by Max Hammonds, MD

Dr. Ron Atchison, internist, waited outside his patient’s room while the current group of medical students and residents filed out behind him. He motioned them to follow him down the hall to a small conference room. When they had all crowded in, he spoke.

“This is just for the medical students. The rest of you hold your peace,” he said. His chief resident and the first year resident smiled at each other and settled in the corner chairs.

“Okay, any one, what did you see in there, just now?” Dr. Atchison leaned against the wall, eyeing the medical students.

Mary Hall, a fourth year student spoke up. “A 67-year-old female with episodes of non-cardiac chest pain, probably esophagitis based on her rapid response to antacids and repeat negative cardiac enzymes, hypertension, high cholesterol and triglycerides, border-line high blood sugar and mildly obese . . . and . . .” Mary paused, knowing there was something more she should say.

“Very good, Dr. Hall. Very well summarized.” Dr. Atchison paused. “But there is one more significant piece to her story.” He looked around. “Dr. Martin.” He spotted the tall, shy third year student behind the others near the door. “Dr. Martin, this is the patient you worked up, I believe. Tell us what the final piece is, please.”

“Yes, sir.” Dr. Martin flipped open the patient’s chart, referring to his notes. “Her father, brother and uncle all died of coronary heart disease and her mother died of colon cancer.”

“Very good. The positive family history. This is a patient to be watched closely. Why is that, Dr. Hall?” Dr. Atchison eyed his favorite fourth-year student.

“Because her chest pain might one day actually be a cardiac episode. Cardiac disease in females is so frequently missed. Females present with different symptoms.” Dr. Mary Hall paused. “We somehow seem to think that heart attacks happen only in men.”

“Very good. Excellent.” Dr. Atchison nodded his approval as he reached for the patient’s chart to sign the orders written by the attending nurse.

“Sir, if you please, I have a question,” Mary Hall said, “about your orders.”

“Yes?” Dr. Atchison’s eyebrows arched upward.

“You didn’t order aspirin, sir. You gave her medicines for her high blood pressure and her high cholesterol. You ordered diabetic and weight control counseling. But you didn’t order a low dose aspirin. And I was wondering why.”

Dr. Atchison slowly closed the chart. “Hmm. Our old friend, aspirin. Yes, we usually give a baby aspirin, 81 mg, to our heart patients.” He eyed her carefully. “Is she a heart patient?”

“Yes, sir. She has a family history and several major risks factors for heart disease and for the possibility of stroke,” Dr. Hall concluded. “And aspirin prevents some cancers, yes?”

“Dr. James.” The first year resident quickly roused from his slouched position. “Dr. James, in whom is aspirin proven to be effective?”

“In those at high risk for heart disease,” Dr. James shot back. “Those who have had a heart attack, who have stents, or who have had a non-bleed stroke. In these patients aspirin has been proven to significantly prevent another episode.”

“But what about those with major risk factors but not an actual heart attack or stroke. Do we give these patients aspirin?”

“I know that aspirin is not appropriate for people with little or heart disease risk. It does not prevent heart disease in those at low risk and aspirin has significant side effects.” Dr. James looked puzzled. “But I’m not sure what it does for those at moderate risk.”

“Dr. Stewart, what do you know about patients with risk factors but no actual heart attack, those at moderate risk?”

The chief resident sat up straight. “A recent study demonstrated that low dose aspirin was helpful in only 20 % of the patients at moderate risk. But more than 30% of them got significant side-effects from the aspirin, mainly gastrointestinal bleeding. In the patient we just saw, the risks for bleeding are probably higher than the chance for benefit. Especially with her esophagitis, it’s too risky to give her aspirin.”

“And what about the prevention of cancer, Dr. Stewart?” Dr. Atchison asked.

“All we have are observational studies in aspirin and cancer, sir. There is no hard evidence yet that aspirin prevents any cancers. It is inappropriate at this time to be giving aspirin to prevent cancer, especially with all the side effects of aspirin, only one of which is bleeding.”

“Thank you, Dr. Stewart. An excellent question, Dr. Hall. An excellent response from our residents. All in all, an excellent teaching day.” Dr. Atchison smiled and started for the door. “Oh, Dr. Hall.” He paused. “Come see me in my office this afternoon. I would like to talk with you about being one of our residents next year.”