The Attending Physician to Congress is a

"MACP" stands for "Master of the American College of Physicians. This is a prestigious standing awarded to only the most senior and accomplished internists.

It it unusual for physicians to list only their academic rank ("professor"), without listing their institution. Dr. Monahan was formerly Chairman of the Department of Medicine at the Uniformed Services University School of Medicine (the military medical school, in Bethesda, Maryland).

Dr. Monahan studiously avoids giving his military rank (rear admiral) here and in his signature block.

Is approximately 3 months after the heart attack. This is timely. Any earlier would not have allowed the clinical condition to settle down. However, the first six months after stent placement carry the highest risk for complications, taking us to April 1, 2020.

SHOULD HE GET A STRESS TEST THEN?

The letter is addressed to the patient. The physician, therefore, could have provided all of the patient's medical information without violating privacy. But because the letter withholds medical information that a physician would clearly provide in such a letter, it is apparent that the patient influenced the content of the letter.

He is writing to the patient. The physician is therefore free to write anything and everything (i.e. no privacy concerns). The patient can then decide whether to release the letter. So there must have been an agreement up front on what the physician would write.

Here the physician says only that the patient requested the letter, but does not say that the patient left him (the physician) free to determine the contents of the letter.

An office can't serve as a physician. Only a human can be a physician.

Typo: "and Internal Medicine" should be "in Internal Medicine"

Using the word "general" to describe the physical examination is potentially a very large weasel word. It can mean that detailed examination of various organ systems -- the heart and the neurological system, for example -- were perfunctory or non-existent. Did the physician even examine the heart or the neurological system? We have no way of knowing. A more likely weasel maneuver, if we make the safe assumption that the physician is competent, is that detailed organ-specific examinations were made, but results from those examinations are excluded from this report because they are not part of the "general" physical examination.

To say the exam (however extensive it may have been) was "normal" is insufficiently detailed for a patient who had a heart attack just 8 weeks earlier. As an extreme example, if the physician examined only the fingernails, then saying the "physical examination was normal" is worthless. Also note that the physician felt compelled in sentence __ to reveal to the patient the values for age, height, and weight -- all of which are completely obvious to the patient -- but did not disclose important parameters which the patient cannot ascertain for himself, including assessments of cardiac gallops, cardiac filling pressures, fluid in the lungs, hypertensive damage to retinal arteries, and on and on.

A physical examination also includes taking a history, but this one doesn't. The letter does not even state whether this was the first hint of coronary disease. Perhaps the senator had a history of stable angina (or angina on a stress test) and did not receive treatment for it (see below) other than low-dose aspiring. We don't know. Perhaps the senator had previous heart attacks that were untreated (this is very common). The letter omits any mention of the vital historical questions that must be asked of heart attack survivors:

A thorough examination would certainly not have been normal. A 78-year-old man is guaranteed to have an enlarged prostate gland.

This is not the preferred way to assess the presence or absence of diabetes. Had the physician truly been addressing this [important] point, he would have checked a hemoglobin A1c level, because it reports the average blood sugar level for the past three months. The fasting glucose reports it for only an instant in time.

Nice. (HDL a little low) Plaque regression?

This is one of the most egregious statements in the letter. Any medical or nursing student who reported an EKG with only this one sentence would be chastised, *especially* when the patient recently had a heart attack. Were there Q waves? T wave abnormalities? In what coronary territories? Was there poor R wave progression? Left ventricular hypertrophy? Left bundle branch block or other conduction delays? The physician is a professor of medicine. It is inconceivable that he does not know the importance of these elements for diagnosis and prognosis, and it is inconceivable that he would fail in an honest report to characterize these elements in some way.

The letter reports only conditions for which he has been treated. This is not forthcoming, in two ways.

1. He may have other unmentioned conditions that he has elected not to treat, of which prostate cancer would be a prime example.
2. He may have two conditions that both have the same treatment, but discloses only the one he is being "treated for." Example: heart attack survivors are treated with aspirin, but so are many stroke survivors as well as many people who are at substantial risk for stroke and want to prevent it. Thus, given that Senator Sanders is being "treated for" his heart attack with aspirin, the letter does not rule out the possibility of stroke or stroke risk.

Was he really never treated for hypertension before his heart attack? It is rare for 78 year old men to be normotensive. (He is now taking the anti-hypertensive medication lisinopril

He has multiple risk factors for coronary artery disease: Gout, Hypercholesterolemia, Male sex, and Age.

His history of esophageal reflux increases his risk for sleep apnea.

"Superficial skin lesions" is too vague to be a useful medical phrase, as it could span the gamut from simple warts (easy) to malignant melanoma (bad). Why did the physician not simply name the types of lesions? This is an example of deliberate obfuscation by the physician. Senator Sanders had a basal cell carcinoma removed from his cheeck in 2016. Furthermore, the phrase "complete removal" adds a pall to the possibilities, because no one -- especially a medical oncologist like the physician writing this letter -- really cares if a wart or a basal cell carcinoma undergoes "complete removal." Did Senator Sanders have a superficial malignant melanoma?

Why is he not on a beta blocker?

Why is he on clopidogrel when more effective anti-platelet drugs are recommended after placement of a coronary stent?

Listing only "daily" medications could exclude several important compounds that are taken only when symptoms flare or are dosed less frequently than daily. Examples might include colchicine for his gout, pain relievers for his lumbar pain (opiates?!), and any of multiple medication types for his esophageal reflux (antacids, proton-pump inhibitors, ...).

Stopped B-blocker?

This statement sounds favorable, but it may be meaningless because the physician's note does not say how and why the strength improved, or how the strength was measured. The difficulty is that heart muscle strength can improve in two different ways. The first way is for the muscle to get better of its own accord. This is common, especially in the first few days after a heart attack. The second is for the muscle to appear to get stronger when it really does not. This occurs in almost every heart attack patient, after the cardiologist prescribes medication to lower blood pressure. This is best understood by thinking about muscle outside of the heart: If I watched you lifting a 50-pound dumbbell with your arm, and also watched you lift a 5-pound dumbbell, both times not seeing the dumbbell itself, I would think that "looked" stronger lifting the 5-pound weight because your arm moved more quickly and more vigorously. It is the same in cardiology. We look at an echocardiogram to see how the heart muscle is moving after a heart attack, but we cannot see the blood pressure that is opposing that movement. So, if I see that your heart muscle is looking stronger on day 2, it may be because your muscle actually is better, or it may be because I've given you medicines to lower your blood pressure. Sick hearts can be very sensitive to even small changes in blood pressure.

The physician's note nowhere says that Sanders has been free of signs of heart failure. The distinction is that "symptoms" are feelings that the patient subjectively experiences. "Signs" are objective findings that the physician detects. So, for example, a physician who hears crackling sounds in the patient's lungs via a stethoscope has detected a sign of heart failure. It is not a symptom because the patient is completely unaware of the sounds.

One important symptom of heart failure is breathlessness when attempting to sleep flat. Because Sanders has esophageal reflux [§1.15e], it is possible that he routinely sleeps with his head elevated, and so never attempts to sleep flat.

While reassuring that Sanders never had symptoms of heart failure, it should be remembered that the main symptoms of heart failure emerge during physical exertion. For many heart attack patients (especially those in whom the left anterior descending coronary artery is obstructed [§1.24]), heart function is most compromised in the first day after a heart attack, which is precisely a time during which heart attack patients are confined to bed. (There is an indication of this with Sanders in [§1.29] where his heart function was noted to have improved.) Without physical exertion, the opportunity to experience the symptoms of heart failure is greatly limited.

Given the above criticisms of even a simple, innocuous-sounding statement, it becomes apparent that physician summaries of a complicated illness like myocardial infarction cannot be trusted. There is too much room for ambiguity (at best) or concealment (at worst).

Does this exclude LBBB?

The maximum predicted heart rate for a 78-year-old is 142 beats per minute (equals 220 minus age), so 92% of that is 120 beats per minute.

OOPS - NOT HEART ATTACK SURVIVORS. This statement is perfidious. The "reference population" to which the physician's note refers is a population of age-matched heart attack survivors [§2.6]. Although it is a true statement, by leaving the "reference population" undescribed, it is clearly intended to deceive non-physician readers by injecting the descriptor "above average." If a physician is going to write a letter with simple language that is aimed at a general, non-physician audience, then it is incumbent on the physician to take care that the concepts are presented as clearly as the language. That did not happen here, and there can be no appeals that it was merely a stylistic error of prose composition. It was deliberate obfuscation.

Even if the physician had here disclosed that the reference population was heart attack survivors, it would still be an underhanded comparison, for reasons discussed in sentence [§2.6].

Omits the plan for follow-up of the heart attack. How often will he be seeing a physician? Is another stress test to occur? Will his list of medications evolve?

Dr. Monahan studiously avoids giving his military rank (rear admiral) here and in the letterhead.

These docs use their titles to create aura of objectivity and neutrality, but clearly not so. Have omitted the obvious negatives in effort to minimize electoral threat.

Does not mention:

• Coronary anatomy. (Doesn't even have indication of STEMI vs. NSTEMI)
• Abnormal aspects of EKG
• Ejection fraction (with low BP, ejection fraction is higher)
• He has a fixed wall motion abnormality (per LeWinter letter). Unsaid dx: "ischemic cardiomyopathy"
• Size of infarct by troponin level not given (Is this still considered valid indication of infarct size?)
• Why not on beta blocker? Is LBBB a [relative] contra-indication? Asthma? COPD?
• He may have average exercise tolerance now, but maybe he lost something (i.e. was better before)
• Was he on beta blockers when stress test performed? (sloppy)
• Doesn't say why exercise tests stopped (sloppy)
• This was a cardiopulmonary [metabolic] stress test. Should have reported peak RER.
• Is there a cardiac rehab. program? [should there be?] [did he complete one?]
• What's in his carotids?
• Monahan letter says exercise tolerance is "above average compared to a reference population of the same age." But letter from exercise physiologist says exercise is [merely] average for a non-diseased reference population; is above average only for an age-matched population with "a similar diagnosis" (infarct survivor?)
• Why did they do cardiopulmonary stress test? Is this now recommended after MI? Should check what the indications are now felt to be.

This letter, and the next one, is written by a state employee. Has the appearance of a conflict.

This letter has no date, a small lapse, but it is an unprofessional mark against the letter-writer. As with all elements of a medical record, letters like this are legal documents and must be dated. It is a further suggestion that the author of the letter was not a physician -- i.e. not the person who signed the letter -- because physicians write such letters frequently and have the practice of universal letter-dating drummed into them.

Exercise test was 9 - 10 weeks post MI. I think is ok re: waiting time after infarct.

This phrasing is ambiguous. See annotations in Fig. 4 of reference 1 to see the two ways to interpret the sentence.

Article covers CABG, MI, PCI, UAP. Sample skewed to dx not impacting LVEF. Has 20% current or recent smoker, but this did not affect VO2max. 75% on B-blocker.

OOPS - NOT HEART ATTACK SURVIVORS. There is no medical reason to include this statement, because the comparison group is so heterogenous. "Heterogeneous" refers to the fact that all heart attacks are not created equal. At one extreme, heart attacks may go unnoticed by patients (Senator Sanders' heart attack was not small). At the other extreme, some heart attack survivors will become bed-bound (it is pretty easy to exercise 50% better than them). Thus, the so-called "reference population" is really not a reference population at all, because the average exercise ability of the group depends entirely on how many severe heart attacks are included in the group vs. how many small ones are included.
    In this particular case, the heart attack survivors were patients who lived to enter a cardiac rehabilitation program. PRIMARY REFERENCE SAYS EXERCISE TOLERANCE IS EXTREMELY LOW. IT IS UNDERSTANDABLE THAT A PERSON WOULD CITE THEIR OWN WORK ON AN OCCASION WHEN IT IS CERTAIN TO RECEIVE NATIONAL ATTENTION, BUT NOT SURE WHY MONAHAN WENT ALONG WITH IT.

Would be interesting to look up, in the article, exactly what that exercise tolerance is.

Typo: "man his age" should be "men his age."

Typo: Sander's should be Sanders'.

"According to" --> further suggestion

Am not sure this ETT informs ability to handle stress.

Is saying that the presidency requires no more stamina than a normal 78yo man can muster.

Physiologist didn't sign, but it appears he wrote the letter.

75% of subjects on beta blockers

Typographical error in spacing.

Typographical error in spacing.

This letter, and the previous one, is written by a state employee. Has the appearance of a conflict.

He gets it wrong, too, like Monahan did: reference population per Ades is coronary population. Plus, LeWinter is just plain wrong when he says "well above average" -- the average person in the USA is in their 30s. So either LeWinter is ill-informed, is sloppy in his language (but look at all those credentials!), or has a secondary aim with his language, i.e. trying to put a shine on the situation.

Now, maybe the criticisms given above will themselves be criticized as hyper-picky and therefore unreasonable. But they are completely valid according to the words that are (or are not) in the officially released documents. If there is a belief that this critique is hyper-picky, people should realize that this is a problem of the doctors' own making. They released English-language summaries of the primary data. Had they released the data itself, a lot of the ambiguity and uncertainty I've identified in their words would have been eliminated. But they chose not to release the primary data. By not releasing it, they are asking us to trust them, but with their obviously slanted and incomplete reports they have shown themselves not to be honest brokers. They could have been honest brokers. In their professional practices, they all have long experience writing letters that clearly and unambiguously describe the medical condition of their patients. It is essential to the successful practice of internal medicine and especially cardiology. The physicians have chosen not to write such letters to the American people. It's not entirely the physicians' fault. They can disclose only what their patient allows them to disclose (well, not Dr. Monahan, since he was writing to the patient). But there are ways to write letters that do not disclose information while making it clear that information is being held back. ("Among the findings on cardiac catheterization...") These physicians have an opinion on their patient's suitability to the job of being president. That is fine. They can certainly write whatever they truthfully believe in their professional judgment. But as soon as they go beyond that sentence or two and start providing data to support their opinions, they have to be intellectually honest. They have to provide data that is both pro- and con- to their stated opinion. If they provide only the pro- information, that is not intellectually honest and is, moreover, unprofessional. Yes, they can advocate for their patient (as any good physician would do) but it must be done honestly & professionally.