Kevin R. Campbell, MD, FACC
This past week, President Trump’s physician released his first full medical evaluation as President. What has in the past been a routine event with a few questions asked in the daily White House press briefing turned into a 90-minute circus with physician journalists such as Dr. Sanjay Gupta of CNN making sweeping diagnoses from afar. A basic tenet of the practice of medicine is that in order to make a diagnosis you must establish a doctor-patient relationship and have seen and examined the patient. In fact, prescribing medications or making diagnoses without an interaction with a patient violates the rules of most state and local medical boards throughout the United States. Why then does the press (and even Physicians who are active in the media) insist on making uninformed and misinformed medical diagnoses when it comes to President Trump?
The mainstream media has used the President’s annual physical report as another tool for furthering a particular political agenda. While I certainly do not agree with all of Mr. Trump’s policies, behaviors and decisions, I do not think that perturbing the facts associated with his health and making sweeping, broad statements about his health status are an appropriate means for political gain. In fact, it serves to only demonstrate the desperation seen among Democrats and liberals throughout the country.
What did the President’s Yearly Physical Reveal About his Cardiovascular Health?
President Trump underwent an extensive evaluation by the White House physician (who, of note, was appointed by President Obama) and this included a history, a physical exam and several diagnostic tests. The results of the exam and all of the tests have been made public and I have personally read through the entire document—but that does not mean I am qualified to make any diagnosis—I have never seen the patient and personally evaluated him. Sir William Osler, one of the founders of modern medicine often said “if you listen to the patient long enough they will tell you what they have”—emphasizing the importance of the history and physical exam in making a diagnosis.
Mr Trump appears to have mild obesity (his BMI or body mass index is 30.1 and above 30 is considered to be obese). He also has an elevated total cholesterol at 223 and a LDL (bad cholesterol) of 129. Current guidelines suggest that we should use a total cholesterol of 200 and an LDL of less than 100 as a treatment goal. Mr Trump also underwent extensive cardiovascular testing including a stress echocardiogram (ultrasound of the heart) which showed an absolutely normal result—no evidence of blockages, normal heart structures and chamber sizes and normal valves.
Sanjay Gupta’s Diagnosis from Afar
Minutes after the White House press briefing where all of Mr. Trump’s health data were made public and available to the press, Dr. Gupta stated on LIVE television that “President Trump has heart disease”. In reality, heart disease is a complex diagnosis that relies on the consideration of risk factors—such as male sex, high blood pressure, high cholesterol, diabetes, obesity, family history and others—just to name a few. In the case of President Trump, he does have risk factors for heart disease including the fact that he is a man and that he has high cholesterol. However, he had a normal stress echocardiogram test—a test that evaluates the presence of any significant heart artery blockages and his cholesterol is being appropriately treated. As mentioned above, the President is slightly overweight and needs to watch his diet and exercise more. Technically, Dr Gupta is right—ALL of us have some amount of heart disease as evidenced by “fatty streaks” in our aorta even as children. A fatty streak is the first sign of atherosclerotic disease and has been seen in very young children. However, Dr. Gupta, who is a neurosurgeon by training and has no experience as a cardiologist, seems to have based the entirety of his comments on the result of a Calcium Score. A calcium score is a test where a CT scan is done to determine if there is calcium in the coronary (Heart) arteries. Some studies have indicated that an elevated calcium score can be predictive of the presence of coronary artery disease (blockages in the heart arteries). According to many researchers, there is a paucity of randomized controlled prospective clinical trials about the accuracy and effectiveness of a calcium score in the prediction of heart disease. There are data that do provide correlation but the widespread use of calcium scores in the evaluation of coronary artery disease has not yet been seen among US cardiologists. In addition, calcium scores can be a useful tool to motivate patients and physicians to treat and modify risk factors for heart disease. Calcium scores have also been shown to help with predictive models BUT are not diagnostic. So, I would suggest that Dr Gupta, rather than making a sweeping statement such as “Donald Trump has heart disease” would be far more accurate by qualifying his remarks and reference the data concerning a calcium score rather than sensationalizing the President’s health during a package for CNN.
What is the Goldwater Rule?
The Goldwater rule was adopted by psychiatrists in 1973 after an incident in 1964 during the Presidential election in which a media outlet (Fact magazine) published a survey of thousands of psychiatrists in which they were asked if Barry Goldwater was psychologically fit to be President. The Goldwater rule prohibits psychiatrists from offering an opinion about a patient they have never met or personally evaluated. In many ways, the comments from Dr. Gupta and others are eerily similar to those made by the psychiatrists who never actually interviewed Mr. Goldwater. For psychiatrists, this principle remains part of the American Psychiatric Association’s code of ethics even today (Section 7.3). As physicians, we are to taught to assimilate the available data—through taking a patient history, performing a physical exam and evaluating laboratory data—in order to come up with a comprehensive diagnosis and treatment plan. Making diagnoses without incorporating all data and actually examining the patient personally is simply irresponsible. This not only applies to psychiatrists but should apply to ALL physicians specialties—even those of us who report in the media.
Is the President Healthy?
Bottom line, President Trump is healthy for a man his age. If the President were my patient I would tell him the following: You has risk factors for heart disease that must be modified—high cholesterol and obesity.
Currently, he is being treated for his cholesterol and his medications are being adjusted appropriately. He does need to focus on making better dietary choices and he should lose some weight. He must incorporate exercise into his daily routine and should have routine check ups to follow his progress.
(Image via screenshot from MikeSheltonCartoons.com)