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Lewis case illustrates patients' tough choices


In the most tragic way imaginable, the death of pro basketball star Reggie Lewis underscores the agonizing choices that confront patients who get differing medical opinions about the conditions that ail them.

Mr. Lewis may have been a man looking for the second opinion he wanted to hear -- that he didn't have a serious heart disorder and could safely return to the court. When he heard it, he accepted it and suffered the consequences.

Also, as many doctors have suggested, it may be true that there should never have been a dispute about the athlete's condition. Heart specialists across the land have stated publicly that the team of 11 doctors who first evaluated him were undoubtedly right when they said he had a weakened heart and should give up basketball immediately.

But the bizarre case of the Boston Celtics star should not obscure the wrenching choices that face people who follow the advice printed in every patient manual. They seek a second opinion about serious conditions or treatments only to find themselves caught in the middle of conflicting views.

"Some patients really do agonize," said Dr. John Fetting, a breast cancer specialist at The Johns Hopkins Oncology Center. "They look to doctors for clarity, and when they run up against the grays and problems that are at the edge of our knowledge, it takes a bad situation and makes it worse.

"Not only do they have cancer, but they can't get their doctors to agree on what to do. Then, they're really stuck."

Dr. Thomas Guarnieri, a specialist in heart rhythms at the Greater Baltimore Medical Center, said cardiologists disagree all the time and encourage patients to weigh differing opinions. But he said he could not remember a single case where medical opinions have been at such extremes as they were in the Lewis case.

"I doubt whether this sort of problem has been dumped on very many people's doorstep," Dr. Guarnieri said. "Quite honestly, in 10 years this is the first time I can remember where people saw things this divergently different."

The saga began when the 6-foot-7 Celtics captain collapsed during a playoff game against the Charlotte Hornets on April 29. At the New England Baptist Hospital, a team of 11 top cardiologists agreed that he suffered from cardiomyopathy -- a weakened heart that can produce abnormal and often fatal heart rhythms.

They recommended that he stop playing basketball and floated the idea of a surgically implanted defibrillator -- a device that automatically shocks the heart into a normal rhythm when it senses something amiss.

Apparently upset with the dire news, Mr. Lewis left the hospital and sought the advice of Dr. Gilbert Mudge at the nearby Brigham and Women's Hospital. In an opinion that stunned many specialists, Dr. Mudge concluded that the player had a "normal athlete's heart" and a benign nerve disorder that subjected him to fainting spells.

Dr. Mudge said the athlete could resume his basketball career without jeopardizing his health. Yesterday, Mr. Lewis suddenly collapsed while leisurely shooting baskets at Brandeis University in Waltham, Mass.

Two and a half hours later, he was pronounced dead.

For Mr. Lewis, the dream of playing out a pro career, reaping financial rewards and wearing the badge of Celtics captain may have motivated him to seek the most palatable medical opinion. But for most patients, the difficulty lies in the grayness of medical science itself.

Medical advances have both heightened a patient's options and complicated the task facing doctors.

For blocked arteries, one physician may suggest bypass surgery; another may recommend a less invasive procedure called angioplasty; others may insist that medication alone can do the job.

Imaging machines have become so refined they can detect tiny masses in a woman's breast that are not evident to the touch. Under a microscope, a tissue sample may show signs of becoming cancerous. But in such cases, doctors may disagree as to whether the breast should be treated with radiation or surgery, or just watched.

"Many patients get a third opinion -- a tie-breaker," said Dr. Fetting of Hopkins. "The really informed patients, the really thoughtful patients, realize when there's a gray area they're really just getting another opinion. There's no certainty.

"There are people who get consults until they hear what they want to hear," he added. "They go to three or four doctors who recommend chemotherapy. Finally, they find another who says it's not necessary."

Dr. Thomas Ducker, an Annapolis neurosurgeon, said patients who suffer from a painful lower back should generally exercise caution when a doctor recommends surgery. It's a controversial issue because the lower back naturally degenerates with age.

"I tell people they've got gray hair and reading glasses of the lower back," Dr. Ducker said. "Where's the fine line where you need surgery? I have colleagues I like and respect who don't come to the same conclusion."

Dr. Ducker said he frequently gives patients lists of qualified back surgeons and suggests they select one for a second opinion. If the issue remains clouded, he will sometimes urge a patient to consult an out-of-town doctor who wouldn't have to worry about offending anyone.

Does the majority rule?

"Ultimately, the patients have to make up their own minds. It's their own body. They've got to go with how they feel about the opinions they've received. Your evaluation can be on the basis of reputations of the people giving the opinions, although that's very hard to do."

Dr. Robert Brook, a professor of medicine at the UCLA Medical Center in Los Angeles, said doctors could lessen their patients' stress if they would admit that certain conditions do not have clear-cut solutions.

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