Dear Marion,

My apologies for yet another letter. My excuse: that you
asked a question, which properly interpreted, seems to me
important. It's ingrained in me not to leave questions 
unanswered, even though I may not know the right answer,
and perhaps especially then.

Let me summarize. Please correct my misunderstanding. Last
week you weren't feeling up to par. A little short of breath,
and a little tired, maybe a little lonely and a little bit
depressed. You needed someone to whom you could talk about
how you felt. You went to Dr. Skarda hoping to be reassured
that there wasn't anything seriously wrong.

What you got was a cursory physical examination, blood tests,
EKG, Chest X-ray, a pulmonary function test, and an echocardiogram.
These tests were interpreted as showing some right ventricular
hypertrophy, moderate pulmonary hypertension, slight emphysema,
findings compatible with your having smoked tobacco in years past.

Although you had no complaints about sleeping or snoring, Dr.
Skarda thought you should be tested for a sleeping disorder,
which, if untreated might exacerbate the pulmonary hypertension.
You asked for my opinion, and by extension, for Klemens'; we
want to be helpful, but remote control medical management has
its limitation and is prone to lead to embarrassment. Although
one can never be 100% sure, I don't think your medical situation
is an emergency.

To answer your specific question: I don't think it's a mistake
for you to go ahead with the examination for obstructive sleep
apnea. I don't think it would be a mistake for you to postpone
it temporarily while thinking things over and making plans. It's
important not to overestimate the sensitivity and specificity
of the apnea examination. Klemens made the comment: "There are
no normal sleep tests." My intuition says that the incidence of
false positives is rather high, but I don't really know. If the
results were ambiguous, the test could be repeated. The C-PAP
(continuous positive airway pressure) treatment may or may not
be a nuisance but it's harmless.

If I interpret Dr. Skarda's comments correctly she is inviting
you onto a slippery slope of diagnostic and therapeutic efforts.
Because you're 70 years old and not in perfect health, Dr. Skarda
is fulfilling her duty of practicing preventive medicine: although
there's not much evidence, looking for obstructive sleep apnea
to explain your tiredness, looking for silent pulmonary emboli
to explain the pulmonary hypertension, (as if the history of
smoking weren't sufficent), looking, by means of stress-testing
for coronary artery disease. Down the primrose path there's
cardiac catheterization, coronary by-pass surgery, and who knows
what else. 

That's how America's "senior citizens" spend their "golden years,"
and far be it from me to try to dissuade you from joining them. But I
myself can't and I won't.  Believe it or not, from time to time I've
tried to explain to my patients Schiller's advice (in Wilhelm Tell):
"Doch besser ist's ihr fallt in Gottes Hand als in der Menschen."
(It's better that you should fall into the hand of God than that
of men.) The lines from Schiller are the classical formulation of
the sentiment from Rilke which I related in a recent letter. (Since
by 1903, God himself was dead, the beautiful line: "Selig sind die
Toten die in dem Herrn sterben", (Blessed are the dead who die in
the Lord), had to be reformulated: O Herr, gib jedem seinen eigenen
Tod ..."

It's not that I would categorically refuse all diagnostic or all
surgical procedures. I would proceed very deliberately, step by
step. When I write that I wouldn't be enticed into a "cardiac workup"
without objective signs of serious heart disease, which you don't
have, I'm writing not about you, but about myself. I like to think
of myself as being open-minded, prepared to change my mind, or as
I prefer to say, prepared to let circumstances change my mind and
my life.

If there are matters you would like to discuss by telephone,
please feel free to call 617-484-8109.

Jochen