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W. Bruce Fye, MD, MA, FACC, Mayo Clinic, Division of Cardiovascular Diseases, 200 First Street, SW, West 16A, Rochester, MN 55905-0001, USA
It’s a great honor and a privilege to serve as President of the American College of Cardiology—and I’m delighted to have this chance to extend a warm welcome to our new Fellows. I also want to welcome your family and friends. They’re proud of you, and they share your joy on this special occasion. As important as this convocation is to each of you and to us, I want to encourage you to look beyond it. This evening’s formal recognition of your many accomplishments is just the beginning of a lasting and meaningful relationship between you and the College.
Thinking about the importance of relationships, I want to emphasize that I have the opportunity to address you this evening because of the encouragement and help I’ve received from many people at critical stages of my life and career. I especially thank my late parents, my wife, Lois, and our daughters, Katherine and Elizabeth, for their love, understanding, and constant support. In the same spirit, I dedicate this talk on the art of medicine to the many patients I have had the privilege of caring for since I graduated from Johns Hopkins Medical School 30 years ago.
But this talk isn’t about me or the past. It’s about our new Fellows and the future. Although I hope everyone here this evening will find my comments on the art of medicine interesting and compelling, I want to direct them especially to our Fellows. You have chosen a very exciting and challenging specialty. Whether you focus your energy on practice or research, on general cardiology or one of its subspecialties, or on cardiac surgery, your career will bring you great satisfaction. You are on the crest of a wave of bright and energetic young physicians and scientists who will live to see cardiovascular diseases controlled and cured in ways we can’t even imagine.
Most of you will practice cardiology, and many of you will do research or teach. Regardless, this is yourCollege. For half a century, the American College of Cardiology has united academic and practitioner cardiologists and cardiac surgeons in their shared commitment to helping heart patients. The founders of the ACC believed that continuing education was an indispensable ingredient of high-quality care. They knew that if you want to provide the very best care, there is much to know—and always more to learn.
That’s still true today, and it will always be true. Going forward, I hope you will take full advantage of the College’s many educational offerings, including our journals and ACCEL, our annual meeting and extramural programs, our various chapter activities, and especially ACCardio, our innovative educational Web site, launched at this meeting.
Remember, the American College of Cardiology is your professional society—not just for education, but also for advocacy. The term “advocacy” reflects the ACC’s special commitment to you and to patients with cardiovascular disease. When your College’s leaders and staff speak to members of Congress and other government influentials, we proudly represent more than 28,000 cardiovascular specialists. With a clear voice—and a consistent message—the ACC proclaims the importance and value of high-quality, specialty care for heart patients. We also lobby for cardiovascular research, especially translational and clinical research, those powerful engines that propel scientific advances into patient care but need lots of financial fuel to reach their goal.
This evening, however, I won’t talk about the science of medicine. Instead, I will address another vital aspect of our professional lives—the artof medicine. For centuries, the art of medicine has focused on the precious and unique interaction between a patient and his or her physician. It reflects the value of caring, compassion, and communication. Although the art of medicine may not be as newsworthy as scientific breakthroughs or as exciting as bold new procedures, it is equally important.
You, our new Fellows, wearing academic robes that acknowledge your accomplishments and signal unlimited opportunities, have the privilege of being physicians. Cardiology, your chosen specialty, is an exciting and important field. The procedures you perform and pills you prescribe help people live better and longer lives. But thoughtful words and actions will amplify the positive effects of procedures and prescriptions. As a cardiovascular specialist, each of you is in a unique position to touch the lives of many others. Your altruism and your education are precious gifts. Treasure them and build upon them to help heal your patients and make our world a healthier and better place.
Optimal patient care requires the skillful synthesis of the art and science of medicine. Most members of the audience this evening are not physicians—you are the family and friends of our new Fellows. You know, either firsthand or through family or close friends, the feeling of vulnerability that accompanies many illnesses—especially heart disease and cancer. Most doctors have not been seriously ill. If you ask those who have been, however, they will tell you the experience transformed them. It heightened their awareness of their body and their sense of vulnerability. Above all, it gave them a dramatic new perspective on how patients feel, what they fear, and what they seek from a physician.
Patients with heart disease want to get well and stay well. They look to cardiovascular specialists for cures and comfort, for remedies and reassurance. Today, cardiac treatments tend to be dramatic—with electrical devices that can speed up or slow down the heart and catheters that can open blocked vessels and valves. But our special procedures take both talent and time, and they can distract us from what may seem to be a less compelling problem: the concerns that many cardiac patients have about their future. Their anxiety is often unspoken, but it’s usually there.
Our new Fellows have been physicians for several years, and each one has already cared for hundreds, perhaps thousands, of men and women. Although each of you has developed a personal style of communicating with patients, I urge you to regularly re-evaluate and refine your approach. Think of every patient interaction as an opportunity to enhance your communication skills, to broaden your understanding of human nature, and to become a better doctor. For feedback, watch and listen to your patients for subtle clues about how they perceive your words and actions.
Most of our communication with patients is verbal. The challenge for busy doctors is to talk less and listen more. In response to your questions about their illness, patients share their personal stories of signs and symptoms. They’re trying to tell you, from their unique perspective, what’s wrong with them. If you interrupt patients repeatedly and distract them with too many leading questions, you’ll get an abridged version of their story. Sometimes, you’ll miss critical clues that would have helped you make the correct diagnosis and prescribe the optimal therapy. Taking a careful history may be time-consuming, but it’s usually worth the effort. Together with a focused cardiovascular exam, a detailed history of the present illness is a crucial step in diagnosis. It is also a vital part of building the doctor–patient relationship.
Patients and their physicians share an interest in prompt, accurate diagnosis and effective treatment. Today, in cardiology, we often achieve these twin goals, but it isn’t always easy. And too many doctors—including cardiologists—have a real problem if their patient’s symptoms, signs, and test results do not fit a specific diagnosis—one with a name and a natural history. When we can’t match a patient’s complaints with a defined illness or with specific test abnormalities, we tend to discount their symptoms. This is most evident with conditions we don’t understand, such as chronic fatigue syndrome or, in cardiology, so-called Syndrome X. But it’s important to acknowledge that patients can have real discomfort and real diseases even if we can’t explain their symptoms, given our present state of knowledge. Author George Orwell put it this way: “Blessed are they who are stricken only with classifiable diseases.”
Fortunately, many cardiac disorders are relatively straightforward when it comes to diagnosis and treatment, but some are not. To illustrate the point, and its implications in terms of the art of medicine, let me tell you about a patient. A 35-year-old farmer, married with two small children, told his family doctor that over the past several weeks he had become progressively short of breath and fatigued, to the point he could no longer do his chores. He had no cardiac risk factors, and he had been healthy, except for a bad case of the flu a few months ago.
After briefly evaluating the man, his family doctor sent him directly to a cardiologist at a nearby medical center. The heart specialist could tell, right away, that the burly young man was sick and frightened. On examination, he had clear evidence of congestive heart failure. After acute treatment and a comprehensive inpatient workup, his cardiologist concluded that he had an idiopathic dilated cardiomyopathy.
For this young man and his wife, these technical terms disguised a devastating diagnosis. Although we have names for his complaints and findings, and natural history studies provide clues to his prognosis, we have no certain cures, and we cannot confidently predict this one man’s clinical course or ultimate outcome. Moreover, the term idiopathic, applied to his diagnosis of cardiomyopathy, is revealing. Quite simply, it means we don’t understand what happened to his heart, and it reminds us that we have much to learn about how and why humans get sick. But while we wait for the science of medicine to help us solve the many mysteries of heart disease, we can use the art of medicine to help blunt the impact of illness.
Let me continue my story. The cardiologist who evaluated this patient did what our new Fellows have been trained so very well to do. She interviewed and examined him and, hoping to identify the cause of his problem, performed several sophisticated tests and procedures. Despite an exhaustive workup, she found nothing to explain his damaged heart. At this point, many doctors would have prescribed medications for his heart failure and scheduled a follow-up visit to review his response. This patient’s cardiologist did those things—but she chose to do more—important things that busy doctors sometimes overlook.
She had studied the young couple’s reactions to her detailed discussion of his test results, his diagnosis, and her recommendations. They clearly understood he had a serious illness. Their fear and frustration were obvious. As the cardiologist encouraged their questions and responded to their concerns with empathy, she was practicing the art of medicine. After describing the likely benefits and common side effects of the drugs she prescribed, she made some suggestions to help them begin to cope with this unexpected illness and its implications for their lives and livelihood.
Importantly, the cardiologist did not extinguish their hope. She told them that despite having a very serious form of heart disease, some improvement was probable with medical therapy and that recovery, although quite unlikely, was possible. They appreciated her care and concern. When they left, they were understandably discouraged, but they weren’t devastated. I think this challenging case points out the importance of hope and humility in the practice of medicine, especially when it comes to predicting the future—a future filled with the promise of medical advances that will greatly enhance our ability to help and heal heart patients.
As new Fellows, you expect patients with heart disease to look to you for expert advice about diagnosis and treatment. Many patients also want you to speculate on the course and outcome of their illness. They may not ask specifically about their prognosis, but it’s surely on their minds—and on the minds of their loved ones. Whenever possible, reassure your patients—and infuse them with hope. Thanks to new and effective treatments, many cardiac patients can and do return to normal or nearly normal lives. Still, our current limitations emphasize the vital importance of promoting prevention as well as research. And because none of us can predict the future, I urge you to err on the side of optimism when you talk to your patients.
Today, prognosis rests on a fairly firm foundation, thanks to more accurate diagnosis, incredible imaging techniques, and large natural history studies. On the other hand, pictures, pathology, and probability cannot predict the course of a given disease in a specific individual. Men and women with serious heart disease want to beat the odds—so don’t take away their hope. As physicians, we must use our complementary skills in the science and the art of medicine to help our patients chart a course that combines optimism with pragmatism.
Remember, medicine is not mathematics. Although the science of medicine seeks to prove that two plus two always equals four, the art of medicine acknowledges that the real answer—the one that matters to each unique patient—is probably somewhere between three and five. Even in this age of randomized controlled trials and meta-analysis, the care of an individual patient can be enhanced significantly by a combination of clinical judgment, common sense, and compassion. These important qualities help define a superior physician—the kind of doctor youwould want if you were seriously ill.
Each of us is a unique biological being, influenced by our genes and our past and present physical and social environments. This helps to explain why each patient reacts somewhat differently to his or her disease and our attempts to treat it. At this point in the history of medicine, we’ve identified only a small fraction of the many factors that modify the presentation, natural history, and outcome of every illness. As we care for patients and seek new knowledge, these uncertainties should inspire both humility and hope.
Before I close, I would like to make a few observations about the image of the physician in contemporary American culture. Today, we doctors must work hard to earn the respect our predecessors took for granted. Professionalism is precious, and it needs to be protected in this era of market-based medicine. A decade ago, for-profit managed care swept over the American landscape like a flood, washing away medical traditions and ruining relationships. Before long, the fast-moving currents of managed care had reached virtually every cardiac patient and every heart specialist in the nation.
The unique doctor–patient relationship, built on a centuries-old foundation of self-sacrifice and trust, was undermined. Individual patients seeking personalized care were sometimes pushed around like pawns on a chessboard. Meanwhile, many doctors confronted hastily constructed but solid barriers that disrupted or destroyed long-standing relationships with their patients and peers. Some physicians were told to see more patients, to spend less time with each of them, to order fewer tests, and to restrict referrals. For-profit managed care denigrated specialists and threatened the nation’s academic medical centers, our factories of new knowledge and talent. Some managed care organizations also devalued the art of medicine by promoting their own proprietary guidelines designed to cut costs—and by encouraging throughput rather than thinking and thoughtfulness.
In this context, a few critics charged that cardiologists ordered too many tests and performed too many procedures. They reminded us, appropriately, that we must guard against conflicts of interest. As professionals, we agreed, but we urged the entrepreneurs who had invaded medicine to look in a mirror. Much more than money motivates cardiovascular specialists to perform angiograms and echocardiograms. These tests, and others, provide unique information that helps us care for cardiac patients in a cost-effective manner. We’re lucky to have so many powerful diagnostic tools and therapeutic techniques. When it comes to invention and innovation, cardiology is a fantastically fertile field—a walk through the huge exhibit halls at this meeting certainly proves the point. Meanwhile, the American College of Cardiology has led the way in creating evidence-based and expert consensus guidelines that enhance care for the sake of the patient and society, rather than limit it for the sake of profit.
Just as the science and art of medicine are inseparable, technology complements clinical judgment—it doesn’t replace it. And there is more to clinical judgment than making a difficult diagnosis and prescribing the proper pills. Clinical judgment also implies awareness and acknowledgment of a patient’s feelings and fears. A complete physician is both compassionate and conscientious. Fortunately, many doctors, like the cardiologist who cared for the young farmer, have these qualities. Still, the pace of modern medicine presents challenges to the art and the science of medicine. As physicians, we must defend them both. It is in the best interest of our patients and our profession to do so.
Looking back, some good things came out of a decade of heated health care debate. Let me give you a few examples. Many outcome studies have confirmed the value of specialty medicine. Most physicians, especially cardiologists, more actively promote prevention. Patients have been empowered, and, today, they take more responsibility for their health. Our nation has increased its commitment to the infrastructure of research. Meanwhile, the public rejected the rhetoric that demonized specialists and the rules that restricted referrals.
Throughout the noisy debate, the American College of Cardiology spoke loudly and clearly, with confidence and conviction, about the value of specialty medicine and the importance of collaborative care. By virtue of our focused training and experience, cardiologists are uniquely qualified to care for and help patients with cardiovascular disease. But as specialists, we must acknowledge the vital role that primary physicians play in caring for our patients’ chronic stable heart conditions and their noncardiac problems.
Finally, I would like to look forward. Some individuals, including some doctors, are pessimistic about the future of American medicine. But they’re wrong! And the future of cardiology is especially promising—for our new Fellows and for our patients. America’s research machine has been re-energized, and our academic medical centers are producing a new generation of bright and ambitious men and women who want to deliver high-quality care as cardiovascular specialists. Several hundred of them are here with us this evening, and we’re very fortunate to have them as colleagues. Their enthusiasm enlivens our specialty, and their diversity enriches our College, our profession, and our nation.
As you—our new Fellows—go forward as cardiovascular specialists, work hard to earn the trust and respect of your patients, your colleagues, and the many individuals you will depend upon in your daily lives as physicians and medical scientists. You have joined the ranks of an elite corps of medical professionals who chose cardiology as their career. You follow in the footsteps of several generations of ambitious and idealistic physicians and scientists who have worked hard to enhance and prolong the lives of heart patients and to advance our understanding of cardiovascular diseases and their treatment.
So, as your professional lives unfold during the coming years, exciting years that will bring many opportunities, I hope that some of my comments about the art of medicine will resonate in your words and actions. Welcome to a wonderful and rewarding career as a cardiovascular specialist. Welcome to fellowship in the American College of Cardiology.
↵1 President, American College of Cardiology
- American College of Cardiology Foundation