True and Recent and Devastatingly Disheartening Story
Ten days ago I had a female patient (65 years old) come in for follow-up. A year ago I ordered a routine calcium score (CT calcium scoring) and it was high. Real high. Almost 1000 high. I sent her to a cardiologist. He did a stress test (a total waste of time and money as she works out hard 5 days a week as an avid runner) and of course, she passed. Six months later she went for a follow-up. She was told that there would not need to be anything else done …
Until…
Symptoms appeared.
Had I been in a position to teach this cardiologist I would have flunked him on the spot. Heart disease presents as its very first symptom – fifty percent of the time – not as angina. Not shortness of breath. Not even heart attack stent or bypass – the most common first symptom is in fact –
Sudden cardiac death.
That golfer of the 12th whole, the runner at mile 18, that teacher found in the lounge, that person found dead on the toilet – yep. Sudden cardiac death. Now the cardiologist had repeated the score, it was just above 1000 now (my options at CT angiogram cut off at 1000 so that was out.) She followed up with me and I started her on an aspirin 81 mg daily and a statin (he had done neither.)
The point – cardiologists in general are treaters. They are not interested in, are not paid to be, and don’t care about prevention. It is why two other local cardiologists called me an idiot for calcium scoring my patients to begin with. So – primary care docs – remember that those patients are yours and those specialists are simply borrowing them from you, but you remain the boss. You are in charge; the specialists are not. And blood pressure and cholesterol treatment – that’s us. We are the specialists in this, not them. Us.
Now, this has been pleasant. I will stop being so. Cardiology saw my patient twice (200 or so a visit) and an exercise stress test was done (about a thousand for that). When and if she needs a stent (a 60 thousand dollar or so trip to the big house) is when the cardiologist can really make that car payment. Since there was not a long-term relationship, the literal 50\50 that she would die versus would provide more income was acceptable.
Our system of healthcare is awfully messed up – this is but a symptom. No one cares about prevention. Hospitals would go broke if prevention were to work – as would pharma. Then we would not need – insurance (at least not this expensive.) It’s why everyone screamed and ranted when Obama made the insanely normal demand that insurance companies start paying for an annual physical, mammograms, colonoscopies, etc. He had to legislate even the small amount of prevention that is covered.
We need more, we need to be paid to stop disease and close hospitals and stop this craziness. Many writers will say to this, “Amen, DPC!” I have opted for small care (membership-driven concierge care) but the point is the same – get paid for doing the right thing. Stop disease, it’s easier than treating it.
“ Yes, we all hate the insurance industry, but without it we would have no access to preventative care.”
Therein lies the trap. It was the third party payer mentality that made primary care expensive. Bastard politicians on both sides of the aisle are arsonists who want your applause for spraying a garden hose on the fire they started.
Bravo. Well said. While I did not vote for Obama, I found that the marketplace was the only place I could obtain medical coverage that I needed at the time. Our recent past president showed absolute disdain for preventative as well as any other type of health care for our citizens. His best plan that we never saw is the philosophy held by most of our hospitals as you noted. If health care is only available to those who can afford it, I personally believe a lot of people will die needlessly. Currently if I wish to see my PCP and do not have health insurance, the cash price is $225 per visit. Yes, we all hate the insurance industry, but without it we would have no access to preventative care.
Fortunately my PCP believes in prevention. My recent PSA was a 10 and a DRE revealed a bump on the side of my prostate. I have absolutely no symptoms. I’m scheduled for a biopsy in January. Potentially life-saving.
I believe the skill lies in detecting and preventing disease, not in curing it once it rears its ugly head.