A Reluctant Interventionist

My middle-aged patient had all the risk factors for a heart attack: high blood pressure, borderline diabetes, high cholesterol, a strong family history and a sixty pack-year smoking habit.

His stress test was positive and the medications that were started in the hospital weren’t controlling his chest pains.

The cardiologist at Cityside Cardiovascular Consultants who took my call, Joe Altman, sounded tired. I have known him for over twenty-five years. He always impressed me by looking beyond just the acute problem of where a patient’s coronary blockage is and how to get rid of it.

Joe has the mindset of a generalist. He pays a great deal of attention to prevention and to each patient’s entire medical history. More than once he has contacted me to make sure I am taking care of a patient’s borderline thyroid function or some other problem most cardiologists wouldn’t concern themselves with. He has never recommended testing or interventions in a knee-jerk fashion, but always considered the patient’s entire case history. I have great respect for his conservative approach.

Joe, the senior member of his group, has seen younger cardiologists replace him in the catheterization laboratory. These days, he is often the one who takes calls from primary care doctors in the community who call with questions or urgent referrals.

“So, has he quit smoking yet?” was Joe’s first question after I finished my brief case presentation.

“He’s working on it, started bupropion today,” I answered.

“Better make sure he does… Well, I guess we’re obligated to cath him.” He paused for a moment, then sighed:

“I’ll tell’ya, I have less and less sympathy with the ones who keep smoking and come back here again and again to have us fix them up, and then go back and do the same thing all over again.”

I was taken aback a little by the emphatic frustration at the other end of the line, but not entirely surprised. Dr. Altman, probably ten years my senior and perhaps nearing retirement, must be looking back at his career. He must be thinking of all the expensive procedures that helped Cityside Cardiovascular Consultants build their magnificent new headquarters on the riverbank outside the city, yet wondering how it is that last-minute interventions seem so much more glamorous than the primary care and public health efforts to avoid and prevent heart disease in the first place.

He should have been a Family Practitioner, but I am grateful to have had him as my consultant cardiologist all these years.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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