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.

Monday, September 14, 2009

This is What I'm Talking About

I have a patient with coronary artery disease.

One of the recommendations for the management of patients with coronary artery disease is that they take a statin medication to lower their LDL cholesterol.

I know this. I prescribed simvastatin, an inexpensive generic statin medication, for this patient.

The results of a recent blood test reveal that the LDL cholesterol is 182. This is too high.

I know this.

Here is what I did:

I called the patient up and said, "Your cholesterol is still pretty high. How often do you forget to take your statin medication?"

The patient admitted that he frequently forgot to take it.

Here is my management plan:

I encouraged the patient to take the medication every day without fail, and after 2-3 months repeat the blood test to see how well simvastatin, an inexpensive generic medication, worked for him.

A week after this, the patient had a routine follow-up appointment with his cardiologist.

Here is what the cardiologist did about the patient's LDL cholesterol of 182:

He switched the patient to Crestor, an expensive brand-name statin medication.


At Mon Sep 14, 09:24:00 PM, Blogger Mule Breath said...

I feel your pain...

High maintenance physician, high cost meds.

At Mon Sep 14, 10:39:00 PM, Anonymous drcharles said...

I wonder if the cardiologist speaks for the makers of crestor? just wondering.

At Mon Sep 14, 11:50:00 PM, Blogger Doctor D said...

Why bother asking all those questions when a hundred dollar a month question works just as well?

At Tue Sep 15, 01:14:00 AM, Anonymous Captain Jean-Luc Picard of the Starship Enterprise said...

Dr. Crusher, please report to reality. Ensign, set a course for the planet that cardiologist lives on. Warp 5, ENGAGE *hand motion*

At Tue Sep 15, 04:46:00 AM, Blogger Ed said...

As for regularly taking the medication, whatever the cost, I recommend a pillbox with seven compartments, each labeled for a day of the week.

At Tue Sep 15, 07:29:00 AM, Anonymous Anonymous said...

Regularly taking medication: all it takes is being organized which, alas, not everyone is. Whether it's the-pillbox-with-seven-compartments method, the calendar-on-the-wall-where-you-cross-off-the-day-after you-have-taken-the-medication method, or whatever, just pick something that works and stick to it. Ah, easily said, but not done by all who need it.

At Tue Sep 15, 08:48:00 AM, Anonymous Anonymous said...

I recently had a patient come back from the cardiologist on 20 mg(!) of Crestor. Their LDL was 19.

At Tue Sep 15, 02:14:00 PM, Anonymous Anonymous said...


At Tue Sep 15, 02:19:00 PM, Anonymous Anonymous said...

Short of hiring someone to pill your patient, the way you would a cat...

At Tue Sep 15, 09:04:00 PM, Anonymous Anonymous said...

Do you really think that he would have gotten to target with simvastatin? He had a long way to go.

At Wed Sep 16, 11:50:00 AM, Anonymous Anonymous said...

The first time you gave him simvastatin, apparently he didn't get the message of the importance of it & why - so it became a drug he could easily forget since he couldn't "feel" it working & didn't know the significance of not taking it - very common for this drug class!

The second time you spoke with him, he still didn't understand your plan well enough to articulate it to the cardiologist - or....the cardiologist just didn't agree with your plan. Did you send a note to the cardiologist about your phone call with the pt?

So - the cardiologist gave him Crestor & who knows what kind of consultation. But, by paying his brand name co-pay for Crestor, this non-compliant patient may take this medication since it treats something he knows (his wallet) and he might have been told the simvastatin would not work.

Who knows what might have happened with more informative consultation about compliance at first - perhaps nothing. But, I agree with the prior anonymous - the simvastatin hill would have been a long climb.

At Sun Sep 20, 10:29:00 AM, Anonymous Anonymous said...

Ugh. I feel your pain.

So PCPs are supposed to send letters to every specialist for every medicine they give to patients? How practical is that?

At Sun Sep 20, 03:12:00 PM, Anonymous Anonymous said...

I don't know.
I assume Dino is sending the patient to the cards for some reason. A courtesy cc of the note to the cards is no unreasonable in this situation. Just as Dino would expect if the shoe was on the other foot. You think the cards is a clairavoyent?

At Fri Sep 25, 05:08:00 PM, Anonymous Anonymous said...

I understand your frustration. There appears to have been a lack of communication among you, your patient and the cardiologist. The previous anonymous poster questioined how was the cardiologist supposed to know what your game plan was with the patient's meds. The post before that questioned the practicality of a PCP sending notes to all specialists.

It's not practical and specialists are not clairevoyant. Communication is a two-way street. Just as PCPs complain that specialists don't communicate with them, specialists also find it frustrating when they get little pertinent info from the patient's PCP.

Perhaps electronic medical records can help alleviate some of this.

At Sun Oct 04, 09:50:00 AM, Blogger The Invisible Woman said...

sooooo interesting. You really should go to Washington....represent US!


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