I Carry Your Heart

In giving the Dack Lecture last year, I took heart from a phrase used by Dr Valentin Fuster in the 2013 Dack lecture: “It is time to get out of the thigh and go to the brain,” a reference to the fact that the coronary lesion was part of a systemic process. I like this idea of the caudal to rostral progression, and in carrying the baton onward in its cephalad migration, I would like to take you from the thigh—not quite to the brain— but to the heart. Or rather to the heart and the brain, because a definition of poetry I once heard (and there is a poem at the heart of this address) is that it is the moment when the heart and the brain are saying the same thing.

You will recognize that the title for my remarks is from the wonderful poem by e. e. cummings, “i carry your heart.”¹ I was emboldened to pick this as my theme because of my friendship with one of your distinguished colleagues, Dr Robert Harrington, and his wife Rhonda Larsen. Bob is Chair of the Department of Medicine at Stanford University where I serve as his Vice Chair. We have established a tradition of a dinner in the lull period between Christmas and the New Year, alternating each year between our homes. Part of the tradition, which I hope will be a very long one, is that we each bring a poem to read during the course of the meal. This year, I picked “i carry your heart” only to find that this is a favorite of Bob and Rhonda’s for a very special reason. They are the parents of beautiful twin daughters, now grown up and out in the world in their separate places. Each of the twins has tattooed on her body the words, “i carry your heart; i carry it in my heart.” I was struck by this. Two twins, connected to each other in that special way that only identical twins might understand, choosing to memorialize that connection with words. The words are a tribute to their oneness; a tribute to their separateness; a tribute to love; a tribute to the heart—to the same organ you all know so well. Or, dare I say, to the organ you think you know so well—because unless you’re a twin, you may never know it quite the same way that the two of them know the heart. It is fitting at this point to quote the poem in its entirety.

I’m always astonished by this poem, by the unabashed love it declares, by the lack of any self-consciousness. We have no doubt what a heart is to this poet. For him, it’s not a cliché. If you are standing on a stage and reading these words aloud, they might make you blush. And yet these are words that define exactly what the word “heart” means outside of a cardiology meeting like this. In the neighborhoods of this city, on the boardwalks outside, the word “heart” is best defined by the poem that I just read you. But then, if you think about it, words are really the glue that make a convention like this happen. There will be billions of words exchanged at this meeting over the next few days: words about new discoveries, words in the hallways, words to summarize data… and yet a poem like this one by e. e. cummings, I’d like to think, reminds us of the broader use of words, the deeply meaningful personal utility of words and how important such usage can be. The wonderful novelist Walker Percy (who was also a physician, author of The Moviegoer and many other great novels)² said that to enter a professional education and to learn the specialized language of medicine was also to enter a “cowpath,” a deeply rutted path that sinks deeper as we accumulate years. Our increasingly technical language works beautifully the deeper the rut, but the language departs further and further from capturing the degree of the patient’s suffering.

Let’s take the electronic medical record: in one sense it’s a record of what happens with the patient. But in another sense it’s a kind of tawdry fiction. I have the great privilege from time to time of visiting other medical institutions, where because of my interest in bedside medicine, I’m often asked to make rounds with students, residents, and chief residents. I delight in this. Sometimes, out of curiosity, I will throw in my own little litmus test. I ask the assembled residents, students, and chief residents to demonstrate to me the ankle reflex on the bedridden patient we’re examining. It’s amazing to me how very often no one in the group will have a reflex hammer. Mind you, if asked, they would know that the ankle reflex is S1, they would know where the center is, and they could tell you all about the gamma efferent and the alpha motor neuron and the muscle spindle. But nobody has a hammer. Yet, if you were to biopsy the electronic medical record that very moment, you would find that it reads, “ankle jerk 3+, knee jerk 3+, biceps 3+, triceps 3+, jaw jerk 3+.” An amazing disjunction between what’s in the record and what is happening in reality. I like fiction, I read fiction, I even write fiction—but I don’t think it has a place in the electronic medical record. (Is it just me, or does the word “electronic” before medical record grate on you? It implies that if there is an electronic medical record, then there might be a hydraulic one, a dorian one, a mixolydian one and so on. Isn’t the medical record simply the medical record?)

Now you might take exception to the example I just used of the reflex hammer. But I would argue that that tool is actually quite indispensable. Ask any neurologist: there is really no better way to diagnose a neuropathy than to find profoundly absent ankle reflexes in the presence of, say, brisk knee reflexes. You can’t send (or you shouldn’t send) a patient for a painful EMG; you would not want your loved one to be sent for a painful and costly EMG because someone did not have a hammer or did not know how to use one. In fact, I would argue that you could probably forgo a stethoscope before you could forgo a reflex hammer. You’ll be proud to know that as an infectious disease person, I carry a handheld ultrasound device and I’m getting competent at taking a quick look at the heart. But I will also tell you that (for reasons that I’m going to get to) you probably can’t get rid of the stethoscope. Not in our lifetime, I don’t think.

But to return to the electronic medical record for just a moment, my problem with it is not that it can be fictional, or that it reads so poorly, or that it’s repetitive and so full of cut-and-paste. My problem is what it does to the actual words we get to exchange with the patient. A study in the American Journal of Emergency Medicine³ in 2013 with the wonderful title “4000 Clicks” pointed out that the average emergency medical physician spent 46% of their time on the computer and only 26% or so in patient care. Four thousand clicks a day was the average. Ordering 325 mg of aspirin is 9 clicks; if you ordered half the dose, it would probably be 18 clicks. To document back pain was 27 clicks, to admit a patient with chest pain to the hospital was 197 clicks—this probably explains the delay in the door-to-balloon time. In an article published by my colleague, Jeff Chi,⁴ part of our group in the Program in Bedside Medicine at Stanford, he pointed out that when our students at Stanford rotate through internal medicine they are spending 6.9 hours logged into the computer. That is half or two-thirds of their day; that is time that they should be spending with the patient. And for all this, the “electronic medical record” is really about billing—it’s putting down words to justify billing—and too often it has nothing to do with your heart as a physician, and nothing to do with the patient’s heart.

I want to quote another favorite writer of mine, long passed away now: Anatole Broyard. Many of you will recognize him for his great writing in the New York Times Book Review and the New York Review of Books. He died of a urological cancer, and he wrote beautifully about his trials in a book, “Intoxicated by My Illness.”⁵ About his urologist, he says, “My doctor, he knows all there is to know about the prostate, but I cannot sit down and have a talk with him about it, which I find a very great deprivation. What a curious organ? What could God have been thinking about when he designed the prostate in this way? I would like to have a meditation with my physician, a rumination, a lucubration, a bombination about the prostate, but I can’t do it. I’m forced to stop people on the street and talk to them about it.”

I would say a patient’s feeling toward their physician, particularly to a cardiac physician, is a bit like love. You’re typically thrust on your physician because of some acute event in your life—the onset of chest pains, the onset of palpitations, syncope—and here comes this very capable, competent individual who cares for you. What you feel for that person is love, and it’s a love that is somehow unrequited because the doctor has too little time and the doctor has many other palpable, measurable, quantifiable interests. Your physician is not there to talk to you about love. He is or she is not there to talk to you about your heart. He or she is there to talk to you about your doppelganger, about that other heart, that is burdened by ejection fractions and pressure gradients and many other such numbers—but not about your heart.

We as physicians are not unaware of this. We sense the patient is pining for some sense of our heart, some sense of our soul. If they could just feel our hearts, it would make them so much better—and yet we have to walk this delicate line between being technical, being forthright (and sometimes cruelly so) vs being mushy and full of platitudes and banalities.

Words are hard. The right word, the right balance is so hard to find, but thank God for the fact that there is also a place beyond words. As Heidegger, the philosopher, says,⁶ sometimes words and speech are just a way of forgetting our being— a way to induce forgetfulness of being—particularly technical words. But what patients crave most from us is a recognition of their being. You hear this in their complaints (I hear it anyway). People will say, “He or she never listened to me.” “He or she never laid a hand on me.” “He or she had one foot in the door, one foot out of the door.” It is a failure of recognition of their being, and a failure of making use of our being, making use of our sense of self as physicians, as caregivers.

In recognizing the being of the patients, something very profound happens. When I enter a patient’s room and when the history-taking is over, I’m always struck by the magical thing that’s about to ensue once the words have stopped. Here I have a stranger who I’ve never met before—often times older than me—telling me things that they would not tell their rabbi or their preacher: secrets. (Secrets might be even more prevalent in my specialty of infectious diseases.) Meanwhile I’m wearing a white ceremonial outfit with shamanistic tools in the pockets and they’re wearing a paper gown, a kind of wardrobe that one never sees anywhere else in society, and which ties in a very particular way. The room has furniture that is unlike anything in their house or mine. In short, we have all the trappings of a ritual. And then the patient disrobes and allows touch, something that in any other context is assault. But you’re allowed it. Tell me that this is not an important ritual.⁷ And we know that rituals are all about transformation. We engage in rituals (baptisms, weddings, plenary lectures like this one) to signal a transformation. I believe that if you shortchange this ritual, if you do a half-assed prod of the belly, if you put your stethoscope on the paper gown instead of on the precordium, you will miss actually miss out on the transformation, which is the sealing of the patient-physician relationship. We are recognizing that placebo is so much more than a sugar pill and that placebo is also about the ritual, about the tone of voice, about the setting. Pretty soon I’m sure you’re going to have clinical trials where one of the randomized arms is high placebo vs low placebo, in addition to whatever the drug you’re testing. That’s the power of your encounter with them.

During your gatherings at professional meetings, you discuss the metaphorical heart. You discuss hearts collectively that have been randomized or not and that have been meta-analyzed. But the real heart awaits you the next time you see a patient. It will come, that heart, with another companion. It will come with the other heart for which you have tracings and images and all kinds of data, and when you recognize both hearts, when you listen and then you touch with skill, your own heart will be fulfilled. Your head and your heart will be fulfilled. You will have accomplished a kind of poetry. You will have said, both to yourself and to the other (and you will have said without words): “i carry your heart; i carry it in my heart.”

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Corresponding Author: Abraham Verghese, MD, MACP, FRCP(Edin), Department of Medicine, Stanford University, 300 Pasteur Dr, Ste S102, Stanford, CA 94305-5110 (abrahamv@stanford.edu).

Published Online: April 20, 2016. doi:10.1001/jamacardio.2015.0353.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Verghese is a board member on the Gilead Global Advisory Board, has received payment as a lecturer from the Leigh Speakers Bureau, and has received book royalties from Simon and Schuster and Random House.

Previous Presentation: This work was previously presented as the Simon Dack Lecture, presented at the American College of Cardiology Annual Scientific Sessions 2015; April 6, 2015; San Diego, California.

Additional Contributions: Wendy Zhang, BA, helped prepare the manuscript. Thanks to Bob Harrington, Rhonda Larsen, and their daughters for permission to mention their names and the poem.