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Who killed Uncle Bobby? We did

For this young doctor, a relative’s unexpected heart attack hammered home an important lesson about helping patients.

By Christine M. Shim, MD
Family Physician/Boynton Beach, FL

When the phone rang at 11 pm, my husband, Bert, and I were already in bed. I barely recognized my father-in-law’s distraught voice on the answering machine. I thought I heard him say "hospital." Did he also say "tragedy"?

As I got up to replay the message, the awful possibilities raced through my mind. Both of my husband’s grandmothers are getting old. One of them had been battling recurrent diabetic foot infections; was she back in the hospital?

The news was worse than that, and totally unexpected. My husband’s uncle Bobby had died of a massive heart attack. He was only 54.

Bobby had coached his 13-year-old son Michael’s baseball team that day, and when he and Michael were on the way home after practice, he began complaining of heartburn. Michael, picking up on possible warning signs, pleaded, "Dad, let’s go to emergency room." Bobby said No; he thought he’d be fine.

After they arrived home, Bobby rested on the couch while Michael showered. They were alone in the house; Michael’s 20-year-old sister, Chrissy, was away at college, and his mother, Lynn, a flight attendant, was flying to California.

When Michael walked into the living room to check on his father, he found Bobby lying quite still, his eyes closed. Bobby loved playing practical jokes, so at first Michael thought his dad was just pretending to be dead. Then he realized it was no joke. He called 911 and started performing CPR, which he’d learned in school, but it was too late.

Bobby’s father also had died of a heart attack at age 54, when Bobby was only 14. Bobby’s death was history repeating itself.

That fact bothered me the most. Hadn’t my teachers told me long ago that a major reason to learn about a patient’s history is to avoid repeating mistakes? Maybe Bobby’s premature death was inevitable, predetermined by his genetic code. But maybe it wasn’t. For my own peace of mind, I had to try to find out more.

The detective in me started gathering all the facts so I could make sense of the situation. A story that’s all too familiar in medicine soon unfolded. Besides Bobby’s strong family history of cardiac disease, he had a personal history of hypertension. Preventive medicine could–and should–have benefited him tremendously.

Before he died, it had seemed he was taking better care of himself. He’d been trying to improve his diet and exercise regimen, and he’d lost weight. Bobby looked and felt great–better than he had for quite a while. All aspects of his life were running smoothly: His business was booming, the kids were doing well in school, and he and Lynn were planning to build a new house.

But as it turned out, he’d stopped taking his antihypertensive meds. Instead, he was taking some natural products that he felt were helpful. I’m sure his doctor didn’t know.

On a personal level, I understood why Bobby had become noncompliant. His high blood pressure had never really bothered him; in fact, he felt better when he didn’t take his medications. But as a physician, I found his resistance troubling. How do we convince a patient to take medications when he feels well, especially if he experiences unpleasant side effects? How many patients don’t take the drugs we prescribe?

Surely Bobby also knew his family history increased his risk of heart disease. Was he in denial? Didn’t he care? Did he figure that he couldn’t change his genetic make-up, so it wouldn’t matter what he did? Did he really think he just had heartburn?

I still struggle with those questions, and with the thought that Bobby’s death could have been prevented. To me, his death represented a collective failure on the part of all of us in medicine. We didn’t give him the best care and education possible. We need to help patients like him long before they show up in the emergency room. Although we can’t foresee or easily prevent sudden death, we can promote healthy lifestyles.

Patient and community education is important–particularly for men, who traditionally don’t visit their doctors as frequently as women. So I give community lectures when I can. For instance, during flu season, I gave talks at a couple of retirement communities about the hazards of taking antibiotics inappropriately, and suggested measures to help elderly patients stay healthier.

Most important, I try to educate all my patients individually, taking every opportunity to review their diets, stress management, and exercise habits. When patients seem overwhelmed by the idea of making lifestyle changes, I try to get them started by suggesting a few small, realistic adjustments they could make–even just cutting out one soft drink per day, taking the stairs rather than an elevator when possible, or parking the car a bit farther from their destinations than usual, so they walk a little more. I try not to lecture, but instead to tell them I care about them and want them to be healthy.

I also use Bobby’s death as an example, because people respond better to emotions and real stories than to numbers and scientific studies. I tell patients that even though Bobby was feeling well before he died, taking his medications might have helped him live longer and better. Rather than run away from family history, I explain, we all have to respect its role and respond to it in a healthy way.

Bobby’s story scares some people–particularly when they’ve already had symptoms of trouble. A 36-year-old patient I recently saw comes to mind. He was having headaches, and I soon learned he’d been diagnosed with high blood pressure previously and had been put on medication. Then, after he lost some weight and started feeling better, he went off the medication, and his headaches returned. He’d already started making small positive changes when he came to see me, but hearing Bobby’s story reinforced his resolve to adopt healthier habits.

Other patients get defensive when I tell them about Bobby. But at least I feel I’m planting an idea that I can follow up on the next time they come in for a visit.

As for those who have no symptoms and don’t want to take medication, I tell them that although I understand their feelings, I believe that medication is their best protection, at least for the moment. Then I flatly ask them if they want to continue to be around for their families. Usually, I get a sheepish "Yes," in reply.

Ultimately, lifestyle choices are up to patients, but I want to know that I’ve given them the information they need to make informed decisions.

Although death is a natural part of life, the unexpected passing of a relatively young person always seems tragic, especially when it could have been avoided. If I can keep history from repeating itself even once by convincing a patient to live a healthier life and take a medication, Bobby will not have died in vain.

Christine Shim. Who killed Uncle Bobby? We did.

Medical Economics

2001;13.