Are we finally seeing the end of Coumadin? In the 9-15-11 edition of the NEJM, we read the results of the ARISTOTLE trial which demonstrated the superiority of apixaban over coumadin in patient with AFib in preventing stroke. Apixaban (also known as Eliquis) in an oral Xa inhibitor. The Averroes study had already shown that in prevented stroke in AFib at 5 mg BID. Now this ARISTOTLE study shows that it is even better than Coumadin at doing so - with less bleeding and less mortality!
Dabigatran (Pradaxa) is already being given to patients instead of Coumadin for non-valvular AFib. It's a direct thrombin inhibitor.
Rivaroxaban (Xarelto) is another oral Xa inhibitor (like apixaban) that's been shown to possibly be better than Coumadin for AFib in the ROCKET-AF trial.
Cost? Well.....Pradaxa will cost patients around $250/month at their local drug store. Ouch! That can be a car payment. That's roughly $8/day, whereas Coumadin can be $1/day or less. Eliquis will likely be similar. So the question is how are we going to get patients to pay eight times more than what they are already paying. Well - in the long run, it's probably is more cost effective, given the blood tests to check the INR and especially if there is truly less bleeding with the newer drugs. Will Medicare put them on a different schedule? The less bleeding and the mortality benefit will certainly get their attention.
What about for indications other than AFib? What about prosthetic valves? What about other hypercoaguable states? PE, DVT, and on and on.... It will be a while before any of these new drugs are FDA approved for use in mechanical valves. Likely, there will need to be large clinical trials and Europe will try it out first and then we'll see.
Honestly, I am looking forward to saying bye to Coumadin - warfarin - rat poison - whatever you want to call it. No more checking PT and INR and worrying about the narrow therapeutic range. Too high? Too low? Too many green leafy vegetables - one of the healthiest things you can eat. What do we do about the cost? Drug companies need to make millions of dollars. Insurance companies need to make millions of dollars. And so patients can't have what doctors want to give them? C'mon...really?
Thursday, September 22, 2011
Friday, September 16, 2011
Marfan Syndrome
Marfan Syndrome is a genetic connective tissue disorder that affects, pretty much, the whole body. It has many key characteristics, such as tall stature, long fingers, wing span greater than height, dislocated lenses, stretch marks, crowded teeth, high-arch palate, flat feet, weak muscles and joints - but with Marfan Syndrome, what you really really worry about is the heart and aorta. The ascending thoracic aorta is weak and susceptible to aneurysm and dissection and unless you catch it early, it can kill you. It was once thought that Abraham Lincoln had it, but now that belief has become less popular.
When I was in med school (Georgetown, Class of '94), we learned all about it and I had many of the physical signs and characteristics. But, you know, I think all medical students, at one point or another, think they have one of the diseases they learn about. But, hey, it's genetic and neither of parents have it, so how could I have it, right? So what that I was a foot taller than my mother and 7 inches tall than my father, wore glasses, had stretch marks and was double jointed with long skinny fingers and flat feet? If this is a genetic disease (autosomal dominant) and my parents didn't have it, then I can't have it - so I blew it off. It actually became a bit of a running joke in the class and some of my friends wrote a song parody called Marfan Syndrome to the tune of "Bad to the Bone". You can see where this is headed, right?
After medical school, I managed to get through Internship and Residency in Internal Medicine (Mount Sinai, NYC) and then my Fellowship in Cardiology (North Shore, Long Island) without myself or anyone else giving it much thought. I do remember than during fellowship, while learning to do echos, we all practiced on each other - and saved the tapes. During my three years of fellowship, learning and then teaching echos, my aorta was normal the whole time. I'm pretty sure I still have the tapes (if anyone alive still has a VCR to play them).
I finished fellowship in 2000 and got a job a little further east on Long Island in Suffolk County. I got married in 2001 and finally got around to seeing a new eye doctor in 2002 - just a check up. But since this was my first visit, he did a more thorough exam - and told me that I had detached lenses bilaterally - also known as ectopia lentis. The second those words came out of his mouth, I knew I had Marfan Syndrome, as my mind flashed right back to med school. So, straight from that office, eyes all dilated and everything, I drove myself to North Shore hospital and asked one of the echo techs that I knew to quickly put the probe on chest and look at my aortic root. He did. And it measured 5.2 cm. The upper limit of normal is 3.7 cm. The surgical cutoff was 5.0 cm for Marfan Syndrome. I had Marfan Syndrome and I had an aortic aneurysm that was beyond the surgical cutoff. In about an hour and a half, I went from a routine check up with the eye doctor, to needing open heart surgery. Quite a day.
Little did I know back in med school that up to 30% of newly diagnosed cases were from a new mutation. I mean, yes, it was a bad day - but how lucky was I? I have echos from 1997 - 2000 showing a normal aorta. Then, all of a sudden, in 2002, it is severely dilated and needs surgery? Obviously, it was caught in a growth phase and if it hadn't been for the eye doctor, it would have gone undiagnosed and probably would have killed me at some point soon thereafter.
My wife and I were married just a year and now her husband needed a big heart operation and I was in danger of passing this gene on to our babies. We did go on to have two beautiful baby girls - both affected with Marfan Syndrome. For a long long time, I was overcome with guilt and depression knowing that the first thing I ever gave my girls was this disease, but they are being closely followed and on meds and taken care of. I found out I had it at age 33 and got very lucky. My kids are lucky because they were diagnosed at age one and will be taken care of and watched closely and they also have a father who is cardiologist and has Marfan Syndrome himself.
More to come on Marfan Syndrome soon.
When I was in med school (Georgetown, Class of '94), we learned all about it and I had many of the physical signs and characteristics. But, you know, I think all medical students, at one point or another, think they have one of the diseases they learn about. But, hey, it's genetic and neither of parents have it, so how could I have it, right? So what that I was a foot taller than my mother and 7 inches tall than my father, wore glasses, had stretch marks and was double jointed with long skinny fingers and flat feet? If this is a genetic disease (autosomal dominant) and my parents didn't have it, then I can't have it - so I blew it off. It actually became a bit of a running joke in the class and some of my friends wrote a song parody called Marfan Syndrome to the tune of "Bad to the Bone". You can see where this is headed, right?
After medical school, I managed to get through Internship and Residency in Internal Medicine (Mount Sinai, NYC) and then my Fellowship in Cardiology (North Shore, Long Island) without myself or anyone else giving it much thought. I do remember than during fellowship, while learning to do echos, we all practiced on each other - and saved the tapes. During my three years of fellowship, learning and then teaching echos, my aorta was normal the whole time. I'm pretty sure I still have the tapes (if anyone alive still has a VCR to play them).
I finished fellowship in 2000 and got a job a little further east on Long Island in Suffolk County. I got married in 2001 and finally got around to seeing a new eye doctor in 2002 - just a check up. But since this was my first visit, he did a more thorough exam - and told me that I had detached lenses bilaterally - also known as ectopia lentis. The second those words came out of his mouth, I knew I had Marfan Syndrome, as my mind flashed right back to med school. So, straight from that office, eyes all dilated and everything, I drove myself to North Shore hospital and asked one of the echo techs that I knew to quickly put the probe on chest and look at my aortic root. He did. And it measured 5.2 cm. The upper limit of normal is 3.7 cm. The surgical cutoff was 5.0 cm for Marfan Syndrome. I had Marfan Syndrome and I had an aortic aneurysm that was beyond the surgical cutoff. In about an hour and a half, I went from a routine check up with the eye doctor, to needing open heart surgery. Quite a day.
Little did I know back in med school that up to 30% of newly diagnosed cases were from a new mutation. I mean, yes, it was a bad day - but how lucky was I? I have echos from 1997 - 2000 showing a normal aorta. Then, all of a sudden, in 2002, it is severely dilated and needs surgery? Obviously, it was caught in a growth phase and if it hadn't been for the eye doctor, it would have gone undiagnosed and probably would have killed me at some point soon thereafter.
My wife and I were married just a year and now her husband needed a big heart operation and I was in danger of passing this gene on to our babies. We did go on to have two beautiful baby girls - both affected with Marfan Syndrome. For a long long time, I was overcome with guilt and depression knowing that the first thing I ever gave my girls was this disease, but they are being closely followed and on meds and taken care of. I found out I had it at age 33 and got very lucky. My kids are lucky because they were diagnosed at age one and will be taken care of and watched closely and they also have a father who is cardiologist and has Marfan Syndrome himself.
More to come on Marfan Syndrome soon.
Thursday, September 15, 2011
More on the Career
Hey there. So I've been thinking about this concierge medicine - cardiology idea and I think I like the idea. I've been doing some research and putting together my tentative plan. Still, I will need to do extensive market research and write up a business plan. I believe my two biggest hurdles will be to set the correct annual fee and figure out how I will get my first 40 or 50 patients.
You see, I need a price that will cover my expenses and make me a decent salary, but not one that will scare everyone off. The patients will need to know that they are getting their money's worth. So what is it worth, really? Why would somebody give me their money for something their insurance already covers? Well - I will have to give them service far above and beyond what their insurance company - and their current cardiologist could ever cover. This is pretty big because I will have to get people to first, switch doctors and then pay extra money for me. People get pretty comfortable and attached to their doctors, so this alone will be no easy task - and then getting them to give me extra money out of their pocket on top of that. Not easy. So I realize I will have to provide something that is pretty special.
Once I am able to get my first 40 or 50 patients, then I believe word-of-mouth will go into effect and it to the growth of the practice. I'm going to need to figure out exactly what my start up costs will be and my monthly nut will be so that will give me a better idea of what I need to start and when I will become profitable.
So what will I provide that is so special? Well, I have tons of ideas - some practical, some way outside the box, some may not be possible. I'd love to hear what you think. Obviously, these patients would be getting ultra-VIP care and attention. They can be seen within 24 hours of calling me - no matter what the complaint or concern. They will have access to my cell phone and e-mail so that I am reachable at all times 24/7. I will not bill through their insurance - no pre-authorization, no referrals, or anything like that. I was actually thinking it would work against me to have an office. If I have an office, these people will need to get to my office and it could be very inconvenient. Instead, I go to them - work, house, whatever, wherever. That would allow me to see patients almost anywhere on Long Island - instead of being limited to one area. Obviously, this would also greatly reduce my start-up expenses and monthly bills. I also think getting hospital privileges would also work against me for the same reason. If they are admitted, I go visit (as a visitor) and be in close contact with the doctors taking care of them. What else would I provide that's so special? Well, their visits will not be at all rushed. I can certainly be much more thorough than whoever they are seeing now. I can educate and focus on prevention as well. Diet and exercise and smoking cessation and diabetes care and weight loss - all these things that doctors should be spending a lot of time on and just can't. What else? How about a chef to the house to teach you how to cook a very easy, very healthy meal? How about a wine tasting of very heart-healthy wines? How about books and literature and handouts proving continuous education on all relevant information. I will need a portable EKG and echo machine with me at all times in my car. I will need a scale, a pulse ox, fingersticks for INR, glucose and potassium.
All that stuff - but most of all, it's the personal attention that the patients will be paying for and expecting. I really need an honest and realistic evaluation and expectation of the feasibility of this venture - before I start getting a line of credit form a bank and start leasing equipment, etc. What number of patients will I cap at? What will happen if I want to take a family vacation? Basically, at this point, this is me thinking out loud - I'd love to hear your opinion.
You see, I need a price that will cover my expenses and make me a decent salary, but not one that will scare everyone off. The patients will need to know that they are getting their money's worth. So what is it worth, really? Why would somebody give me their money for something their insurance already covers? Well - I will have to give them service far above and beyond what their insurance company - and their current cardiologist could ever cover. This is pretty big because I will have to get people to first, switch doctors and then pay extra money for me. People get pretty comfortable and attached to their doctors, so this alone will be no easy task - and then getting them to give me extra money out of their pocket on top of that. Not easy. So I realize I will have to provide something that is pretty special.
Once I am able to get my first 40 or 50 patients, then I believe word-of-mouth will go into effect and it to the growth of the practice. I'm going to need to figure out exactly what my start up costs will be and my monthly nut will be so that will give me a better idea of what I need to start and when I will become profitable.
So what will I provide that is so special? Well, I have tons of ideas - some practical, some way outside the box, some may not be possible. I'd love to hear what you think. Obviously, these patients would be getting ultra-VIP care and attention. They can be seen within 24 hours of calling me - no matter what the complaint or concern. They will have access to my cell phone and e-mail so that I am reachable at all times 24/7. I will not bill through their insurance - no pre-authorization, no referrals, or anything like that. I was actually thinking it would work against me to have an office. If I have an office, these people will need to get to my office and it could be very inconvenient. Instead, I go to them - work, house, whatever, wherever. That would allow me to see patients almost anywhere on Long Island - instead of being limited to one area. Obviously, this would also greatly reduce my start-up expenses and monthly bills. I also think getting hospital privileges would also work against me for the same reason. If they are admitted, I go visit (as a visitor) and be in close contact with the doctors taking care of them. What else would I provide that's so special? Well, their visits will not be at all rushed. I can certainly be much more thorough than whoever they are seeing now. I can educate and focus on prevention as well. Diet and exercise and smoking cessation and diabetes care and weight loss - all these things that doctors should be spending a lot of time on and just can't. What else? How about a chef to the house to teach you how to cook a very easy, very healthy meal? How about a wine tasting of very heart-healthy wines? How about books and literature and handouts proving continuous education on all relevant information. I will need a portable EKG and echo machine with me at all times in my car. I will need a scale, a pulse ox, fingersticks for INR, glucose and potassium.
All that stuff - but most of all, it's the personal attention that the patients will be paying for and expecting. I really need an honest and realistic evaluation and expectation of the feasibility of this venture - before I start getting a line of credit form a bank and start leasing equipment, etc. What number of patients will I cap at? What will happen if I want to take a family vacation? Basically, at this point, this is me thinking out loud - I'd love to hear your opinion.
Saturday, August 27, 2011
Career Path
Hello all. Recently, I've been thinking about a new career path. I'd love to give my patients the time and attention they require without having to worry about a hectic schedule. Doctors, as you know, in general, are in a funny situation these days. Much of our reimbursement have been drastically cut. Many of the tests we order are denied by insurance companies. We need to see more and more patients in any given day in order to cover the overhead and make a decent salary. You see - I'm a cardiologist and that's what I've always wanted to be. When I was in medical school (Georgetown, Class of '94), I learned to be a doctor who really cared for his patients. Listened. Thoroughly examined. Listened more. Thought about. Explained everything. Followed closely. I graduated from med school in 1994 and, you know, that really wasn't that long ago - and it's close to impossible to be that doctor in today's healthcare environment. I see some doctors - they are rushing, and still falling behind - so they need to rush even more. A patient waits an hour to see the doctor for three minutes. I've heard it being compared to waiting on line at Disney for Space Mountain for an hour and then once you finally go, it's over in a two minutes. That's not what the patients want and it's not what the doctors want either.
So, how do I get around it? When I first heard of concierge medicine, it sounded too "elitist". However, the more I think about it, the more i am starting to really love the idea. As you may know, concierge medicine is medicine by way of retainer. For an annual fee, you have priority access to your doctor 24/7. Appointments whenever you want - essentially no waiting in the waiting room - and, get this, you have your doctor's full and undivided attention for as long as necessary. The patient gets the doctor he/she deserves and the doctor gets to be the doctor he/she always wanted to be. No rushing through patients like they're on an assembly line. Imagine - I can give my patients my full and undivided attention and really think their situation through without being rushed and interrupted. How can that not lead to better care?
Can I make this work as a cardiologist? I think I can. I know it will work - the only difficult part will be getting patients to agree to pay extra money for something that they are already getting with their health insurance, right? Well - the thing is - they will be getting a level of care that their insurance coverage cannot even approach. For example - I get a phone call from a patient - let's call him Mr. Smith. Let's say it's at 9 pm and Mr. Smith tells me he is having a little trouble breathing. While I'm on the phone with him, I quickly look up the details of his history on my iPad and we have a conversation, but I soon realize that this phone coversation will not be good enough. I need to see him. Regularly, this is when the doctor says, "Go to the Emergency Room and I will see you there." So - after waiting in the ER for two hours, the patient will be seen, admitted and I would be called and go in and see the patient - approximately 3 hours after the call. However, now I would say, "Mr. Smith, I can be at your house in 30 minutes." I take my stethoscope, my blood pressure cuff, pulse ox, my portable EKG and echo machine and Mr. Smith, no matter what the problem is, is already getting a much higher level of care. This lost art of the house call may have just either prevented an unnecessary hospital admission or facilitated a much needed one. Better care.
I'm going to spend some time thinking about this in much more detail and I'll check back soon. I'd love for you to drop me a message with your thoughts. Thanks.
So, how do I get around it? When I first heard of concierge medicine, it sounded too "elitist". However, the more I think about it, the more i am starting to really love the idea. As you may know, concierge medicine is medicine by way of retainer. For an annual fee, you have priority access to your doctor 24/7. Appointments whenever you want - essentially no waiting in the waiting room - and, get this, you have your doctor's full and undivided attention for as long as necessary. The patient gets the doctor he/she deserves and the doctor gets to be the doctor he/she always wanted to be. No rushing through patients like they're on an assembly line. Imagine - I can give my patients my full and undivided attention and really think their situation through without being rushed and interrupted. How can that not lead to better care?
Can I make this work as a cardiologist? I think I can. I know it will work - the only difficult part will be getting patients to agree to pay extra money for something that they are already getting with their health insurance, right? Well - the thing is - they will be getting a level of care that their insurance coverage cannot even approach. For example - I get a phone call from a patient - let's call him Mr. Smith. Let's say it's at 9 pm and Mr. Smith tells me he is having a little trouble breathing. While I'm on the phone with him, I quickly look up the details of his history on my iPad and we have a conversation, but I soon realize that this phone coversation will not be good enough. I need to see him. Regularly, this is when the doctor says, "Go to the Emergency Room and I will see you there." So - after waiting in the ER for two hours, the patient will be seen, admitted and I would be called and go in and see the patient - approximately 3 hours after the call. However, now I would say, "Mr. Smith, I can be at your house in 30 minutes." I take my stethoscope, my blood pressure cuff, pulse ox, my portable EKG and echo machine and Mr. Smith, no matter what the problem is, is already getting a much higher level of care. This lost art of the house call may have just either prevented an unnecessary hospital admission or facilitated a much needed one. Better care.
I'm going to spend some time thinking about this in much more detail and I'll check back soon. I'd love for you to drop me a message with your thoughts. Thanks.
Subscribe to:
Posts (Atom)