Conversations With Kohli | The Meaning of Doctoring: A Look Into Our Own Hearts
February brings with it Valentine's Day, which cardiologists everywhere seize as an opportunity to raise awareness of heart disease. The national Go Red for Women campaign has been a tremendous boost to educating the community about the impact of heart disease.
At a hospital-sponsored event in our hospital lobby this year, we taught hands-only CPR, provided blood pressure screenings and nutritional advice, and asked survivors of cardiovascular disease to come and share their stories.
Despite having heard hundreds of patient stories, I got goosebumps when I heard a young, healthy 35-year-old mother with sudden cardiac arrest tell her story of survival and recovery.
Equally as moving was the 73-year-old woman who delayed seeking medical care for her acute coronary syndrome because she was caring for her husband with advanced dementia. Hearing such stories makes me appreciate the strides we've made in treating heart disease – but also makes me aware of the challenges still ahead.
After the event, I went up to my office where my 1 p.m. patient was waiting patiently. A 79-year-old man with coronary artery disease, diabetes and chronic kidney disease, he has the most resistant hypertension I've come across in my career.
That day his blood pressure was 168/92 mm Hg. He was already on a diuretic, beta blocker, angiotensin converting enzyme inhibitor, clonidine, hydralazine and an aldosterone antagonist. He has an intolerance to calcium channel blockers. I didn't have many choices left so I offered him a long-acting nitrate.
As I was just about to sign the prescription, his medication list caught my eye and I realized he was on sildenafil. Without hesitating, I launched into my usual discussion about the drug interaction between sildenafil and nitrates. He allowed me to finish my soliloquy and then politely declined the nitrate, stating plainly it was "just too important" to his relationship not to take sildenafil.
More important to him, in fact, than all the scary outcomes I'd just warned him about if we didn't lower his blood pressure – the risk of stroke or dissection, death, heart attack or worsening renal function if his blood pressure wasn't under better control. I couldn't really understand why this elderly patient with so many comorbidities couldn't simply understand the lasting benefit on his longevity compared against a transient pleasure.
How about you? What do you counsel your patients when a life-saving medication is compromising your patient's quality of life? How about when your treatment priorities and your patients are in conflict?
It was at that point I realized just how much doctoring is truly a balance between improving patient outcomes and maintaining (or improving) a patient's quality of life. For the most part, those two ideals are aligned.
Heart failure is a great example – medications for CHF tend to improve not just what matters to us as doctors (MACE, readmissions, BNP, 6-minute walk distance, etc.) but also those things that matter to patients (quality of life, fewer symptoms).
But, every so often, we realize how the goals are actually working against each other. The more I looked for it, the more I found it – whether it was the patient who asked me to cut down the number of pills she takes every day (24 pills between morning and evening medications) or the one who was furloughed during the federal government shutdown and couldn't afford her sacubitril/valsartan and apixaban – it was all around me.
And, it got me thinking. We are so quick to give patients a laundry list of medications that are "evidence-based" and "goal-directed."
But, whose goals are really most important here? Ours? Or the patients? And, when the two goals are in conflict with each other, how do we remain mindful of the patient's values while educating them about the benefit of these medications so we can turn our misaligned goals into aligned ones or meet halfway?
When we all took the Hippocratic oath in medical school, there was verbiage, which translates as follows:
"I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."
While its clearly written and we all agreed to it, we sometimes tend to push our own agenda blindly on our patients fighting for their "benefit" and behave emotionally, from the heart rather than the head.
What we forget is that the "benefit" we can offer to our patients comes not only from reducing MACE, but also from understanding their goals and how we can improve both the quality and quantity of his/her life. Perhaps the "net clinical effectiveness" parameter we so often discuss at meetings should also include "quality of life."
I realized that to best help my patients I would have to look into my own heart and become comfortable with altering my definition of "optimal medical therapy" when it came to caring for my patients.
Payal Kohli, MD, FACC, practices at the Heart Institute of Colorado in Denver, where she treats a variety of cardiovascular diseases. She is also the lead physician of the Women's Heart Center.
Keywords: ACC Publications, Cardiology Magazine, Heart Defects, Congenital, Geriatrics, Hypertension, Pulmonary, Mineralocorticoid Receptor Antagonists, Calcium Channel Blockers, Coronary Artery Disease, Hippocratic Oath, Blood Pressure, Acute Coronary Syndrome, Schools, Medical, Federal Government, Quality of Life, Longevity, Patient Readmission, Angiotensin-Converting Enzyme Inhibitors, Heart Failure, Myocardial Infarction, Diabetes Mellitus, Treatment Outcome, Drug Interactions, Cardiopulmonary Resuscitation, Renal Insufficiency, Chronic
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