Well, after two and a half years, I'm finally on a cardiology rotation. Not medicine, not find-the-heart-patient-in-OBGYN, not a summer research program where I got to hang out on cards rounds- I've finally made it to the bona fide third year selective of INPATIENT CARDIOLOGY!
Needless to say, I've been looking forward to this for a very, very long time. But boy, I was in for a big surprise.
I've seen like 30 patients this week on the cardiology service. And NONE of them were in the hospital for HEART problems!!! So far I've seen gastroenteritis, cholecystitis, personality disorders, immune disorders, poisonings, you name it. And they all have some sort of cardiac problem, but that's not their immediate problem.
So really, this is just a glorified internal medicine rotation. But I started thinking...I've got three years of medicine before cardiology fellowship! AND three years of cardiology fellowship with patients just like these! Then who knows after that. So really, this has just been a bit of an eye-opener about what the rest of my life is going to be like.
I don't love cardiology any less, but I'm 5 days "less naive" about my career choice.
One of the most useful lessons I've learned this week (well, saw put into practice) was jokingly referred to today as troponinitis. The layman's description is best describe by one of the laws of The House of God which is one of the best books ever written about being a resident (the details are a bit outdated but the concepts are timeless):
IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.From a patient's perspective, this sounds terrible. But clinically, it's an essential part of medicine. If you do an MRI on every patient, you'll find something in every patient. As cliche as it is, it's so important because you may be worsening an outcome by finding something (what if the patient dies in the OR, but otherwise would have lived another 5 happy, relatively healthy years?).
So troponinitis is fairly specific to cardiology- troponins are a marker of muscle death, which is part of the diagnosis during a heart attack. It's easy to jump the gun and order the test on every patient on the cardiology service- these patients have a higher risk, so why run the chance of missing a heart attack, right?
Wrong. For explanation's sake, the cutoff of normal is less than 0.06 (hospital-specific, for you picky people). People having heart attacks typically have levels over 5, and sometimes much higher. But what happens when you get a number just above normal, but isn't really suggestive of a heart attack?? Today my patient's was 0.07. She was obviously not having a heart attack.
Then the problem shifts from "how to save the patient" to "how to save the hospital." As horrible as it is, a lot of medicine these days is focused on how to prevent malpractice suits. (This is another soapbox of mine which I would NEVER blog about. But I honestly wonder how morbidity and mortality rates would change if there were no lawyers.) The appropriate thing is to do a full, expensive, time-consuming, potentially-damaging workup on a patient who doesn't need it.
So this is a good example of how medicine is more of an art than it is a science, and what clinical years of med school and residency are about, rather than the details of physiology and things like that.
PS. "Troponinitis" is medical jargon, not an actual term (although many doctors would understand the reference), in case that wasn't clear. It's basically a complaint that the levels came back elevated even though heart attack is EXTREMELY unlikely, leaving a clinical predicament.
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