The Problem: When it came to a heart condition called mitral valve prolapse (MVP) that occurs when the valve doesn't close properly between two chambers of the heart, Sheldon Michael Retchin, MD, wondered if giving patients this diagnosis actually caused them to develop symptoms and functional disabilities.
Programee Background: The oldest son in a family that still operates a fourth-generation retail furniture business in Wilmington, N.C., Sheldon Michael Retchin set out to be the only physician in his immediate family. He received his undergraduate and medical degrees from University of North Carolina at Chapel Hill, and in 1980 completed his internship, residency and chief residency programs in internal medicine at the Medical College of Virginia Hospitals, Virginia Commonwealth University in Richmond, Va.
But something he noticed during his chief residency intrigued him enough to postpone the hands-on practice of medicine and to continue researching another aspect a bit more. "I was always much more interested in the behavioral aspects of health care from organic disease or perceived organic disease," says Retchin. "At that time, there was a phenomenon that had been described as 'labeling'—basically the consequences of receiving a diagnosis and the psychological consequences of the diagnosis. David Sackett, MD, and his colleagues from McMaster University had described this among hypertensives and I wondered whether it was prevalent with other conditions as well."
In particular, Retchin was interested in labeling as it pertained to MVP, a highly prevalent anatomical variant that, in most cases, results in no morbidity. During his chief residency, Retchin noticed that "a huge percentage" of patients were being diagnosed with the condition—a fact he attributed to the 1970s' introduction and subsequent prolific use of echocardiography (ECHO) or cardiac ultrasound, which suddenly and easily made MVP detectable with a noninvasive procedure.
He noted that the MVP diagnosis seemed to create changes in the patients that the condition didn't necessarily warrant, a phenomenon he unwittingly captured on video when he happened to be testing the use of film as a teaching and training tool during grand rounds, and videotaped two patients diagnosed with MVP. "When I looked at the interviews on tape, I was astonished," he recalls. "I had interviewed two very healthy 40-year-olds, and one was impotent and the other could not carry items any heavier than groceries—they had been so disabled by the label of MVP, thinking that they had a serious heart condition. I was no longer interested in looking at the biomedical consequences of the condition, and turned to look at it from a behavioral standpoint."
Programee Perspective: In 1980, Retchin was accepted into the Robert Wood Johnson Foundation Clinical Scholars program at UNC, where Robert H. Fletcher, MD, MSc, the director and an alumnus of the program, served as his mentor. Retchin used his two years as an RWJF Clinical Scholar to expand his research into MVP and the labeling phenomenon. He conducted a study of 274 MVP patients from Duke University Medical Center's echocardiography laboratory designed to answer the question: Is the diagnosis of MVP by ECHO associated with disability, health care use or reported symptoms?
"The Clinical Scholars program was a great fit for this research," Retchin recalls. "Bob Fletcher was a guiding light, a mentor, and he had a similar social framework for medical care and delivery as I did. Just looking at this particular illness and labeling phenomenon, he was a first-rate scholar and superb mentor. That helped in terms of my career, and it has always given me a bit of a balanced perspective about the risks and benefits of medical care. While our medical repertoire is extraordinary, some of the things we do are unnecessary and even harmful."
To Retchin's delight, he found what he considered a perfect literary reference to illustrate his research, taken from a conversation between Thaddeus Sholto and John H. Watson, MD, from the collected works for Sherlock Holmes:
"Have you your stethoscope? Might I ask you—would you have the kindness? I have grave doubts as to my mitral valve, if you would be so good. The aortic I may rely upon, but I would value your opinion upon the mitral." I listened to his heart, as requested, but was unable to find anything amiss, save, indeed, that he was in an ecstasy of fear....
"The quote was perfect on two fronts," says Retchin. "I was interested in the phenomena of MVP and second, I was interested in the nonmedical consequences of disease, which in the case of this quote, was the fear of something going wrong."
Results: The results of Retchin's Clinical Scholars' research, incorporating the Sherlock Holmes passage, were published in 1986 in the Archives of Internal Medicine. In this study, Retchin reported that:
"Patients with MVP by echocardiography were comparable with patients with negative echocardiogram. There were virtually identical rates in the two groups for symptoms, functional disability and utilization of health services. While echocardiography MVP seemed to be unrelated to symptoms or disability, both were often attributed to the condition by the patient. For example, though 38 percent of those who retired because of a medical condition identified MVP as the reason for retirement, one third of these patients had normal echocardiograms."
According to Retchin, there were two major findings: "First, patients reported a high rate of functional impairment one to three years after echocardiography was performed. Second, the presence of MVP by echocardiography was not related to symptoms of functional disability at the time of follow-up."
During his two years as an RWJF Clinical Scholar, Retchin conducted and published several additional studies of patients suspected of mitral valve prolapse, including one study on various treatment decisions. But after he received his Master's Degree in Public Health in 1982 and concluded his two-year Clinical Scholar assignment, Retchin says he never studied MVP again: "I left the field behind."
But he never left behind the benefits of the Clinical Scholars program. "It was nothing short of transformative. It made me question a lot of things that we do and made me realize that we could change things and that we could lead," Retchin says.
"Another thing that the program taught me that I had not learned in my rigid traditional training is that the way medical care is delivered had to be questioned. I had never learned that. Just something as simple as questioning outcomes and care delivery was really a profound point of view that I never forgot. It reminds me of the "Wizard of Oz." Everything is black and white and you land in Oz, and all of a sudden, everything is in color. Medicine is a very rigid training regimen. And when you emerge from that you are so focused on the organic view of medicine that you don't see the social perspective, much less population health."
Today, Retchin is senior vice president for Health Sciences at Virginia Commonwealth University and chief executive officer of the Virginia Commonwealth University Health System. As CEO of the VCU Health System, he directs a teaching hospital, a faculty practice plan and two provider-sponsored Medicaid Health Maintenance Organizations. As vice president, he has responsibility for five health science schools: medicine, nursing, pharmacy, dentistry and allied health. In 2000, Retchin helped establish the Virginia Coordinated Care (VCC) program, an HMO owned by VCU Health System and designed to deliver health care to eligible uninsured individuals in the greater Richmond area.
"The perspective I got from my RWJF training is that I wanted to have an influence on the health of a population," Retchin says, pointing to the development of the HMOs as a reflection of that training. "The VCC program is used to taking care of an inner-city population. We think it is the vehicle, the bridge to the way coverage will expand for health care reform. And all of that came out of my work with RWJF. It was the most important career decision I ever made."
RWJF Perspective: Originally authorized in 1972, the Clinical Scholars program is RWJF's oldest national program. It fosters the development of physician leaders by ensuring that they develop the clinical, policy-making and research skills necessary to effect change in health and health care nationwide. See the Program Results and other Grantee Profiles.
David M. Krol, MD, MPH, FAAP, a 2001 Clinical Scholar, director of RWJF's Human Capital Team and senior program officer, appreciates the depth and breadth of scholars' individual career paths as clinically active physicians, academic researchers, directors of medical school departments, health care systems and federal, state and local health agencies—and he credits the RWJF program with preparing them to function in each of these worlds.
"You learn the skills necessary to navigate the worlds of the clinician, researcher and policymaker," says Krol. "A Clinical Scholar is able to speak fluently in those languages and translate between them. Clinical Scholars go on to become leaders in diverse areas, with critical thinking skills that can be applied widely across numerous career paths."