In medicine we use many technical terms - perhaps too many. Here's one you've probably heard -"myocardial infarction." It means "heart attack." A myocardial infarction is caused by a blood clot in one of the coronary arteries of the heart. When the artery is closed off, the heart muscle (myocardium) does not receive blood with such necessary ingredients as oxygen. As a result, part of the heart muscle is damaged. This is called "infarction" (death of tissue).
Who should treat a heart attack? This was the question raised in a recent article, "Outcome of Acute Myocardial Infarction According to the Specialty of the Admitting Physician," published in The New England Journal of Medicine , (Vol. 335, No. 25, December 19, 1996), pp. 1880-1887. Specifically, the authors wondered if patients did better under a cardiologist or someone other than a heart specialist, like a general practitioner or internist.
In order to make this determination, they began by examining data from 8,241 Medicare patients who were hospitalized for heart attacks during 1992 in four different states - Alabama, Connecticut, Iowa, and Wisconsin. The result of their study indicated that the first year mortality rate of patients treated by cardiologists was 12 percent less than those who were cared for by internists, family doctors, or general practitioners.
To check their conclusions further, they also examined the insurance claims and survival data for 220,553 patients - the total number of Medicare claims of hospital care for heart attacks during the year 1992. The Medicare group was older, with an average age of around 76, with almost equal distribution between males and females, roughly 90 percent of whom were white.
The results were similar: Patients cared for by cardiologists did significantly better. The one year survival rate for this larger group was close to that found in the earlier study.
So why would this be the case?
While many general practitioners are interested in cardiology and are able to render highly competent medical care, others may have a greater interest in another area (e.g., allergies, gastrointestinal disorders, blood problems). Cardiologists devote their entire practice to treating heart conditions. They read medical journals that GP's don't read. They attend seminars and clinics on diseases of the heart - and have had 2-3 years specialized training in that field.
They also administer more tests and utilize more procedures. For example, cardiologists are much more inclined to use coronary angiography (visualization of the coronary arteries) and "revascularization" techniques such as by-pass operations. These procedures cost the insurance companies more money. However, the benefits are substantial, as this study affirms - a 12 percent reduced mortality rate. Most people would say the additional cost was worth it - particularly if they happened to be among the 12 percent.
But suppose a cardiologist is not available when you have your heart attack and you are initially treated by a general practitioner? I would advise you to ask your doctor to consult with a cardiologist, particularly during the first day, when mortality is highest. It is also a time when complications are more likely to set in. So a cardiologist is helpful in anticipating problems and handling emergencies. After the first day, his presence may or may not be required further.
This study raises one additional question: Can managed health care companies (HMO's) really give the best possible service when they place patients under the care of a general practitioner and brush aside the more expensive specialists? This study indicates that a specialist - in this case a cardiologist - can save more lives. If your HMO is reluctant to do so, tell them you want to be among the extra 12 percent that survived.
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Copyright © Dr. Charles A. Bertrand.
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