Updated–
Should doctors tell patients that they are walking time bombs? We all know this is a commonly used metaphor. When it comes to the heart people are often told they have a “ticking” time bomb.
Here’s one recent very public example from a story about statins by Jane Brody in the New York Times:
“My friend Richard Erde may owe his life in part to the benefit of a statin. Mr. Erde, a former smoker, had a heart attack 22 years ago and has been on a statin ever since. Last winter, after two years with shortness of breath and vague chest discomfort, he had an angiogram that revealed three severely clogged coronary arteries — one at 100 percent, another at 90 percent and a third at 80 percent — in a then 74-year-old man who had been playing singles tennis three times a week. The cardiac surgeon who performed a triple bypass said Mr. Erde was a walking time bomb. A consulting cardiologist suggested that, if not for the anti-inflammatory and plaque-stabilizing effects of the statin, Mr. Erde might have had a second, possibly fatal, heart attack years earlier.”
I think this is an egregious example of fear mongering. There are a number of nuances to this case, but if this man was playing tennis three times a week it’s hard to believe that after two years of symptoms a “time bomb” was the best analogy for his condition. I hope his doctors at least congratulated him for quitting smoking and exercising regularly, but I don’t see why they needed to terrify him about his imminent doom, or to claim that his interventions saved him from certain doom. Couldn’t his doctors have found a better way to talk about all this?
We also need to recognize that this kind of language has a much broader effect on many people, not just a few heart patients, since this way of thinking takes place all the time. The message is delivered not just by health journalists and TV personalities but by hospitals and clinics promoting unnecessary screening and television advertisements for prescription drugs. They are all promoting the message that everyone, to one degree or another, is a walking time bomb. Health conscious adults– perhaps especially the type who read Jane Brody– are especially susceptible to this sort of message, and can’t help but hear the beat of their hearts as the ominous ticking of a time bomb.
I think Lisa Rosenbaum (Brigham & Women’s Hospital, NEJM correspondent) offers the best defense for using this kind of language:
“I truly think communication about need to take medications and behavioral change needs to be individualized. The best docs have a deep sense of who their patients are and what makes them tick, and communicate accordingly. So while I understand that some may find the “ticking time bomb” analogy aversive, I wonder if it is effective for some and ultimately helps them change their lives in a health-promoting way. I think the more we focus on patients’ ratings of doctors and “bedside manner,” the more we risk discouraging these types of very frank conversations that may do a whole lot of good. Basically we have much to learn!”
I hope she’s right. I suspect that her patients do indeed benefit from her extraordinary communication skills. But I also strongly suspect that this kind of sensitive discussion does not happen nearly as often as it should. And I also strongly suspect that many doctors think they’ve delivered a nuanced discussion about risk, but that most of their patients came away only remembering the words “time bomb.”
Update:
Here’s a terrific response from the comments section by Carolyn Thomas, author of the Heart Sisters blog:
Larry, I agree with your assessment of the “egregious” time bomb analogy. I have noticed over the years how frequently my blog readers, for example, describe their heart attacks as “massive” – some of whom had been treated with elective – NOT emergency – interventions. After a while, I started wondering: are there any other types of heart attacks out there besides the “massive” ones? And who is telling all of these patients that it must have been their timely and heroic treatment that had saved them just in the nick of time during these “massive” heart attacks?
This fear-mongering reminds me of an old Baltimore Sun interview with some of the many patients who had been implanted with unnecessary coronary stents by the discredited cardiologist Mark Midei (before he was relieved of his license to practice medicine). When one of his patients was notified by Midei’s Maryland hospital that she had not in fact had a 90% blockage in a stented coronary artery as Midei had warned her at the time (during an investigative review, this was found to be barely 10% blocked), she insisted:
“No one can ever tell me that I didn’t need that stent. Dr. Midei saved my life!”
No doubt another “massive” heart attack barely averted…
regards,
C.
Appreciate your posts – share them widely – thank you..
“You could drop dead any minute!”
A friend told me she could still remember the handsome young doctor, how he put his polished shoe on the side of her hospital bed, and told her she had only two to three days to live. She had acute leukemia. She told him only ‘God’ knew how much longer she had to live. She went into strong remission without medical intervention. The doctor died a week later of a heart attack in front of the hospital – he was 43. She lived another ten years and died of a cause unrelated to leukemia.
Another friend was told 20 years ago – after three botched surgeries – and countless life-threatening hospital errors, she did not have long to live – maybe six months. She had an inoperable adrenal gland tumor. But she’s had 20 years with her husband and six kids.
My husband (now 73) had not missed a day of school or work for the first 60 years of his life – never sick. Age 60, he developed atrial fibrillation. Now we learn that he has been improperly medicated for ten years and has severe heart failure in addition to atrial fibrillation. I’ve been fighting with his cardiologists all these years and have been vilified in their correspondence exchange. I was right all along.
The various ever-changing and contraindicated drug combos were lethal. His heart stopped and his blood pressure was so low he passed out frequently. He’s had numerous concussions. His head is ‘not on straight’, he can’t move his head from side to side, his jaw is dislocated, his teeth don’t meet, he can’t swallow properly, he chokes on his food, his rib cage is rotated, he’s had multiple lacerations and concussions
Ignorance of drug effects is rampant.
An EP appointment (Jan 2014) ended this way: Doctor: ‘You could drop dead any minute.’ Patient’s wife:: ‘But he’s feeling a lot better.’ Doctor: ‘People often feel better just before they drop dead.’ We were devastated.
In March 2015 another team of specialists told him the same thing – in nicer words – and that he needed an ICD immediately ‘DON’T WAIT!
Mid-July the referring cardiologist wrote that my husband was no longer a candidate for the procedure – his heart had improved significantly “for whatever reason”. We had dropped one of the remaining meds, lowered digoxin. Kept the warfarin.
He can’t get cardiac rehab because he has not had a heart attack! ,
Larry, I agree with your assessment of the “egregious” time bomb analogy. I have noticed over the years how frequently my blog readers, for example, describe their heart attacks as “massive” – some of whom had been treated with elective – NOT emergency – interventions. After a while, I started wondering: are there any other types of heart attacks out there besides the “massive” ones? And who is telling all of these patients that it must have been their timely and heroic treatment that had saved them just in the nick of time during these “massive” heart attacks?
This fear-mongering reminds me of an old Baltimore Sun interview with some of the many patients who had been implanted with unnecessary coronary stents by the discredited cardiologist Mark Midei (before he was relieved of his license to practice medicine). When one of his patients was notified by Midei’s Maryland hospital that she had not in fact had a 90% blockage in a stented coronary artery as Midei had warned her at the time (during an investigative review, this was found to be barely 10% blocked), she insisted:
“No one can ever tell me that I didn’t need that stent. Dr. Midei saved my life!”
No doubt another “massive” heart attack barely averted…
regards,
C.