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A Piece of My Mind
May 14, 2019

Listen to Your Heart

Author Affiliations
  • 1Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania
JAMA. 2019;321(18):1769-1770. doi:10.1001/jama.2019.5165

On an ordinary Thursday morning this past February, I ate breakfast at home and then drove to the train station to travel to Philadelphia to go to my clinic at a Federally Qualified Health Center downtown. This particular Thursday, I felt a little funny as I was preparing to leave my home with some tingling in my left arm, which I thought was related to how I had slept. On arrival into Philadelphia, I knew something else was going on because I found it hard to lift my left leg to walk up the stairs from the station to the street. I limped the 4 blocks to my office, took an aspirin, and called a colleague who immediately came and got me an Uber to a nearby hospital.

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    1 Comment for this article
    The Heart of Medicine
    Ken D Winkel, MBBS BMedSci PhD | 1. School of Population and Global Health & 2. Medical History Museum, Faculty of Medicine, University of Melbourne, Victoria, Australia 3053
    As students, we absorbed the stories of our University lecturers about the art and science of medicine. Loosed onto the wards, we gathered patient stories and were absorbed into the history of that institution. We slowly became narrators of our professional story when we moved, as actants, into laboratory and operative theatres of medicine. Graduated, we became daily story tellers ourselves. At first, we were anxious and uncertain, too fast or too slow. Then, with experience, came confidence and finally, with fatigue and focus, conciseness.

    At some point, these meta-narratives merged - as busy midlife practitioners, or elderly
    family members, perhaps, became a patient in those same institutions. We knew a personal story and heard the abbreviated medical story, but no-one knew the full story. Especially the family story. Worse, we noticed, the doctors appeared not to be listening or really looking. It reminds us of the old veterinary joke about who is the real doctor – we who treat one species or they who treat all species ? Vets do not have the ability to speak with their patients, but they can look, listen and feel.

    Dr Kostman narrates his story about listening but also about memory. At the heart of medicine is personal, family and social history; genetic and epigenetic, microbiome and metabolome all combined in molecular memory manifest as health status here and now. Too often history taking is contextually abbreviated or, worse, truncated, around the prevailing disease algorithm. Patients are not gadgets and the art of medicine is not an app. Common things occur commonly, but a zebra is not a horse. Unrecognised, rare diseases can kill, sometimes quickly. How safer medicine would be if we did not flip straight to the index but rather, started our reading at the first page. Then we might discover that what is rare for most, is common for our patients’ family. Dr Kostman made his diagnosis by listening to his heart, not to his familial memory.

    My final examination, in my final term as a medical student, was a short case in a cardiology ward of a cardiothoracic specialty hospital. The middle-aged patient was sitting up quietly in his bedclothes. The cardiologist asked me to examine his cardiovascular system. No rhythm disturbance but there was an obvious, even for me, mid-systolic click. Was it followed by a late systolic murmur ? The mitral value was implicated. What might be the cause, the Professor asked ?

    I knew about mid-systolic click syndrome, Marfans, Graves disease, connective disease disease…I paused, my mind froze with uncertainty, what could it be ? His question hung in the air, gleaming with the intent of an executioners’ blade. He was the head of cardiology, an internationally acclaimed physician-scientist.

    I was silent. Defeated. I had not seen the patient before but had heard the distinct click of the prolapsed mitral value in others. It was frequently incidental: a reassuring clear sound for uncertain medical student ears. This was an answer straight out of the textbooks but, alas, not from my walks on the wards. The patient was an aboriginal Australian. He was the first such patient I had seen in the hospital. What was very common for his family experience, was unknown to me, an archetype European Australia. Same continent, different worlds. He had rheumatic heart disease. Compared to non-aboriginal Australians, aboriginal people are 50 times more likely to develop rheumatic fever and heart disease. So listen to your patients’ story, therein lies the answer to most of medicine.