I like to tell my women’s heart health presentation audiences that, if you’re going to have a heart attack, you should really try to have one here in Victoria, British Columbia – or in any other city that boasts a healthy ratio of cardiologists-per-square-city-block.
My theory on this is that cardiologists, just like the rest of us, want to raise their families in a charming historic town with good schools, good restaurants, good shopping, fun night life, live theatre, sports teams, 200 km of cycling trails, a symphony orchestra, picture-postcard ocean/forest/mountain scenery, and a near-perfect coastal climate allowing them to garden or play golf 12 months a year. If this town also has a major university and a good-sized teaching hospital that attracts both students and cardiac researchers, that’s also going to go a long way in appealing to cardiologists. You’re welcome, Tourism Victoria . . .
I have a wonderful cardiologist here with whom I’ve spent a number of engaging hours talking about All Things Cardiac since we first met under less-than-ideal circumstances in the Emergency Department in 2008. I was busy having a heart attack at the time, and had no clue that he would become “my” regular cardiologist.
He also has many experienced colleagues here, including new-to-us female cardiologists who have just moved to town.
It turns out that geographical proximity to skilled heart specialists is rare for many people living with heart disease. Like most freshly-diagnosed heart patients, I rarely gave a thought to having nearby cardiologists until I really, really needed them. I know now that I’m one of the lucky ones.
This problem of proximity hit home for me while volunteering at our local Royal Jubilee Hospital’s cardiac unit one day. In front of me was a 7-page list of all cardiac rehabilitation programs being offered throughout the province of British Columbia. This list had not been updated for three years.
My volunteer task: to phone all the rehab programs on the RJH master list to make sure all the info we had was up to date.
Not surprisingly, if you’re lucky enough to experience a serious cardiac event in or near a big city, chances are there’s generally a comprehensive cardiac rehabilitation program running somewhere near you. This is a good thing, because we know that a professionally-supervised rehab program of physical exercise and patient education on heart-healthy diet, stress management, and lifestyle improvement topics can significantly improve longterm outcomes for heart disease survivors. See also: Failure to refer: why are cardiologists ignoring cardiac rehabilitation?
But once I finished updating the pages for major coastal cities like Vancouver and Victoria, my phone list moved into communities in the interior and rural north of our big beautiful province.
Not only did cardiac rehab programs in these small town or rural areas provide fewer services (if they had them at all), but in some cases, I was told alarming news. One small town program’s future, for example, was in jeopardy “because the cardiac nurse has just moved away.” In another town, a local YMCA staffer told me that their cardiac rehab program had now been “combined with seniors’ fitness classes” – as if this merger were even remotely appropriate.
Consider one of our northern interior cities, for example, that’s situated about 800 km north-east of Vancouver. Their local hospital has 209 beds (10 of them combined Intensive Care/Coronary Care Unit beds) and serves an immediate population of 80,000, acting as a referral centre for over 200,000 more in the surrounding region. The hospital has about 120 physicians on staff, of whom 55 are specialists.
This sounds like a regional hospital that provides a broad range of comprehensive medical care, doesn’t it?
But when I asked the very helpful hospital switchboard operator to connect me with the Heart Health Promotion program on my checklist, the response was:
“Oh, that program is no longer in service.”
Too bad, thought I, as I reviewed my list’s description of the (former) cardiac rehab program:
“This program offers education programs including lipid management, smoking cessation and home exercise. It is designed for patients recovering from a recent heart attack, heart surgery or angioplasty, including those considered at low, moderate or high risk.”
Even better, the Heart Health Promotion cardiac rehab program was free of charge as long as you had a standard provincial government Care Card (that’s essentially all of us) along with a physician referral. Thank you Canada, a.k.a. commie pinko land of socialized medicine . . .
I asked the very helpful switchboard operator what the people of her town do if they suffer a heart attack and then need to go to cardiac rehab afterwards? Although she wasn’t sure, she did think that the hospital’s cardiologists must surely arrange “some type of program” for them, adding generously:
“Let me see if I can track down a cardiologist who is still in town to answer your questions.”
She put me on hold, but then came back shortly afterwards to say, sorry, no cardiologists were in town. Summer holidays and all. . .
I was gobsmacked.
No cardiologist in the whole city?
Not even one!? As a spoiled heart attack survivor in Victoria, I tried to imagine what would have happened to me on the day I was rushed from the E.R. to O.R. in mid-heart attack for emergency treatment of a blocked Left Anterior Descending coronary artery had there been “no cardiologists in town” that day.
The grim reality in most small towns and virtually all rural communities is that, in this scenario, I’d likely be facing either a long and terrifying ambulance ride, or a shorter and terrifying medi-vac helicopter flight to the closest big city in search of a hospital capable of providing the kind of expert cardiac care I’d need.
And that’s only considering the cardiac event emergency itself – not the ongoing appointments for follow-up care that may involve hours of travel each way.
Estimates vary on the recommended ideal number of cardiologists we need – some suggest that 4.2 cardiologists for every 100,000 people is a pretty darned good goal to shoot for. This source compares that ideal 4.2 cardiologist ratio to 1.3 for allergists, 12.4 for emergency physicians, or 25.2 for family physicians. (These ideals, by the way, are rarely achieved and are often entirely dependent on where you happen to live).
Cardiac care itself has changed dramatically since the mid-20th century. Back then, the x-ray was the only imaging technique available, there was no coronary angiography, no coronary surgery or cardiac transplants, no Coronary Care Units for recovering heart patients and certainly no cardiac rehabilitation programs.
In fact, the predominant concerns of the average post-World War II cardiologist were congenital and rheumatic heart disease. Coronary artery disease (like the kind that caused my heart attack and subsequent diagnosis of Inoperable Coronary Microvascular Disease) was mostly the responsibility of the general practitioner and internist, but as explained in this overview of cardiology:
“Even at that, there was little treatment available. All of this changed beginning in the 1960s with the development of new coronary care drugs and the introduction of coronary surgery and angioplasty.”
Cardiologists today have job descriptions that are broad and hugely complex compared to just a generation ago.
That’s another reason for the many factors that influence the decision of where doctors will end up working. Cardiologists, for example, start a long road of training as internists, including four years of medical school, plus three years of internal medicine residency training. After completing residency, a prospective cardiologist may enter one of many different types of cardiology fellowships, another three years of additional training depending on the type of fellowship (interventional cardiology, electrophysiology, etc). Cardiac surgeons can either enter a cardiac surgery residency directly from med school, or first complete a general surgery residency followed by a fellowship, and may then further sub-specialize cardiac surgery by doing another fellowship in a variety of topics including pediatric cardiac surgery, cardiac transplantation, etc. Here in Canada, cardiac surgery training programs offer 6-year direct-entry programs following four years of medical school.
The relatively late age at which all of these new medical specialists graduate and enter full-time practice also means that many new cardiologists have family and personal responsibilities that might make it harder to move to where they’re most needed (sandwich generation, spousal employment opportunities, etc.)
When computing our current ideal ratio numbers for cardiologists, experts look at factors like general prevalence of heart disease and death rates from cardiovascular causes. But although heart disease deaths help to determine a base requirement for cardiologists, heart patients who do not die continue to make ongoing demands on the profession. That’s why prevalence of heart disease may be more important than death rates in determining the ideal number of cardiologists required for your region.
But all of these numbers are meaningless unless factored in with other influences like the demographics and location of your community.
So if you happen to live in a community where you have more than one nearby cardiologist in practice, and where you can see your own cardiologist on a regular basis (or a specialist in any other medical field), perhaps it’s time to give that doctor a big grateful hug next time you meet.
NOTE FROM CAROLYN: I wrote more about hugging your cardiologist in Chapter 10 (Making Peace With an Errant Organ) of my book “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, 2017).
Q: How has the presence (or absence) of a nearby medical specialist impacted your care?
image: Chat Wszelaki