Every doctor should spend some time as a patient.

I’m not claiming an original idea here. Countless essays by physicians and ethicists have espoused the same suggestion, maintaining that doctors can never fully sympathize with their patients until they walk a mile in their drafty, open-back hospital gowns, IV pole in tow.  Some of you may even recall a movie made about the subject.  “The Doctor,” starring William Hurt as an unabashedly arrogant surgeon laid low by throat cancer, is a sappy, over-the-top study in stereotypes that follows the eponymous character through his transition from egotist to humanist.

The funny thing about this movie for me was the timing of its release.  In 1991 I was a third-year medical student just starting my clinical rotations when I abruptly transitioned from caregiver to care-receiver.  I was riding my motorcycle one Sunday evening when I was clipped at high speed by semi-trailer truck.  If I think about it hard enough I can still hear the crash of the bike and feel the impact of my head against the side of the truck.  I was flung far from the collision site and came to a stop up on the sidewalk where I quickly wiggled my toes to make sure all those neural connections I’d studied in neuroanatomy were still intact.

The first thing I noticed was that my blue jeans were no longer blue, but rather a dark, sticky purple all the way from my waist to my boots.  The pain began to set in as the police and ambulance arrived and I nearly passed out from the shock of it all by the time I arrived at the emergency room.  I begged the doctor for a painkiller but he refused, telling me I had to wait until he was able to complete a thorough neurological assessment.  Attempting to prod him into action, I quickly ran through all the cranial nerves, the motor and sensory efferents and afferents, and even offered a dermatome-by-dermatome summary just so he’d expedite his examination and order up some much needed relief.  It was at that point he conceded the soundness of my white matter and proffered a cocktail of narcotics that began to blunt the misery.

My relief was short lived.  Next up for me was a series of x-rays that required me to contort my legs into unnatural configurations (developed, I’m sure, by self-loathing yogis) while the technician shot the pictures.  Because I’d suffered so much soft-tissue trauma to my thighs and lost so much blood the surgeon requested an angiogram to assess the damage to my femoral arteries.  Thinking back on it now I find it ironic that angiography—using a catheter to inject dye into a vessel—would ultimately become one of my bread-and-butter procedures despite my ignorance and utter confusion at the time (under the best of circumstances a combination of morphine and panic tends to cloud one’s interpretation of events).  I simply couldn’t figure out why all this testing was necessary.

It was about midnight when they rolled me into surgery and it took several more hours before I was finally deposited into the room that would become my resting place for the next few days.  Once I was released from the hospital I spent a couple of weeks under the care of my parents (feeling much like a helpless infant) before I could ambulate well enough to move back to my own apartment.

As I recovered enough to resume my life some friends of mine took me out to see the movie “The Doctor.”  The lessons I was supposed to take away from the film seemed trivial and contrived compared to those I had just experienced.  Here are a few insights I gained without help from Hollywood:

• A universal constant about being a patient is vulnerability and loss of control.  Once I entered the hospital I lost power over nearly everything: what I ate, what I wore, how much activity I was allowed, whether I was permitted to get up to the bathroom—it was all dictated by someone else.  I sing the praises of whoever invented the PCA pump.  This handy device allows you to dose your own IV pain medications but prevents you from overdoing it.  It’s one of the few things that I actually had some control over.
  
  
• You can’t do anything productive when you’re lying in the hospital.  As a medical student I had stacks of books I was supposed to be studying and nothing but time on my hands—it should’ve been the perfect arrangement.  I found, however, that the options offered to me—either endure the pain or take the narcotics—put me in a state of mind that prohibited any meaningful concentration.  If you’re wondering how studying in this environment might go, just try this little experiment: whack your toe with a hammer then try to memorize the Krebs citric acid cycle.  Step 2: try popping a couple percocet and then map the physiology of the nephron (with that subject sedatives become superfluous).  Either option didn’t lend itself to studying, so I just sat there and watched television.
  
  
• Everything hurts.  I got stuck with needles, had dressing changes, physical therapy—even going to the bathroom—and none of it was benign.  Just rolling over in bed was excruciating.  At no point did anyone say those magic words “This won’t hurt a bit,” and thankfully not.  I’m sure I’d have launched from my bed and strangled them with my IV tubing out of sheer spite for their blatant disingenuousness.  Oh, and one final pearl: Foley (urinary) catheters hurt more coming out than they do going in.
  
  
• Modesty is a luxury that patients don’t get.  After a couple of days of wearing breezy gowns I asked my family to bring me a pair of sweat pants.  What a relief.
  
  
• You become dependent on others for everything.  Even weeks after the accident there were things I couldn’t do on my own.  I still remember vividly the first time I was able to haul myself out to my car and take a drive by myself.  The sense of freedom and accomplishment was overwhelming.
  
  
• The not knowing may be the worst of all.  The day after the wreck the attending surgeon came to my bedside to give me a wrap-up of my injuries.  As he finished describing the anatomical distortions I’d suffered he confessed that he didn’t know if I’d be able to run again.  Walk, yes, in time. But, knowing I was a runner, he sadly shared with me that I’d suffered too much damage to my adductor muscles to be able to run any distance.  I digested that information over the next few days and slid into a deep depression as I contemplated my future limitations.

It turns out my concerns were exaggerated and unfounded.  Over time I mounted a complete recovery and it’s for this reason that I remain incapable of fully understanding the plight of many of my patients.  Sure, mine was a bad accident with plenty of pain, but it was no cancer, no disabling stroke, no permanent impairment.  It was just enough to provide me with an education that my medical school instructors couldn’t.  My bones and muscles have long since healed and forgotten the experience from nearly two decades ago, but, thankfully and to my benefit, my mind hasn’t. 

Every time I consult on a patient I’ve not previously met I have to go through a series of questions to obtain what we call a medical history.  On some people, especially the young and healthy ones, this is a very quick process (What medical problems have you had?  None.  What surgeries have you had?  None).  In older, chronically ill individuals it is a bit more laborious (What medical problems have you had?  How much time you got, Doc?).

When I provide a cardiology opinion on a patient’s condition I need to take into account all the pertinent information I can obtain.  Such information includes occupation, heritable illnesses, and recent non-cardiac symptoms.  For the purpose of the medical record (and to satisfy increasingly finicky insurance companies) I have to include a lot of material that is not particularly pertinent but is required to produce a thorough dictation.  A detailed family history in a 93-year-old patient having a heart attack is an example of information that really doesn’t aid me in formulating a treatment strategy.

Some patients are very good at providing details of their personal history whereas others are more of a challenge.  I once had a mildly demented, elderly patient brought to me by his family who claimed he had never had any heart problems.  I had no reason to doubt this as I looked over his medication list and saw no cardiac drugs.  When I examined his chest I was surprised to find a scar running down his breastbone and a lump below the left shoulder that looked suspiciously like a defibrillator.  “Oh that,” the family replied, “I guess he’s had a couple surgeries.”

The opposite end of the spectrum is the patient who brought me a hundred-page typed manuscript detailing every medical exam, test, drug, and symptom he’d ever had.  The only diagnosis missing from the voluminous dissertation was obsessive compulsive disorder.

I have to believe that patients get a little tired of recounting the same details to every doctor that comes to see them when they enter the hospital.  What medical problems have you had?  What about surgeries?  Medications?  Allergies?  Over and over.

What we need is some centralized electronic medical record that is available to you and any doctor you’d like to share it with.  The first time you compile your medical history you could go through the lengthy litany of questions and then never have to answer them again.  Sure, things change all the time, but there are some parts of your health history that are pretty much set in stone.  Never again would you have to recount how your Aunt Melba died of gangrenous onychomycosis, or how you came down with beriberi while trekking through the Belgian Congo, or how you once had a hallucinatory reaction to a dose of Anusol.  These pearls of your medical past would be available for all to assess and would never again require repeating.  Of course security for such information would have to be airtight.  No one (especially nosy employers or insurance companies) would be allowed access without your explicit permission. 

The advantage of such a system is obvious.  It saves you and your doctor time and doesn’t rely on your sometimes-sketchy memory.  No longer would you be subjected to unnecessary repeat testing just because a doctor’s office doesn’t have your most recent results.  Pertinent points of your history would never be forgotten or overlooked. 

The good news is that many such electronic health records already exist.  The bad news is that none of them gracefully combine ease of use and meticulous thoroughness.  I test drove one just the other day to see how good it is.  Google Health (brought to you by the same people who bring practically everything else to you) is a nice, simple system that allows you to enter your medical data and store it on their secure site.  Then, from anywhere in the world, you can simply log on and retrieve whatever information you’ve stored.  Stuck in Antananarivo with a nasty recurrence of malignant logorrhea?  Hop on the net and in seconds your doctor will have every detail he needs to get you on your way.

The site starts by querying you about demographics and quickly moves into prior medical problems, surgeries, medications and the like.  If you happen to have had tests or procedures done at a select few hospitals in the U.S. (such as the Cleveland Clinic) you can request and upload those records to your collection (sorry, Alegent has yet to link into this system).  Numerous pharmacies allow you to access your prescription history and add it to the mix.  For a fee (they quoted me $98), a third party affiliated with Google Health will track down records from other sources for you, digitize them, and add them to your file.  The website also helps you search for a doctor in your area and you can arrange to have your profile forwarded to his or her office.

The down side is that you have to be pretty computer savvy to get this up and rolling, and it works best for patients with a fairly uncomplicated medical history.  For some of my patients getting all the complex twists and turns distilled down to this antiseptic site is a bit of a daunting task.  Of course, precisely those patients are the ones who’d benefit most.  The site also has no place for things we doctors need, such as family history, occupational exposures, and unhealthy habits (smoking, drinking, carousing, being a Sooner fan).

Also, what if you want to see a doctor but don’t want all aspects of your past made available? What if you did inhale when you were “experimenting” back in the sixties?  That information you may want released to your pulmonologist but not necessarily to the guy doing your Botox.  I saw a patient just last week who explicitly asked that I not review his prior dictations and testing so that I could approach his case with a fresh, unbiased perspective.  From what I can tell Google Health doesn’t allow you to send out a selectively amended version of your record.

Give it time and I think we’ll see some form of centralized health record rise from the sea of chaotic confusion that we currently rely on.  At that point I will finally be able to spend more of my time focusing on your immediate problem and less on the twentieth recounting of your 8th grade appendectomy, all the while having access to all critical details of your past.

As you probably already know, former president Bill Clinton recently underwent a “heart procedure” upon his return from a visit to Haiti that the press later clarified as angioplasty and placement of a stent.  Mr. Clinton used to have quite a reputation as a man who never met a greasy hamburger he didn’t like and was rewarded for his habits with coronary bypass surgery in 2004.  Nowadays, things are a little different around the Clinton household—from what I can tell he has given himself over to a healthier, more ascetic lifestyle with more time spent on the treadmill than at the drive-through. 

After the procedure the ex-president (and current UN envoy to Haiti) had nothing but praise for his doctors, but reserved his most flattering comments for the technology itself:

"It's miraculous with the stents," Clinton told reporters, referring to the devices used to clear a clogged artery during the operation Thursday.

Clinton, 63, was speaking publicly for the first time since entering the New York Presbyterian Hospital. He was released earlier Friday.

"I didn't (take) any sedatives or anything, so I was alert. I wanted to watch it. I got to watch it on the monitor," he said.

Since catching wind of this story I have tried desperately to find a way to spin this into a clever yet respectful blog topic that would both entertain and inspire my readers.  Something bold, something different—more than just a recitation about the merits of coronary stenting.  Instead of my usual tired commentary I wanted to find a truly inspired angle.

But then I thought, why break with tradition?  So, here you have it—everything you ever wanted to know about coronary stenting but never learned in junior high health class.

First off, a little nomenclature (that I’ve found is frequently misunderstood among non-medical people):

Angiogram (synonyms: heart catheterization, cardiac catheterization, cath) is where we run a small tube (catheter) through the artery to inject dye into the coronary arteries to take pictures.  With this procedure we don’t fix anything.  It’s more or less just a fancy x-ray with dye in the arteries.  That’s the difference between this and . . .

Angioplasty (synonyms: balloon angioplasty, PTCA), where we actually expand a balloon inside a blocked vessel to open a passageway for blood to get down the clogged artery.  Up until about 15 years ago, before the widespread use of reliable stents, most patients had angioplasty alone.  The problem with angioplasty alone, though, was that the vessel frequently closed up again within 6 months and the patient had to return to get the whole thing done again.  While this was good for the cardiologist wanting to make payments on his second home in Aspen, it wasn’t so good for patients.

Angioplasty with stenting is the most common approach today and this is what I’ll explain now.

Have you ever taken apart a ball point pen that has one of those little tiny spring thingies in it?  Now picture the spring, but very small, looking more like chicken wire and made of really, really expensive metal.  Good.  Now that you have that image in your mind click on this hyperlink to see if I did a reasonable job of explaining the appearance of a coronary stent.

To place a stent, the interventional cardiologist first performs angiography to take a picture of the blocked vessel so that he or she can make an estimate of how best to fix the vessel (please click here to see how not to do this).  At this point the operator will thread a very small and flexible wire into the coronary artery and snake it through the narrow center of the blockage.  He* then advances the wire as far out into the vessel as possible. 

Using the wire as a rail the doctor slides a small catheter equipped with an inflatable balloon out to the point of the blockage.  The balloon expands and all the cholesterol and platelet gunk simply gets squished outward into the wall of the vessel (click here for a nice picture or here for brief video).  He will then repeat the process, but this time with a balloon that is wrapped with a non-expanded stent.  The balloon inflates and the stent expands.  The doctor deflates and removes the balloon and the stent stays in place.  If he’s satisfied with the final result he’ll remove the wire and catheter and the patient is returned to the recovery room.  The whole process generally takes less than 45 minutes.

When I first started out in cardiology I was a little surprised to learn that we don’t really clean out the cholesterol build-up from inside the artery when we fix it.  This is not the roto-rooter job you get from a plumber when your pipes are clogged.  All we do is use the stent to compress the unwanted plaque into the vessel wall and pin it out of the way with the stent.

The process of expanding a balloon is actually quite traumatic to the vessel wall (on a microscopic scale) and triggers a cascade of cellular reactions that makes the body want to heal the vessel with something akin to a scab.  That sort of response is good for a scraped knee, but not so desirable inside a vessel that measures only a few millimeters and provides flow to what is arguably one of the more important organs of the body.  A combination of the metal stent (to prop open the vessel) and the use of anti-clottting drugs such as aspirin and clopidogrel (Plavix) allows the vessel heal without unnecessary narrowing to the artery.

If done right the chance of a modern stent closing down is very, very low.  In my experience a patient with a previous stent is more likely to develop a new blockage elsewhere in the circulation than inside the stent.  Patients also recover very quickly from this procedure.

An article from February 13 reported on Mr. Clinton’s quick recovery and eagerness to get back to full activity.

"I feel great. ... I even did a couple miles on the treadmill today," Clinton said, speaking to reporters in a leather jacket from the driveway outside his home. He said doctors advised him "not to jog but walk. Not to walk fast up steep hills for a week."

While some commentators have suggested that Clinton needs to tame his active schedule I think is the wrong approach.  If I were his doctor—knowing what I do about the success of modern stents—I’d encourage him to get back into life at full speed (especially on the treadmill).  Since he’s become the go-to guy for massive natural disasters I don’t think we can afford to have him sidelined for long.

*Sexism alert:  Please note how I’ve switched from the more correct “he or she” to the less verbose “he” when I refer to the cardiologist.  I don’t mean to denigrate the other half by eliminating the “she,” but since only 17% of cardiologists in this country are women, and of those only 10% specialize in stent placement, I’m probably statistically on safe ground in adopting the masculine pronoun to describe my hypothetical interventionalist.

Last week one of my patients brought his 5-year-old granddaughter with him to his appointment.  When I came into the exam room the child was visibly disappointed to see me and told her grandpa that she didn’t believe I was a doctor because I wasn’t wearing a white coat.  Once I retrieved my lab coat and returned to the room I got a clear nod of approval from my young critic (this is why I didn’t go into pediatrics—way too much pressure).

I really don’t like white lab coats.  They’re hot, they snag on doorknobs and edges of desks, and stuff dumps out of the waist pockets when I sit down.  Moving around the ICU in a long lab coat is like touring a china shop in a poorly tailored trench coat.  Add to this my own perception that with my thin frame I can’t really pull off the “doctor look” in a lab coat. I look more like somewhat trying to look like a doctor—like I’m going to work wearing a Halloween costume.  Some patients also react somewhat unfavorably to the attire.  White coat hypertension is a well documented syndrome of artificially elevated blood pressure in patients nervously sitting in front of their white-clad doctor, and my heart patients don’t need any more problems than they already have.

In training I relied heavily on the oversized pockets as a repository for my many medical handbooks, but the invention of the PDA and smart phone—with their ability to provide immediate electronic access to a library of reference sources—has largely obviated my need for pantry-sized pockets. 

When I started medical school I was pretty excited to get my first lab coat.  Wearing the white coat around the hospital as a third-year student was a pretty big deal.  Nowadays medical schools have managed take this one step further with “white coat ceremonies” where earnest professors robe their medical trainees in the holy white vestiges of Hippocrates (I graduated medical school a few years before this silly trend began).

The white coat has been the visible symbol of medical authority ever since the medical profession hijacked it from their scientific colleagues over a century ago.  Prior to formalized medical training in the United States the early practitioners of medicine were viewed as quacks and mystics and needed a visible display of their new trend toward healing through the scientific method.

The public has come to expect their medical professionals to be wrapped in white cotton, largely thanks to the image of the fictionalized physician that has been formally codified in every movie and television show from General Hospital to Gray’s Anatomy.  Marcus Welby adhered strictly to school of formal fashion and would have never deigned to appear clad only in khakis and a polo shirt.  Outside the world of Dr. McDreamy the reality is not much different: scientific studies on the subject confirm the theory that patients perceive their physician to be more competent and capable if he or she appears in a white coat.

Well, times may be changing.  It turns out that the white coat is coming under increasing scrutiny and criticism, and not just by people like me whose complaints are more of a sartorial nature.  Numerous reports in the last decade demonstrate that the lab coat—with its oversized sleeves and overcoat design—tend to make more contact with our patients than we’d like.  Resourceful microbiologists and infectious disease specialists have taken to culturing the garment and finding a frightening world of microbiological flora that we are dragging from patient to patient.

In one such study researchers randomly sampled the lab coats of dozens of attendees at medical and surgical grand rounds at a large academic hospital.  After culturing the sleeves of these residents, interns and medical students, they found that 23% of the 149 volunteers were contaminated with Staph aureus, a common but problematic pathogen that is currently to blame for many hospital-acquired infections.  A significant 18% of white coats were colonized with the far more virulent and difficult-to-treat multi-drug resistant variety.  You can find public restrooms more sanitary than this.

Just last summer the American Medical Association voted on a motion to recommend banning the venerable white coat from use inside hospitals.  They cited numerous studies (like the one above) that show that we practitioners could cut back on the rate of hospital infections if we’d just give up our Typhoid Mary attire (oh, and do a better job of washing our hands—but that’s another story).  If they follow through with their recommendation they will be taking a cue from our relatives across the pond who’ve already banned white coats as part of their far more aggressive “bare below the elbows” campaign than prohibits coats, long sleeves, watches, jewelry, and neckties. (Neckties?  Sure.  According to one study half the ties worn by doctors in one New York City hospital contained bacteria known to cause hospital infections.  And how often do you send your ties out for laundry?)

So, are white coats destined to suffer the same fate as nursing capes and fade into extinction?  Despite my personal fashion and comfort misgivings and the dire warnings from our microbiology colleagues, I actually hope not.  Somewhere we have to find a compromise between the science of antisepsis and a respect for tradition and image.  For, like the child in my office, when I see physicians sporting well-pressed, bright white coats I have to admit they look wiser, more capable, and, in the end, more doctorly.