Posted by: notdeaddinosaur | 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.

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