In the book, the history of blood transfusion is wrapped around a historical murder mystery involving a French physician, Jean-Baptiste Denis, whose experimental transfusions were as much about trying something new, as it was making himself rich and famous. Denis had a fair number of detractors who wanted the transfusions to end.

Denis began transfusing animal-to-animal, finally working up to animal-to-man transfusions. The two transfusions he did on mentally ill man ended in his death (for the record, it was calf blood). Denis was accused of killing him, though it turns out to have been murder via poison.

Who did it and why? I’ll let you read the book. But I thought about that a lot because Tucker told me how excited she was when she found the actual documentation (in France) of the murderer’s identity.

What I loved about the book, aside from Tucker’s beautiful writing, were the details she threw in about the times and the history. It’s been awhile since I’ve studied Europe in the 1600s, and this was enlightening. Tucker paints a picture of what the crowded Paris streets were like, with the mass of humanity, “the grey and polluted waters of the Seine,” the “heavily perfumed prostitutes who strolled along the bridge in décolleté dresses by day, and men of all persuasions fulfilled their passions under the bridge by night.”

From early times, scientists and physicians thought that blood was cooked in the digestive tract and filtered in the liver. Circulation was not well understood. The heart produced heat and burned the blood like fuel. Breathing was a way of releasing the fumes from the heart. This explains the practice of bloodletting (practiced by the barber-surgeons; get a shave and a boil lanced at the same time). “Modern-day barbershops commemorate the early origins of the profession. Now quaint and certainly less macabre, metal-capped red-and-white striped poles, displayed prominently outside barbers’ doors, evoke the bloody bandages and bowls of earlier days.”

Bloodletting was thought to release the bad humors in the blood, and to cool off the body. Then again, Tucker notes that they also avoided bathing back then, reserving water to clean only the face and hands. They’d use perfumes over the body to cover up the stench, and to “purify the disease-causing corrupt air with which the person came in contact.”

Tucker notes that in Egypt around that time, they’d export mummies, where “small bits of dried mummy flesh, ingested either whole or powdered, were believed to cure a wide range of ailments.” If that’s not bad enough, the mummy exporters would find any dead bodies they could, including those with leprosy, plague, or smallpox.

You can appreciate how difficult early transfusion would be, without modern equipment (or anesthesia) to move blood from one creature to another. They used quills and rudimentary ways to try to measure how much blood was transfused. The animals were often bled to death. Before the blood transfusions, experimenters transfused milk, water, alcohol and other substances into the animals.

You have to remember that anesthesia really wasn’t available then. Tucker notes that when doctors went to remove bladder stones, they often did so through the penis, or by making such a large cut in the perineum that the surgeon could insert his whole hand. It took four men to hold the patient down during the procedure. Surgery and medicine then were barbaric and their medical knowledge was so much more limited than now.

The concern over transfusion was this: people in the 1600s worried about the effects of merging animal and human blood. Would the human turn into an animal? Take on animal characteristics and behaviors? Would the human lose its soul to the animal? Tucker points out that the Red Cross went through something similar starting in the 1940s. They segregated blood of blacks and whites, so a different race’s blood wouldn’t “corrupt the purity of bloodlines for generations to come.”

While there are animal welfare activists who protest animal experiments today, the scientific world today has a much higher standard. Scientists have to get permission from institutional review boards for their animal (and human) work, doing the experiments in the most humane way possible. Back then, they grabbed an animal (or a human – willing or not), strapped it down, and began to work.

Word of the transfusions (and also political news) was sent by couriers, because there was legitimate concern about postal censors and royal spies. They sent their words in code, bound letters in books, or used invisible ink (even urine) to disguise their writing. They diluted the ink with special substances and had antidotes that could make it readable again. And for good reason. Tucker tells of one man who was thrown in jail (the infamous Tower of London) after his letters were intercepted. Jail guests had to pay their own way for the privilege.

Denis was acquitted from killing his patient, but the French government took the opportunity to ban blood transfusions for another 150 years. It was only when an English physician saw one too many women die in the hospital that he wondered what more could be done to help.

A timeline (taken from the book):

1665 – the first animal transfusion in England (dog-to-dog)

1667 – Denis begins animal-to-animal transfusions, then transfuses a 15 year old boy with lamb’s blood. Later that year he transfuses Mauroy (the mentally ill man), who dies after a few weeks (of arsenic poisoning).

1669 – France bans transfusion

1818 – an English surgeon performs a successful human-to-human transfusion

1908 – an Austrian doctor discovers the three blood types in humans (A, B, O). AB is discovered in 1909.

Methods to prevent clotting, anticoagulants for blood storage and blood banks came later.

You can listen to Tucker talk about her book and blood transfusion history on Science Friday (April, 2011). Look in the upper left corner for the “listen” or “mp3″ buttons.

With this in mind, it was gratifying to read a New Jersey Star-Ledger article recently, which showed a new program used for medical students interviewing at Robert Wood Johnson Medical School. Instead of just being assessed on educational background and a personal interview, they’re now assessed partly on their ability to deal with people. They use a structure called a multiple mini interview (MMI). It’s  described as “medical admissions speed dating,” focusing on treating patients as people, not symptoms.

The students go into six to 10 different rooms in short order, pausing first to read a scenario, question or task which may involve a doctor’s personality and possible ethics issues. They then share their insights with the interviewer. The program was developed at McMaster University in Canada, and is used by 17 medical schools there. A handful of schools in the U.S. have adopted it too.

I think that’s a great approach. I recently finished writing a hospital newsletter (volume III) and was impressed writing about an award one physician received from his surgery students. One reason the students liked him so much is that he actually inquired about their personal lives, to see them not just as students, but as people. The resident giving the award said “by the end of our four years…he has somehow learned more information about our personal lives than our parents.”

That’s exactly what patients want as well. To be treated like a person and not a symptom. It’s a good lesson for the medical community.

When I investigated medical malpractice claims, I was usually the only person in the doctor’s waiting room in a suit. Unless there was a drug rep there. We’d smile at each other, and the drug rep would sometimes ask what drug company I was from. I wasn’t allowed to tell them I represented the doctor’s professional liability carrier. I just said I was there on business. I’d hand my card to the receptionist and the rep would look annoyed when I got called back before he or she did.

Drug reps are one way that doctors learn about drugs. These reps, often attractive, young men and women, tote in samples, pamphlets, candy and often lunch (I benefitted from this food too – sometimes the doctor and I would grab sandwiches to eat during our discussion, or they’d give me pastries to take home).

Doctors are in on the goods too. A recent investigation by ProPublica detailed how. For example, over 18 months, seven New Jersey physicians were paid between $100,000-$212,000 to talk up specific pharmaceutical products in medical conventions, conferences, consulting and lunch-and-learns.

This is not news in the industry, but bringing the actual numbers to the public eyes is a good way to question the ethics.

Earlier this year, NPR’s Fresh Air had an interesting interview with Dr. Daniel Carlat. He wrote the book Unhinged: The Trouble with Psychiatry – A Doctor’s Revelation about a Profession in Crisis.

The book topic merits its own blog post (the premise being that many doctors are abandoning talk therapy and just prescribing medications, partly due to time and financial issues). In the Fresh Air interview, Dr. Carlat talks bout his experience getting paid by Wyeth to give other doctors information about depression and its treatment, including the use of Effexor (that part of the interview starts at 25:17). When he started doing these lunch-and-learns, he was getting paid to tell doctors what he already believed about treating depression, and using Effexor as part of that (along with a slide deck supplied by Wyeth). Dr. Carlat’s message coincided with Wyeth’s marketing message.

As time went by, Dr. Carlat realized he was being influenced by the payments, and found himself embellishing Effexor’s positive effects, and diminishing his talk of side effects. He felt the pressure from having the drug rep in the room listening to him, and felt he needed to keep up the positive talk if he wanted to keep earning money from these “educational” seminars. At one talk, Dr. Carlat told the doctors that the studies on Effexor’s benefits were based short term studies, and that if the studies were longer, that Effexor might not be advantageous over other options. That turned out to be his last talk. The drug company expressed concern, and Dr. Carlat realized he wasn’t useful to the company when he gave the unvarnished truth – only when he towed the line.

Listen to the whole interview here and read Dr. Carlat’s account in his New York Times Magazine story here.

To be sure, using doctor to sell to doctors in an educational format is effective. These doctors are seen as peers and thought leaders. When you see someone speak at a conference, you don’t automatically assume they’re being paid to do so (though often there’s a written acknowledgement of a financial relationship in the conference brochure). Doctors may learn something about a topic they’re less familiar with from these paid speakers. But the teaching may be unintentionally (or even intentionally) biased.

How does this affect patients? On the plus side, doctors might be better educated about a specific disease or treatment. But patients might also get prescribed a drug based on learnings from a biased seminar. Or they might be prescribed a drug without knowing that the drug company is monitoring and rewarding doctors for their prescription patterns – whether or not its the best drug for the patient.

It would be nice to think doctors are independent of this, but throw money into the mix, and it just muddies the water.

For more information:

–ProPublica broke the story with detailed analysis and databases on what pharmas paid to what doctors. Read more here:

–Profiles of the top-paid doctors

–Not all the doctors on pharma payroll have good credentials, according to ProPublica

–New Jersey doctors on the take

When I worked as a medical malpractice claims investigator, one of my (frequent) clients was a cosmetic surgeon (his specialty was otolaryngology). Not a plastic surgeon – there’s a difference (you’ll get an earful if you ever mix them up in front of a plastic surgeon). My client got in trouble after a calf implant procedure didn’t take. He also had claims filed against him from a man who received pec implants, and a woman receiving a chin implant. Had he done many of these procedures before? No. Was it beyond the scope of what an otolaryngologist should be doing? Well, that was up for debate. The doctor wasn’t criticized for going beyond his scope of expertise with the chin implant, but the pec and the calf implants were harder to defend. He received medical training in those areas, but the expert plastic surgeons we (and the plaintiffs) hired, had a field day.

What was the lesson learned? As a patient, make sure your physician has performed MANY of these procedures before, so you’re not in the guinea pig group. And make sure you’re going to the right specialist for the procedure. The other lessons learned? Check out your doctor before you agree to a procedure. A few places to look:

-State Licensing Boards. The American Medical Association has a list of state medical boards on its website. You can look up whether the doctor is licensed, and often whether there’s been any actions against that physician. I looked up the otolaryngologist, and found that he completed his probation, there was a malpractice award against him, and he had a citation resolved. Is this helpful to a potential patient? You bet.

-Health Grades - you can look up 750,000 doctors across the country. While the patient reports can be helpful, take them with a large grain of salt. I again looked up the otolaryngologist, and there were 8 positive patient ratings. Based on the ratings, I would go to this physician. But the background check (which I didn’t run) should show his disciplinary actions, confirm whether he’s board-certified, and more. There’s a fee for the background check ($12.95), plus you may get charged more for their ‘watchdog service’ if you don’t cancel in 14 days.

-Ask for references. Of course the ones the physician gives you will probably be glowing. Ask around. Speak to others who have had the same procedure, so you’ll know what to expect in terms of healing and complications. Ask whether the doctor was easily accessible after the procedure, if you had questions or concerns.

-Make sure you know the risks involved with the procedure. Ask about the worst possible things that could happen. The doctor will give you an informed consent form to sign – it’s often generic, and will list complications like death and unforseen consequences. Ask the doctor for specifics. Granted, bad results can always happen, even to the best of physicians. But if you’re aware of the potential complications, and you’re still game for the elective procedure, then it’s buyer beware.

These days, we tend to take for granted the use of sterilized equipment, anesthesia and life-saving surgical techniques. Sure, the problem of hospital-aquired infections is still a big one. The epidural during labor isn’t always 100% effective. And the surgery that’s supposed to irradicate a disease sometimes misses some of the diseased cells. We do have have advantages, though, that weren’t available 140 years ago, when physician William Stewart Halsted was practicing.

Last month, the NPR program Fresh Air featured a fascinating interview with author Gerald Imber. He wrote the book Genius on the Edge: the Bizarre Double Life of Dr. William Stewart Halsted.  Halsted was quite the medical pioneer, starting the first residency program and developing the radical mastectomy (lowering the cancer recurrence rate from 100% to 50%). Halsted was the first medical practitioner to implement rubber glove use - after a nurse developed dermatitis issues from Halsted’s mandate that staff clean their hands with mercuric bichloride. He was the first documented physician to do a blood transfusion, using several syringes of his own blood, to revive his sister who hemorrhaged after childbirth.

Halsted performed the first gall bladder surgery – on his mother, no less. He saved her life – especially since he steralized his tools with carbonic acid, lowering the risk of infection from the operation. He realized the value in steralization and tried to convince New York City’s Bellevue Hospital, where he practiced, to build him a sterile operating room. They laughed at him, so he raised the money himself, building a antiseptic operating tent outside on hospital grounds.

Of course not all his discoveries were healthful ones. Cocaine was known to be a numbing agent, and he experimented with it, trying it first on himself and then on his students and patients. Halsted became addicted, as did his students. However, he realized that anesthesia could be used to numb a larger area of the body, resulting in general anesthesia. His research into anesthesia won him awards from the American Dental Association.

I’d recommend listening to Terry Gross’ interview with author Imber. You can listen on your computer or download it to your MP3 player. Then get the book. It’s now on my reading list.