Yes, he replied. In California, Nevada, Arizona, Kansas, even New York. Every one was normal. My puzzlement must have been obvious. So was his annoyance. “They tell me it is Syndrome X,” he growled.
The next day, I obtained a tape of one of his angiograms from a nearby hospital. It confirmed what my patient told me. His coronary arteries were pristine, not a trace of obstruction anywhere. So what was wrong with him?
Most people with angina have atherosclerotic plaque in the large coronary arteries that supply blood to the heart. But up to 20 percent of angina sufferers have normal coronary angiograms, a condition cardiologists have dubbed Syndrome X. These patients often have chest pain that mimics coronary angina and even abnormal stress tests. There appears to be a problem with their hearts, but no one knows exactly what it is.
One theory is that Syndrome X is a disease of coronary arteries too small to be seen by angiography. In one study, researchers using magnetic resonance imaging found that adenosine, a drug that dilates coronary arteries, does not increase blood flow to the inside surface of Syndrome X hearts, an area mostly fed by small arteries. They concluded that these arteries did not dilate appropriately and that the angina in Syndrome X was therefore from inadequate blood flow, not in the major branches of the coronary tree but in the twigs.
This theory appears to unify the mechanism of Syndrome X with obstructive coronary artery disease, the leading killer in the Western world, but there are holes. For example, if the chest pain in Syndrome X is due to diminished blood flow, then ultrasound studies of the heart during painful episodes should show some abnormalities, which they do not. EKG studies should reflect this inadequate blood flow electrically, but they do not. Another theory is that Syndrome X is a result of abnormal pain sensitivity, the so-called sensitive-heart syndrome. The chest pain in some patients can be evoked by electrical stimulation of the lower right heart chamber, which should have little effect on blood flow.
So which theory is correct? Maybe both. Syndrome X is probably not a single disorder but a constellation of disorders with many different causes. There is even evidence that psychological factors come into play. It is well known that patients with atypical chest pain often have an abnormal preoccupation with their health and anxiety or depression. One study found that two-thirds of patients with chest pain and normal coronary angiograms also have psychiatric problems.
It would not be the first time that a common cardiac symptom was thought to be predominantly psychological. In the 1990s, Dr. Arthur Barsky at Harvard Medical School studied patients with frequent palpitations. In one study he hooked up 145 patients to a continuous, twenty-four-hour EKG monitor and instructed them to record the exact time of their palpitations in a diary. He found that only 39 percent of their palpitations were accompanied by an objective arrhythmia. The patients whose symptoms had the weakest correlation to EKG abnormalities also had the most hypochondria and other psychiatric problems.
Although Syndrome X can be debilitating—not to mention a drain on hospital resources—patients who have it tend to experience normal life spans. I tried to tell my Russian patient that despite his symptoms, he did not have a life-threatening disease, but this did not mollify him. Like the difficult patient in the clinic the previous month, he accused me and other doctors of insensitivity. He demanded another angiogram to make sure his disease had not progressed. After several days of intensive but ineffective medical therapy, the team finally acquiesced. He was taken to the cardiac catheterization lab once again, where more pictures were taken of his coronary arteries. Shortly after the procedure, he went home. He was still feeling chest pain but had a clean bill of health, a reminder that even in a field as highly developed as cardiology, some symptoms retain their essential mystery.
WHEN I WAS ON CALL on 4-North, Sonia, who had recently moved in with me, often came to the hospital to bring me dinner. I’d meet her downstairs, in front of the library, where she’d hand off the curried chicken or lamb kebabs, or sometimes daikon paranthas with spicy cauliflower, courtesy of her mother. Occasionally she’d bring a plate for Mira, too, and sometimes even for the medical students on my team, and then we’d all sit in the conference room and scarf it down. She was now on a fourth-year GI elective, and it was good to see her in the hospital during the day. I always waited for her page; it was the one number I always called back immediately, no matter what I was doing. We sometimes discussed her difficult cases, and my advice was usually accompanied by a few words on appropriate etiquette for a fourth-year medical student. Afterward, I’d bask in the same sort of glow I’m sure Rajiv enjoyed when he advised me.
One night when I was on call, I was paged to the ER for a chest-pain consultation. I hated going down to the ER because the staff was so surly, so hardened by the constant swirl of illness drifting through the sliding doors. I walked past the resuscitation rooms. Stretchers bearing patients were already lined up in the hallway, even though it was only nine o’clock. An elderly woman was bellowing, “Help me, help me,” over and over, but people were ignoring her. (“Who’s screaming? Is that a cat?” someone joked.) I scanned the admit board next to the nursing station: sprained ankle, pancreatitis, vaginal odor for one week, depression, alcohol withdrawal, swollen eyelid, motor vehicle accident, flank pain, shortness of breath, hematuria, earache, fever, palpitations, allergic reaction to drug, stroke, vaginal bleeding, foot ulcer, syncope, lung cancer/failure to thrive, asthma, bloody stools, nausea/vomiting/diarrhea, and ascites. No chest pain. I walked over to the other side of the ER, where a nurse pointed me in the direction of a small, curtained space. I jerked open the drape. A middle-aged man, round as a beach ball, was sitting at the edge of a stretcher, panting. He looked up when I entered. It was Ira Schneider, a man I had taken care of a few months back after his heart attack.
“Well, hello,” I said, closing the curtain behind me.
He took off his oxygen mask. “Hi, Doc,” he said, his face brightening. He must have weighed at least four hundred pounds. Thick, fleshy folds encircled his belly, falling out of a hospital gown, which functioned more like a bib. Numerous streaks zigzagged across his abdomen and back like thick wrinkled worms. His legs resembled small tree trunks with hyperpigmented patches of skin, like tiny whorls in bark, probably a consequence of chronic edema. Large gaps interrupted his teeth. Even his mouth seemed to be too big for him.
I asked him how he was doing. “Not well,” he replied, shimmying his body on the stretcher to face me. Since I had last seen him, his angina had been getting more frequent and more severe, and it was now often accompanied by an oppressive sensation of breathlessness. He had been popping nitroglycerin pills like Tic Tacs. I remembered that six months ago, in February, when he was hospitalized, he had undergone a coronary angiogram, but the pictures came out fuzzy because of the fat around his chest. Still, there appeared to be severe limitations in blood flow to several parts of his heart. His coronary arteries looked like sausage links, sectioned off by numerous tight blockages. Cardiologists had tried opening one of the blockages with a balloon catheter, but the procedure failed because of the poor view. So Schneider had been transferred to the wards for medical management, which meant drugs but no further invasive procedures.
But what he really needed was bypass surgery. A surgeon, a short, stocky man who in manner and deportment resembled a bulldog, was consulted, but he said that heart surgery would be too risky. Since Schneider was already almost totally immobilized by his weight, wound healing and physical rehabilitation would be prohibitively slow. To compound the problem, Schneider had severe atherosclerosis in the arteries in his legs, which further inhibited his mobility. “This guy isn’t even a candidate for a haircut, let alone bypass,” the surgeon had said. When someone argued that Schneider would die without surgery, the surgeon answered: “He’s going to die anyway, but I don’t have to wear the black hood. This isn’t a Chinese restaurant; we don’t take orders. We’re doctors. We have to do what is right.”
So surgery was s
helved, Schneider’s drug regimen was tuned up, and he was sent home.
Earlier that evening, Schneider now told me, he had experienced a protracted bout of chest pain while watching television. The pain started out as “ten out of ten” and was accompanied by a drenching sweat. Two hours later, he vomited four times and then took a sublingual nitroglycerin tablet, which brought the pain down to a seven or eight out of ten. He took two more nitroglycerin pills and two aspirin, with no further relief, so he called 911. The paramedics gave him supplemental oxygen, which helped a bit, but when he arrived in the ER, his pain was still present: four out of ten. He took one more sublingual nitroglycerin in the triage bay and only then, a few minutes later, did his pain finally go away.
I turned a green knob controlling the flow of oxygen to his mask. A tiny ball bearing shot up in a plastic meter, suspended by the increased flow of air. I asked Schneider if he had seen any doctors since being discharged from the hospital.
“Just my cardiologist,” he replied. And what had the cardiologist told him? “He said I had to learn to live with the pain.”
“Have you consulted with another surgeon?” I asked.
He shook his head, puzzled. “Was I supposed to?”
“No . . .” I hesitated for a moment. “I mean, you could have, but . . . well . . . let’s just talk about it when you get upstairs.” Frankly, at this point I didn’t think getting a second surgical opinion would be a bad idea. Surely something, I thought, even risky surgery, would be better than waiting for the time bomb in his chest to go off.
Schneider was transferred to 4-North, where Mira and I wrote his orders. We started him on a blood thinner and intravenous nitroglycerin, and continued the rest of his medication regimen. But even though he was pain-free now, I was pessimistic that drugs alone could manage his disease.
The next day, I spoke with Dr. Carmen, the CCU attending, Schneider’s cardiologist. Conceding that medical management had failed, he said he was going to consult the surgical team again; perhaps now, with Schneider’s condition worsening, they would see things differently. I was skeptical. The surgeons had been firm and persuasive in their arguments, and I didn’t expect them to change their minds.
“Still, I wonder if the surgical option was dismissed too quickly,” Carmen said. “Sometimes we look at a patient like this and make a judgment that isn’t always fair or rational or even medical.” He left, but his comment stayed with me. Had we discriminated against Mr. Schneider because of his weight?
It didn’t appear that our prejudice, if it existed—I wasn’t sure—had been conscious. Granted, his obesity had been on our minds in deciding on his treatment. It would have been impossible, not to mention bad medicine, for it not to have been. But had we been hyperconscious of his obesity, to his detriment? Had we made a value judgment that, because of his weight, surgery would be wasted? Or worse, that he was somehow less deserving of surgery because he was unable or unwilling to control his weight?
Doctors can be a judgmental sort, a point that had been driven home to me by the discussion on difficult patients the previous month. Of course, it can be argued that making judgments is the essence of what doctors do. That elderly man in the intensive care unit: Should we treat the patient aggressively or pull back? Should that alcoholic with liver failure get a transplant? These are medical judgments but moral ones, too.
Judgments about personality, character, and worthiness are reflected in all aspects of the doctor-patient relationship, from the language doctors use to describe patients (hysterical, difficult, solid, scumbag), to the attitude they take into the examination room. Every day, in clinics and emergency rooms, doctors encounter drug addicts with endocarditis, smokers with lung cancer, and others seemingly bent on self-destruction. To treat them with perfect equanimity, without any trace of moral or value judgment, would be impossibly Zen. But to act upon these judgments, to allow them to alter treatment, would be to violate fiduciary responsibility.
Personal judgments, however, can lead to prejudgments and prejudice. Not long before I admitted Schneider to the hospital, Sheila Jones, the clinic attending, had given a lecture on disparities in health care. She presented several studies on health outcomes in various patient populations that suggested that subtle prejudice might be widespread in medicine. For example, a study showed that blacks not only waited longer than whites for kidney transplants, they waited longer to get on a kidney transplant waiting list, even though they suffered disproportionately from kidney failure. Why do doctors delay? There was more: compared with whites, black women were twice as likely to receive inappropriate treatment for ovarian cancer, and they had a worse prognosis; blacks with lung cancer were less likely to receive possibly curative surgery; and blacks with heart disease got fewer cardiac angiograms and bypass operations, had worse outcomes after a heart attack, and were less likely to receive standard drugs like aspirin and beta-blockers. The difference in angiogram rates was independent of the doctor’s race, and it persisted even after correcting for disease severity, insurance status, geography, and income.
The disparities were not limited to race. Women with heart disease got fewer cardiac angiograms and catheter procedures than men, and they were more likely to die from heart attacks and unstable angina. A recent study had shown that women with chest pain waited longer than men did for emergency room examinations. Perhaps, influenced by behavior stereotypes, doctors were more likely to minimize symptoms in women and attribute them to emotions.
The list went on, encompassing gays, the elderly, and other groups. These and other studies suggested systemic discrimination in medicine, though it was hard to draw any firm conclusions from them. Why did it take longer for doctors to put black patients on the kidney transplant list? Was it racism, or was it because blacks have a higher rate of transplant rejection? Why were doctors more likely to withhold artificial ventilation, dialysis, and surgery from seriously ill elderly patients than from their younger, equally ill counterparts, even after preferences regarding aggressive treatment were accounted for? Was it ageism, or rational, merciful medicine? Bias, unconscious or not, might account for these disparities, but it was camouflaged, which was perhaps why it was so hard to root out.
I couldn’t help but wonder: Had our own bias toward Ira Schneider been camouflaged, too?
In the hospital, Schneider continued to have severe chest pains—small heart attacks, really—that were inadequately relieved by medications. One morning, he nearly doubled over while washing up. The surgeons, reconsulted, turned him down again. Rajiv told me it was because agencies monitoring surgical outcomes were putting tremendous pressure on cardiac surgeons to produce good results. Over the past decade, while surgeons with higher-than-expected mortality statistics had lost operating privileges, others with lower-than-predicted rates had taken to advertising on the radio. Because surgeons who had been aggressive about treating very sick patients like Schneider had incurred higher mortality rates, they had been penalized. Apparently this was an insult many surgeons could no longer countenance.
I didn’t know what to do, but I knew I had to do something. I thought of Dean Dowton in St. Louis and his commencement address. “Believe in something,” I remembered him saying. “What are you willing to compromise? Where are you going to take a stand?” If there was one ethic I was sworn to uphold, it was to do whatever I could to prolong life.
I knew I couldn’t go talk to the surgeons—they would have no patience with my second-guessing—so I decided to talk to Schneider himself, in the hope that I could spur him into getting a second opinion. In Dr. Klein’s world, there were private patients and service patients. Fortunately for Schneider, he was a private patient with good insurance. He would have no problem finding another doctor.
I went to his room one afternoon. When he saw me, he tried sitting up, transferring his weight this way and that, as if trying to fall upward. With a heave that almost pulled me off my feet, I helped him up.
“I wanted to talk to you
about something,” I said. He leaned forward on the bedside table, pushing his lunch tray aside. I hesitated. “I should have talked to you about this before, but—” I stopped.
“What is it, Doc?” he said, sounding worried.
“It’s nothing, really. It’s just, I wanted to make sure—do you know that you can go somewhere else for a second opinion?” He stared at me with the same puzzled look he had had when I tried to bring up the subject on the night he was admitted.
“You can go somewhere else to have surgery,” I went on in a hushed, conspiratorial tone. “You can see another doctor. You’re the one in charge. You can do what you have to do to protect yourself.”
He continued to stare at me silently.
“It’s just one surgeon’s opinion, see,” I said, feeling treacherous. “You can go to another hospital. For another opinion.” I wasn’t sure he was getting it. “Maybe another doctor will agree to operate. Do you understand what I’m saying?”
“Yes, I understand,” Schneider replied testily. “You’re telling me that I can go to a surgeon who is willing to operate on me.” He paused. “Listen, I’m just grateful to God for being alive. Look at me! I would never survive an operation!”
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