A while ago, I wrote about my experience during an attack of atrial fibrillation (afib), lamenting the fact that my management never included a proper physical exam. Nevertheless, chemical cardioversion was successful, and my hospital stay was brief.
The episode was precipitated by a small pulmonary embolus acquired during sinus surgery the day before. I had experienced an episode of afib some 15 years previously and had remained free, I think because I was on metoprolol for hypertension. This drug has some limited antiarrhythmic effects.
A couple of months after the contemporary episode, I experienced another, this time without an obvious cause, and it required electrical cardioversion to restore sinus rhythm. Thus, here I am, technically the victim of “paroxysmal” afib.
There are two concerns here: the first is preventing another episode, and the second is preventing a stroke. To this end, my cardiologist has me on an anticoagulant and maintenance antiarrhythmic.
And that’s it. There’s been no discussion of other things I might do to avoid another attack, such as avoiding alcohol or caffeine, exercising regularly, or losing weight. There’s also been no discussion about what I should do if I have another attack (e.g., try Valsalva maneuvers). But there are two other very important items my cardiologist has completely failed to address.
The first is electrolyte imbalance. During the first contemporary episode, my plasma potassium was found to be low, requiring several doses of oral potassium to get it into the normal range. I attributed the cause to the diuretic I was taking for my hypertension (despite it being “potassium sparing”) and a recent course of oral prednisolone in preparation for the sinus surgery. However, this issue was never subsequently addressed. Addressing it might have prevented the next episode of afib.
The third episode was once again marked by hypokalemia but also hypomagnesemia, both corrected by intravenous infusion in the hospital and never subsequently addressed by any of the physicians attending me, including my cardiologist. Both of these conditions predispose to afib. How could such an important issue be “overlooked”? I now have my daily banana, a glass of tomato juice, and a daily supplement of both potassium and magnesium.
A more important issue, perhaps, is that I am quite overweight, and no one ever asked me a critical and key question, even during my years of hypertension treatment and follow-up with the cardiologist (a different one). The question? “Do you snore?” Thanks for asking, yes, I do. There is no doubt that I have sleep apnea. This is an important etiological factor for both hypertension and afib, and its relief can considerably benefit both. Ironically, the triage room of my latest cardiologist has a large patient information poster on the wall discussing sleep apnea and its consequences. Perhaps he should take a look at it.
The antiarrhythmic I am on has significant potential side effects. Although these were discussed with me, the recommended surveillance of liver and thyroid dysfunction through blood testing has not occurred. After some research, I have realized that this is a second-line drug. There is no clear reason why I should have received this as opposed to a first-line drug.
To my mind, these sorts of “overlooks” are bad medicine and make me both disappointed and ashamed of my profession.
I am not writing this essay to castigate my cardiologist but rather to draw attention to something I have observed throughout my 30-year career: poor-quality, substandard care. I have encountered this professionally and personally, both for myself and for my family (I wrote about my daughter’s misadventures with food allergy in an earlier essay).
The Lown Institute is an organization devoted to: “… ensuring that patients get all the care they need, and none that they do not.” In this respect, they have drawn considerable attention to “low-value care” (LVC), which they define as: “… Unnecessary care resulting in substantial physical harm to patients and wasting money and resources.”
A JAMA article in 2015 defines the opposite of LVC as “high-value care” (HVC): “High-value care means providing the best care possible, efficiently using resources, and achieving optimal results for each patient.”
The American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign is a valiant attempt to promote HVC by issuing over 700 briefs in a variety of specialties. The American College of Physicians has its own “Initiative for HVC.” Sometimes HVC is referred to as “best care.”
LVC is rampant in U.S. medicine. Essentially, it constitutes sins of commission, whereas the focus of this essay is more upon sins of omission – not doing what should be done. Neither LVC nor HVC describe this situation adequately. Perhaps we need a new term: “poor-quality care” or my favorite, “wrong care” (WC), something that seems reasonable as the Institute also uses the term “right care” (RC) in its so-named series published in the journal American Family Physician.
My own specialty – pediatrics – could be considered the poster child for WC. Indeed, it is so bad that a fellow pediatrician was moved to write about it in a published book, Suffer the Children: Flaws, Foibles, Fallacies, and the Grave Shortcomings of Pediatric Care. A 2022 paper in American Family Physician titled “The Importance and Challenges of Reducing Low-Value Care in Children” states:
First, it (LVC) is widespread. In an analysis of Medicaid and private insurance claims data from 12 U.S. states, 11.0 percent of publicly insured children and 8.9 percent of privately insured children received any of 20 low-value services at least once during 2014.
Designated Children’s Hospitals set the tone. A cross-sectional study (JAMA Network Open, 2021) of LVC among over 1 million encounters across 49 children’s hospitals in 2019 revealed a prevalence ranging from less than 1 percent to 60 percent, with nearly $17 million in standardized cost attributable to 30 measured low-value services. A major LVC source of admitted patients was community-acquired pneumonia, with six in ten children inappropriately receiving broad-spectrum antibiotics, an embarrassing and appalling observation.
WC needs to stop and be replaced by RC. But I think there is one great difficulty in doing so: WC, in many places, has become the standard of care. Take, for example, the use of antacids in infants. These are widely prescribed for infants who are experiencing normal “spitting up” (WC) when they are only indicated in true gastroesophageal reflux disease. I know from personal experience that denying antacids in the innocent spitter, when all around are acceding, will be detrimental to one’s career. Paradoxically, parents see the RC advocate as providing WC! Too often, WC is what earns patient satisfaction. Until we end our fetish preoccupation with the latter, we may not be able to do the former.
Martin C. Young is a pediatric endocrinologist.