Learning Curve: Lessons from the Suburbs

Patients are not always right, and we ought not to make a pattern of simply "leaving it up to" a patient. They have come to us for an opinion.

By: Daniel Munoz, MD
Date: May 20, 2011

illustration by Sherrill Cooper

If you time the traffic lights just right, you can make the trip from the Hopkins Hospital to the cardiology clinic at Hopkins White Marsh in 22 minutes. As a newly minted cardiology fellow two years ago, I confess that my initial reaction to my White Marsh clinic assignment was disappointment—about travel time, global fuel prices, and about leaving the downtown nest of clinical activity.

Now, after two years of trekking out to the suburbs, I humbly admit that this has been an indispensable ingredient in my training. The primary reason? Dr. Ernest Arnett.

Dr. Arnett has overseen my clinical practice, serving as the cardiology attending of record for the patients who come to see me each Monday. He bears ultimate responsibility for the recommendations I provide to patients. The leash has gotten progressively longer, but we still discuss each patient in detail. These weekly huddles in his office have yielded enduring lessons. It is the part of medical education that cannot be found in a textbook or a medical journal.

One lesson from my first days at White Marsh stands out.

Referrals to our cardiology practice come for many reasons. Often, the reason can be addressed quickly and narrowly: get a stress test, start a medication, draw a blood test. Established clinical algorithms create automaticity in what we often recommend. But in a sub-specialty clinical practice like cardiology, there exists an important distinction between: 1) What are we being asked to do by a patient or referring primary care physician? and 2) What actually can and should be done beyond the initial reason for the referral? As I presented one of my first cases to him in 2008, Dr. Arnett taught me this subtle lesson in a not-so-subtle way.

Mr. G was a 51-year-old man who came to see me in clinic for routine pre-operative assessment prior to a knee replacement. After efficiently taking his history, reviewing his labs, and performing a physical exam, I confidently concluded that he was ready for surgery, with no need for further cardiac testing. I sat down in Dr. Arnett’s office and reported my findings, deriving satisfaction from his nods of agreement. As I began to stand from my chair, Dr. Arnett calmly asked, “So what else did you talk about with Mr. G?” My confusion must have been apparent. Had I missed something? Did he doubt my assessment? After racking my brain, I embarrassingly admitted, “I’m not sure what you mean.”

Our exchange ended. We then spent the next 20 minutes in the exam room with Mr. G. Dr. Arnett did not rehash the history or the particulars of my pre-operative assessment. He instead dissected the underlying reasons for why Mr. G had knee trouble in the first place. They talked about Mr. G’s undisciplined eating patterns, indifference toward exercise, and years of nighttime snoring combined with chronic daytime sleepiness. Mr. G almost surely suffered from untreated sleep apnea, a condition that perpetuates fatigue, immobility, obesity, and—in Mr. G’s case—knee problems. Our final report to Mr. G’s primary care doctor reflected these thoughts, with a recommendation to get a formal sleep study—to prevent his other knee from going bad, among other things. 

Stepping back and thinking broadly about how I as a cardiologist can help (even if my recommendations have little to do with the initial consult question) should be part of my obligation. When I limit myself to narrowly answering a specific question from a primary care doctor or patient, I miss opportunities. Dr. Arnett never told me this. With Mr. G, he showed me.

Two other lessons from Dr. Arnett have left a permanent imprint.

In an era of patient-centered care and autonomy, paternalism seems to have fallen out of fashion. But many times in medicine, paternalism is necessary. Patients are not always right, and we ought not to make a pattern of simply “leaving it up to” a patient. They have come to us for an opinion. That opinion ought to be delivered, whenever possible, with clarity. Resisting the urge to dip into the reservoir of qualifiers like “on the other hand, it depends, it’s up to you, either way is fine, etc.,” can avoid patient confusion or ambivalence about what needs to be done. Dr. Arnett is a master of these exam room moments, combining compassion and hard truths with remarkable effectiveness.

Finally, Dr. Arnett has sharpened my focus on the fundamentals, not just of cardiology, but of medical care in general: testing and procedures ought to confirm our suspicions, not be used as fishing expeditions. Fishing expeditions result in avoidable harm, avoidable stress, and avoidable costs. Our emphasis should be on delivering thoughtful assessments, rather than a reflexive battery of tests and procedures. Clinical courage manifests in two forms: taking necessary action in times of concern, and resisting action when reassurance is all that is needed.

My 22-minute Monday afternoon commutes end this summer as Dr. Arnett retires. Just as his patients will miss him, so, too, will those of us in training who have benefited from his example.