Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, March 30, 2008

Attention Cardiologists:

I'd like to have a few words with my cardiological colleagues: stick to inpatient medicine and acute care and forget about trying to take care of outpatients. You're not very good at it.

I don't deny that when someone's having an acute MI you are the knight in shining armor! All hail the cardiologist as he comes dashing in, rumpled green scrubs flashing beneath the crisp white coat, name embroidered in red over the breast pocket (that he reads as "Dr. God"), hustling the infarcting patient off to the cath lab to save the day, along with all the salvageable myocardium he can. You definitely earn your white horse image on those occasions. My hat is off and I bow low with gratitude. I am not worthy.

On the other hand, don't let all that adulation go to your head. Once you've worked your magic, stented your arteries, prescribed your cocktail* and gotten the patient out of the hospital, take a page from the surgeon's book: follow them for 3 months or 6 months or whatever interval you're comfortable with to assure that their heart attack has "healed," then discharge them back to primary care; ie, me.

I'm perfectly capable of ordering stress tests and echocardiograms at whatever intervals you advise, just as I continue to do annual mammograms after the surgeon has removed a benign lump. I can also manage their blood pressure, cholesterol and diabetes and monitor their medications; probably better than you can. I diagnose and manage hypertension every day. I write a shit-load of statins and monitor them regularly. Despite what you might think, I really do talk to them about quitting smoking every time I see them. Part of your God-like delusion is your belief that somehow when you say, "You really need to quit smoking," it somehow makes more of an impact than when I say it. Of course, I do more than say it. I also do more than just write a script for Chantix (or, in previous times, Zyban or the patch or the gum) and throw it at them. I actually discuss strategies for quitting along with wielding my Rx pad. Why do I think you do this? Because the patients come back to me with your unfilled script to ask me about it.

If you put a pacemaker in, I have no problem with your interrogating it at will. For patients with arrhythmias, the electrophysiologist is the hero. Ablate to your heart's content. But do you really need to see that patient every year for the rest of his life? I'm more than happy to do an annual EKG and whatever else you think you need.

If I think a patient needs surgery, I send him to the surgeon. If the surgeon agrees, he operates, follows up and discharges the patient back to me. If the surgeon disagrees, he tells me (and the patient) why, suggests an alternate course of action, and sends the patient back. Cardiology should work the same way. If I think a patient needs a cardiac cath or an EP test or procedure, I'd like to be able to send them over and get your input. If you agree, cath him (or whatever.) If not, tell me why and suggest medical management (which I'm perfectly capable of implementing, thank you very much!) Certainly it's within your purview to mention to the patient that he ought to quit smoking and be more compliant with the diet, exercise and medication regimen I've tried to get him on. But don't go ordering lipids (which I just did a month ago) and prescribing Chantix (which I've already given him twice) and basically trying to do Primary Care. You don't know what you're doing, and you don't even realize it.

And for crying out loud, when I talk to you about a patient with godawful coronary artery disease (at least two perioperative MIs during diverticulosis surgery) with extensive myocardial scar and segmental wall motion abnormalities AND evidence of continuing anterior ischemia on stress testing -- who you agree needs to be seen and cathed promptly, DON'T:
  • Wait three weeks to get him in, then
  • Have your office call the morning of the appointment asking why he's coming, and THEN
  • Write me a letter saying you're going to cath him, but also that you told him he's killing himself with obesity and smoking, gave him Chantix and recommended bariatric surgery! Think about that for a second: you can't even clear him for anesthesia! Geez.

*I'd love to market a beta blocker, ACEI, statin and aspirin in a single pill. I'd call it the "Cardiac Vitamin" and make a fortune.


At Sun Mar 30, 01:50:00 PM, Anonymous Anonymous said...

See here:


At Sun Mar 30, 06:31:00 PM, Anonymous Anonymous said...

Real world resuscitation of American healthcare requires proximate mortality of as many ER minority admissions, under eight months gestation, and over-65 years as quickly as possible. 100 million excess deaths over a decade is the worthy target.

A more draconian approach recouples cost to price by making folks pay out of their own pockets for what they get. That will never fly.

If you think healthcare is expensive now, just wait and see what it costs when it is all free from the government.

At Sun Mar 30, 09:36:00 PM, Anonymous Anonymous said...

Well said, Dino. And another thing: after you do all that for the Lord's sake DON'T refer him out to some specialist for something I can handle and then think I'M going to do the referral paperwork for you. Unless you WANT to a)make me crazy and b)make me refer to the big cardiology group in the city.

At Sun Mar 30, 11:49:00 PM, Blogger Dreaming again said...

Too many PCP's do not see it your way.

I'm referred to a specialist for every problem I have. My PCP is simply, to be frank, the organizer for all my specialists .. while she does an incredible job ..and it's *NOT* by any means an easy juggling act to make sure that my meds are not being overlapped or specialties being overlapped ... she certainly has her hands full.. I would much prefer her to handle my insulin resistance instead of the endocrinologist. The Blood pressure/pericarditis/ instead of the cardiologist (which is secondary to lupus by the way. I don't understand why she can't manage the frequent uti's that come with the immunosuppresion, why is a urologist really necessary?
I have ... 9 doctors ...I kid you not. 24 medications ... 9 doctors ..
yes, Lupus,Myasthenia gravis, insulin resistance that's gotten critically close to diabetes a few times ...
I get the dermatology .. I've had skin cancer that was missed ... my immunosuppression meds make it a bit diferent.
I get the neurologist for the MG.
I get the rheumatologist.
I get the pulmotologist.
I get the orthopedist (I don't want anyone else sticking that needle in my shoulder thank you!)

But the rest?????
but here in T Town .. it's specialist territory!

Really, do they think that those of us with serious medical issues really have the energy to be going to all these docs?

At Mon Mar 31, 07:15:00 AM, Blogger DHS said...

all these cardiologists were internists once upon a time - or at least they graduated from an IM residency. the same isn't true for surgeons.

At Mon Mar 31, 11:37:00 AM, Blogger DrWes said...

Okay, okay. I get it. Wish there were more like you, with the time to do a good job and all. But as a cardiologist and realist, I see it differently.

Now, who's gonna be YOUR mother when YOU get sick?

At Mon Mar 31, 04:34:00 PM, Blogger CrankyProf said...

I just want a picture of my chest cavity, so I can frame it and put it on my office wall. When students bitch, I can point to it and say, "See -- I really do have a heart!"

At Mon Mar 31, 07:25:00 PM, Blogger #1 Dinosaur said...

Cranky: Mount it backwards, so it looks like the intro on Scrubs.

At Tue Apr 01, 10:52:00 PM, Anonymous Anonymous said...

In case you don't understand the genesis of the situation you decsribe, drwes, see the above. Primary care is a thankless task--no respect, poor pay, and maximum hassle. Those of us who are still doing it are just waiting to retire. The new guys coming out are NOT DOING IT--no FP or IM residency has filled their slots with all American graduates for years.

At Wed Apr 02, 10:52:00 PM, Blogger Amanda said...

I much prefer to see my primary doctor, a DO. He is caring, compassionate, and doesn't treat me like a brainless moron. He has 1 late night a week, and Sat. hours. Whenever I call, I see him within 24-48 hours, often the same day. I'm out of the office within an hour. The neurologist I see for migraine management books 4-6 months out, I generally wait at least an hour to get a room, then wait in the exam room 45-60 minutes to see the neuro for 5 minutes. I swear he switches my medication dependent upon what pharma rep was in that day. 4 months ago it was to a $200/ 9 pill medication that don't work as well. His English is difficult to understand, and has an irritating God complex. I would much prefer to have my condition handled by my PCP. Come to think of it, next time I'm in... I need to ask if I can stop going to the neuro and just see him.

At Sat May 03, 01:05:00 AM, Anonymous Anonymous said...

Take for instance the AHAs proclamation that all kids to be treated for ADHD need an EKG first, even though an arrhythmia that theoretically makes the drugs dangerous is easily missed in the 10 seconds of monitoring. The false positives mean all the wasted Echos you can imagine with the bill lining the good Cardiologists wallet. Cardiology 1 Outpatient care 0.

And yet their recommendation without any evidence or thinking through is now gospel and standard of care.


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