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.
“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.”
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…