Risk factor: The stranger will see you now

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April 10, 2004, 1:35AM

Risk factor: The stranger will see you now

By JAY NEUGEBOREN

Two surprising medical studies -- one questioning the value of so-called

good cholesterol and another finding that extremely low levels of

cholesterol may reduce the risk and severity of a heart attack -- have

put the debate over coronary disease back on the front pages.

And while any new scientific knowledge is, of course, a good thing, 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.

Consider my experience. Five years ago, at the age of 60 and without any

conventional risk factors or symptoms, I received a diagnosis of

coronary artery blockage -- over the phone, from a cardiologist 3,000

miles away -- and underwent emergency quintuple bypass surgery.

Two doctors had examined me in the previous months (I had been

experiencing some shortness of breath and a burning sensation between my

shoulder blades), but they failed to discern my problem. This may have

been somewhat understandable.

For the previous 25 years I had swum a mile a day and regularly played

tennis and basketball. I had never been a smoker. My cholesterol and

blood pressure levels were normal. And, at 5 feet 7 inches tall and 150

pounds, I was perhaps five pounds heavier than I was in high school.

One of the doctors performed an electrocardiogram and an echocardiogram

and diagnosed a viral infection of my heart muscle. Fortunately, I had

also been talking frequently to a childhood friend who was the former

chief of cardiology at Cedars-Sinai Medical Center in Los Angeles. When

I told him that my cardiologist thought the problem was viral, he

replied, " It's not viral -- I want you in the hospital as soon as

possible! "

Within a few days I was admitted to Yale-New Haven Hospital, where an

angiogram revealed that two of my three major coronary arteries were 100

percent blocked, with the third 90 percent occluded. In a

six-and-a-half-hour emergency operation, my life was saved.

Since then, I have been thinking: as miraculous as the technology is

that saved my life, if not for the clinical judgment of an old friend

who took the time to consider my entire case, all the medications and

machines in the world would have been useless.

In cardiology, I've learned, getting the diagnosis right is no simple

matter. If you add up all the commonly known risk factors -- smoking,

high cholesterol, high blood pressure, obesity, lack of exercise,

genetics -- they account for only about half of heart disease cases.

Moreover, according to the American Heart Association, 50 percent of men

and 63 percent of women who die suddenly from heart disease have no

previously known symptoms.

Although baby boomers tend to obsess about cholesterol scores the way we

used to obsess about SAT scores, such figures are often meaningless or

misleading. Add to this the fact that the way doctors are now taught,

and the way the health care system is now run, have undermined the

traditional doctor-patient relationship.

Not only do doctors have less and less time to meet with us, but, given

the vagaries of health insurance, the doctor we see one time may not be

the same doctor we see the next time, and so we often remain strangers

to one another.

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 mindset has

become, `Well, the tests will tell me anyway, so I don't have to spend a

lot of time listening.' "

This, I suspect, was the mind-set I ran into. I was seemingly healthy,

two doctors who examined me failed to discover the gravity of my

condition, and I nearly died.

So, while it is surely important to pay attention to cholesterol

research and advances in technology, it might do at least as much good

if hospitals and insurers would simply give doctors the time to know and

hear us.

The dictum of the great physician Osler -- listen to the patient

and the patient will give you the diagnosis -- still holds true.

Neugeboren is the author of Imagining : My Brother, Madness and

Survival and Open Heart: A Patient's Story of Life-Saving Medicine and

Life-Giving Friendship.

http://www.chron.com/cs/CDA/ssistory.mpl/editorial/outlook/2497562

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org