Thread by @ethanjweiss

I want to tell a two-part story. I'll allow that I have no way of knowing what is "right" here. I just want to share the story.

So I have a patient who is in his late 70's. He has extensive CAD with multiple stents and is post-CABG. He first came to see me a few years ago

At that time, he was having significant angina. He could not play golf or walk his dog which are activities he loved to do. We eventually took him to the cath lab where there were not many obvious or easy targets for intervention, so we elected to advance his medicines

Over the next few years, he did great. He was working out at the gym and playing golf and walking his dog!

Then, in August, his wife died.

His daughter called me to tell me he was not doing well. He was having chest pain, shortness of breath and labile hypertension

It was either late on a Friday or early on Saturday, and my first instinct was, he should go to the emergency room. I even told her to have a low threshold to take him. But I also said, that either way, I would see him early next week

He did not go to the ED and I saw him and his daughter in the office. He was so obviously sad. It was impossible not to see it. He described his symptoms and they were not really typical for CAD of CHF. He said he felt cloudy. He was taking a lot of Ambien for sleep

This is still just a month or so after the death of his wife of >50 years. Sitting there with him, it was so obvious that his problem was not primarily cardiovascular. I told him that what he was feeling was NORMAL and that this intense grief he is feeling can have many effects

I explained how it is normal to be depressed and what depression looks like. I explained that grief and emotional trauma can also cause physiological changes. I also just sat there and listened

Ultimately, I decided that my first instinct to send him to the ED was wrong. Of course he is high risk with his history, but here was this man who was so clearly broken emotionally. He very was obviously depressed (of course) and he was taking depressive medicines on top

I explained all this to him and decided that we'd do an echo mostly to reassure him and his daughter but also on the 1% chance that he had stress cardiomyopathy. I told them to call with any problems and walked them out...

Last night, I got an email from his daughter. I won't share the most personal parts...:

"I left today with a new dad - a man who felt so much better just being told that his symptoms were "normal" and that with time he would likely be ok.
We can't thank you enough!"

There are a lot of lessons here. There are too many lessons here. So which one do I take away?

Well the first is that there is no substitute (yet) for sitting face to face with a patient. My first instinct last week was to send him to the ED which may have triggered troponin, stress. test, cath...

Instead, after sitting with him, it was clear that his problem was not his (physical) heart. I won't get too corny, but I could not see the little tears in the corner of his eyes or their redness or his body position on the phone or even video

Also, as Dr. Tumulty said, "This brings us to one of the last but surely one of the most essential considerations of what it is a clinician does – a clinician spends a great amount of his working hour communicating with his patients...

...What the scalpel is to the surgeon, words are to the clinician. When he uses them effectively, his patients do well. If not, the results may be disastrous."

utmedhumanities.wordpress.com/2014/10/13/wha…

And lastly, a Tumulty thread from last year on this same speech...

https://twitter.com/ethanjweiss/status/908470991705186305

Brief follow-up note from my patient

“Ethan,
Thanks for the diagnosis yesterday. I was frustrated by a (hopefully)
once in a lifetime event..
Good to see you again
Sincerely...”

No amount of money, no academic rank, no grants, no awards can replace the simple joy I get out of these kinds of interactions. We are so very lucky