Physicians think differently about coronary artery disease (CAD) than we patients do. We’re mostly thinking in terms of our own actual risk or risk factors.
Evidently, the best physicians need to think in terms of what’s best for all their patients. I realized recently that it might be useful to try to understand CAD management issues from the point of view of the physician.
Dr. William Blanchet recently made an informative post at the WebMD forum along these lines and I’ve excerpted his entire post there below. I think his post speaks for itself and makes it clear that there are some incredibly good doctors out there. There are a couple of points and a question that I wanted to put on the table first, however. I missed his point entirely for a good while and it’s an important point so please indulge me for a moment.
- A hole in the boat is not someone like me who already clearly has CAD. I am part of the population that has already burst a hole in the boat and is now floating around in it.
- Be clear that YOU are potentially one of the holes in the boat if you currently have no symptoms of CAD.
- Notice that Dr. Blanchet is an ardent believer in Coronary Artery Calcium Score imaging to discover holes in the boat.
- When it comes to CAD, are YOUR doctors “bailers” or “caulkers”?
I’m going to get out the yellow pages and try to find a caulker close to where I live. Let’s see, that’s spelled C–a–u–l…
Without further introduction, I give you Billy “TheCaulker” Blanchet.
(images courtesy of auxodept.org and Boulder Community Hospital)
Put statins in the water?
I don’t necessarily disagree with “the put statins in the water” mentality but it is a hard sell to intelligent patients. A positive calcium score is a great motivator for compliance.If we maintain everyone on a stain, that will only prevent 33% of events at best. If we treat to coronary calcium stability, we prevent the vast majority of events.
Based on the “virtual incredulous stares” I got after reporting a 90% reduction in coronary events, I have done a brief review of my practice. I have been practicing Internal Medicine since 1983, private practice since 1986. In 2007 I capitulated to economic reality (that an Internist who cares for Medicare and Medicaid folks and actually talks to his patients cannot survive economically) and sold the practice to the hospital for a small loss.
We currently have over 7,000 active charts (defined by a visit within the last 24 months) shared by 3 physicians, 1 PA and 1 NP. 48% of visits are Medicare.
I have nearly 100% compliance with primary prevention strategies however only about 85% of patients tolerate statins. Roughly 70% of patients I start on niacin continue it. I do use a lot of zetia and omega-3 fatty acid. The <50% compliance quoted in the literature is not an issue here.
How is this possible? I don’t really know. Perhaps I am more charismatic than I was a few years ago. My ability to image the plaque and measure its progression is a monumental motivator and provides the direction I need to treat the patients. I credit EBT calcium imaging as the proximate cause for my success.
My practice has seen only 4 heart attacks in the last 3 years, 2 in the last 24 months. The last time that door to balloon time mattered for one of my patients was over 3 years ago when a patient’s electively placed DES [Drug Eluding Stents] thrombosed and he arrested in the ER. Tragically, he did not recover.
Regarding risk factors being adequate, 4 out of my last 4 patients who died from coronary disease did not qualify for lipid lowering medicine prior to their MI, sudden death, or symptomatic angina. Ignoring these deaths as unavoidable is not OK with me, they were all friends.
Regarding the “unnecessary cost of EBT imaging”, I am getting better results than I could possible expect or ever got back in the day when I did the extensive stress testing similar to your recommendations (a much more expensive technology). Until about 5 years ago, I did a large number of stress tests. My new paradigm has reduced the number of stress tests that I do by 90%. The cost savings from the stress tests I don’t do more than covers the costs of the coronary imaging that I do.
How tragic it is that insurance companies generally don’t cover coronary calcium imaging. One of the reasons they don’t is because “experts” continue to give them the ammunition they need to disallow this life saving technology.
Here is the allegory… Coronary events are like a sinking boat and you are bailing water out of the boat as fast as you can. I am describing how to caulk the boat. Caulking the boat does not make sense to you with all this water all around you can’t stop bailing. Besides, everyone else is bailing, no body is caulking, except for a few idiots who think caulking is a good idea. Maybe we can throw something into the water to make the boat sink slower. The fact that bailing water makes good bank while caulking the boat causes one to sell their practice to the hospital and drive old cars complicates this dilemma further.
December 4th, 2007 at 5:46 am
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