perform physiological measurements in patients with congenital heart disease and valve disease, but in the last 50 years, the landmark work of Mason Sones at the Cleveland Clinic, who developed coronary arteriography, propelled cardiology forward by enabling surgeons to develop coronary bypass surgery. Then, of course, there is coronary angioplasty and Andreas Gruentzig. Andreas joined us at Emory and performed thousands of angioplasty procedures while he worked in my department. Regrettably, he died five years after he arrived. He changed the world, because his procedure is now performed in catheterization laboratories all over the world. I also want to give the cardiac surgeons the credit they deserve. They can correct numerous congenital abnormalities, most valve abnormalities, and can transplant the heart. They developed coronary bypass surgery, which was also a landmark event. Many useful new drugs have emerged as well. The development of pacemakers and defibrillators has also been a huge forward step. What do you see as the future of rapid computed tomography and some of the other diagnostic imaging modalities for cardiology (i.e., PET, MRA, etc.)? I suspect that magnetic resonance imaging will someday make coronary arteriography unnecessary, in many patients at least. I think other breakthroughs will also occur that will be equally important. What words of wisdom might you give to students who would like to follow in your footsteps? I would advise students to choose what they love to do and to be persistent. Students must constantly push ahead in the subject they enjoy. Persistence is the key. Most students who complete medical school are reasonably intelligent, but intelligence won’t make the new physician above-average unless he or she is persistent and works toward a goal that is above-average. You continue to regularly publish in the literature are there any upcoming articles that readers should keep an eye out for? I try to write a book every year, as well as four or five articles each year. Two articles were recently published in the Journal of Clinical Cardiology. These relate to a modern look at the ventricular gradient in the electrocardiogram that I hope will be of interest to the readers. Also, I have an article coming out later this year in Residents and Staff Physicians that focuses on the self-learning aspect of medicine. We are now in an era where self-learning must be mastered and pursued by every student, house officer and fellow. After so many years as a leader in the cardiology field, do you feel that you know it all or know nothing at all? I have never felt that I knew it all! In fact, I knew without question that I didn’t know it all. I was interested in certain aspects of medicine and excelled somewhat in them, but I saw clearly that I could not excel in all aspects of modern medicine. I am interested in medicine in its entirety, but I can only claim that I know a very small bit of it. The old saying is true that the more you know, the less you know. I feel that I know less now than I ever have. I have more questions today than ever before. It’s just amazing what research has brought to the table. The only comfort comes in realizing that no one knows it all we are all ignorant.

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