A Cautionary Tale
Ok, I’m talking about Florida and not Kansas and perhaps I could have called this “Alligators, Sharks, and Cardiologists, Oh My,” but I needed to get someone’s attention, especially since I haven’t been able to get the attention of my patients who visit Florida every winter. And while I don’t want anyone to mistake this essay as something from Mutual of Omaha I do wish many of you would think of the classic video of the thousands of wildebeest attempting to cross a river full of dangerous predators – with the wildebeest acting as the elderly patients migrating down to Florida for the winter and the lions and wild dogs as the carnivorous doctors looking for their prey.
It was an ordinary “Snow Bird” trip to Florida for Mr. Irving Schwartz (not his real name), an elderly Jewish fellow with heart disease, accompanied by his girlfriend. Prior to his departure, Irving got his usual warning from me: “Don’t let the doctor do anything to you unless you call me first.”
Every year, just before the winter storms hit up north, thousands of elderly patients make their way down to Florida. Many of these patients have lot of health issues and are in need of a doctor to care for them until they make the migration northward in the Spring. It’s a boon to the ailing Florida economy, for the restaurants, markets, and also for the doctors. With the economy in a tailspin and a relative glut of physicians in some of these communities, some physicians await these naïve elderly patients to boost their income.
Irv had a heart attack years ago and as a consequence of this large MI, developed a rather large clot in the apex of the heart chamber. But aside from his medication, which includes the blood thinner Coumadin, and a bad stomach, which once caused some bleeding from his stomach a few years ago, Irv was feeling great. His last stress test, several years ago, was pretty good and because he remained active and had no symptoms, he never had another.
Irv likes to have a cardiologist when he runs down to Florida for the winter, “just in case”, and to take his blood level for his Coumadin. But he made a big mistake when he didn’t call me after the first visit with his new doctor (we’ll call him Dr. Moe Howard), a doctor that was referred to him by a few of his friends. Dr. Moe told him he needed a nuclear stress test. Irv was told, “Don’t worry about it your insurance will pay for it” and decided it might be a good idea to have it. I guess Irv forgot what I had repeatedly told him when he asked me why I didn’t do a stress test on him every year like so many of his friends have, “there is no clinical indication for you to have a stress test other than your friend’s cardiologist’s need to drive a Mercedes Benz while I am fine with my Subaru.” And I always reminded Irv that abnormal results sometimes lead to inappropriate and dangerous procedures, like an unnecessary cardiac angiogram.
But Irv figured, why argue with Dr. Howard. Irv did tell me that he checked Howard on the computer and did find that he was under criminal investigation in the past but that had to do with insider trading and nothing to do with the practice of medicine. So Dr Moe, who apparently works with his relative Dr. Shemp Howard, performed a stress test on Irv and, wouldn’t you know, it was abnormal. Irv is an old man, has a previous heart attack and, although he had no symptoms, and didn’t need the stress test was more than likely to have an abnormal study. And Irv got what the doctor ordered.
Dr. Howard apparently told Irv he was at risk of having a heart attack (what eighty-year-old with a previous heart attack isn’t) and he recommended he have a cardiac angiogram as soon as possible — performed by Dr. Howard, of course.
I guess at that moment Irv must have heard a voice in his head, kind-of like the Obi-Wan Kenobi voice, “Irv, call me. Call me before you let a doctor down there do anything on you.” And so Irv called my office. But the day Irv called was a day I was off playing with the kids, and wouldn’t be back for a week, and Irv got too tempted, too worried, by the words of Dr. Moe Howard; Irv went for his angiogram — wish I had a visual of an old-style cash register showing the enormous cost for these worthless and dangerous tests.
Dr. Howard performed the angiogram (I later reviewed the films of the study) at the hospital he apparently runs. The first catheter, not meant to go into the chamber of the heart, slipped into the heart chamber. He injected dye into that chamber to look at the heart function (not that he needed to since he already had imaged the heart during a stress test) and could have broken off that clot that I mentioned that could have caused a huge stroke. He then made some other injections and found a blockage in a relatively small artery.
If you recall, I mentioned Irv had stomach problems and with that the risk of a bleed from it. Dr. Howard could have left that lesion alone or, at the most, put a type of stent in without a drug coating but instead he put in a drug coated stent. The problem with drug coated stents vs. stents without a coating is that those stents require very aggressive blood thinning drugs (usually aspirin and Plavix) for as long as the patient can take it or preferably three years. The non drug coated stents require a much shorter duration (as few as three months) of therapy with both agents. So now, this old man with a risk of stomach bleeds is on the blood thinner Coumadin plus Aspirin and Plavix.
Amazingly… no bleeding so far!
So what can we conclude? Well, in spite of the fact that our healthcare system suffers from a severe shortage of primary care physicians, in some places there are just too many cardiologists around, especially in some areas of Florida, and the more there are, the more machines they have to use, the more mouths they have to feed, the more tests people like you and I and Irv are going to have, especially in those winter months.
So please be advised: Before having a stress test or a cardiac catheterization, ask the following questions:
- Is the doctor board-certified in cardiology, nuclear cardiology, or invasive cardiology?
- Does the doctor own the invasive cardiology lab?
- Is the center you are going to a university hospital staffed by doctors affiliated with a major medical school?
- Can you show me where this type of procedure fits into the recommendations by the American Heart Association.
- Can you call my doctor to discuss this before proceeding?
Dr. Evan S. Levine is a cardiologist in New York and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.