Letters from Maine

Missing in Action


Honey, I heard a heart murmur this morning!” I'm sure that every year hundreds of first-year medical students share this educational revelation with their spouses and significant others, but when a 60-year-old pediatrician is tempted to e-mail the same message to his wife, one has to wonder.

When I was a medical student, I struggled to hear the bruits that my instructors were waxing so eloquently about. As a house officer, I delighted in hearing murmurs that my peers had missed, and in my first few years of practice, it seemed as though every third or fourth patient had a cardiac sound worthy of comment.

Over the last 20 years, though, heart murmurs have silently crept onto my list of endangered physical findings. Thinking back over the last 2 days, I can't recall recording a single murmur on one of my patient's charts. During a quiet moment I pondered the possible causes for this threatened extinction.

My first thought was that I wasn't discovering as many murmurs because age has clearly taken a heavy toll on my hearing. This may be true to some extent, but my relative deafness doesn't explain why my two younger partners aren't documenting any more murmurs than I am. Furthermore, I think I still continue to hear rales, rhonchi, and diminished breath sounds in the appropriate situations, and my patients haven't suffered from an unusual number of auscultatory oversights.

Could it be that heart murmurs have simply joined nephrotic syndrome, observation hip, epiglottitis, and bacterial meningitis on the list of rarities in my pediatric neighborhood? Since murmurs can be caused by a wide variety of anatomic variations, I find this explanation untenable.

Prenatal diagnosis of congenital heart disease certainly has siphoned off most of the clinically significant murmurs to the cardiologists and surgeons before they get to my office, but the bulk of the murmurs I was noticing a generation ago were benign flow murmurs that, by definition, were insignificant.

Therein, I think, lies the critical clue to the mystery of the missing murmurs. It doesn't take very many years of barking up empty trees before one's definition of normal broadens to the point that physical findings that once appeared as bright blips on the radar screen fade into the background static.

There are also significant disincentives to acknowledging the presence of a benign flow murmur.

In the interest of complete disclosure, I used to compulsively share my observations with parents, but explaining the difference between “slightly out of the ordinary” and abnormal was time consuming and sometimes so unnerving that I would have to do a cardiogram to quell the fires of anxiety I had kindled with my good intentions. There were also the scores of phone calls from dentists' offices wanting to know if our mutual, inadequately informed patient with a benign flow murmur needed antibiotic coverage.

There is one more possible explanation. Like most physicians, I do the chest auscultation at the beginning of my exam, so an insignificant murmur often gets forgotten or pushed off the agenda by other findings or questions by the time I scribble my office notes. As our friends in the risk management business tell us: If it wasn't documented, it didn't exist.

So there you have it. Like the ivory-billed woodpecker, cardiac murmurs have not gone extinct. They still lurk in the dark swampy recesses of our subconscious, occasionally swooping out to surprise us when we decide to pay attention.

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