Bernard Lown, MD
The above title, instead of enlightening, mystifies. Is this some sort of reverse sexism or political correctness gone awry? Actually, it reflects a deep clinical truth that took me years to fathom. Wives know more about their husbands’ health problems than husbands know about their wives’ or even their own.
Many years ago I began to encourage husbands to make sure that their wives accompanied them on medical appointments. At times I was very insistent that the wife come along, and rarely I even indicated that a return visit would be postponed if the wife could not be present. Yet I cannot recall ever telling a married woman to bring her husband. I must confess that at the time I began this practice, I did not fully understand the basis for my insistence that wives be present.
Patient have come to believe that modern medicine is embodied by scientific clarity enabling a direct traverse to the correct diagnosis, followed by effective therapy. Such a directness between assessment, judgment, action, and success may be possible with physical, as distinct from biological, systems. But leaping from initial input to cure rarely works when confronting the myriad of variables offered by complexity. Nothing is more complex than an individual human being.
To deal with complexity one needs multiple inputs flowing from various perspectives. How often have I made a complete turnabout from the first impression based on initial inputs! Numerous times after listening to a wife, I have been forced to reformulate a rendered prognosis, or change the very diagnosis, or alter prescribed medications. By “listening” I don’t merely refer to verbal input. As I have previously noted, “We each possess a powerful nonverbal repertoire based on body language and facial expressions. … A conversation involves, besides words, complex subliminal tuning constantly adjusting to a host of signals. This may involve a tiny narrowing of gaze, a stare or diversion of eyes, a drooping of lip, a shrug of shoulders, a tightening or unfolding of hands, a shuffling of feet or uncrossing of limbs.”(1)
A misinformed prognosis
One of the earliest patients I encountered taught me painfully that his wife knew more about the gravity of his heart condition than I did even after a thorough examination. It was in 1957, at the outset of my medical career. My cardiology consulting practice had attracted only a handful of patients. It was lonely sitting in an empty office day after day waiting for patients who never arrived.
One morning a patient did appear, a businessman in his late fifties who tried urgently to see Dr. Samuel A. Levine, one of Boston’s leading cardiologists. As no appointments were available, he was referred to me. The patient, Mr. G, came with great reluctance. The judgment he sought required a good deal of experience, which I could not offer. The visit turned out far better than either the patient or I had anticipated. I was able to spend more than two hours on the consultation. This was not an expression of inordinate virtue; rather, it was due to no one else wishing to see me that week.
Mr. G posed but a single question: Could he go to his daughter’s wedding in Chicago two weeks hence? The trip was to be undertaken overnight in a sleeper. It was clear he had extensive coronary artery disease, having sustained a massive heart attack two months earlier.
After a careful examination that showed his heart condition to be stable, I was encouraging about the trip that would add so much joy to Mr. G’s life. My advice visibly disturbed his wife. She appeared uneasy, even frightened, and pleaded for me not to sanction the journey. Her stark words were, “Jack won’t survive it.” Her apprehension was understandable, since he had barely made it through the recent heart attack. To the delight of her husband, I emanated certainty and reassurance. As he left the office, his final words were, “I am glad Dr. Levine was overbooked so I could get to see you.”
About three weeks later, his wife sought an appointment for herself. I was preening at my beginner’s luck that augured success in building a practice.
She entered the office, plunking down in a chair without even looking in my direction. My heart began to race. Something was terribly wrong. Why was she dressed in black? No, it couldn’t be!
She began in a dirge-like monotone.
“We left on the train for Chicago as you had urged. But we didn’t get there. My husband never reached Chicago. He died on the way from another heart attack.” These words flowed out in a voice drained of emotion. “On the day of our only daughter’s wedding, I brought her father’s dead body to the chupah.(2) What we had both anticipated throughout our lifetime to be the happiest day for us turned out to be a day of pain I would not wish on my worst enemy. I ruined my daughter’s wedding. It will haunt her for the rest of her life.” She was talking quietly to no one in particular, pouring out this bitter soliloquy of ache.
Then suddenly she turned, looking at me with unconcealed rage, and began to scream: “What right have you to practice medicine? You are completely incompetent! You murdered my husband! The trip and the shaking train were too much for him. You didn’t have to go to medical school to know that.” By this time I was in a sweat. Each of her words, like an ever-tightening hoop of steel around my chest, was constraining my every breath. Seemingly endlessly, as though time had stopped, she continued to assail me. No response could have reached her. Whatever I said would have magnified her hurt.
This tortured, humbling experience thereafter made me shy away from prognosticating. When compelled to provide some prediction, I sought the insight of close family members.
The wives of patients have helped me inordinately in diagnosis as well. At times a new direction was suggested by their shrewd comments, or by their divulging information the patient avoided, or by some nonverbal cue. I recall a man in his mid-fifties who came to see me because of chest pain that his family doctor had diagnosed as angina pectoris due to coronary heart disease. He was told to seek a cardiologist’s opinion with a view to bypass surgery. This was in the days before stents had been popularized.
The severity of the discomfort, and its location and radiation, were consistent with coronary artery disease, though other features were quite incongruent with the diagnosis. Angina pectoris, the pain resulting from obstructed coronary artery disease, is predictably choreographed. Transient rather than long-lasting, it is provoked by exercise or emotional stress, more likely to occur in the morning than evening, and more commonly outdoors than indoors. In all those respects his pattern of pain differed. It invariably occurred while he sat at his desk and never during exercise. He had a good family life with three well-behaved children and ran a successful engineering business. He was psychologically well adjusted and rarely visited a doctor.
I was at a loss as to what was going on. His pain was so intense and disabling that it seemed not unreasonable to consider a costly invasive coronary artery workup.
I noted that the wife had winced when her husband talked about their children. I asked the wife to remain after her husband was taken to the testing area. When I inquired about the family, she responded with a sorrowful expression that they had had four children. The oldest, Tommy, their 17-year-old son, had committed suicide six months earlier. Tommy had just graduated as the valedictorian of his high school class and had been accepted to MIT, the father’s alma mater. Tommy was his father’s favored child. The two were closely bonded,
One summer weekend the father discovered Tommy hanging in the attic. She heard a frightening animal howl. When she reached her husband, she found him crawling doglike on all fours beside his son’s body. The sound continued to haunt her. It was a primal howl of a mortally wounded animal, not the plaintive wail of a grieving human being. She indicated that while her husband had heart pain, it was not caused by his heart. Indeed, she was right. Her husband did not need any workup. With grief counseling and the passage of time the pain did not recur.
As I am recalling these clinical experiences, flashing through my mind are numerous patients where cues from the wife set me on the right diagnostic track. Once, a Chinese patient I had followed for nearly ten years did not let on that his condition had strikingly deteriorated. Worse still, he lied to me about what was transpiring. He morbidly feared heart surgery. Fortunately, his wife was present. In past visits she looked at me unwaveringly though never uttered a word. This time her eyes were riveted on the ceiling.(3) Troubled by her changed behavior, I urged her to tell me what was going on. Initially she refused, insisting, “Chinese wife not supposed to talk behind husband’s back.” After some pressuring, she related that her husband had been forced to stop exercising and retire from his job because of the frequency and severity of angina pectoris. An immediate workup revealed that he was verging on a cardiac arrest. He had a heart operation that very day and made an uneventful speedy recovery. Had his wife not accompanied him, and had I not “listened” with my eyes, I would have missed this profound change in his status. He probably would not have survived such an error.(3)
It is indubitable that Charles Sanborn (a fictitious name) owed his life to his wife, Peggy. Leading cardiologists in Chicago had concurred that he suffered from an advanced form of cardiomyopathy, a congenital heart muscle disease with a dire prognosis. Cardiac catheterization had confirmed the diagnosis. Several heart specialists thought he would be lucky if he survived to age fifty, a mere eight years away. When pressured by Peggy, he asked his cardiologist whether he should seek a second opinion with Dr. Bernard Lown in Boston. The doctor responded, “I know Bernie well. Your money would be better spent if you contributed the cost of the consultation to some worthwhile charity.”
Charles accepted his doctor’s judgment but was overruled by Peggy, and they both came for the consultation. Clearly the Chicago cardiologist was on target. Charles had severe cardiomyopathy with an ejection fraction of only 30 percent(4) and was in chronic atrial fibrillation.(5) He was receiving appropriate medications, including digitalis and a beta blocker for controlling the heart rate. He was on anticoagulant drugs to prevent a thromboembolic event(6) and diuretics to drain away extra fluid. Sadly, I had nothing to offer. He should have heeded the wise counsel of his Chicago physician and contributed the cost of the visit to charity.
Before rendering such an unpleasant judgment, I talked extensively with Peggy. I learned that she was a schoolteacher, a loquacious, intelligent, boisterous, fun-loving woman of Italian descent. She had much to say and did not hesitate informing me of her opinion on the state of her husband’s health.
Peggy complained that though Charlie was only forty-two, he was already an old man. Due to his low energy level they rarely had sex. She appeared both frustrated and caring. I perked up when Peggy recalled that the year before, when he was in and out of atrial fibrillation,(7) she could tell exactly what his heart rhythm was. When in normal rhythm he would chase up the stairs; a few minutes later, he did “the old man act.” She explained that their home environment was difficult because of a misbehaving 17-year-old daughter determined to drive them both to distraction.
For reasons unclear at the time, I asked, “How does Charles function away from home, for example, while on holiday?”
“Interesting that you should ask,” she said, her eyes lighting up.
Peggy burst forth: “This past summer the whole family went to Tuscany for a monthlong holiday. It was my idea. When we got there, I thought that I’d indulged in a secret wish to kill my husband. Charlie was dragging his body through the mountainous terrain in a vain attempt to keep up with the two girls and me. He was constantly winded, stopping every few minutes as we climbed up and down in that splendid scenic countryside. What was interesting is that, day by day, Charlie did better, and by the time we returned home, he was his youthful self.”
As she talked, my excitement mounted. My hopping thoughts were almost audible. “I can help this guy!” kept rumbling through my brain.
Peggy’s information was illuminating. “The old man act” might be due to an unduly rapid heart action provoked by exertion. Though Charles was receiving the appropriate medications, the dosages may not have been adjusted for his distinctive requirements. Exercise training increases vagus nerve tone. The vagus is part of the autonomic nervous system that moderates the heartbeat, thereby continuously adapting cardiac work to ever-changing bodily needs. Peggy’s vivid description of the events in Tuscany was consistent with this analysis. It also provided an easily testable hypothesis. I had him hyperventilate, breathing as deeply and rapidly as he could for 30 seconds. In someone properly medicated whose atrial fibrillation is well controlled, the heartbeat barely speeds up. But Charles’s heart rate rose to 110 beats per minute. This extraordinary acceleration proved my thesis. It was likely that a better regulation of his heart rate would ameliorate his symptoms.
What needed to be done was straightforward. I doubled the dose of digitalis, increased the beta blocker, and added a third medication to slow the heartbeat. On a return visit some months later, both Charles and Peggy were awed by their good fortune. He was symptom free and able to lead a normal unencumbered life. It seemed indubitable that without Peggy’s observations, “this miracle” they referred to would not have happened. Nor would he have survived to the present, for twenty-nine years.
These clinical experiences speak to the power of a comprehensive medical history to expose vital insights. The absence of such information may mislead a doctor, to the detriment of the patient. To my knowledge the medical literature has not noted the treasure trove of invaluable information that wives may provide. These constitute invaluable clues, frequently helping to guide a physician’s uncertain journey.
The observations in this essay may largely serve as a historical footnote. As women increasingly enter the workforce and men scurry to several jobs, wives are less informed about their husbands’ health and less likely to accompany them to doctor’s visits. The problem is far more disconcerting though. Physicians are no longer skilled in communication. Worse still, many doctors think the time is better spent having patients undergo imaging or other technologic tests. But an ineptitude in communicating is not limited to the medical profession. People are increasingly alienated from one another and even from their own inner selves. A chilling loneliness is all-pervasive. These changes derive in part from the digital revolution and the ever-increasing commodification of values. Hopefully I will soon be able to muster the intellectual wherewithal to address these important issues.
1. Lown B. The Lost Art of Healing (Ballantine Books, New York, 1999).
2. Chupah is the Jewish word for a canopy under which a wedding is performed.
3. The Lost Art of Healing, 10-12.
4. Ejection fraction refers to the amount of blood expelled by the left ventricle with each heartbeat. Normal values are 50 percent and above. Thirty percent indicates a very serious malfunction.
5. Atrial fibrillation refers to a rapid, irregular, chaotic beating of the upper chambers of the heart, which causes a tachycardia that may provoke heart failure.
6. Thromboembolic events are due to blood clots that frequently come from the upper chambers of the heart. They may be propelled to any part of the body, though they commonly go to the brain, causing strokes. Atrial fibrillation predisposes to thromboembolism.
7. Before atrial fibrillation becomes the established heart rhythm, it may occur episodically, in what is referred to as paroxysmal atrial fibrillation. In fact, one goes in and out of this rhythm