The Patient Was…

We’ve all heard it many times.

“It happened so suddenly.”

“There was no warning.”

“He was never sick a day in his life.”

“It came out of the blue.”

“Nobody ever expected it.”

This is the myth of the “medical black swan”: the surprise event, the sudden, unexpected, unpredictable, medical catastrophe; the disaster without warning.

Bull!

Can there be a medical black swan? Probably yes, but realistically rarely.

To understand why the common perception of unexpected and unforeseen medical events is incorrect, you must understand three things: symptoms, signs, and risk factors.

A symptom is something a person feels. It is subjective. It could be one of many things: for example, pain, weakness, nausea, fatigue, dizziness, etc. If you experience it, it’s a symptom. Nobody else feels your symptom. It’s personal, reportable, describable.

A sign is something somebody else can observe. It is objective. It could be your color, your posture, a deformity, tenderness on touch, swelling, fever. Sometimes it’s measurable, like weight, blood pressure, heart rate, breathing rate.

A risk factor is something  —   a condition, behavior, circumstance, characteristic, etc.  —  that makes an event or occurrence more likely. It is a predictor of sorts, a prognosticator, even a warning at times.

An example of a risk factor might be smoking; the ultimate event might be lung cancer or COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that makes breathing more difficult). Another risk factor might be high blood pressure, which is a known risk factor for heart attacks and strokes. (Incidentally, high blood pressure is also a sign, as described in a paragraph above, since it can be observed and measured by somebody other than a patient themself. It is not usually a symptom, however, because except in rare instances, high blood pressure is not felt by a patient. It is often called “the silent killer.”)

 Now, the reason that medical black swans are really so rare is that they are almost always preceded by either symptoms, signs, or risk factors. The problem is that these symptoms, signs, and risk factors are either ignored, disregarded, or misunderstood, and their impact on health is under-estimated.

The belief that a sudden, unexpected heart attack occurring without any warning  —   where one or more of the coronary arteries carrying blood to the heart muscle is blocked by a cholesterol-laden plaque with an overlying blood clot  —  is not uncommon, is an old idea. When I was in my Cardiology training, it was a prevailing notion. My limited experience interviewing and examining patients with acute heart attacks made me realize that most of them had had symptoms before the actual attack. I decided to investigate this as part of my training.

With approval from my Chief of Cardiology, and the hospital, and with the help of another colleague in training, I designed a research study that would try to find out how common these prodromal symptoms actually were. Our study showed that a large percentage of heart attack patients  —  a higher percentage than ever reported before in medical literature  —  experienced symptoms  related to the heart attack in the days or sometimes even weeks before the actual event occurred.

We published the results of our study, titled “Prodromata in Acute Myocardial Infarction” (a myocardial infarction is a heart attack) in one of the leading medical journals, Circulation, and it has been subsequently cited many times by other researchers. (It was described by an expert as a “seminal” paper, making the adjective one of my favorite descriptors.)

What was striking, and disturbing, about the findings that so many patients had had premonitory warnings of an impending attack, was that the symptoms were either ignored or misinterpreted by the patient and, if reported to a doctor, ignored or misinterpreted by the physician, as well. Chest pains were often dismissed as “gas” or “indigestion.” Shortness of breath was frequently attributed to being “out of shape.” Fatigue was sometimes considered to represent “overwork” or “stress.”

So, from symptoms alone, the idea of a sudden, unexpected, unpredictable, out-of-the-blue heart attack is unlikely. What about signs?

Remember, a sign is something objectively detectable. Moving away from cardiology for a moment, consider the patient who notices occasional blood on the toilet tissue after a bowel movement. Perhaps the patient is experiencing a slight change in bowel habits, as well, such as slightly more frequent bowel movements. The patient thinks “irritation” or perhaps hemorrhoids. A physician can detect blood on a simple stool test, and now patients can do the same test at home. If it’s recognized as a potential warning sign of a serious bowel condition, further investigation may reveal a polyp that could be pre-cancerous, and could be simply removed. But if it’s ignored, bowel cancer might develop.

It’s notable that colon and rectal cancer is on the increase in society now, especially in younger adults. The reasons are unclear. But routine colonoscopy or other bowel investigation can detect problems while they are still curable, and such testing is now often recommended, even for people with no warning signs.

Returning to cardiology, there are many signs that physicians can detect that may herald serious disease, even in the absence of any symptoms felt by a patient. A heart murmur (sound made by turbulent blood flow), for example, may be heard by the doctor listening with a stethoscope; it could be innocent, but it also could represent a serious heart valve problem that has not yet produced any symptoms experienced by the patient. Proper investigation and treatment could avert what might have otherwise resulted in a sudden catastrophic event that people would have said “came out of nowhere, without any warning.”

So, just as with symptoms, from the point of view of detectable signs the sudden, unexpected, out-of-the-blue event is quite uncommon.

Finally, there is the issue of risk factors. Remember, these are things that can predict a later bad event, that make such events more likely. They are like omens, things that portend a future event. Having a risk factor doesn’t mean you absolutely will experience an adverse event, but it greatly heightens the likelihood of such an event happening. And it presents the opportunity to address the risk factor, to treat it, to normalize or reduce its impact.

Prominent risk factors for common diseases, especially heart and lung diseases, are well known. Smoking and air pollution are prime risk factors for both heart and lung disease; high blood pressure, elevated levels of “bad” cholesterol, and obesity (especially visceral or intra-abdominal fat deposition) are major risk factors for coronary heart disease, including heart attacks and heart failure (inadequate pumping of blood by the heart muscle). Some risk factors, such as age, cannot be modified, but many of the negative effects of aging are often magnified through other, modifiable factors, such as high blood pressure and cholesterol.

The fact is that by recognizing and addressing modifiable risk factors, many diseases and adverse events can be delayed or even prevented. This is true for many major areas of medicine, including cardiovascular disease, lung disease, oncology (cancer), kidney disease, diabetes, and more.

 So, let’s abandon the myth of the sudden, unexpected, unpredictable, out-of-the-blue medical event.

Let’s move from, “It happened so suddenly; there was no warning,” to, “We should have known and done something.”