Total Occlusion of the Heart

This week, we started our Cardiovascular block, the first of the true “Systems” blocks during our second year curriculum. During the last block, the Neoplasia/Hematology block, we began to have more clinical lecturers (physicians/M.D.s), which seems to have correlated in a dramatic increase in lecture attendance in our Pathology/Pathophysiology course. Not surprisingly, I think most of my classmates are interested in practicing medicine, eschewing graduate school and future careers dedicated to research in favor of medical training. While I doubt anyone would reasonably argue that research is not an important venture in medicine, I think that most medical schools fail to effectively indoctrinate medical students in the importance of improving clinical practice with research pursuits and the ability (and importance) of individual physicians to engage in both (including Harvard Medical School’s most recent attempt to introduce a mandatory course on the role of discovery in medicine). I suspect that the significance of research as a corollary to clinical practice is more readily accepted and learned during the fellowship stage of medical training.

Why mention research now? If nothing else, I am very fascinated by both the cardiovascular and pulmonary systems, and if it were possible, I might happily choose to be a cardiopulmonologist in lieu of pursuing a career as a Pulmonary and Critical Care physician. The mixed inpatient and outpatient work of Cardiology and Pulmonology might be broad enough to keep me as engaged as I would be with the inpatient consult and ICU work of an intensivist. Then again, perhaps I might have more interest there than just the clinical practice.

For the first time this year, I have felt inspired enough by the subject matter of my medical school coursework to read and learn more than required (by either the course, or the USMLE). Interestingly, Robbins and Cotran’s <u>Pathologic Basis of Disease</u>, the authoritative text on pathology, suggests that the atherosclerotic plaques that are at the core of Ischemic Heart Disease, the number one cause of death in the U.S. and globally (more than cancer or accidents), often rupture asymptomatically prior to a total occlusive event. That is, plaques that rupture and cause a thrombotic, coronary artery occlusion have usually ruptured previously with few or no symptoms. The authors express concern over this notion of a silent disease: there is a very large number asymptomatic individuals who are at great risk of a sudden coronary occlusive event, and we currently have few or no methods of evaluating the likelihood of plaque rupture in an individual patient.

While there have been many mysteries and insufficiencies in our knowledge of medicine and disease that have been presented during my medical training thus far, this is perhaps the first time I’ve felt compelled to actually seek out the answer. How might we effectively and inexpensively screen individuals for risk of atherosclerotic plaque rupture, and in doing so, possibly prevent the occurrence of heart attacks (myocardial infarctions)? Right now, the emphasis in cardiology is on saving lives from MIs and other cardiopathologic events, and then subsequently preventing the new MIs and maintaining heart function for as long as possible. What if it were possible to prevent MIs in the first place by screening all patients with the major predisposing risk factors? Doing so might make the risk of heart attack more real for individual patients and motivate them to pursue aggressive lifestyle changes (much like genetic screening for BRCA1 and BRCA2 genes with respect to breast and ovarian cancers).

When I think about my own heroes in medicine, I tend to think of those who changed the practice of medicine through social and clinical practice means rather than through basic science. I wonder if perhaps this is my future career path: clinical practice paired with motivated and aggressive clinical research into new methods of practicing medicine. Two of Tulane University School of Medicine’s greatest medical heroes were pioneering surgeons, Rudolph Matas and Michael E. DeBakey. Dr. Matas was the first physician to use spinal anesthesia, the first to repair aneurysms, and the inventor of the intravenous drip. Dr. DeBakey, a student of Dr. Matas, has similarly won world reknown through his innovations in cardiovascular surgeon and the invention of numerous surgical tools and devices. Maybe I too will be motivated to leave my mark on the frontlines rather than in the books.

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