Wednesday, March 9, 2011

In Honor of Starting the Cardiology Module

18 Stethoscopes, 1 Heart Murmur and Many Missed Connections

One by one, the medical students bent down to listen to my heart.
There were six of them, led by a bright-eyed physician with a charming Irish accent — so charming I almost didn’t care that he never called me by name. All told, 18 second-year Harvard medical students would listen to me on this darkening winter afternoon, each group of six overseen by a different cardiologist.

“Place the diaphragm of your stethoscope here,” the Irish doctor was saying. “Start at the base of the heart and move down to the apex.”

He listened quietly. “Ma’am, take a breath in, and breathe out and hold it.”

I felt like an oddly invisible prop: part artist’s model, part one-night stand, heard but not seen. At first nobody made eye contact or spoke to me, a situation that evoked the universal vulnerability of patients: exposed, invisible, dehumanized.

Amplified through a stethoscope, the human heartbeat sounds like the muffled cadences of a marching band. Thuh-rhumm. Thuh-rhumm: A low washboard rumble, signifying a poorly functioning ventricle. Thhrrum-BUM. Thhrrum-BUM: A diastolic murmur, with its bass-drum finale. PAH-da-da-PAH. PAH-da-da-PAH: The crisp roll of aortic stenosis. Flutters, skips, thunks, whooshes, crescendos, decrescendos, telltale pitches and tempos — each conveys a diagnostic meaning.

Indeed, it was my “click” that had brought me to this class in the first place. The click is a prime feature of mitral valve prolapse, a generally benign condition in which the valve separating the upper and lower chambers of the left side of the heart doesn’t close properly.

During my annual physical, my doctor at Massachusetts General Hospital had remarked how loud and distinct my click was. Would I consider volunteering as a “patient,” so fledgling medical students could listen and learn?

I was intrigued by the chance to gain perspective on the doctor-patient interaction. Make that “Patient-Doctor II,” the intentionally reversed name of this second-year course that focuses on learning the physical examination.

Now, as I sat in an open-stringed green-and-blue-print cloth gown, I began to wonder if the students realized they were examining a live human being, as opposed to a particularly sophisticated anatomical model.

The fourth student who strode to my chair was a guy I remembered from a cardiology lecture I’d attended at the outset, taught by Dr. Katharine Treadway. He’d sat up front and answered her toughest questions, brimming with enthusiasm and brains. I had found myself rooting for his medical career. Now he listened, smiled at me and said, “Awesome!”

That broke the ice. At last I was a person, not a prop.

The next student opened with “Hi, how are you?” When she finished, she said, “Thank you very much!”

In this class “listening” had more than one meaning, as Dr. Treadway had illustrated with a cautionary tale. About 10 years earlier a woman agreed to let students hear her heartbeat. She had an advanced condition called severe mitral regurgitation and needed a valve replacement.

One student examined her, removed the stethoscope and blurted to the instructor, “How can she live if her heart is this bad?”

“This was a student who is not uncaring or unkind,” Dr. Treadway told the class. “But in that moment she did something all of us do all the time: she was so engaged with the problem that she forgot about the person who had the problem.”

As students master the intricacies of the physical exam, “the experience of that patient’s illness will be completely invisible to you, unless you consciously look for it,” she warned, adding: “At the end of every interview, say to the patient, ‘How has it been for you, being in the hospital?’ I want to bring you back to the patient.”

Now the Irish physician’s group departed, and the second group trundled in. This doctor introduced me right away. He had an easy and personable way about him, and I admired his arty cuff links.

Again, some of the students spoke to me, while others did not. One let his hand linger too long on my shoulder as he thanked me and turned to walk away: creepy.

Another remained stony-faced as he fumblingly examined me, never saying a word: really creepy. So inept was he that I decided not to lean forward, thus making my heart more difficult for him to hear. (Doctors who don’t earn the trust of their patients, by the way, are more likely to be sued in a malpractice claim.)

I didn’t become a full-fledged person until the 10th exam, this one at the hands of a student with short combed-forward hair and rectangular wire-rims.

“Hi, my name is Ben,” he said with a warm, professional smile as he looked me in the eye and shook my hand. I was instantly at ease.

Ben moved with natural confidence, as if he had been practicing cardiology for decades. While listening he closed his eyes, the better to hear the subtly separate click between the two heartbeats.

He made such a vivid impression in person — kind, compassionate, smart, capable, intuitive — that when I later played back our exchange on my digital recorder, I was surprised that his soft voice had barely registered. At the end of the session I asked him why he wanted to be a doctor.

“I had an experience in the hospital with my mom, who passed away,” he told me. “That’s when I realized what I wanted to do.”

The third group seemed to have picked up a few pointers. The doctor in charge not only called me by name, but rubbed her hands and the stethoscope to warm them up, which the students mimicked. They greeted me at the start and thanked me at the end.

Before beginning, they explained where they would be placing the stethoscope and why. And they listened to my heart intently, for longer stretches — one fellow for 5 minutes 25 seconds: a lot of listening.

Feeling like an acknowledged human being, I was more apt to adjust my posture for them and inquire whether they had heard what they were listening for. I wanted to meet them halfway; I felt I owed them a good click.

Still, it was not until the 18th student — the last — that someone bothered to ask my first name. She told me hers and shook my hand. How wonderful it felt to finally say my name, to be heard and seen.

At the end, I asked if I, too, could listen to my heart. The doctor handed me her stethoscope and placed the diaphragm on my chest. I donned the headset. “Other way,” the students said in unison. I turned it so the earpieces pointed in the right direction.

Like them, I had to listen silently and for a long stretch. At first I couldn’t discern the click. I leaned forward, breathed in and out, and held my breath.

Then I heard it. To my ears it didn’t sound like a click so much as a rolling wave with an accent in the middle. But I heard it — my billowing valve, my flapping leaflet — and I was transfixed.

A few minutes later my Mass General doctor, Diane Fingold, walked in. Dr. Fingold is helping to rewrite the Harvard Medical School curriculum.

At Harvard, she explained, students don’t touch patients until the second year; some schools even delay that fundamental skill until the third. Now a move is afoot to make this happen right away, in the first year, so the connection quickly becomes natural and ingrained. Blending the mechanics of the physical exam with meaningful conversation is what Dr. Fingold calls “the unwritten curriculum.”

I asked what she had learned about listening in her 20-some years as a physician.

“When I was not able to help someone or not able to cure a disease,” she replied, “my personal temperament and way of coping was to talk a lot.

“What I’ve learned is to shut up and listen and be comfortable with silence. Because that allows people who are not talkers to have a place and a space to speak. As the doctor who’s in a position of power, there’s this feeling that taking a medical history is something active — but you need to be an active listener.”

I told her I had seen stark differences among the students. Some, like Ben, seemed to be born doctors. Others appeared to have no grasp of human connection.

“We used to assume,” she said, “that people who went to medical school were all compassionate, were all good listeners — that we just needed to give them the knowledge and they would be good doctors. We now know that’s not the case.

“But we don’t give up on the ones who don’t have it from the beginning. We can give feedback that helps. It won’t make a stiff lab-rat type into a palliative-care oncologist. But it can make a difference.”

Dr. Treadway quietly leaned in the doorway, listening to our conversation. After a few minutes, she said: “There are some doctors who do not view you as a patient. They view you as someone with a heart murmur who they’re going to listen to.”

Then she told a story about a physician who had lectured her second-year medical school class in the 1970s. He described being in intensive care for three weeks with a frightening, potentially fatal condition.

“He told us that one of the things that had surprised him most about being a patient was that every single person he interacted with — be they nurse, resident, senior physician, respiratory tech, physical therapist — it was as though they had a neon sign on their forehead that said either ‘I care’ or ‘I don’t care.’ ”

But what illuminates those neon signs? What are the clues that were so starkly apparent to me, even in second-year medical students?

Perhaps the answer lies in the medical lexicon. Auscultation — listening to heart sounds with a stethoscope — is a required skill. But actually feeling the vibration of a murmur through the chest wall is a rarer proficiency.

The students had just learned the technical term for a heart murmur that a physician can feel: a “thrill.” As any patient knows, the touchstone of a good doctor is the ability to feel one’s heart.

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