Springtime’s finally here.  Around my house this is the time of year when my seven-year-old daughter and I call upon our years of collective gardening experience and expertise to create chaos in our vegetable and flowerbeds.  Every year I seem to find new ways to take what should be a fairly simple and straightforward practice—till soil, plant seeds, add water—and create nothing more than a jungle of poorly blooming stalks, barren vegetable plants, and an unusually hardy crop of weeds.  Even the easy ones, such as tomatoes and cucumbers, end up as nothing more than a puzzle of fruitless vines.  This is Nebraska, for goodness sake, and I can’t even grow corn.

One thing we’re pretty good at, though, is foxglove.  This beautiful perennial is a favorite of my daughter’s and we plant it in front of our house year after year.  The pink, tubular blossoms look as if God had designed them with fairy tale illustrators in mind and could easily grace the pages of any work featuring brownies and sprites.  For me, the allure of this plant has more to do with chemistry than aesthetics.

The scientific name for the most common form of foxglove is Digitalis purpurea (the “digit” part of Digitalis connotes the human fingertip over which the delicate blossoms can easily fit) and it is from an extract of this genus that we acquire the commonly used cardiac drug digitalis, currently available as digoxin (Lanoxin, Digitek, Lanoxicaps).

Digitalis is a cardiac glycoside, a chemical that affects movement of sodium and potassium in and out of heart muscle cells and thereby indirectly increases the concentration of calcium inside the cell.  This leads to a couple of therapeutic effects that are quite favorable for patients suffering from various heart ailments.  Elevated calcium levels promote a stronger force of ventricular contraction—a particularly useful byproduct for patients with weak hearts and congestive heart failure.  It also leads to a slowing of electrical conduction in certain areas of the heart’s wiring.  In patients with atrial fibrillation or other rhythm disorders that lead to rapid heart rates, digitalis can slow the pulse rate to a more moderate pace.

The therapeutic effect of foxglove extract was first formally described by Dr. William Withering in 1785.  Ten years earlier, Withering, who plied his trade among the poorer and more destitute patients of England, was introduced to an uncommon folk remedy for dropsy (congestive heart failure) that “had long been kept a secret by an old woman in Shropshire who had sometimes made cures after more regular practitioners had failed.”

His 1785 paper on the use of foxglove in the treatment of dropsy had limited impact on local medical practices at the time but years later makes for fascinating reading.  In it he confesses to the use of a decidedly unscientific method for testing the dose of the drug needed to achieve the desired action in his patients, all the while avoiding the nasty, somewhat toxic adverse effects.  You see, digitalis is also a potent poison when used in excess (in fact, one of the most notorious serial killers of the last twenty years was a nurse who used digoxin as his weapon of choice to claim the lives of at least 45 victims).

Dr. Withering would blend the leaves and petals of the plant and distill them into a soupy mix that he would feed to his patients.  Over time (and with several notable failures) the good doctor learned to give just enough to bring on nausea, weakness and a peculiar change in vision (the colorful world starts to fade to shades of yellow).  The goal of therapy was to saturate the patient to within a sip or two of fatal overdose.  We now recognize these symptoms as the final stages of severe digitalis toxicity and try to never let our patients get even close to Withering’s benchmark.  Thanks to precisely formulated dosing and the ability to test blood levels of the chemical, the problem of digitalis toxicity has become quite rare.

Once Dr. Withering’s cure for dropsy spread to the wealthy upper crust of London it became an smash hit in the world of botanical pharmacopoeia, even inspiring a ode to the chemical by the grandfather of Charles Darwin.  The elder Erasmus Darwin was a physician and contemporary of Dr. Withering and jointly consulted on numerous dropsy patients:

Pale Dropsy rears his bloated form, and pants;
"Quench me, ye cool pellucid rills!" he cries,
Wets his parch'd tongue, and rolls his hollow eyes.
Divine HYGEIA, from the bending sky
Descending, listens to his piercing cry;
Assumes bright DIGITALIS' dress and air,
Her ruby cheek, white neck, and raven hair.

Erasmus Darwin

Historians have argued whether Mr. Darwin was himself dipping into the foxglove stew or if he was just plain crazy as he penned some of the most regrettable stanzas in the history of botanical poetry.

I, on the other hand, have a deep appreciation for the beauty of foxglove on both an aesthetic and chemical plane.  Thus, in honor of this plant and its place in history, as well as a nod to Drs. Withering and Darwin, I’ll end this week’s post by offering the literary world the second great piece of digitalis poetry:

Ode to Foxglove
by Eric Van De Graaff

Now my heart is weaker,
Breathing getting bleaker,
Swelling in my hallus--
Need some digitalis.
Seed a planter box of
Tasty, juicy foxglove.
Water, weed and tend,
Leaves and blossoms blend.
With one gulp I swallow
Hope effects will follow.
Dose it right it’s great,
Too much seals your fate.
For many sick and ill
A truly useful pill;
But if you’re dumb like me
And brew a foxglove tea
The only thing you’ll see
Is it’s toxicity.
Dizzy, weak and mellow,
World is turning yellow,
Heartbeat now so slow,
To the ground I go.
With final words I jot
A lone, last dying thought:
Why ever did I raise these?
Shoulda stuck with daisies.

The New England Journal of Medicine just published a study that followed the course of nearly four hundred thousand patients at 663 American hospitals who were referred for elective diagnostic coronary angiography.  The typical patient in this mix was someone with risk factors for coronary disease who had undergone a stress test suggestive of possible blockage.  None of the patients had a diagnosis of prior heart attack or coronary artery disease.

In this group, 38% were found to have significant coronary blockage (a narrowing that’s worth fixing by angioplasty/stenting or bypass surgery) and 23% had blockage that was not severe enough to cause obstruction to flow.  The remainder (39%) had absolutely clean coronary arteries.

The general verdict among medical pundits is that we are performing too many coronary angiograms and that the testing we do to determine need for angiography (i.e. stress testing) is inadequate to allow us to screen for those patients most in need of this procedure.  After all, if only 38% of patients actually need to have something fixed, then 62% were exposed to the risk of the procedure with no apparent benefit.  What follows are higher medical expenses, unnecessary risks and avoidable emotional stress to the patient.

The publication isn’t so much a blemish on the coronary angiogram as it is on our ability to determine who should actually get sent for a cath.  Normally, a patient with some type of chest discomfort and risk factors for coronary disease will see a cardiologist and subsequently undergo some type of stress study to determine if there is impairment to blood flow in any region of the heart muscle.

I have previously bored my readers with a lengthy diatribe about the uses and limitations of stress testing and I’d encourage you to read it again if you’re suffering any form of insomnia.  The bottom line is that the science of screening for coronary disease is very inexact.  At this point, and for the foreseeable future, there is no test that will easily differentiate chest pain that arises from a coronary blockage from chest pain of noncardiac provenance.  As a cardiologist, the best I can do is listen intently to the description of the symptoms, assess the patient in his or her entirety (risks, genetics, bad habits), and rely on stress testing that at times seems only slightly better than flipping a coin.

As an aside, the world of medical screening has had its share of black eyes recently.  Take testing for prostate cancer, for example.  Just last year the New England Journal of Medicine published a comparison of the two main screening tests for prostate cancer and the ability of each to cut the risk of death from this common malignancy.  The high-tech laboratory assay prostate specific antigen (PSA) and the decidedly low-tech digital rectal exam both did an equally poor job of lowering the death rate from cancer among asymptomatic men.  This is bad news for any primary care doctor who, like me, feels that running the tip of their finger over the top of your prostate is actually a useful mechanism for determining the presence or absence of cancerous cells lurking inside this well-buried gland. 

A very interesting opinion, authored by Dr. Richard Ablin, the inventor of the PSA assay, appeared in the New York Times last weekend and criticized the fact that we in the medical community have embraced the generalized use of PSA as a screening test:

“I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”

Now back to the subject of coronary angiograms: I take some exception to the idea that we are burdening the population with unnecessary trips to the cardiac cath lab and I think we can view the results of this recent study through a slightly different lens.

In this population, 61% of patients were given the firm diagnosis of coronary artery disease (the 38% with high-grade blockage and the 23% with less severe narrowing) and I would argue that the coronary angiogram—despite the fact that it is an invasive test with possibly serious risks—served these patients well.  Faced with the understanding that their blood vessels are prone to cholesterol build-up and narrowing, these patients will be treated more aggressively for blood pressure and lipid control, will have additional incentive to give up smoking and start exercising, and may pay more attention to diet.  Ultimately, I have to believe that this group of individuals will suffer fewer heart attacks and strokes as a result of risk factor modification.

I would argue that even those patients with normal arteries received some benefit, provided they didn’t suffer any complication of the procedure.  By having the “gold standard” test, they learned that the symptoms they are suffering are not related to the heart and are thus not something that could potentially lead to life-threatening complications.  There’s a certain value to the peace of mind that this knowledge provides. Unfortunately, there’s no way to factor this ephemeral reward into research studies such as these.

I agree that we need better testing—better testing that is inexpensive, low-risk and noninvasive—but this will not be coming any time soon.  Until then we as doctors will keep doing our best and ask for understanding from those patients we send on an unnecessary tour of the cath lab.

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.