Read an Excerpt
The Handbook of Heart Drugs
A Consumer's Guide to Safe and Effective Use
By Martin E. Goldman, Nancy Kriebel Henry Holt and Company
Copyright © 1992 Martin E. Goldman
All rights reserved.
ISBN: 978-1-4668-8427-4
CHAPTER 1
Doctor-Patient Issues
Heart disease is a very personal illness because no effective understanding of it can be expected without a detailed knowledge of the patient. The way we live our lives has a great deal to do with this illness: how it occurs and how it should be treated.
As you will see later, many heart patients share intimate and confidential information about themselves, their families, and their disease with their cardiologists. In turn, the effective physician respectfully probes into personal and professional lives, all in an effort to examine the integral bond between the stress and strains of patients' lives and the characteristics of their illnesses.
As a result, a relationship between you and your cardiologist that is trusting and personally disclosing will serve both your and your doctor's needs. You benefit because you will more likely understand and believe in the commitment demanded by treatment and recovery; your cardiologist benefits because openness usually provides the kinds of information the treatment requires.
How personal that relationship becomes depends upon your doctor's willingness to ask and your willingness to disclose. It also depends upon the nature and severity of the illness and how your own life-style affects it. But I believe that better treatment results when patients, especially those who may have cause to be fretful and worried, find that they can be safely revealing to their doctor.
Need to Disclose
Probably your relationship with your cardiologist will differ from past relationships with doctors, because this relationship involves life-and-death issues. In the case of heart disease and its potential for a sudden catastrophic event, your health care takes on a heightened sense of urgency — or at least it should.
Most people with heart disease understand, at least in theory, that they could die without prior warning, which usually makes them not only more anxious but also more vigilant. By comparison, it is unlikely that you would die suddenly as a result of an ulcer. Worse, if you had Crohn's disease, which produces abdominal cramps and bloody diarrhea, you would suffer days of genuine sickness, and your general health would be seriously affected, but you wouldn't have to worry about dying the next day. Cancer may be the most depressing disease to experience, but even cancer patients can be told of therapeutic options, though their prognosis may be poor.
With heart disease, however, many patients hear a different story. More than once I have had the unpleasant task of telling people after they had an angiogram that unless they had coronary bypass surgery, they were at significant risk of having a major heart attack or possibly dying suddenly. I did not say this to frighten them, but to alert them to the gravity of their illness. Striking this note of urgency has often set the tone for a very effective and intimate medical treatment program.
For some patients the need to be direct and candid about their private lives with a medical doctor is unfamiliar and stressful. But most people do realize it's in their best interest to trust and cooperate with their cardiologist. Unfortunately, however, I still find some patients who either do not appreciate the seriousness of their illness or outright deny that they are sick. Admittedly, disclosing certain feelings, behaviors, or circumstances of your home or business life can be difficult. It is reasonable to protect our privacy and reveal personal information only when we believe it is appropriate or necessary. It's important to recognize how heart disease can be adversely affected by our private lives. Omitting to tell your physician significant details of your disease experience can undermine your care. For example, it may be embarrassing to talk about chest pain during intercourse or an argument with your spouse or another family member. I would be embarrassed, too. But not sharing these important signs of heart disease may place you at grave risk.
Many doctors find the experience of having a noncompliant, uncooperative patient who continues to complain of symptoms frustrating and dissatisfying. If a doctor comes to believe that a patient is undermining the therapeutic regimen prescribed, the doctor, I believe, could actually become less interested in that patient's care.
All heart patients need to take an active role in the treatment of their disease: understand it and what arouses or triggers any of its symptoms; accurately report all your symptoms to your doctor; follow any instructions about diet, exercise, and medications; and especially report any unusual reactions to your drugs. To do all this, you must feel comfortable with your doctor. Think of your relationship with your cardiologist as a partnership. If one member of a partnership doesn't provide all the information needed to conduct its business, or the other is not sufficiently skilled to deal with that information, the aim of that partnership — in this case, your health care — may very well fail.
You are unique, and this fact governs how your doctor creates your treatment program. Your cardiologist will start with some initial guidelines based on knowledge of how other people in similar circumstances have responded to your disease. But this general information is inadequate to predict the course of your treatment with absolute confidence. Increasing reliability of any treatment for heart disease is dependent on the unique and characteristic data you provide the doctor. It begins with being absolutely candid about your disease during your first visit and then letting your doctor know precisely how you are responding to the treatment and medications during subsequent visits. We'll discuss the first visit in more detail later in this chapter.
The guiding principle in clinical medicine is to treat the person, not the disease, and this is especially true in cardiology. If your feedback to your doctor about yourself and your response to therapy is vague or inaccurate, it could be said that your doctor is not treating you, but your disease.
Your Attitude Toward Your Disease
It can be very important to your care for you to know what your attitude is toward your illness. Many heart patients begin therapy fearful that they may not recover. Health-care professionals believe that such attitudes strongly influence how and when the patient recovers.
After you've had your illness professionally diagnosed, there are two important areas to think about: First, how will you accept professional treatment and your patient role? Second, how will you accept your recovery and rehabilitation?
In some respects, doctor and patient are dependent on each other: You rely on the doctor for care and supervision, and the doctor depends on your input and cooperation for successful treatment. Matching yourself with the right doctor for your personality is just as important as seeking a doctor well qualified in cardiology. Some doctors demand that their patients be absolutely obedient and never deviate from their directives. Some patients find this attitude acceptable, or even preferable. Increasingly, however, patients find that an autocratic tone makes them uncomfortable. Hence, you need to know yourself well enough to realize whether working under this discipline will lead to subtle resistance on your part. If you feel that a policing attitude might cause you to rebel and not comply or to fear the doctor's disapproval were you to disobey some instructions, you should discuss this feeling openly on your first visit. You would not want to feel you had to hide from your doctor instances when you were unable to follow the regimen. You may also realize that you need a physician who spends more time discussing options and planning care rather than being dictatorial.
The second attitude concerns recovery. It's reasonable to assume that all patients want to recover, but some people struggle with the fear that they will never actually be "normal" again. It's important for patients to know in advance that they will be experiencing unfamiliar emotions and reactions. I tell my patients that following surgery they might become emotional and suddenly start to cry. Such moments can be startling, especially for someone who has seldom expressed his or her feelings. The trauma of surgery, the anxiety and sleeplessness, the effect of medications, and the general weariness all contribute to a feeling of vulnerability. Understandably, some patients come to feel they are falling apart and, worse, that they are going to die or be permanently incapacitated.
In truth, there is no way to have a heart attack and not be upset by it. But I find that many patients initially hear only the "worst-case scenario," which can cause significant anxiety and disrupt their normal life pattern. There are steps to take to minimize anxiety, anger, or depression. First, realize that they may occur. Also, understand that your recovery will take time; it will occur day by day, often more slowly than you want. You must have patience.
Everyone's recovery is different. Just because a friend or relative has had the same heart disease or surgery, it does not necessarily mean that your recovery will be similar. Your recovery depends on several factors: the extent and complications of your heart attack, the level of your activity before the heart attack, and your heart's response to increases in activity. Recovery from surgery is discussed in more detail in Chapter 5.
It's important to address fears and anxieties, because people who are constantly fearful or depressed often recover more slowly and less thoroughly. Discuss your apprehensions with your doctor, even if you think they are crazy. Some of these "crazy" thoughts may, in fact, lead your doctor to a helpful diagnosis. If your depression or anxiety continues for four weeks or more, your doctor may give you some medication or, if necessary, suggest counseling.
Your Attitude Toward Your Doctor
As discussed before, your relationship with your doctor can affect your treatment. A few years ago a colleague of mine was treating a fifty-year-old man for hypertension. Instead of taking his medications as he was instructed, the man said he took them only intermittently because they affected his libido.
Because the patient reduced the dosage of his medication, his blood pressure remained dangerously high. Believing the original dose was ineffective, his doctor increased the dosage in an effort to improve the patient's performance. This time the patient was significantly alarmed over the dangers of his hypertension and, instead of arbitrarily reducing his dosage, he faithfully and correctly took his new medications, as instructed. Within two weeks, he became gravely weak, a serious sign of a medication overdose. Once the doctor learned that the man had not been taking the earlier dosage as scheduled and that his patient was, in effect, now being overmedicated, he immediately lowered the dosage to the original dose. The patient's symptoms disappeared and his blood pressure was controlled.
Sexual issues are always difficult to talk about, especially a diminished sexual drive. But as delicate an issue as it may be to discuss, the patient should not take it upon himself to treat the problem by adjusting his own medication. Perhaps the doctor did not adequately explain the potential for this side effect, or failed to explain the seriousness of reducing the dosage. In any event, the patient so disliked his physician that he decided to take matters in his own hands rather than reveal that he had not taken the medication as directed and the reason.
Another issue to consider is the self-esteem of a doctor. As strange as it may seem to some patients, doctors are human and fear rejection like everyone else. If they feel rejected by uncooperative patients, or their professional integrity is challenged, it can affect the quality of care they provide. A study by a group of medical experts about doctors who had disrespectful patients revealed troubling findings: Doctors who felt resentment toward a patient could be less attentive or meticulous in their treatment.
A different study suggested that people accustomed to intimidating others by exercising their authority over them often treat their doctors in a similar manner. Out of a misguided belief that this is the way to get the best care, they actually harass and bully their doctors if dissatisfied with the care. If someone thinks he may die, this may be understandable behavior. But if someone uses such behavior merely to establish authority during routine care, it can be counterproductive.
Senior corporate executives who are always struggling for control of their business fate may have difficulty relinquishing control of their medical fate to their doctors. Regrettably, the study showed that instead of getting the best care, their bluster could be endangering their health. Experts believe that a doctor who feels intimidated may be reluctant to make health-care demands on the patient that might anger or alienate him and may actually defer tests or needed procedures.
A case in point: I have a patient who is an extremely wealthy and powerful businessman and a board member of several prominent medical schools and universities. Because he's always in a rush, people in his path suffer from his haste and sharp tongue. But he and I share a different kind of relationship. As dominating as he is in his world, he has come to understand that his health depends on my being dominant in mine. Early on, I said that if he had to hurry during our visit, he was free to leave. But I added that it would be in his best interest to sit and discuss his medical problem until he and I were both satisfied. I likened it to a business deal: I wanted to serve him as best I could so he could leave with the assurance that he would be healthy enough to keep making money. That approach appealed to him immediately. The man still storms, blusters, and boasts in his own world, but when we interact in my office at the hospital, he's utterly cooperative — almost congenially so. He uses his experience and intelligence to ask prudent questions regarding his illness or therapeutic plan rather than to exert his authority.
Private Lives
Sometimes it is difficult to be candid with your doctor; but remember, your health is far more important than any momentary embarrassment. A few years ago I had a patient with angina and a complicated story that threatened to compromise my ability to treat his heart disease. He was forty-one years old and twenty pounds overweight. He came to the emergency room because of an anginal episode. When he came back the next day for our first visit, I learned that he had been having chest pains two and three times a week for almost a month. I also learned that he had been under the care of another cardiologist for the past six months and was receiving medication from him, but was not happy with his care because he felt the doctor disliked him.
He said he had been under a lot of financial stress since he was a struggling architect in a weak economy. As we talked further, he admitted he was divorced with a fifteen-year-old daughter, whom he missed very much. He was in relatively good health and in no immediate danger of having a heart attack. However, I told him he had to reduce the stress level in his life. I also suggested some regular exercise.
It took him three visits and a catheterization (a procedure that involves passing a tube through an artery) before he told me what he believed was the principal problem related to the anginal episodes: two years earlier he had declared to his wife that he was gay, which led to the divorce. Since then he had often been lonely. But when he went to gay bars he felt more anxious and troubled because of his physical appearance. His hair was thinning and he was overweight.
His deep-seated anxiety came from his fear that he would be rejected if he told anyone he had a heart condition. "Other gay men want younger companions," he said, "not a fat old man with heart disease." His heart condition was his secret.
I subsequently learned that he had not told his other cardiologist about his personal life for fear that he would be rejected by his doctor as he had been by his mother, father, and brother. No one outside the family knew the details of his gay life-style or his heart condition. He said it was a relief to open up and tell me what was troubling him. I was sure that his disclosure was the beginning of his accepting responsibility for his health and, thus, improving the possibility of a successful outcome.
There was more to come. On his next visit he told me that he had been seeing a psychiatrist for almost two years. He felt such shame about his secret life, however, that he forbade his psychiatrist for almost a year from calling the other cardiologist and then me about the fact that she had prescribed a psychiatric drug, amitriptyline, for his depression. Since one of the potential adverse reactions of amitriptyline is a heart rhythm disturbance, the therapist was afraid that his cardiologist might treat him for these symptoms not knowing they were the side effects of the amitriptyline. But she could not compel him to tell his other cardiologist, nor could she telephone herself, as the details of his treatment with her were held in absolute confidence.
(Continues...)
Excerpted from The Handbook of Heart Drugs by Martin E. Goldman, Nancy Kriebel. Copyright © 1992 Martin E. Goldman. Excerpted by permission of Henry Holt and Company.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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