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Doctors in Hub practice caution

Maureen Imbrescia recalls that her obstetrician in Boston was openly skeptical about the Florida doctor who said he could correct a potentially fatal circulatory problem in her unborn twins. Though Dr. Ruben Quintero had done 250 of the laser surgeries, no long-term studies proved his approach worked and Boston doctors had never done it.

 

Imbrescia flew to Tampa for treatment anyway, and, three years after the operation, little Sophia and Sydney Imbrescia are free of the "twin to twin transfusion syndrome."

Boston gets more federal money for medical research than any other city, but when it comes to actually using new drugs, devices, and techniques on patients, many doctors in this region retain a strong conservative streak. Boston has lagged behind other cities in adopting new technologies and treatments from disposable contact lenses to gene therapy to a less painful method of tonsillectomy, sometimes forcing Boston patients to go to other cities for their medical care.

"New England is the bastion of old guard medicine," said Dr. Matthew Budoff, a cardiologist at the UCLA School of Medicine in Torrance, Calif., who is writing national guidelines expected to boost a high-tech test for early heart disease that Boston has been slow to embrace. "It's not bad at all, but they want to be the most evidence-based group that exists."

Of course, in a city with six hospitals that consistently rank among the best, there are many areas where Boston leads the nation, from improving the survival chances of heart attack victims to repairing damaged vocal cords.

But numerous Boston doctors say their caution is both real and justified, sparing patients from treatments that either have not been perfected or carry unforeseen consequences. For instance, Boston surgeons did not perform heart transplants until 16 years after the first such operation in the US in 1968 because so many patients were dying when their bodies rejected the new organs.

"Those that have waited [before adopting innovations] have served their patients well," said Dr. David Acker, chief of obstetrics and gynecology at Brigham & Women's Hospital, where the Imbrescia twins were born. "Most of us know what's going on around the country . . . and we are not telling our patients that they have to stay in Boston and never get the benefit of Florida medicine or Texas medicine."

However, the conservative medical culture has frustrated some would-be innovators, including current US Senate majority leader Bill Frist, a former heart surgeon, who said he left Boston in 1985 because hospitals were reluctant to perform the heart transplants he dreamed of doing.

When researchers in suburban Danvers created the first artificial heart that doesn't have to be hooked to machines, they naturally hoped Boston doctors would test it on their sickest heart patients. But, 2 1/2 years after the first patient received an Abiomed artificial heart, hospitals in Kentucky and Texas have done nine of the 11 operations. The Boston surgical team trained in the procedure has yet to implant a single heart in part because they can't find the right patient.

"Any other area is easier to get a new procedure established than Boston," said Dr. Melvin Clouse, vice chair of radiology at Beth Israel Deaconess Medical Center, a Harvard teaching hospital. "My standard joke is that if it isn't invented in Boston and by Harvard -- and I am at Harvard -- it's not good."

In fact, many observers say the city's conservative streak begins at Harvard Medical School, the dominant force in Boston medicine for generations and arguably the nation's best medical school. The 13 major Harvard-affiliated hospitals, research centers, and other institutions collectively get more federal research funding for medicine than all but a handful of states, but the Harvard review panels that approve the use of new treatments on people have a reputation for being extremely cautious about exposing patients to risk.

For example, Harvard's microbiolologic safety committee, a joint panel of the medical school and its teaching hospitals, repeatedly rejected gene therapy experiments until 1997 -- seven years after the first federally-approved test of the treatment. Andrew Onderdonk, longtime chairman of the committee, said the panel was concerned about the way researchers got the genes inside cells, encasing them in viruses whose safety was untested. The death of a healthy patient in a gene therapy trial at the University of Pennsylvania in 1999 underscores the concern, he said.

"Boston scientists tend to want good factual informaton to support going forward with some new technology, and gene therapy was no different. The early stuff, let's face it, was witchcraft in terms of what science was available," said Onderdonk, director of the microbiology lab at Brigham & Women's.

Harvard also has one of the most restrictive policies on researchers' financial stake in their work. That reduces the risk that doctors could put profit ahead of patients' well-being in testing new treatments, but critics say it also reduces the incentive to produce commercially valuable results such as life-saving medicines. Some faculty members have been pressing for fewer restrictions, and Harvard Medical School Dean Joseph B. Martin is expected to announce a revised conflict of interest policy soon.

Taken together, the medical schools at Harvard, Tufts, and Boston universities give Boston one of the most academically-oriented medical communities in the country, where the leading hospitals are full of doctors who are also professors. Drug and medical device industry sales people say they often tailor their marketing campaign to Boston's more exacting approach, soliciting more top specialists to test the product and focusing on favorable medical journal articles.

"You almost have to pretend you are a nonprofit and you're only interested in the science," said Sherri Lazear, a former national account manager at Johnson & Johnson who was involved in the market launch of Acuvue disposable contact lenses in the late 1980s. Sales of the lenses, which reduced the risk of infection while improving convenience for contact wearers, trailed in Boston through 1990, according to a former company official.

But the bureaucracy of such a large medical community can also slow innovation. For example, surgeons from Brigham & Women's and Mass. General initially hoped to play a lead role in testing Abiomed's artificial heart, but the logistics of coordinating a team from two hospitals, along with the cost of doing animal tests in Boston, made it easier for Abiomed to work closely with Jewish Hospital in Louisville, Ky., said Dr. Gregory S. Couper, a Brigham & Women's heart surgeon on the Boston team.

Today, surgeons at Jewish have implanted five artificial hearts, extending the life of one patient by 512 days. The Boston team is still looking for a patient who is too sick for any other treatment, but strong enough to survive the operation. "I wish what turned out to be Louisville would have been right here in Boston," said Couper.

Dr. John Parrish, director of the Center for the Integration of Medicine and Innovative Technology, spends much of his time lowering barriers that prevent innovation from reaching Boston patients. The 5-year-old center, supported by research centers including Mass. General and the Brigham, brings scientists and physicians together to find technological solutions that doctors alone might not have known about.

For instance, Parrish's center brought together three-dimensional image makers from the Charles Stark Draper Laboratory and doctors at Mass. General to devise a better way to grow replacement livers, kidneys, or other organs in the lab.

"Medicine in general is relatively conservative as far as adopting new innovations because the stakes are so high," said Parish. "We're trying to change that to be less conservative, but in a safe way."

But delay in adopting new technology carries its own risks. Washington attorney John Sellinger, 53, is convinced he would be "pushing up daisies right now" if he hadn't undergone a relatively new test this year that can detect calcium deposits in coronary arteries, a key sign of heart disease.

The $395 test, which uses an electron beam tomography scanner to make images of the beating heart, found that he had 20 times the normal calcium level in his left anterior descending artery, the same region where his brother had a heart attack a few years before. As a result, when he felt strangely one morning last June, he went to the hospital where doctors found advanced heart disease that required quadruple bypass surgery.

"If I hadn't had the scan, I probably wouldn't have paid any attention," recalled Sellinger.

But Boston doesn't have an electron beam tomography scanner, the $2.2 million device that normally provides the calcium images. The region's leading advocate for the test, Clouse of Beth Israel Deaconess, has adapted a conventional spiral CT scanner. Clouse said he gets relatively few referrals from area cardiologists for the calcium screen and he's done only about 2,000 screens over the last three years, the most in New England, but miniscule compared to the number of people in the region with heart disease. By contrast, one company, HeartCheck America, has tested 75,000 people for heart disease in Illinois alone in the last few years.

The heart scan "was originally marketed the wrong way. It was marketed by people seen as entrepreneurs and that turns the academic community off like a switch," said Clouse, referring to HeartCheck's attempt to enter the Boston market.

The tide may turn this winter when the American Heart Association is expected to adopt new guidelines endorsing the calcium screen for men over 35 and women over 45 who have at least one heart disease risk factor. Budoff of UCLA, who chaired the committee writing the guidelines, said that people who score above 100 on the test are 10 times more likely to have a heart attack or stroke.

But Boston area doctors are unapologetic for insisting on extensive evidence before embracing new technologies. In the case of Maureen Imbrescia's twins, doctors were intrigued by the fetal surgery offered in Tampa to correct the blood imbalance between the twins, but not enough to recommend it.

After Imbrescia's delivery of two healthy girls, Acker from Brigham and Women's visited Quintero repeatedly to learn about the laser surgery, finally bringing a team to Florida to learn how to do it. By next year, he predicts Brigham & Women's will begin offering the surgery in certain cases.

"We have moved slowly, which I guess is our way, but I'm not apologizing," said Acker, who says the laser surgery is no longer experimental, but still lacks the long-term studies that would make him more comfortable.

Ultimately, Boston doctors may simply reflect the conservative sensibility of their patients. For instance, Boston consistently had among the lowest numbers of volunteers willing to undergo tests of vision correction surgery in the late 1980s and early 90s, recalled Dr. Roger Steinert of Harvard Medical School, who pioneered the highly popular Lasik technique locally.

"The patients who would come in for it had to have some willingness to take risks and it has absolutely been my consistent impression that people in the Northeast and Boston in particular are a little more conservative," said Steinert. "That's not necessarily a criticism. They've probably saved themselves a lot of grief over the years."

Scott Allen can be reached at allen@globe.com.

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