Alpha Docs

by DANIEL MUÑOZ

  6

  ROTATION: PREVENTIVE CARDIOLOGY, PART I

  Patient, Heal Thyself

  The day after the case conference, I drive into the main hospital parking lot to begin the initial two-week segment of a four-week rotation in preventive cardiology. (I’ll do the second part of it in a few months.) It’s a clinical rotation, which means that we see patients all day, every day at Hopkins’s Center for the Prevention of Heart Disease.

  And it’s intense. Not in the sense of endless days, sleepless nights, and dramatic paddles-to-the-chest resuscitation, but because of the single-minded determination to reform and alter a patient’s lifestyle, to rewire human behavior from a live-for-today to a live-to-see-tomorrow attitude. On top of that, the center itself is so well respected that it is almost synonymous with the practice of preventive cardiology as a whole. It’s a team of true believers whose members live, breathe, and eat (in moderation, of course) what they do.

  Their leader is Dr. Franklin, a lanky and lean, six foot four sixty-year-old who looks more like a small forward for a Division III college basketball team than the embodiment of preventive heart care at Hopkins. I’ve heard that Dr. Franklin went to medical school with the idea of becoming a sports team physician or Olympic training doctor but that his interests in the heart evolved when he came to Hopkins for his cardiology fellowship. He helped to establish the center, and preventive has been his passion ever since.

  At first glance, Dr. Franklin’s office looks like a heart condition hall of fame. The walls are adorned with pictures of him next to somebody famous—a professional athlete, a coach, a team owner, a politician, a writer, an executive. It seems that even world-renowned specialists such as Dr. Franklin can have a weakness for stars. But Dr. Franklin speaks so enthusiastically about the work he does that it becomes clear that these pictures serve an ulterior purpose. He’s dedicated, almost religiously, to preventive cardiology. He’ll do anything to advance the cause and fortify the temple, the Center for the Prevention of Heart Disease. That takes money. And stars—business, Hollywood, sports, political—have access to money, whether it’s through their own deep pockets or through their affiliations with foundations, important donors, or sources of government funding.

  The center also needs young cardiologists. Not very subtly, Dr. Franklin wants to get me, and as many of the other Fellows as possible, interested in a career in preventive. He says, “The point of these two weeks is to teach you as much about prevention as possible, and have you see the patients,” then hands me a stack of articles on the latest prevention guidelines and adds, “When you get a chance, read these over and let me know what you think. There may be some ways we can improve upon these published guidelines.” I can’t tell whether he seriously believes that I, a Fellow in training, can actually improve the guidelines or he’s trying to woo me into his field through challenge and flattery. In either case, he leaves me feeling that the future of the guidelines rests on my shoulders…which makes me want to perform at my best, so his methods work.

  For the next two weeks, my role is to be Dr. Franklin’s advance man at the clinic: I’m him until he gets there. As the head of preventive cardiology, Dr. Franklin sees the patients with significant risk factors—very high cholesterol, very high blood pressure, pronounced family history of heart disease, major heart events—and/or the famous and powerful people who are concerned they might develop a serious heart problem.

  For the first half hour, I see the patients, take their history, do the preliminary examination, and look at their charts, so that when Dr. Franklin walks in, I have a summary ready: “Mr. McDonnell is back for his regular yearly visit, and here are the issues….” Normally, the next step is for Dr. Franklin to ask his own questions and draw his own conclusions—but what he does first is formally introduce me to each of his patients as well. “Mr. McDonnell, Dr. Muñoz is one of our finest cardiology Fellows, a graduate of Johns Hopkins Med School and residency, whom we’re honored to have in our program. Dr. Muñoz is destined to be one of the stars of the field.” This introduction may sound impressive, but the reality is that it’s better than the alternative: “This is Dr. Muñoz. He’s just learning to be a cardiologist.”

  Once the flattery is over, Dr. Franklin zeroes in on key areas, based on his experience and instinct: It could be the patient’s cholesterol, blood pressure, most recent EKG, or even how the patient reports feeling. With every patient, we ask the same questions—habits, meals, snacking, drinking, work patterns, stress levels, family history, prior treatment. And with every one, Dr. Franklin uses the patient’s answers to piece together what appears to be a custom-tailored routine that he is careful to call “our” plan: “Dan and I feel that the best course would be…,” or “I concur with Dr. Muñoz’s recommendation for a test of…” In reality, the conclusions are his, but his implication that I’ve been an integral part of generating the recs is part of his teaching and subtle recruiting method. He is constantly enlisting those around him—Fellows into his preventive enterprise, patients into adopting better approaches to their health. It’s strong-arming with a smile, rather than through fear or intimidation.

  Nearly every patient’s plan follows an ordered mnemonic device known as A-B-C-D-E. A is aspirin; B is blood pressure control or beta-blockers; C is cholesterol; D is diet; E is exercise. Dr. Franklin hits every one, in order, with every patient, and he does it in a conversation, connected by clues the patient gives him.

  In most cases, the people who visit the center are still relatively healthy. A forty-year-old man comes in, panicking because his dad died of a heart attack at age forty and he now thinks his own arteries might be closing. A woman comes in with dangerously high cholesterol, even though she hasn’t eaten fatty food in two years—just a case of bad genetics. Another guy is flirting with disaster because he smokes, is gaining weight, can’t walk a block without panting, and wakes up every third night with chest pains. Here’s a diet. Here’s a calorie count. Here’s a portion-control guide. Here’s an exercise regime. Here’s your target weight. Make an appointment for six months from now. It could easily get mundane.

  But even when the patient gets the standard A-B-C-D-E review, Dr. Franklin makes the effort to create a personal connection: “Middle-aged paunch? We all get it.” “You play golf? Me too. I never take a cart. Walking relaxes me, and you get three miles of exercise.” He will tell patients to lose five pounds instead of twenty-five because twenty-five is discouraging, but an initial five is doable. His method is so smooth and natural that it is almost an art form. He says, “Switch to Miller Lite,” even though he means, “Stop drinking beer.” But Dr. Franklin wants allies, not enemies—he understands how people work and think. It’s my job to learn by observation, and I’m truly struck by Dr. Franklin’s deftness in plying his craft, how attuned he is to each patient’s personality, cooperation, or level of resistance. He seems to have mastered the notion that practicing medicine is more than just a series of tests and cases; he grasps that being a doctor is more than just the procedures that save lives, but also involves the lives that the patients lead. Again, this brings to mind my recent thoughts on the basic human need for practical, effective, realistic doctors. And it drives home to me that this is the kind of responsiveness and empathy I want to master.

  Dr. Franklin’s ability to listen and connect to his patients also means that they are often extremely well informed. They know their own conditions and take an interest in the preventive practices that can change their fates. They can rattle off their family histories, their parents’ cholesterol levels, as well as their own levels, exercise routines, and weight goals. Sometimes, they even speak the language of heart disease, using words like triglycerides and stent and bypass as easily as other people spout sports jargon. They become proactive authorities on their own health—and all because Dr. Franklin gets through to them.

  It helps that Dr. Franklin practices what he preaches. He wears a fitness tracker at all times and is a “walking” ad
for it, directing patients to a website that sells them. Every day he measures how many steps he takes, with his personal goal of ten thousand steps, or five miles, in mind. At the end of the day, if he comes up short, he takes the stairs in the parking garage. If he’s still short, he walks around his neighborhood with his wife. On weekends he still plays basketball and lacrosse, and boasts a single-digit handicap in golf. He coaches neighborhood kids’ sports teams as well. He eats right. The message to patients is clear: If I can do this, so can you. By the time we finish an exam, the patients always seem rededicated to losing another five pounds, walking farther, doing more push-ups, or lowering their stress. And I’m recharged to go to the next exam room.

  During the rotation, I also work with the other doctors on Dr. Franklin’s team, each of whom specializes in a specific aspect of prevention. One is the world’s expert on lipids and cholesterol, and sees only patients who have horrifically high cholesterol. Like Dr. Franklin, he combs through the clues of each patient’s lifestyle, looking for ways to modify his or her behavior, and prescribe the right combination of drugs to stave off deadly LDL (low-density lipoprotein) advancement.

  Two days later, I follow the team’s ace diabetes doctor. Our first patient, Adele, is forty-five years old, five foot two, and weighs 212 pounds. She has two daughters: a sixteen-year-old who is the same height and weight as her mother, and an eight-year-old who already weighs more than 100 pounds. Since diabetes is a significant risk factor for coronary disease, controlling it helps prevent heart trouble. But the converse is also true: If the patient can’t control his or her diabetes, the probability of coronary disease skyrockets.

  Adele is on cholesterol medication and following a diet that she is struggling to maintain. She and her daughters live on her welfare check, and for better or worse, it goes pretty far at the neighborhood fast-food joints. Since she started coming to the clinic six months ago, she’s lost fifteen pounds, but her weight loss has plateaued since her last visit three months ago. The doctor says, “You’ve made some progress. Keep it up. What did you eat this week?” She tells him, and he winces. He encourages her to cut back on fried foods, to go to KFC no more than twice a week. Adele promises to try. Her younger daughter, hearing only “KFC” in an otherwise dull conversation, asks, “Can we go on the way home?”

  This doctor, dealing with the consequences of diabetes daily, preaches some version of this to a patient population that grows every year, figuratively and literally. Obesity is becoming commonplace in America, and diabetes, unfortunately, often coincides with obesity. According to the Centers for Disease Control, from the late 1990s to 2014, the incidence of diabetes in the United States more than doubled. Type 2, formerly known as adult diabetes, is now rampant in a substantial portion of adolescents and young adults. The size of the problem and of the patients is not a fluke; it’s driven by business—supersized, sweetened, salted, corn oil–injected, drive-through, fast and cheap food—and exacerbated by a lack of physical activity.

  That night, I drive out of the clinic parking lot, and in the space of ten blocks I count six high-cholesterol chains: KFC, Applebee’s, Wendy’s, Burger King, Pizza Hut, and Bob Evans. Suddenly, I have a craving for a plate of wings or nachos. But after a day of working alongside Dr. Franklin and his team, observing the effects of fast food and sedentary lifestyles, I change my mind and opt for a run and a salad. Still, my moment of weakness highlights what is most difficult and frustrating about preventive cardiology. We know a lot about diabetes, what doctors can do, what patients should do. But preventive cardiology requires the patient’s initiative, and its success relies on his or her ability to master every single moment of weakness, to consciously choose salads and push-ups over cookies and sleeping in. Preventive isn’t just fighting heart disease; it’s also an uphill battle against human nature.

  —

  Even the most successful, educated, and privileged people can fall into, and become comfortable with, their bad habits. Plenty of Dr. Franklin’s celebrity patients—the business tycoons, movie moguls, pro athletes, media stars, Washington politicos, and Wall Street executives—ignore his wisdom. They may try to follow their plan, but they struggle exactly the way Adele and her daughters do. And some of them just want medicine to “fix” the problem.

  In the middle of my second week, we see a certified hotshot who has been referred to us by his internist. The patient, Mr. Gardner, was an Ivy League undergrad who went to an Ivy League law school and is now an attorney at a prestigious firm for high-profile clients. He wears an expensive suit and is articulate and funny—not arrogant, totally likable. Once a track athlete, he still looks fit enough to run the hundred-yard dash. But these days he can’t run a hundred feet without getting winded. His cholesterol levels are off the charts, with high blood pressure to match, unlucky genes that he shares with his father and his older brother. In fact, his family is the reason he’s here: Mr. Gardner is devoted to his wife and two kids, and his wife made a point of bugging him until he agreed to come to the center.

  In the course of our conversation, it quickly becomes clear that the patient is a denier. Dr. Franklin’s questions and Mr. Gardner’s answers are revealing. He tells us how good he feels, and how tough he is. He apologizes for wasting our time, and says he shouldn’t be here, that he came only to mollify his wife. Even as he recounts the story of his father’s two massive coronaries—complete with ambulance, EMTs pounding on his father’s chest, and a subsequent bypass operation—he jokes that he’s too young to worry, and that his high cholesterol and blood pressure are just by-products of representing fat cats in court and racking up billable hours. Even the fact that his older brother is going through the same situation—same genetics, same symptoms—doesn’t seem to alarm him. Instead, he cracks a joke: “My brother is four years older, and he never could catch me on the lacrosse field.”

  Dr. Franklin recognizes the challenge of getting through to Mr. Gardner. Before laying out the plan for prevention, Dr. Franklin takes an interesting tack. “Mr. Gardner, you’re an active, successful guy. That’s great. But I worry, not about how you feel now, but about the risk of a heart attack or a stroke. And I want to do everything we can to avoid either of those two scenarios. It’s in our power to do so, but only if you acknowledge the importance of prevention and the serious consequences of failing to engage in it. A heart attack would sideline you from many of the things you enjoy doing. Your family history suggests you’re at risk. We can’t control your genes, so let’s focus on the things we can control.”

  Mr. Gardner is, for the first time, quiet and appears to be listening.

  Dr. Franklin then lays out a plan: diet, exercise, medication, and regular monitoring. This is serious treatment for a serious problem. For a moment, it looks as if the patient gets it. But then he jokes, “I should pass this advice on to my brother and bill him for it.” Mr. Gardner knows what to do, and he has the means and the support system to do it. But will he start the regimen to change his life? Or will he put it off “until it’s really a problem,” when he’s on a gurney with EMTs hovering over him? This is my biggest issue with preventive medicine: Because it aims to be routinely proactive, it is far too easy for patients from all walks of life to ignore.

  —

  No matter how often he repeats the same conversations, it’s clear that Dr. Franklin isn’t bored by this routine. Preventive cardiology is the most important thing in the world to him, and after spending two weeks by his side, I find that some of his enthusiasm has rubbed off on me. Though it delivers essentially the same lessons to twenty different people a day, preventive is all about the ripple effect. If more doctors help more patients change their behavior, then little by little, these incremental changes can accomplish a lot. Twenty patients a day, year in and year out, and all for the hope that one day, you will read that the average person is living to be eighty-five instead of eighty-two. This is Dr. Franklin’s purpose in life. It’s why he writes books and makes speeches, raises money, w
ants to win over Fellows, and tries to get every patient to make at least some progress. But is it for me?

  Dr. Franklin helps people every single day, and he is both a compassionate cardiologist and a practitioner of such skill that he makes it look effortless. But gross tracking of populations, trends, and life expectancy means that it is hard to ascribe success to any single treatment or factor. And he’s battling not a disease, but risk: an unpredictable, resilient enemy that constantly fights back, and will surge forward in one area even when he defeats it in another. In an instant, it can attack and sabotage years of good effort. By definition, you can only reduce risk but not fully eliminate it. You can’t win. Have you then failed? Have you lost a life? Or is success simply holding off the inevitable for as long as possible?

  In medicine, heroic procedures that defy death for the moment gain more attention than steady, behavior-changing routines. A clinical cardiologist tests for and diagnoses heart disease in order to prescribe medication that will relieve debilitating symptoms. In the process, she may slow the disease and save a life. An interventional cardiologist puts in a stent and opens an artery, thereby perhaps staving off a coronary incident. Again, he may save a life. Practicing preventive medicine is the opposite of the dramatic interventions that you see on television. Instead, the goal is to keep these scenes from ever happening and stall death for years, even decades. But how do preventive cardiologists know when they’ve made a difference?

  I’ve finished my third rotation, but I am still unsure whether preventive is for me. Could I see the same case with a different name over and over again without getting bored? Would I get frustrated wondering whether each patient was hearing my exhortations but choosing to ignore them? Would the big-picture successes be enough reward for the daily battles against beer and nachos?