Cardiac care for the whole patient – not just the heart

13 Apr

A serious medical crisis can yank you unceremoniously right out of your normal game and hip check you into the boards, leaving you metaphorically bruised and literally traumatized.The freshly-diagnosed wear a familiar look – that look which seems to ask plaintively:

“What the hell just happened to me, and what’s going to happen next?”

But it’s often a delayed question, surfacing only after the most serious part of a health crisis has been survived, finally allowing reality about what’s just happened to you to sink in.

Ironically, our ability to physically recuperate and heal may have as much to do with the psychosocial stress accompanying the crisis as it does with the heroic medical interventions that saved us.

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What causes this psychosocial stress? 
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A 2007 Institute for Medicine report accurately describes the fears and worries that accompany most life-threatening illnesses, regardless of the diagnosis. These include basics like:

  • The physical pain and exhaustion of the condition and its treatment.
  • Not understanding about the diagnosis, treatment options, and how to manage your illness and overall health.
  • Not having family members or other people who can provide emotional support and practical day-to-day help such as performing important household tasks.
  • Not having transportation to medical appointments, pharmacies, or other health services.
  • Financial problems, ranging from concerns about health insurance to payments for treatments, or problems paying household bills during and after treatment.
  • Concern for how family members and loved ones are coping.
  • The challenges of changing behaviours to minimize impact of the disease (smoking, exercise, dietary changes, etc.)

When I read this list recently, it struck me that when I was being discharged from CCU (the Intensive Care unit in cardiology), not one of the cardiac nurses, residents or cardiologists who cared for me during my post-heart attack hospitalization had said one word to me about any of the important and commonly-experienced psychosocial issues on this list.

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Not one of them asked, for example, if I’d be able to afford to buy the fistful of expensive new cardiac meds I’d been prescribed as a new heart attack survivor.
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Not one asked if there was anybody at home to help take care of me there, or if there was anybody at home who needed me to take care of them.
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Not one asked if I’d be returning to a high-stress job, or if I had enough banked sick time or vacation days to take sufficient time off to recuperate before going back to work.
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Such real life issues are simply not the concern of most of our health care providers.
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It’s almost as if they are unaware of the considerable research that suggests ignoring the psychosocial issues of their seriously ill patients increases the risk of poor outcomes and higher hospital re-admission rates down the road.
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Indeed, the 2007 report adds that patients may pay a hefty and under-recognized toll when experiencing the kind of psychosocial stress that can accompany any medical crisis:

“Those suffering from psychosocial issues can have difficulty remembering things, concentrating, and making decisions. These mental health problems can also decrease patients’ motivation to complete treatment, take their medications, change unhealthy practices such as smoking, and decrease their ability to cope with the demands of a rigorous treatment process.
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“There is also growing evidence that stress can directly interfere with the working of the body’s immune system and other functions.”

As cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic, once explained:

“Cardiologists may not be comfortable with ‘touchy-feely’ stuff. They want to treat lipids and chest pain. And most are not trained to cope with mental health issues.”

According to the 2007 report, studies on patients diagnosed with a wide variety of chronic illnesses (including but not limited to heart disease, diabetes, arthritis, chronic obstructive lung disease, depression, asthma) have identified specific obstacles that get in the way of how well patients are able to realistically manage their illness and health (Wdowik et al, 1997; Riegel and Carlson, 2002; Bayliss et al, 2003; Jerant et al, 2005).

These obstacles include things like distressing symptoms, poor communication with physicians (with resultant poor understanding of their illness and how to manage it) or lack of family support at home.
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And worse, patients are often unaware of resources that may be available to help them overcome or manage these obstacles. Even when they are aware, however, limitations in mobility, fatigue, pain, transportation problems, cost issues, or lack of insurance often prevent them from taking advantage of the resources that could actually help them (Jerant et al, 2005).
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.As in most areas of medicine, it seems that once a patient survives the immediate crisis, their medical team seems to breathe a collective sigh of relief – and then shifts attention directly to the incoming wounded who need your hospital bed more than you now do.
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So that may be why it’s only when we are finally back at home, away from the reassuring 24/7 monitoring of our medical team in hospital, that reality slowly begins to trickle back in.
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This is particularly true among certain populations, say the authors of the 2007 report. For example, psychosocial problems – and the effects of failing to address them – can appear magnified in these demographic groups:

  • vulnerable and disadvantaged populations such as those living in poverty
  • those with low literacy
  • members of cultural minorities
  • those over age 65 who are more likely than younger patients to experience the compounding effects of other chronic conditions that occur with aging

What’s the price of ignoring psychosocial issues that affect patients so profoundly? Increased rates of hospital re-admission, lower rates of adherence to recommended treatments, inferior quality of life, and worse longterm outcomes/mortality.

Doctors, you choose..

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(1) Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting; Adler NE, Page AEK, editors. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington (DC): National Academies Press (US); 2008. 1, The Psychosocial Needs of Cancer Patients.

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Q: How have you experienced medical care that addressed you as a whole person?

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See also:

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The under-appreciated joy of making a meat loaf

6 Apr

by Carolyn Thomas  @HeartSisters

meatloafGripped in the throes of sweet nostalgia recently, I spent part of an enjoyable morning making a version of my mother’s homemade meat loaf recipe for our family. (If you’re creating your meat loaf masterpiece in the afternoon, I recommend having a nearby glass of heart-smart red wine on standby to keep you company).

It was a highly therapeutic kitchen experience that I’m afraid will soon become extinct. Meat loaf is an old-fashioned dinner that now makes hipsters sneer, nutritionists groan, and vegans turn even more pale than usual.  And like a lot of home cooking, it takes a bit of effort to whip up, so busy people doing Very Important Things believe they simply do not have time to make it. Goodbye, homemade meat loaf.  Continue reading

When your “significant EKG changes” are missed

30 Mar

by Carolyn Thomas  @HeartSisters

A new cardiac study out of Montréal tells us yet again what women heart patients have already known for years: women receive poorer care during a heart attack than our male counterparts do. Quelle surprise . . .  But one specific finding caught my eye: one of the cardiac procedures that these researchers compared in this study was the use of the diagnostic electrocardiogram test (ECG or EKG) in male and female heart attack patients.(1)

They found that women were less likely than men to receive an electrocardiogram within the recommended 10 minutes of arriving in hospital with suspected cardiac symptoms.

It turns out, however, that even when we do finally get hooked up to a 12-lead EKG in a hospital’s Emergency Department, the doctors there may not be able to correctly interpret the “significant EKG changes” that identify heart disease. Continue reading

Cardiac gender bias: we need less TALK and more WALK

23 Mar

by Carolyn Thomas  @HeartSisters

News flash! Yet another new cardiac study from yet another group of respected researchers has been published in yet another medical journal suggesting that (…wait for it!) women receive poorer care during a heart attack compared to our male counterparts.(1)

As my irreverent Mayo Clinic heart sister and heart attack survivor Laura Haywood-Cory from North Carolina once observed in response to a 2011 Heart Sisters post:

“We really don’t need yet another study that basically comes down to: Sucks to be female. Better luck next life!’, do we?”

Well, Laura - apparently we do.  Because those studies just keep on coming. Continue reading

“I’m the least depressed person on earth, except when I’m depressed”

17 Mar

by Carolyn Thomas  @HeartSisters

When I learned that Dr. Sherwin Nuland was going to be doing a guest lecture at the University of Victoria here back in 2012, I was among the first in town to book tickets. I loved his book called How We Die (a finalist for the Pulitzer Prize) ever since I’d featured his chapter on death and heart disease three years earlier here.

His sold-out UVic audience was enthralled by his engaging manner and compelling excerpts read from his newest book called The Art of Aging: A Doctor’s Prescription for Well-Being.

But I was even more intrigued by this famous surgeon/Yale University professor’s personal stories of his own experience living with debilitating depression – a depression so crippling, so impossible to shift, that in his 40s his doctors were considering doing a pre-frontal lobotomy.   Continue reading

Dr. John Mandrola: “AFib is your body talking to you”

10 Mar

by Carolyn Thomas  @HeartSisters

If you or somebody you care about has been diagnosed with Atrial Fibrillation (AF),  you likely already know this about the diagnosis: it’s an irregular heart rhythm affecting the heart’s upper chambers (the right and left atria) – and it’s also the most common heart-related reason for hospital admission. As Kentucky cardiologist Dr. John Mandrola likes to describe the disorder:

“AF is both a disease and a consequence of actions. It’s your body talking to you.”

Dr. John is a bike racer and one of my favourite writers in cardiology. As my heart sister Jaynie Martz once sized up his writing: “concise, charming, compassionately light, adult-to-adult, uber-digestible with nary a whiff of condescension or pomposity.” Amen, Jaynie.  His particular cardiac specialty is electrophysiology, the diagnosis and treatment of heart rhythm disorders. Here’s his overall take on the diagnosis of atrial fibrillation, as delivered to a Utah conference of his fellow electrophysiologists recently: Continue reading

Stress test vs flipping a coin: which is more accurate?

1 Mar

by Carolyn Thomas  @HeartSisters

You may not have any signs or symptoms of coronary artery disease while you are just sitting there quietly reading this post. In fact, your symptoms may occur only during exertion, as narrowed arteries struggle to carry enough blood to feed a heart muscle that’s screaming for oxygen under increased demand. Enter the diagnostic stress test, used to mimic the cardiac effects of exercise to assess your risk of coronary artery disease.

During stress testing, you exercise (walk/run on a treadmill or pedal a stationary bike) to make your heart work harder and beat faster.  An EKG (aka ECG) is recorded while you exercise to monitor any abnormal changes in your heart under stress, with or without the aid of chemicals to enhance this assessment.

So for doctors who like to order stress tests for their patients with possible heart issues, imagine their reaction to this blunt warning from Dr. David Newman:    Continue reading

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