Clin. Cardiol.

22,611-613 (1999)

Speclal Artlcle
Crotchets (1999)
J. WILLIS HURST, M.D.

Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia,USA

Introduction
The word crotchet may be used to describe bothersome attitudes, habits, opinions, and language. My previous artic l e ~ on ~the ~ subject created considerable interest and prompted some who read them to send me a few of their own crotchets. Accordingly, this communication includes more of my own crotchets as well as a few crotchets sent to me by others. Remember, a crotchet may initiate an unrealistic response in the one who detects it, although the stimulus may or may not be serious. For example, the sky will not fall if someone is persistently late, but it is irritating to someone who is persistently early (or vice versa). On the other hand, to use the absence of risk factors to exclude coronary atherosclerotic heart disease is a serious crotchet. Although the sky may not fall, it will turn dark, growl, and produce sparks of displeasure.

More Crotchets
Doing well is commonly written in the patientsrecord. Do these words guarantee that the physician knows what to observe in the follow-up of a particular medical problem, or are the words used because the patient simply feels better? For example, supposethe patient has stable angina pectoris due to coronary atherosclerotic heart disease. Suppose also that the patient develops the angina only when he or she walks up a little incline near his or her home. The physician advises the patient to discontinue walking up the incline and the patient no longer has angina pectoris.Is doing well the proper entry for the physician to make in the patientsrecord?

Address for reprints:

J. Willis Hurst, M.D. 1462 Clifton Road, N.E. Suite 301 Atlanta, Georgia 30322, USA
Received: May 4, 1999 Accepted: May 4, 1999

When a coronary arteriogram appears to be normal, it is not accurate to state that the coronary arteries are normal; one should state simply that the coronary arteriogram is normal. Is rule-out angina pectoris a diagnosis?This entry is commonly written in the patients record. Is such an entry simply an escape from creating a differential diagnosis? It is not uncommon for the one who writes it on a Problem List to perform a coronary arteriogram. When the coronary arteriogram is normal, shows luminal irregularity, or 30 percent diameter narrowing, the patient is often told the chest pain is not due to the coronary arteries but is not told what the pain is due to, because no differentialdiagnosis has been created. The word nonsigngcant is misused: When there is 30 percent diameter narrowing of a coronary artery, the physician concludes that the narrowing of the diameter of the coronary arteries was not sufficient to decrease coronary blood flow,but we now know that such lesions may rupture and produce coronary thrombosis. We also know that a crack in the plaque is all it takes to cause the platelets to aggregate and produce a clot that is sufficiently large to obstruct blood flow. Accordingly,the word nonsignijicantmust not be used by the physician or patient to indicate that the lesion is unimportant. Such patients may not need angioplasty or coronary bypass surgery,but they need a full-court press directed at the prevention of coronary atherosclerosis. The misuse of the riskfactors to exclude coronary atherosclerotic heart disease is a serious crotchet. I am fortunate in that I work daily with medical house officers. At morning report I review the problem lists they create on their patients. When they make diagnoses, I am likely to ask them to state the data they used to create the diagnosis. Likewise, when the entry on the Problem List is less than a diagnosis, I may ask them to present the data they used to state the problem the way they have stated it. For example, when the entry on the Problem List is chestpain I ask for the details of the patients story. Occasionally, a smart trainee will give an excellent description of a patients chest pain that has all of the usual features of anginapectoris but may add, it cant be angina due to coronary atherosclerotic heart disease because there are no risk factors. This is agross misuse of the risk factor concept. From the beginning it has been known that coronary atherosclerotic heart disease can occur in patients without risk factors-the disease is simply more common in patients with risk factors. Also, the lipid profile is not alwaysknown when the physician

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Clin. Cardiol. Vol. 22, October 1999 internal as applied to medicine. I have in my possession the marvelous book on Medical Etyrnologv by O.H. Perry Pepper, given to me by Dr. Pepper when 1 was on the University of Pennsylvania faculty. Dr. Pepper concerned himself because the term medicine was used in two senses: (1) to indicate the entire field of the medical sciences,including surgery and other disciplines;and (2) to indicate medicine as a limited subject on a par with surgery,neurology, etcetera. Dr. Pepper went on to say that attemptsto avoid this confusion have led to the use of such inadequate terms as internal medicine. Dr. Pepper often said that internal as applied in this context is one of the few medical terms devoid of an etymologicrationale. The legitimacy-or the converse-of a given term is often 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-presumably dermatology.That inference, in fact, is not farfetched.In William S. Haubrichs Medical Meanings: A GIossLiiy of Word Origins, internal medicine is considered a term of disputed origin. One explanation that Haubrich offered was that the term arose in 19th century Germany as Znnere Medizine to distinguish internist from the large number of doctorswhose specialtywas dermatologyand the external manifestationsof various diseases,especially (sic) those of venereal origin. The word data is pleural. One should not say the data was good enough to prove the point. One should say the data Mwr good enough to prove the point. A doctors signature that is nor legible is a common crotchet. Poor handwriting causes a great deal of trouble. At times, nurses cannot determine whom to call when a physician has left a confusing order on a patientsorder sheet. The wordq incidence andprevalenceare commonly misused. The assumption that a normal ejecfionfrucfion determined by 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 is a lecture. The speaker stands behinda lectern. He or she stands 011 LI podium. Actors in television wear stethoscopes arnund their nrcks to show they are doctors. Worse still-real doctors who advertise on television commonly drape stethoscopesaround their necks. My worst crotchet is a urologist who identifies himself as a doctor by draping his stethoscope around his neck, as he sells his treatment for impotence on television. I always wonder whether he can identify the fixed splitting of the second heart sound that usually occurs in patients with an ostiuni secundum atrial septa1 defect, or whether he is faking his knowledge of auscultation. The advertisements on television shou>ing a patient Mirh retrostemalpain who is relieved pmmptly by some drug used to treat gastroesophugeal reflux is a frightening crotchet. James Herrick would picket the television station,because in some of these patients it is not easy to exclude myocardial ischemia as the cause of the retrosternalpain.

first sees a patient with chest discomfort. I agree with Eugene Braunwald who wrote the following in his excellent Shattuck lecture. It is quoted here with Dr. Braunwalds permission. Although much has been learned about the causes of coronary heart disease, the gaps in knowledge are noteworthy; for example, fully half of all patients with this condition do not have any of the established coronary risk factors (hypertension,hypercholesterolemia, cigarette smoking, diabetes mellitus, marked obesity, and physical a~tivity).~
It is wise to make a definite diagnosis of anginapectoris in a patient without any of the currently known risk factors for coronary atherosclerosiswhen the history of chest discomfort is convincing. This, of course, impliesthat the physician knows the predictive value of the symptomsthat have been elicited.

Dr. David Lubell, who is Chief of Cardiology at Mount Sinai Hospital Medical Center in Chicago, sent me the following four crotchets. They are quoted here with Dr. Lubells permission. The patient had (or needs) a cabbage.The common and widespread use of this expression by medical personnel trivializes what should be understood as a very serious undertaking. And if, heaven forbid, someone uses such slanguage with a patient or family, it could cause considerable distress and consternation.Explaining coronary artery bypass (a better expression)is difficultenough without the use of a degrading form. Heart attacldMJ conflation. When a patient answers yes to the question .....haveyou had a heart attack?, the inexperienced physician may not realize that heart attack is usually understood by nonphysiciansonly in general, and does not have to mean myocardial infarction. For example, heart attack could refer to such events as syncope, tachycardia with palpitations, cardiac arrest, congestive heart failure, pulmonary embolism, and unstable angina, as well as true myocardial infarction. Delving a little further into the details may clarify the true nature of the event. The patient (who is alive!) had an episode of sudden death. We know what is meant by this expression,but it is semantically wrong. Biological organisms do not recover from death. Death is ... death. I am not sure that the expression I use to describe survival after ventricular fibrillation is better, but I prefer near sudden death, The patient is on dipxin, ... etc. One can visualize a patient sitting on a little pill! My friend Joseph Perloff, M.D., who is Professor of Medicine and Pediatrics at the University of California in Los Angeles, sent me his pet crotchet. It is quoted here with Dr. Perloffs permission.

You said in your conclusion that you would save other crochets for another time, at which time you might wish to include what for me is an especially irritating term-

J. W. Hurst: Crotchets (1999)

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Many people believe that a lecture is the best way to teach.8 This is a crotchet. At best, a lecturer can only dispense information. Accordingly, the value of a lecture is determined by what 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 be more useful than a lecture.This is especially true if the person is looking up the answer to a question he or she has about a patient. Many people try to mwwrize electrocardiographicpatterns associated with cardiac disease. This approach is a crotchet. It is clear-this is not the way to become competent in the interpretation of electrocardiograms.This is a major reason why the interpretation of electrocardiograms has deteriorated during the last two decades. I favor the use of the Grant method of electrocardiographicinterpretationbecause, when his method is used, basic principles of electrocardiographyare employed to interpret each electrocardiogram?-12 When patterns are linked to the basic principles that are stored in the brain there is some chance the patterns will be understood and remembered. Enough for now. Although I am not running out of crotchets, please send me your favorite crotchets for publication in my next article.

References
1. Kilpatrick JJ: The WritersArt, p. 151. Kansas City: Andrews, McMeel and Parker, 1984 2. Hurst Jw: Crotchets: Bothersome attitudes, habits. opinions. and l i n Cardiol1998;21:544-546 language. C 3. Hurst W. Electrocardiographiccrotchets or common enurs made in the interpretation of the electrocardiogram. Clin Curdid 1998; 21:211-216 4. Hurst Jw:A medical crotchet. The Emov UnivJMrd 1987;1 :7ft77 5. Hurst Jw:Acardiovascularcrotchet. The Emory IlnivJ Meii 1990: 4:143 6. Hurst Jw:The improper use of the words significant and nonsignificant for the classification of coronary atherosclerotic plaques (letterto the editor).Circulution 1994;90:2163-2 165 7. Braunwald E Shattuck Iecture-Cardiovascular medicine at the turn of the millennium: Triumphs, concerns. and opportunities. NEngl JMed 1997;337:1364-1369 8. Hurst J W The Bench andMe: Teaching undkarnirig Medicirir.p. 19-26. New York: Igaku-Shoin, 1992 9. Grant RP,Estes EH Jr: Spatial VectorElectrocurdirt~riph?.. Philiidelphia: The Blakiston Company, 1951 10. Hurst W.CardiovascularDiagnosis: The Initial E.rcimination. p. 191-425. St. Louis: Mosby, 1993 11. Hurst Jw:Cardiac Puzzles, p. 33-88. St.Louis: Mosby, I995 12. Hurst Jw:VentricularElectuocardiogruphy. lntemet by Medscape