Heart Of The Matter: Treating The Disease Instead Of The Person

Heart Of The Matter: Treating The Disease Instead Of The Person

June 25, 201411:05 AM ET
Maria Fabrizio for NPR

Maria Fabrizio for NPR

A 56-year-old man is having lunch with his wife at a seafood restaurant just outside Boston when he develops crushing chest pain. He refuses an ambulance, so the man’s wife drives him to the ER.

What happens next says a lot about the difference that being a doctor or a patient can make in how one feels about the health care system.

First, how did the patient and his wife see the trip to the hospital?

When the man arrives in the ER, he is told to take off his shirt. He lies in the hallway, in pain, naked from the waist up. Strangers surround him. They don’t introduce themselves, and they talk over him, at each other.

Pagers ring and there’s a lot of beeping. Someone else must be really sick, he thinks; that must be why no one is paying attention.

After a few minutes, he signs some forms and finds himself being wheeled into an elevator. Masked figures enter. He feels a cool liquid flowing into his veins. The lights go out.

He wakes up hooked up to machines, uncertain what has happened. It takes several hours for the staff to find his wife, who is still waiting in the ER lobby and has no idea why her husband is in intensive care.

They are both surprised when they find out, two days later, that he’s had a heart attack. As soon as they get home, they file a complaint with the hospital about their terrible experience.

Now, how did the staff at the hospital see it?

A triage nurse greets the patient immediately upon his arrival and finds out that he has chest pain. Within three minutes, he gets an electrocardiogram that shows he is having a heart attack. The ER doctor activates the special heart attack pager, which immediately summons the emergency cardiology team.

The doctors and nurses arrive and bring the patient up to the catheterization suite. There, the attending cardiologist threads a catheter through an artery in his groin and pushes it all the way to his heart, where the doctor sees on an X-ray machine that a vessel is blocked. She inflates a small balloon in the catheter, opening the artery and restoring the flow of blood to the man’s heart.

All told, it took only 22 minutes from the time the man entered the hospital for the cardiology team to clear the blockage. The cardiology team is proud that they beat the national averagefor what they call door-to-balloon time by 42 minutes. The faster a blockage can be cleared, the better the odds are for a full recovery.

The patient gets well without complications. Two weeks later, he’s back at work and exercising again. The ER and cardiology teams consider the man’s case a resounding success.

Why then are there such different views of the same ER visit? Who’s right? The doctors who believe they delivered exemplary care, or the patient and his wife who feel he was treated badly?

As an emergency physician and advocate for my patients, I frequently hear clashing stories like these. When I review the cases, I find that the doctors and nurses are often surprised by the patient’s complaint because they did everything by the book and made no medical mistakes.

Indeed, in this case, every measure of sound medical care was met: prompt diagnosis, speedy and effective treatment and an uneventful, full recovery.

The objective measures that health care workers focus on are necessary, but they’re not enough by themselves. Every provider in this man’s case had good intentions and was working hard to respond to the medical emergency. But in their rush to open the blocked heart artery, they treated him as a disease to be cured, not a person to be cared for.

Would it have alleviated the patient’s anxiety for the doctors and nurses to introduce themselves, and to ask if he wanted his wife by his side? Would it have helped to assure him that all the activity was happening around him because everyone was trying to take care of him?

I think those simple courtesies would have made a difference.

These instructions aren’t on typical checklists for treatment of heart attack, yet they are part of caring for people as human beings. In modern medicine, we are fortunate to have incredible high-tech options available, but we must not forget the low-tech approaches that can improve communication and quality of care.

Patients and family members can also speak up when they are confused and scared. It’s possible that doctors explained what was happening, but not clearly enough.

What if the patient said he didn’t understand what was going on? What problems could have been avoided if the patient and his wife didn’t wait until after he was discharged to raise their concerns?

The two viewpoints of this ER visit end with one thing in common. Just as the providers were surprised by the patient’s complaint, the patient and his wife were taken aback when the team that I was part of presented them with their doctors’ point of view.

“We had no idea they were trying so hard,” the man said. “It’s too bad we didn’t know that at the time.”

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of“When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care,” and founder of Who’s My Doctor, a project to encourage transparency in medicine.

Source:  http://www.npr.org/blogs/health/2014/06/25/324005981/heart-of-the-matter-treating-the-disease-instead-of-the-person?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20140625

Exercise lacking as medicine for secondary prevention

Exercise is Medicine….so why don’t some patients get the medicine they need?

Cardiac Rehabilitation remains under utilized, is this due to lack of referrals by physicians, lack of insurance so patients don’t attend, co pays and program expenses prohibitive for patients, or are patient barriers to significant to  attend? Probably all of the reasons listed.  I know when working in the industry it wasn’t unusual for patients to have co-pays of $50-$100 for one session of rehabilitation, at that price few will ever receive  the full secondary  prevention. There are limited hours and availability especially in rural areas.  Dr. Franklin and Dr. Wenger  are the movers and shakers within the cardiac rehabilitation industry, but this issues may be more of the health care reform issue of lowering costs for healthcare. Embracing telemedicine for secondary prevention and putting it not in the hands of the insurance companies, but those who have a vested interest the cardiac care departments, the cardiac rehabilitation units, and the hospitals themselves.  If the benefits of exercise came in a pill form rather than physical effort I bet it would be a megablockbuster drug.

Albany, NY - If exercise is a miracle drug, as it has been recently described, then it is a drug that is not prescribed enough for the prevention of cardiovascular disease. And if exercise is a “central and indispensable component” of a strategy in the primary prevention of coronary artery disease, then it is even more valuable in secondary prevention, according to a new viewpoint in the Journal of the American Medical Association [1].

In the article, published January 8, 2013, Dr William Boden (VA Medical Center Albany Medical College, NY), DrBarry Franklin (William Beaumont Hospital, Royal Oak, MI), and Dr Nanette Wenger (Emory University School of Medicine, Atlanta, GA) argue that despite the known benefits of physical activity and structured exercise for patients with stable ischemic heart disease, it is neglected and “woefully underutilized.”

“The mantra here is that exercise is medicine,” Boden told heartwire. “We focus so much of our attention on modifiable risk factors, such as treating cholesterol with statins, treating blood pressure to target, reducing hemoglobin A1c levels, and getting people to stop smoking, but we don’t view physical activity in quite the same context as a modifiable risk factor. So the viewpoint is really a call to arms, to get physicians to look at physical inactivity in the same context as they do with other treatments for other risk factors.”

In addition, Boden said that if physicians focused on getting patients to exercise 30 to 60 minutes a day, five days a week, it would go a long way toward reducing the prevalence of overweight and obesity in society, which are becoming epidemic.

In the viewpoint, Boden, Franklin, and Wenger note that increasing exercise or physical activity and cardiorespiratory fitness can mitigate cardiovascular disease progression, with exercise having known antiatherosclerotic, antithrombotic, anti-ischemic, antiarrhythmic, and positive psychological effects. Secondary-prevention programs that utilize physical activity with optimal medical therapy have been shown to reduce total mortality by 20%, cardiac mortality by 26%, and nonfatal MI by 26% [2]. Despite the proven benefits, many patients, including women, older patients, patients with limited education, and non-English-speaking patients, are frequently not referred for clinic-based cardiac rehabilitation.

“I think there are many factors involved,” Boden told heartwire. “In some instances, physicians are reluctant to recommend exercise or structured rehab programs. There are often uncertainties about whether such costs will be reimbursed by healthcare plans. Cardiologists often see patients for subspecialty referral care, and they view exercise to be more the realm of the internist or the primary-care physician. I think there are reasons why exercise might fall into the category of a ‘missed handoff.’ “

Reluctance among patients, conservative docs

In addition to some patients falling through these healthcare cracks, Boden said that some patients might be overly cautious or reluctant to participate in exercise programs, as they view an acute coronary syndrome or MI as a life-altering event. Some physicians might also be overly cautious or conservative and not recommend exercise as part of the recovery process. However, low to moderate exercise, such as walking, ideally started in a structured cardiac-rehabilitation program, can promote self-confidence and reassurance so that patients can transition to unstructured and unmonitored programs outside the clinic, he said.

“We also know that angina is exercise-induced and related to physical exertion, so there might be a fear of undertaking additional exercise because of concerns that it might provoke or exacerbate angina or worsen coronary disease, yet most of the data would support the opposite,” said Boden. “And one of the things we don’t preach enough in training our residents and fellows and younger physicians is the prophylactic role of short-acting nitrates before the activity. This can actually be a prophylactic measure to prevent or forestall angina during exercise.”

Boden said that most physicians regard short-acting nitrates as a treatment for angina and not as a preemptive strategy. “If physicians were aware of this, they might be inclined to better prepare patients for how to manage and live with their ischemic heart disease.”

After heart attack caring for your heart

The piece below is from a blog is written by Dr. Fogoros. He has presented the information very well. Every person discharged should have a care plan, they or their caregiver should have an understanding of what happens with a heart attack, what medications are necessary including how and why to take them, a plan to address the risk factors that contributed to the disease, and an action plan for recovery. He has summed it up very well. If you had a heart attack and were discharged from the hospital recently did you have a plan like the one listed below? From experience patients often have had such a whirlwind experience  with a rollercoaster emotional response, topped off with plenty of medications that upon discharge they are overwhelmed and confused. This is why the Cardiac Rehabilitation Programs are so important, they help you understand the what, where, why and how, and how to emotionally and physically recover.

 

After you’ve survived a heart attack (also called a myocardial infarction, or MI), you’ve got a lot to learn about and a lot to think about. While in the good old days you might have had a week or two of hospitalization to go through all the testing, risk assessment, education, and initiation of therapy necessary to optimize your long-term prognosis, today whatever is going to get done must happen in the first three (or four, if you’ve got a liberal health plan) days.

Doctors and hospitals have mobilized nicely to provide adequate acute care for the patient showing up with an acute MI. But too often, many have dropped the ball when it comes to giving appropriate care after those first critical hours. As a consequence, all too often patients don’t receive all the assessments, education, and treatment they need to assure an optimal outcome. For instance, recent studies show that less than half the patients who need statin drugs receive them. Other studies show that only a minority of heart attack survivors receivebeta blockers. And the proportion of patients who get an adequate assessment for the risk of sudden death, let alone those who receive the implantable defibrillator when it is indicated, is laughable.

The key to successfully navigating your way to a long, healthy life after a heart attack is you. You need to insist that the appropriate tests are done, the appropriate referrals are made, and the appropriate medications are begun. To this end, here is a convenient checklist of the things that should be done — ideally before you even leave the hospital — after your heart attack.

Doctors really do want to do the right thing. It’s just that, given all the pressure and constraints they’re operating under, from both insurance companies and the government, sometimes you need to remind them of who they’re really obligated to, and what your expectations are in that regard.

The Post-Heart Attack Checklist:

1) Lifestyle changes and other education:

  • I have been fully instructed on the warning signs and symptoms of heart attack, and the actions to take if I experience these signs or symptoms. (y/n) _____
  • If I am a smoker, I have been counseled to stop, and referred to one or more smoking cessation programs. (y/n) _____
  • I have been fully instructed on a heart-healthy diet. (y/n)_____
  • I have received detailed activity instructions for the next 4-6 weeks, and have been referred to a cardiac rehabilitation program. (y/n) _____
  • The importance of long-term exercise has been explained to me. (y/n) _____
  • My doctor has talked to me about when I can resume sexual activity. (y/n) _____
  • My doctor has talked to me about when I can resume driving. (y/n) _____

2) Assessing the risk of another heart attack in the near future:

  • The status of my coronary arteries has been assessed by either stress/thallium study (y/n) _____ or cardiac catheterization. (y/n) _____
  • The condition of my coronary arteries has been explained to me as follows: __________________________
  • The plan for following the status of my coronary arteries over time is: __________________________

3) The amount of damage done to my heart has been assessed by:

4) Important numbers I need to know:

  • My lipid profile has been measured, and the results are: Total cholesterol _______ LDL cholesterol _______ HDL cholesterol _______ Triglycerides _______
  • My blood pressure is _______
  • My ejection fraction is _______

5) Names and doses of medications prescribed for me:

  • Aspirin ___________________________
  • Beta blocker ___________________________
  • ACE inhibitor ___________________________
  • Statin ___________________________
  • Note: All of these medicines have been shown to help prevent further heart attacks and reduce the risk of death. If I have not received a prescription for one or more of these medications, the reason is ___________________________.

6) Preventing sudden death

  • If my ejection fraction is 30% or less, (or if I have had heart failure, and my ejection fraction is 35% or less) I have been referred to an electrophysiologist to discuss the possibility of an implantable defibrillator on: ______ (date)
  • Members of my family have been trained in CPR (y/n): ______

Sources:

Smith, SC Jr, Allen, J, Blair, SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006; 47:2130.

Richard N. Fogoros, M.D.
Heart Health Center Guide

Health Devices

Today’s technology allows heart patients to monitor their own health changes and be proactive in caring for themselves. I believe we are on a medical breakthrough using the internet and new technologies. In the past one would have to go to their doctor and report transient changes in blood pressure, heart arrhythmia - (palpitations) out of range blood sugars, etc.  The modern healthcare approach is to then order several very expensive tests in hopes of capturing the data and then making changes to the patients care plan once there is evidence of the changes. Today’s rapidly emerging technologies now allow patients to capture this information with home devices which cost much less than the tests ordered by our modern healthcare system.

Let’s look at heart rhythm monitors as an example. Atrial fibrillation is a very common heart rhythm problem, and for many patients they will go in and out of this rhythm. They may feel the heart racing, skipping beats, or feel shortness of breath and fatigue when the rhythm is abnormal. If A fib is dangerous immediate care can be initiated and then  managed with blood thinners to decreased risk of stroke. Therefore it is worth monitoring and catching it earlier vs. later.   There are now  monitors one can purchase for about $200 that would capture the rhythm put it to memory, then you can send to your physician electronically. Other heart arrhythmia that can be detected and managed this way  include heart blocks, abnormally slow heart rhythms, tachycardia -  fast heart rhythms.  The modern course is to order a holter monitor or an event monitor. The holter monitor is worn for 24 hours or more, then it takes up to two weeks for it to be interpreted  dictated and the reports received and acted on by the ordering physicians. Event monitors are placed below the skin and worn for 30 days or more. Consider given the progressive nature of heart problems, that these tests are not  usually run only one time on an individual over the course of their life.

HOLTER MONITOR SCANNING $312.00
HOLTER MONITOR RECORDING $345.00

Handheld home devices purchased for about $200 can be used by the patient with  little education,and a plan of care is devised  between the patient and the physician..  This could potentially allow you to  manage their issues more in a much more convenient and timely manner. The device is owned by you and thus can be used over many years. Below is the typical physician algorithm for managing arrhythmia’s.

 

Figure.

 

With today’s hand held monitors available at a cost of approximately two hundred dollars, patients can capture the irregular rhythm when it occurs, save the data, report it to physicians and have their care evaluated much quicker – provided they can get an appointment with their healthcare practitioner. Wouldn’t it be even better to be able to transmit the information to the physicians email, and then be triaged based on the data?

The problem is $$$$$$$, and the medical system in the US is slow to adopt change. If it cuts in to the profit of healthcare it isn’t likely to be adopted.  This a role where I believe mid level practitioners like PA’s, CNA’s can play a role in triaging care, as the current work demand doesn’t allow most physician the time to undertake electronic care of patients. It may take patients to make the change, those who are under insured, uninsured, or have significant financial obstacles which impede access to traditional care.

On a side note I really enjoyed Eric Topol’s book The Creative Destruction of Medicine. It makes one think about how medicine can change practice models.

With personal technology, doctors can see a full, continuously updated picture of each patient and treat each individually. Powerful new tools can sequence one’s genome to predict the effects of any drugs, and improved imaging and printing technology are beginning to enable us to print organs on demand. Topol offers a glimpse of the medicine of the future—one he is deeply involved in shaping.

Below are a couple of examples of how patients can control and manage their health data:

http://www.misfitwearables.com/health_device_at_a_glance

health_device_at_a_glance.jpg

http://online.wsj.com/article/SB10001424052702303404704577311421888663472.html

TOPOLcollage

http://www.favoriteplus.com/easy-ecg-handheld-monitor-fp180.php