Wednesday, November 8, 2017

Best Medicine & Listening: It's Not Viral!


..….listen to the patient
and
the patient will give you the diagnosis……
 
William Osler 1849 – 1919


I suppose in life, it is lucky to have school friends that might one day save your life.
 
Medicine.
 
I suppose without sounding racist, it helps if you are Jewish, went to a Jewish school as you are likely to have Jewish school friends who are good doctors.
 
As they say, God works in mysteriously ways!
 
I was in the middle of some Scandinavian Fjord on a cruise when I came across a book called Open Heart. Yes, old habits die hard and I still find myself drawn to books about medicine or other people’s medical stories.
 
The Cruise ©2012 Am Ang Zhang


It is peculiar that the commonest diagnosis the average punter, sorry patient is going to hear from their doctor is:
 
Yes: It’s viral.
 
Well, remembering my biology, these creatures are smaller than bacteria and is not really easy to cultivate.
 
Or is it just a way of saying to the punter/patient, go home and do not ask for the antibiotic.
 
Now, it may well be OK if it were a simple cough. But what if you were told it is a viral cardiomyopathy?  
 
 
Now, this is getting serious.
 
Yet this is what happened and it happened to Jay Neugeboren
after some investigations by two doctors, one a cardiologist.
 
About Jay Neugeboren:
Did he smoke?  No!
Was he overweight?  No! 5’7 150lb.
Did he exercise?  Yes, swims a mile every day and plays tennis  full court basketball regularly.
 
He must have a high cholesterol or BP or family history, it just is not right: No, he had no family history of heart disease, and had normal blood pressure, and better-than-normal levels of cholesterol (both 'good' and 'bad').
 
His symptoms:
 
“I had, however, for two months prior to the surgery, been concerned about some shortness of breath I experienced, if intermittently, while swimming, and by an unfamiliar, sporadic pain -- more like a burning sensation -- in my back, between my shoulder blades. When my family doctor suggested I have a check-up with a cardiologist, the cardiologist performed an echo-cardiogram and diagnosed 'a viral cardiomyopathy.' But he saw no urgency in my situation.”
 
Call his friend 3000 miles away:
At the same time, I had been talking regularly with a childhood friend, Richard Helfant, who was a cardiologist in Los Angeles, and had been Chief of Cardiology at Cedars-Sinai Hospital in Los Angeles. When I told him of the viral cardiomyopathy diagnosis, he shouted into the phone, "It's not viral, goddamnit -- I want you in the hospital as soon as possible."

So, to cut the long story short, a health New York Times author of some 20 books with no family history of heart disease, a better than normal cholesterol level non smoking 1 mile swimmer that would have been classed as healthy by NICE standards had at the age of 60 --had two of his three major coronary arteries turned out to be 100% shut down, and the third major artery, the LAD (Left Anterior Descending Artery, the so-called 'widow-maker') was more than 95% shut down.

His life was saved by emergency quintuple bypass surgery.
 
What went wrong or what went right?

His childhood friend had made an accurate diagnosis from 3000 miles away because he knew his friend and thus could place his specific symptoms in the context of his full story. What the cardiologist who had misdiagnosed him had done was to pay more attention to tests and numbers and, thus, to forget about the pain between his shoulder blades, which symptom -- referred pain from the heart -- was inconsistent with a diagnosis of viral cardiomyopathy.

His operation took six and half hours at Yale, New Haven Hospital: Medicine at its best and that was over 13 years ago.


It is also not comforting that a study in 1997 of 453 residents in internal medicine and family practice revealed that they failed to identify the distinctive sounds of common heart abnormalities with a stethoscope 80 percent of the time. True, using a stethoscope, listening to the patient and taking a careful history may not be the only ways to accurately diagnose heart disease. But in the words of Dr. Bernard Lown, inventor of the defibrillator, listening to the patient and taking a careful history remains ''the most effective, quickest and least costly way to get to the bottom of most medical problems.''


My old friend the cardiologist has similar concerns. ''The diagnostic acumen of the physician at the bedside, on the phone or in the office, has been severely compromised,'' he told me. ''Because the mind-set has become, 'Well, the tests will tell me anyway, so I don't have to spend a lot of time listening.' ''


…….I worry that our continued focus on medical testing and prescription drugs as the primary ways of preventing heart disease will distract us from a more important element in treating illness: the well-trained doctor who knows his patient.





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