Today we saw a patient, a man in his mid-50s, sent over directly from the stress-testing unit because his stress test was so strongly positive. Some 20 years ago he had one episode of angina, which led to angioplasty. He has been asymptomatic ever since then. Six months ago he decided to amend his sedentary habits, and has been working with commendable effort to change his diet and take regular exercise.

The intern and I got this history from him. Then Dr. B came in and pulled up the stress test results on the VA computer, and gave the two of us a lecture on the significance of EKG changes during stress testing. After about five minutes, he stopped to talk to the patient. Like this: “You understand that your stress test is significantly abnormal, and you have other risk factors, such as history of smoking, obesity, hyperlipidemia, and positive family history. We need to do a cardiac catheterization. Do you agree to this test?”

And of course the patient didn’t agree at all. He is one of the more involved patients I’ve seen in the VA: he had the correct terms for all of his medical history, he had spontaneously decided to take responsibility and make “lifestyle modifications,” as we say, and by the look in his eye he wanted to have some say in the plan of care. He argued that he had only recently started exercising seriously, and that he wanted to take some more time to work on his lifestyle changes, and see if those wouldn’t help.

Now, he didn’t understand what we did: that with a stress test like that, with major EKG changes and no symptoms, the fact that he felt fine and had no symptoms for the last 20 years was actually scarier than if he had had some warning signs.

But he didn’t understand because we – Dr. B – didn’t explain.

So then Dr. B spent a while trying to explain, and not really getting through to the patient, and the intern tried some too, and seemed to be communicating better. Finally the patient agreed, mostly because there were three of us in white coats standing in the room telling him that he absolutely had to do something, and we obviously weren’t about to leave the room, end the encounter, or change the subject, until he agreed.

I’m frustrated. We just forced the patient to do something he doesn’t understand and doesn’t truly consent to, and this is a patient who I think is intelligent and interested enough that he could understand if it had been gone about the right way. But, on the other hand, he is at serious risk for a sudden, fatal MI, with no warning signs. And now he’s going to get the next necessary step in screening/trying to prevent that. That’s good, right?

I was trying to think how I would have said things differently. I think the most accurate statement might have been, “The EKG done while you were on the treadmill showed changes which mean that a large part of your heart muscle was not receiving enough oxygen. That’s the same kind of problem and the same kind of EKG changes that occur during a heart attack. You weren’t having any symptoms at the time. This means your body has no way of sensing whether your heart muscle is getting enough oxygen or not. That means you’re at risk for having a serious heart attack at any moment. This could be fatal. The only way we can find out how much blood and oxygen your heart is getting is by doing this catheterization.”

In other words, we would have had to explain, in so many words, that he’s liable to die, suddenly, any time now. Not something most doctors would like to say to their patients, even if true. But our reluctance to go into painful areas can hurt our patients even worse. (But aren’t we all liable to die at any moment? What’s the big news?)

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