“One of the essential qualities of the clinician is interest in humanity,

for the secret of patient care is caring for the patient.”

Francis Weld Peabody (1881-1927)







Cardiology has progressed from a purely bed side effort at diagnosis and management to that of hi-tech interventional stage. This is in conformity with the parallel progress in other sub-specialties of medicine; all of whom have been riding piggyback on technology going to town proclaiming to the world that the present hi-tech divine interventionists are there to save lives and drag patients back from the cruel jaws of death. Life has, of course, become bearable to a sizeable percentage of patients with heart failure almost from the time the diuretics came on the scene. This is palpable because the number of people with heart failure is mounting by the day, thanks to people living to older age brackets all over the world due mainly to prosperity, education, and better standards of hygiene. Concurrently, the killer contagious diseases have been controlled significantly raising the average age of death, threatening to bring on an epidemic of heart failure in the old elderly.



While the horrible patient experiences of ganglion blockers for treating hypertension are being replaced by more tolerable drugs now the same does not hold good in other areas.1 Many of the blood pressure and cholesterol lowering drugs have been a big bane to a large section of the apparently healthy who takes them in the fond hope that they derive benefit in the long run. Modern cardiology’s biggest problem has been its mathematical basis of linear reductionism.2 While the human body in non-linear and dynamic, wherein time evolution is not based on patchy information of the initial state, our efforts to stabilize various body parameters into the assumed “normal” levels might not (will not) have the linear benefit that we predict. Future predictions in human physiology are not possible based only on the phenotypic features.3 Many of the audits in such interventions, in the apparently healthy, have been counter-productive! Epidemiology has failed us in this field of anticipating chronic degenerative diseases while it did help us in the field acute epidemics.4 Death rate in genuine cardiogenic shock still remains prohibitively high and the disease burden of heart failure vis-à-vis hospitalizations and recurrences is still a problem awaiting solutions.5



With refinement in anesthesia and better surgical techniques and favorable outcomes even in infants with congenital defects and in acquired valve diseases we certainly can be proud of our achievements.6 Thanks to Werner Forssmann, Cournand, Lewis Dexter, Paul Wood, Taussig, Sir John Mac Michael and many others cardiac physiology could be better understood now. The new breed of interventionists, however, can not claim similar credit as many of the newer interventions, especially in the field of coronary artery disease and heart transplant and many of the new cardiological drugs have not been shown in good light in some audits lately.7, 8, 9



More and more people are opting out of modern medical system, thanks to this kind of skewed developments and commercialization of cardiology. The total budget of complementary and alternate systems of medicine, so-called CAM in the US, has gone up to the tune of $ 70 billion per year.10 While 62% of the upper middle class find it difficult to go to hospitals, thanks to the high insurance premia in the US, large number of Britons, who have free access to the NHS, would want to opt out to other systems. This is very glaring in cardiology. While pointing our finger at many other things that have led to this sorry state, time has come for us to do a bit of soul searching and introspection to see if we have faltered anywhere.11 We must remember that the practice of medicine is no longer paternalistic-it is more of a mutually agreed partnership.



Have we lost our core competency of empathy and concern for our patients? Do we have enough time for our patients? Do we get to know our patients? “Know thy patient better than his disease” averred Hippocrates. We have started treating reports, angiograms and charts rather than the sick human beings who have their worries, cares, anxieties, fears and obsessions.12 Studies have shown that the human mind plays a vital role in cardiological disease scenario, as in any other field. In a manner of speaking every single disease is slightly “mental”. While we fret and fume about the diet for the patient, a recent very large prospective study revealed that it is not what one eats that kills him but it is what eats him (negative thoughts) that kills him more often.13 Our competitors on the other side of the fence and many quacks have more time for their patients and they are placebo doctors while we, drunk with the arrogance of our technology, have become in effect nocebo doctors. “Primum non nocere ”-first do no harm- has been given a go by in cardiology, to a great extent.



Teaching of bedside cardiology has hardly changed over the years. Most of what we teach our undergraduates has no relevance today. Most of the subtleties taught to them will only make them confused. A large study of three generations of cardiology teachers at the St. Andrews University over a period of 60 years showed this lacuna. The disease scenario is also changing in cardiology today.14 However, bedside diagnosis, based mainly on the history and physical examination, is still very valid and accurate according to a recent prospective double blind study of out-patients in London teaching hospitals using even PET scanners.15 We need to reinforce our bedside teaching to make future generations better equipped to be compassionate to patients and spend more time with them to get the accurate final diagnosis at the end of “listening” to the patient and reading the referral letter. This will bring down the cost of treatment drastically eliminating the unwanted investigations and interventions. There is an urgent need for parsimony both in investigations and interventions.



“Time has come” the Walrus said “to talk of many things—cabbages and Kings….” Time has come to go to the basics in teaching and learning cardiology. Hyposkillia, lack of bed side skills, is being lamented even in the west.16 One of the recent meetings of the American College of Cardiology had its key note address by a noted teacher of teachers, Proctor Harvey, on “How to auscultate the heart?” This should not surprise us as many of our own cardiologists couldn’t care less about auscultation while they are lost in their scopes, scanners and catheters conveniently forgetting the economic burden on their hapless patients of the hi-tech stuff that they practice. The latter could easily be dispensed with many a time if one trains the most important part of one’s body-the stuff between the ear pieces of the stethoscope!17 Long live bed side cardiology, elegantly shown to be very effective by generations of cardiologists on both sides of the Atlantic-Evan Bedford, Paul Wood, Walter Somerville, Paul Dudley White, Sam Levine, Nobel Laureate Bernard Lown and many others. May their tribe increase! We must always remember that patients could survive without doctors but doctors can not survive without patients. Let us try to be compassionate to keep our patients happy and not lose them to our competitors.



“From our desolation only does the better life begin.”



Sir William Osler in AEQUANIMITAS.

Valedictory Address, University of Pennsylvania, May 1, 1889.





Bibliography.





1) Hegde BM, Shetty MA, Shetty MR. Hypertension Assorted Topics. 1993. Bharatiya Vidya Bhavan, Bombay.

2) Hegde BM. Chaos- a new concept in science. Jr. Assoc. Physi. India 1996; 44: 167-68.

3) Firth WJ. Chaos-Predicting the unpredictable. BMJ 1991; 303: 1565-1568.

4) Milloy S. Science without Sense. Cato Institute Washington DC. 1997.

5) Goldberg RJ, Samad NA, Yarzebski J, et. al. Temporal trends in Cardiogenic shock complicating AMI. N. Engl. J. Med 1999; 340: 1162-1168.

6) Yusuf S, Zucker D, Peduzzi P, et. al. Effect of coronary artery graft surgery on survival. Lancet1994;344:563-570

7) Hegde BM. Coronary artery disease-time for reappraisal. Proc. Roy. Coll. Physi. Edinb. 1995; 26: 421-24.

8) The Anti-hypertensive and Lipid lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA 2002; 288: 2981-2997.

9) Chalmers J: Hot Study: brilliant concept, but a qualified success. J. Hypertens. 1998; 16(10):1403-1405.

10) Complementary and alternative systems of medicine.www.mayoclinic.com/health/alternative-medicine/PN00001.

11) Starfield B. Is US medicine the best in the world? JAMA 2000; 284: 483-485.

12) Editorial. Bedside Medicine-Oslerian Reliquary. Med. J. Aust. 1971; 1(24): 1251-1252.

13) Howard BV, Manson JE, Stefanick ML et. al. Low-fat dietary pattern and weight change over 7 years- The women’s health initiative dietary modification trial. JAMA 2006; 295: 39-49.

14) Finlayson JK, Kenmure ACF, Short DS. et. al. Cardiac signs for students: the wheat and the chaff. BMJ 1978; 1: 1471-1473.

15) Hampton JR, Harrison MJG, Mitchell JRA. et. al. Relative contributions of history taking, physical examination, and laboratory investigations to diagnosis and management of medical outpatients. BMJ 1975; 2: 486-489.

16) Fred HL. Hyposkillia-deficiency of clinical skills. Texas Heart Institute J 2005; 32: 255-257

17) Reynolds R and Stone J. Ed: On Doctoring. 1991. Simon and Schuster, New York.