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Clin. Cardiol. 22,611-613 (1999)

Speclal A rtlc leCrotchets (1999)J. WILLISHURST, .D.Division of Cardiology,Emory University School of Medicine, Atlanta, Georgia, USA

IntroductionThe word crotchet may be used to describe bothersomeattitudes, habits, opinions, and language. My previous arti-c l e ~ ~ - ~n the subject created considerable interest and promp-ted some who read them to send me a few of their own crotch-ets. Accordingly, this comm unication includes more of myown crotchets as well as a few crotchets sent to me by others.Remember, a crotchet may initiate an unrealistic responsein the one w ho detects it, although the stimulus may o r maynot be serious. For example, the sky will not fall if some-one is persistently late, but it is irritating to someone whois persistently early (or vice versa). On the other hand, to usethe absence of risk factors to exclude coronary atheroscle-rotic heart disease is a serious crotchet. Although the skymay not fall, it will turn dark, growl, and produce sparks ofdispleasure.

More CrotchetsDoing well is commonly written in the patients record. Dothese words guarantee that the physician knows w hat to ob-serve in the follow-up of a particular medical problem, or arethe words used because the patient simply feels better?For example, suppose the patient has stable angina pectorisdue to coronary athe rosclerotic heart disease. Suppose alsothat the patient develops the angina only when he or she walksup a little incline near his or her home. The physician advisesthe patient to discontinue walking up the incline and the pa-

tient no longer has angina pectoris.Is doing well the proper en-try for the physician to make in the patients record?

Address for reprints:J. Willis Hurst, M.D.1462 Clifton Road, N.E.Suite 301Atlanta, Georgia 30322, USAReceived: May 4, 1999Accepted: May 4, 1999

When a coronary arteriogram appears to be normal, it isnot accurate to state that the coronary arteries are normal; oneshould state simply that the coronary arteriogram isnormal.Is rule-out angina pectoris a diagnosis?Thisentry is com-monly w ritten in the patients record. Is such an entry simplyan escape from creating a differential diagnosis? It is not un-common for the one who writes it on a Problem List to per-form a coronary arteriogram. When the coronary arteriogramis normal, shows luminal irregularity, or 30percent diam-eter narrowing, the patient is often told the chest pain is notdue to the coronary arteries but is not told what the pain isdue to, because no differential diagnosis has been created.The word nonsigngcant is misused: When there is 30percent diameter narrowing of a coronary artery, the physi-cian concludes that the narrowing of the diameter of the coro-nary arteries was not sufficient to decrease coronary bloodflow, but we now know that such lesions may rupture and pro-duce coronary throm bosis. We alsoknow that a crack in theplaque is all it takes to cause the platelets to aggregate andproduce a clot that is sufficiently large to obstruct blood flow.Accordingly, he word nonsignijicantmust not be used by thephysician or patient to ind icate that the lesion isunimportant.Such patients may not need angioplasty or coronary bypasssurgery, but they need a full-court press directed at the pre-vention of coronary atherosclerosis.The misuse of the riskfactors to exclude coronary athero-sclerotic heart disease is a serious crotchet. I am fortunate inthat Iwork daily with medical house officers. At morning re-port I review the problem lists they create on the ir patients.When they make diagnoses, I am likely to ask them to statethe data they used to create the diagnosis. Likewise, when theentry on the Problem List is less than a diagnosis, I may askthem to presen t the data they used to state the problem theway they have stated it. For example, when the en try on theProblem List is chestpain I ask for the details of the patientsstory. Occasionally, a smart trainee will give an excellent de-scription of a patients chest pain that has all of the usual fea-turesof anginapectoris but may add, it cantbeangina due tocoronary atherosclerotic heart disease because there are norisk factors.This is agross misuse of the risk factor concept. From thebeginning it has been known that coronary atheroscleroticheart disease can occur in patients without risk factors-thedisease is simply more com mon in patients with risk factors.Also, the lipid profile is not alwaysknown when the physician

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612 Clin. Cardiol.Vol. 22, October 1999

first sees a patient with chest discomfort. I agree with EugeneBraunwald who wrote the following in his excellent Shattucklecture. It is quoted here with Dr. Braunwalds permission.Although much has been learned about the causes ofcoronary heart disease, the gaps in knowledge are note-worthy; for example, fully half of all patients with thiscondition do not have any of the established coronaryrisk factors (hypertension, hypercholesterolemia, ciga-rette smoking, diabetes mellitus, marked obesity, andphysical a~tivity).~It is wise to make a definite diagnosisof anginapectoris n apatient without any of the currently known risk factors forcoronary atherosclerosis when the history of chest discomfortis convincing.This,of course, implies hat the physician knowsthe predictive value of the symptoms that have been elicited.Dr. David Lubell, who is Chief of Cardiology at MountSinai Hospital Medical Center in Chicago, sent me the fol-lowing four crotchets. They are quoted here with Dr. Lubellspermission.The patient had (or needs) a cabbage.The common andwidespread use of this expression by medical personnel trivi-alizes what should be understood as a very serious undertak-ing. And if, heaven forbid, someone uses such slanguagewith a patient or family, it could cause considerable distressand consternation.Explaining coronary artery bypass (a bet-

te r expression) is difficult enough without the use of a degrad-ing form.Heart attacldMJ conflation. When a patient answersyes to the question .....have you had a heart attack?, the in-experienced physician may not realize that heart attack isusually understood by nonphysiciansonly in general, and doesnot have to mean myocardial infarction. For example, heartattack could refer to such events as syncope, tachycardia withpalpitations, cardiac arrest, congestive heart failure, pulmon-

aryembolism, and unstable angina, as well as true myocardialinfarction. Delving a little further into the details may clarifythe true nature of the event.The patient (who is alive!) had an episode of suddendeath. We know what is meant by this expression, but it is se-mantically wrong. Biological organisms do not recover fromdeath. Death is . death. I am not sure that the expressionI useto describe survival after ventricular fibrillation is better, but Iprefer near sudden death,The patient is on dipxin, . etc. One can visualize apatient sitting on a little pill!

My friend Joseph Perloff, M.D., who is Professor of Medi-cine and Pediatrics at the University of California in LosAngeles, sent me his pet crotchet. It is quoted here with Dr.Perloffs permission.You said in your conclusion that you would save othercrochets for another time, at which time you might wishto include what for me is an especially irritating term-

internal as applied to medicine.I have in my possessionthe marvelous book on Medical Etyrnologv by O.H.Perry Pepper, given to me by Dr. Pepper when 1 was onthe University of Pennsylvania faculty. Dr. Pepper con-cerned himself because the term medicine was used intwo senses:(1 ) to indicate the entire fieldof the medicalsciences, including surgery and other disciplines; and (2)to indicate medicine as a limited subject on a par withsurgery, neurology, etcetera. Dr. Pepper went on to saythat attempts o avoid this confusion have led to the use ofsuch inadequate terms as internal medicine. Dr. Pepperoften said that internal as applied in this context is one ofthe few medical terms devoid of an etymologic rationale.The legitimacy-or the converse-of a given term is of-ten raised in bold relief when the converse is considered.Assuming that there is such a thing as infernal medicine,the converse would be external medicine-presumablydermatology.That inference, n fact, is not farfetched. nWilliam S. Haubrichs Medical Meanings: A GIossLiiyof Word Origins, internal medicine is considered a term ofdisputed origin. One explanation that Haubrich offeredwas that the term arose in 19th century Germany asZnnere Medizine to distinguish internist from the largenumber of doctors whose specialty was dermatologyandthe external manifestations of various diseases,especial-ly (sic) those of venereal origin.The word data is pleural. One should not say the data wasgood enough to prove the point. One should say the data Mwrgood enough to prove the point.A doctors signature that is nor legible is a common crotch-et. Poor handwriting causes a great deal of trouble. At times,nurses cannot determine whom to call when a physician hasleft a confusing order on a patients order sheet.The wordq incidence andprevalence are commonly misused.The assumption that a normal ejecfion frucfion determinedby echocardiography excludes heart failure is a serious crotchet.A learning center is not afacility-it is the human brain.A lecture is not Grand Rounds. It isa lecture.The speaker stands behinda lectern. Heor she stands 011 LIpodium.Actors in television wear stethoscopesarnund their nrcks

to show they are doctors. Worse still-real doctors who adver-tise on television commonly drape stethoscopes around theirnecks. My worst crotchet is a urologist who identifies himselfas a doctor by draping his stethoscope around his neck, as hesells his treatment for impotence on television. I always won-der whether he can identify the fixed splitting of the secondheart sound that usually occurs in patients with an ostiunisecundum atrial septa1 defect, or whether he is faking hisknowledge of auscultation.The advertisements on television shou>ing patient Mirh ret-rostemal pain who is relieved pmmptlybysome drug used totreat gastroesophugeal reflux isa frightening crotchet. JamesHerrick would picket the television station, because in some ofthese patients it is not easy toexclude myocardial ischemia asthe cause of the retrosternal pain.

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J. W. Hurst: Crotchets (1999) 613Many people believe that a lecture is the best way to teach.8This is a crotchet. At best, a lecturer can only dispense infor-mation. Accordingly, the value of a lecture is determined bywhat the listener does after he or she leaves the lecture hall.Regrettably, most listeners do very little with the information

dispensed at a lecture.An hour with a journal or book may bemore useful than a lecture. This is especially true if the personis looking up the answer to a question he or she has abouta patient.Many people try to mw wr ize electrocardiographic atternsassociated with cardiac disease.This approach is a crotchet.It is clear-this is not the way tobecome competent in the in-terpretation of elec trocardiograms.This is a major reason whythe interpretation of electrocardiograms has deteriorated dur-ing the last two decades.I favor the use of the Grant method ofelectrocardiographic nterpretationbecause, when his methodis used, basic principles of electrocardiography are employedto interpret each electrocardiogram?-12 When patterns arelinked to the basic principles that are stored in the brain there issome chance the patterns will beunderstood and remembered.Enough for now. Although I am not running out of crotch-ets, please send me your favorite crotchets for publication inmy next article.

References1. Kilpatrick JJ: The WritersArt, p. 151. Kansas City: Andrews,McM eel and Parker, 19842. HurstJw:Crotchets: Bothersome attitudes, habits. opinions. andlanguage.Clin Cardiol1998;21:544-5463. HurstW.Electrocardiographiccrotchets or common enurs madein the interpretationof the electrocardiogram.Clin Curdid 1998;4. HurstJw:A medical crotchet. TheEmov UnivJ M rd 1987; :7ft775. HurstJw:Acardiovascular crotchet. The Emory IlnivJ Meii 1990:

4:1436. HurstJw: he improper use of thewords significant and non-significant for the classification of coronary atheroscleroticplaques(letter o the editor).Circulution 1994;90:2163-2 1657. Braunwald E Shattuck Iecture-Cardiovascular medicine at theturn of the millennium: Triumphs, concerns. and opportunities.NEngl JMed 1997;337:1364-13698. HurstJ W The Bench andMe: Teaching undkarn irig Medicirir.p.19-26. New York: Igaku-Shoin, 19929. GrantRP, stes EH Jr: Spatial VectorElectrocurdirt~riph?..hilii-delphia:TheBlakiston Company, 195110. HurstW.CardiovascularDiagnosis: The Initial E.rcimination. p.191-425. St. Louis: Mosby, 199311. HurstJw:Cardiac Puzzles,p. 33-88. St.Louis: Mosby, I99512. HurstJ w Ventricular Electuocardiogruphy. ntemet byMedscape

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