The patient described and interviewed below faces a crossroads in his medical care. Consider his medical history and perspective, expressed in his own words, and review the questions posed. How would you approach this crossroads? Using evidence from the literature as well as your own experience, respond by using the link to the right. Responses will be selected for posting online based on their timeliness and quality, including use of the available evidence, weighing the issues, and addressing the patient's concerns. The discussion of this Clinical Crossroads case, authored by Michael D. Howell, MD, MPH, will be published in the December 2, 2009, issue of JAMA; responses must be received by November 29, 2009, to be considered for online posting.
CASE PRESENTATION
Mr A is a 37-year-old executive who is looking for a new physician and health care system.
In November 2006, Mr A awakened with dull chest heaviness; after about 90 minutes, he called 911 and was brought to a local hospital, where he was diagnosed as having a myocardial infarction by electrocardiogram and enzyme measurement. Emergency cardiac catheterization revealed normal coronary arteries. Twenty-four hours later, he again experienced chest discomfort. Catheterization again showed normal coronary arteries.
Hematologic consultation revealed a slightly elevated dilute Russell viper venom time (dRVVT) test result on 2 occasions. Mr A's hematologist interpreted these results as suggestive of the presence of lupus anticoagulant and suggested anticoagulation with warfarin and, later, retesting of dRVVT values, with consideration of discontinuation of the warfarin if the levels decreased to normal.
Mr A therefore carries diagnoses of Prinzmetal angina and hypercoagulable state.
After discharge, Mr A initially followed up with the cardiologist who cared for him during his inpatient stay at the local hospital. However, Mr A ultimately decided to transfer his care to a larger center a longer distance away, seeking a cardiologist who would provide care with attention to the etiology of his myocardial infarction and who practiced in a "less chaotic" environment. He appreciated his new cardiologist's attention to his medication adverse effects and the system of care that included reminders about getting his international normalized ratio (INR) measured.
In the spring of 2009, Mr A's new cardiologist decided to leave the area and Mr A again found himself looking for the right physician and hospital for his health care.
Mr A's current medications include extended-release diltiazem, 180 mg/d; aspirin, 81 mg/d; nasal steroid spray; and warfarin, adjusted to an INR of 2 to 3.
Mr A lives with his wife and 2 children, 1 of whom has a congenital heart defect; he works and has commercial medical insurance. He does not smoke tobacco or use drugs; his alcohol use is limited.
On physical examination, he was normotensive with a normal cardiovascular examination; an electrocardiogram showed nonspecific ST-T wave changes and stress test results were normal aside from a left ventricular ejection fraction of 47%.
MR A: HIS VIEW
I was a mid-30-year-old who had standard problems. I had a general practitioner that I would go to for an every-5-year physical and various illnesses I would have.
All that changed when I unexpectedly had the heart attack, and at that time I had no cardiologist or anything. Obviously, I called 911 and went to the hospital that they took me to. A cardiologist on staff there was assigned to me.
The cardiologist I’m seeing now has transferred hospitals. As a result, I may technically be, at the moment, without an assigned cardiologist. So I am now at a point where I need to evaluate what it is I’m looking for in a doctor.
First, I have an interest in finding a hospital of a high caliber but that is also close enough that I could be transported there. [One] of the things that I really appreciated [from my cardiologist's practice was] a registered nurse that was under the cardiologist I was seeing, was extraordinarily good about following up to remind me to get my PT [prothrombin] and INR scores. . . . I could easily go 3 or 4 months without realizing I had to take this test. So having her chase me down, just send me an e-mail once in a while, was fantastic.
I do have a primary care physician and I do like him. I’m also looking for a practitioner who is going to dive in a little more than the surface of the studies and try to really understand. But I will admit that I don't have a way to find out who that is other than trying different cardiologists over the years.
If I had to choose whether it was more important to find the right cardiologist or the right hospital, I think my first priority would be finding the right cardiologist because of the unusual nature of my case. But, even as I answer that question, I’m questioning it because hopefully the cardiologists go back and discuss with the whole department and bounce ideas off each other. So a strong department—as well as having strong nursing staff to support them, to follow up with me—would also be important.
In order to make my decision, I have talked to some friends who are doctors and who have some knowledge at this level. I’ve also looked on the Web but, unfortunately, what you wind up finding is the US News and World Report that ranks the top 100 cardiac hospitals, which only has some value. The reports are very superficial and they don't get to the questions I was asking.
The reason I have shrugged off the US News and World Report and other large distribution magazine "top-whatever" lists is that the methodology used is based on how much time the facility is willing to invest in filling out the form and returning it. The reports are also biased toward measurements such as success—number of deaths per admitted patient–type statistics. An excellent hospital may take on much tougher cases, but as a result they are going to have a higher death rate, and that isn't an adequate measurement of quality.
The other thing I do is actually "Google" some of the doctors' names and see what I can find about them and read their bios that they put up on hospital Web sites. But half of the profiles don't even exist or are empty templates. Others haven't been updated in a decade.
I’m such an unusual case that I often wonder: Do the general findings overall—since most people are going to go in with clogged arteries from lifestyle choices—do those outcomes impact me?
I would be very interested in how to improve this process of looking for a doctor. Getting information and evaluating it is tough. I want to know what the trends in health care quality are and I want to know what information patients can use.
AT THE CROSSROADS: QUESTIONS FOR READERS
How many individuals in the United States change care in health systems, hospitals, and/or clinicians each year and why? Should a patient choose a primary care physician, a specialist, or a health care system? How can consumers/patients learn about the quality of care provided by hospitals, health care systems, and physicians? How reliable and accurate is the public information and does it actually measure quality of care? What do you recommend for Mr A?
AUTHOR INFORMATION
We thank the patient for sharing his story and for providing permission to publish it.
