An Octogenarian’s Anamnesis on a Primary Care Career in a Premier Academic Medical Center

My career as an internist in the Massachusetts General Brigham Academic Medical Center has been kind to me, albeit having been drafted out of Brigham residency for service in Vietnam in 1969. My initial assignment in 1973 was to start medical practice next to the Brigham hospital emergency room to address the needs of the surrounding under-resourced neighborhood. This undertaking morphed into the venue for outpatient training for primary care in the newly created division of general internal medicine. A one-year junior faculty award to research medical care for marathon runners evolved into a career-long effort to transpose evidence-based concepts in internal medicine to the finish line medical tent. This effort drilled down to a focus on preventing acute cerebral edema secondary to exercise-associated hyponatremia and cardiac arrest, occurring during races mainly in young novice women and middle-aged male participants respectively.1,2 Acute inflammation consequent to exertional rhabdomyolysis after runners “hit the wall” was identified as the root cause of both conditions, leading to strategies for prevention and treatment based on evidence-based internal medicine concepts. My ultimate clinical assignment was to launch a consultation liaison practice embedded in McLean Hospital, Belmont, Massachusetts, our network’s flagship psychiatric facility. I discovered at that venue that the same evidence-based clinical paradigms for treating acute cerebral edema and preventing acute cardiac events applied in this psychiatric hospital setting as in the sports medicine venue. These transpositions became my professional story. CEREBRAL EDEMA DUE TO ACUTE WATER INTOXICATION The occurrence of life-threatening exercise-associated hyponatremia is acute water intoxication, which may occur due to over-zealous fluid intake in runners fearing dehydration especially during hot-weather conditions and also promoted by dysregulation of the stress hormone arginine vasopressin. While delirium in mild cases can resolve with oral hypertonic solutions such as concentrated broth, seizures or coma are indications for emergent administration of intravenous hypertonic (3%) saline optimally by bolus infusion, to reverse the flow of water down an osmotic gradient out of the central nervous system. Acute cerebral edema as occurs in marathon runners may also present in psychiatric patients with psychogenic polydipsia.3,4 Acute hyponatremia should therefore be in the differential diagnosis when psychiatric patients experience the sudden onset of unresponsiveness or seizures. This condition is illustrated by the case of a patient who was an ultra-marathon runner rescued after a suicide attempt by clandestine water intoxication which presented as seizures on an inpatient unit.5 This same complication may occur as an adverse event due to psychopharmacological agents.6 The emergent treatment for acute cerebral edema is the same for psychiatric patients and marathon runners with this same life-threatening condition. ENHANCING PRIMARY CARDIOVASCULAR PREVENTION WITH LOW-DOSE ASPIRIN Low-dose aspirin use guided by coronary artery calcium scoring was initially recommended to decrease the transiently elevated race-related risk for cardiac arrest mainly in middle-aged male marathon runners.7 This approach was based on a 44% decrease in first heart attacks in same-aged men in the final report on aspirin in the Physicians Health Study, a randomized controlled primary prevention trial.8 This recommendation was subsequently expanded to enhance primary prevention in the absence of contraindications for all persons at risk with subclinical coronary heart disease as shown by coronary artery calcium scores greater than 100 Agatston units Figure 1.9 This strategy is supported by a 31% reduction in major acute cardiac events in persons at moderate cardiovascular risk with the addition of aspirin to the polypill in the randomized controlled (TIPS-3) primary prevention trial.10Figure 1: Recommendations for pre-race aspirin useLow-dose aspirin use is congruent with guidelines of the American Heart Association and the American College of Cardiology for primary prevention in persons at high risk,11 carrying their class IA recommendation for pre-hospitalization administration to persons with acute coronary syndromes. This approach is promising as well for reducing the shortened life expectancy and excess risk of sudden cardiac death due mainly to coronary atherosclerotic heart disease in persons with major psychiatric conditions such as schizophrenia.12,13 My career has been unanticipatedly rewarding, perhaps guided by a core motivation to justify my graduation from Harvard Medical School after having received a post-interview letter advising me not to turn down any other opportunities. Having a daughter in our practice who trained in the primary care residency tract at the Brigham, in which I played a foundational role, might be a sufficient reward. The opportunity to make marathon running safer for runners of both genders at all ages and levels of ability by transposing evidence-based practices from internal medicine to sports venues is a penultimate accomplishment. Decreasing the excess cardiovascular risk in patients with severe psychiatric illness with low-dose aspirin guided by coronary artery calcium scoring is surely qualifies as an add-on accomplishment. The prospect of reducing sudden deaths as the presenting symptom of coronary heart disease by using this intervention and primary care practice would be a career goal come true grateful for serendipity, my hope is to alert younger colleagues to be open to seeking out similar experiences to support of their own personal and professional resilience. Ethical statement Ethical statement is not applicable for this article. Declaration of patient consent Patient consent is not applicable for this article. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.