Two VIPs — not necessarily very important, but rather, very influential people — present with newly diagnosed atrial fibrillation (AFib).
The first patient presented with palpitations to the Emergency Department and was found to be in AFib with a controlled ventricular response. He was obese and also diagnosed with untreated diabetes. After initiation of a direct oral anticoagulation (DOAC), he underwent a transesophageal echocardiogram (TEE) guided electrical cardioversion (CV) over the weekend — had he not been a VIP, the CV would likely have waited until Monday. The procedure was successful, and the patient was discharged on a beta-blocker and DOAC. Unfortunately, over the next couple of weeks, he had recurrent episodes of symptomatic paroxysmal AFib, documented on a phone-based monitor. The episodes persisted, despite higher doses of the beta blocker. The cardiologist who took care of him in the hospital arranged for an outpatient stress echocardiogram, which was normal, as well as a sleep study, which showed moderate sleep apnea. The patient continued to have symptomatic AFib, and opted to undergo catheter ablation as first-line therapy prior to starting an antiarrhythmic drug. This was performed without complications. After the procedure, he was seen by a sleep specialist to initiate CPAP therapy and was started on medications for his diabetes.
The second patient presented after he noted his heart rate to be elevated on a heart rate monitor at the gym. He contacted his concierge internist, who documented him to be in AFib. His doctor promptly emailed an electrophysiologist, who arranged to see the patient as soon as the patient’s schedule permitted. After discussing the case with the internist, the electrophysiologist also recommended initiation of a DOAC prior to the clinic appointment, anticipating that a cardioversion would be indicated. The patient was still in AFib at the clinic appointment. Arrangements had already been made for the patient to have an echocardiogram on the day of the clinic appointment, and a CV was scheduled for the following week. On the day of CV, the patient had been taking oral anticoagulation for at least three weeks and was scheduled to undergo cardioversion without a TEE. This recommendation was based on published evidence that this approach is associated with a very low risk of stroke, and is consistent with societal guidelines on the management of AFib. However, on the day of the scheduled CV, the patient expressed uncertainty as to whether he had taken his DOAC a few days before his CV. Given that his compliance was in question, he was advised to undergo a TEE, which unfortunately showed a probable left atrial appendage thrombus. He was discharged with plans to follow up in 6 weeks for a repeat TEE, and if the thrombus was resolved, he would undergo electrical CV.
Within hours after the patient left the hospital, the concierge internist sent another email to the electrophysiologist asking for a phone call. When called, the internist stated that the patient had expressed concern that the TEE was not initially scheduled before the CV, and that if the CV had been done without a TEE, he might have had a stroke. The electrophysiologist emphasized that the TEE was only performed because the patient was uncertain about anticoagulation compliance and that the standard of care is to perform CV after three weeks of anticoagulation without a TEE, as long as it is uninterrupted. The internist stated that standard of care is often based on cost considerations and that his patients “don’t want the standard of care, they want the best care.” The patient followed up elsewhere.
Concierge medicine is a product of our broken healthcare system. Large healthcare systems with centralized scheduling systems tend to triage patients based on factors other than medical need. This system results in patients who need help soon waiting weeks for an appointment, and encourages patients to find other ways around the scheduling system, often using other connections they might have. It is understandable that patients seek out boutique medical practices that market themselves as being able to help patients navigate the system. However, concierge medicine continues to perpetuate the mindset that ultra-prompt attention and more medical testing is better medicine, and that the standard of care is not enough for their patients. It promotes the notion that 24-hour physician availability results in better care. Concierge medicine has created a two-tiered healthcare system. It is unfortunate that those in our society who have the most resources and influence are not using those assets to improve the healthcare system for all.