By Dr. John Mandrola
Published on Medscape
Originally Published on/by drjohnm.org

I knock, then enter the exam room.

“Hi. My name is John Mandrola.” (Maybe it is my age but I am moving away from calling myself Doctor Mandrola.)

“I am a heart rhythm specialist. I have looked at your chart so I know a little about your medical history.”

“Can you tell me how you are? What complaints bring you to see me?”

What follows is increasingly (and painfully) common:

“Doc…I feel good…I have no complaints. The doctors say…”

At this point, I reflexly make a questioning face. The patient sees it. He repeats: “No, really, doc, I am okay. I walk three miles a day. I play golf. I do yard work.”

“No chest pain?’

“Nope.”

“Shortness of breath, dizziness, racing heart?”

“Nope.”

“You must feel fatigued?”

“Nope.”

I need to be sure so I ask it another way:

“If there were no doctors, no tests, no scans, would you be aware of any problems?”

“Nope.”

I have been to this place before. Sorry. But the problem–finding disease when there is none–is not getting any better.

It takes a doctor right up to the precipice of failure. The danger, of course, is breaking the first rule of doctoring: if a patient tells you he is well, your first job is to not mess it up. Do no harm. Resist the urge.

Maybe the ECG machine shows something–the heart is out of rhythm. Maybe a shadow from an ultrasound machine is amiss–a valve is leaky. Or perhaps contrast dye seen on an X-ray image shows a partial blockage–the trap of coronary artery disease. Yet, if not for doctors, this human being would have no disease. He would be well. “I exercise 3 days a week. I play golf. I work.”

To be sure, I am no nihilist. I believe in what I am trained to do. I can vanquish aberrant pathways with a catheter. I can place pacing leads into the hearts of people with failed natural pacemakers. These are beautiful procedures. They took years to master. It is intensely gratifying to think a one-time slacker could do these things.

But these fellow humans had complaints. They were sick and I tried to make them better. I am not frightened to work on these patients. The cause is just. The patient informed. Alternatives and risks explained. No inflammation. A clear mind.

What a different story it is with well patients. Like those referred because of “something” found during an annual check-up.

I recently wrote about this precarious scenario on Medscape. I talked about the ultimate medical error.

Taking patients who grade their health as an A and making them a D or F is the ultimate medical error. This is the risk of preventive maintenance: Once in the machine of healthcare, it is hard to get out.

I told a story of a terrible mishap. The disaster began with an annual physical. A blip on an ECG. Perhaps the title of the piece was too provocative: Redefining the Annual Physical: A (Broken) Window Into American Healthcare.

The comments were decidedly mixed. My concern about over-diagnosis and over-treatment did not go over well. I have thick skin but it stings when fellow frontline doctors criticize my words. Maybe I was too hyperbolic. Words are so damn important. I second-guessed myself.

Then I had clinic the day after the essay was published. Three of the four new patients I saw were sent for spurious findings discovered during unnecessary screening tests. Thankfully, I was able to extract them from the machine of healthcare. It was not easy. It is far harder to unscare patients than it is to scare them.

These experiences helped me feel a little better about the criticism.

Then, this weekend, in preparation for two presentations I am giving soon, I came across the work of cardiologist Dr. Bernard Lown, a recipient of the Nobel Peace Prize. Dr. Lown was a self-described maverick. He believed in old-fashioned doctoring. He believed in listening to the patient, that the patient would tell you the diagnosis. He went against the grain of cardiology and its plumbing thesis: coronary artery disease can be a stable disease with a low mortality. Angina was not terrible. Nitroglycerin was underused. He railed against the use of fear:

Patients are led to believe that inaction is likely to have threatening consequences to their very survival. The ensuing fear assures a docile acceptance of the interventionist course of action.

Now I am energized. I am okay. For it seems Dr. Lown’s wheel is a good one to follow.

~JMM

Here is a link to Dr Lown’s blog. Therein lies a trove of valuable reading.

Here is a documentary on Dr. Lown.