by Carolyn Thomas ♥ @HeartSisters
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.
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♥
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).
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Q: How has the presence (or absence) of a nearby medical specialist impacted your care?
image: Chat Wszelaki
See also:
If I’d had my heart attack decades ago . . .
Female cardiologists chat about heart disease
My cardiologist: “the devil himself”
Does your hospital have a Women’s Heart Clinic yet? If not, why not?
Cardiac care for the whole patient – not just the heart
‘Women-only’ cardiac rehabilitation curbs depression for heart attack survivors
Why aren’t women heart attack survivors showing up for cardiac rehab?
Study: “91% discharged from hospital without care plan”
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Heart Sisters 
I am very fortunate to live 15 minutes from the excellent care of my cardiologist. About eight months after my heart attack, however, I went to visit my grandmother in her small hometown in Iowa. I was a nervous wreck the whole time because the nearest heart center is about 40 miles away. There is one ambulance in town. I was absolutely terrified about having another event in this small town. I didn’t let my family know because I knew it would just worry them. I definitely do not take for granted how fortunate I am to live in a large metropolitan area with ample choice in hospitals and cardiologists.
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Although the odds of you needing an ambulance or a cardiologist while visiting your grandmother might be very slim, it’s still a compelling reminder of your very good fortune at home, isn’t it? It also makes me hope that your grandmother doesn’t have a cardiac emergency.
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Hi Carolyn! I would hug him if I ever saw him, remembered what he looked like.
Since my heart attack one and a half years ago I saw him once for 10 minutes six months afterwards. I begged my family doc to see him this year and finally did in February for another 10 minutes. He remembered nothing about me and we are strangers. I would not recognize him if I saw him on the street!
Obviously I cannot see him regularly as it took a long time to get a second visit and my family doc was not happy about making the referral. However I did have immediate care during the heart attack and had the stent put in within two hours of the attack. It is the subsequent care after discharge I am critical of, particularly as I had a great deal of heart damage.
Hug yours for me and count yourself lucky to have such a great relationship with him.
B.
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Hello Barbara – you bring up such an interesting point: the availability of excellent emergency cardiac treatment vs. ongoing follow-up care after the fact. As you describe here, the first does not necessarily guarantee the second!
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Hi Carolyn, I had an experience that may not have occurred to you. Lucky for me, I live in a big city with fabulous cardiac care, so before and after my mitral valve replacement I was seen regularly by my cardiologist, and participated in an an excellent cardiac rehab program after surgery.
Then my cardiologist retired. He told me that because a number of cardiologists worked out of the same address, someone would pick me up, but he didn’t know who it would be. No cardiologist picked me up as a patient. I fell through the cracks. For a couple of years I had no cardiologist at all (and was lucky enough to be stable).
When my husband was referred to a cardiologist who was just starting his practice in the city, we both liked him so I asked him if he would take me on as well. He said he’d be glad to if my family doctor sent him a letter, which she did.
He has provided excellent care for my husband and me since then. The only bother is that while he works at three big hospitals here, he doesn’t work at the biggest cardiac centre, so when I’ve been admitted, I’ve had to ask the cardiologist looking after me in hospital to call my cardiologist, to keep him “in the loop”. Fortunately, this has been done.
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Hi Jennifer and thanks for sharing your story. A good example of how patients have to be their own best advocates – from making sure you don’t fall through the cracks to reminding care providers to talk to each other!
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This post was very thought provoking, as usual.
I am lucky enough to live in an area that does have wonderful cardiac care. The local hospital, a cardiac destination of its own, actually had the hubris to know when it was time to transfer me to a a hospital that could do a transplant, if it came to that. Thank goodness, it hasn’t.
I am lucky enough to have wonderful Cardiologists at both hospitals that continue to care for me. My heart failure Doc at the inner city hospital actually hugs me and my family every time I come in for a visit. I am lucky, indeed!
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You ARE lucky to have more than one local hospital providing good cardiac care!
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Carolyn, when it was determined that my odd feelings and debilitating symptoms were indeed my heart, I had the incredible good fortune to be seen by a leading electrophysiologist in my small hometown of Prince Rupert because he is compassionate enough to hold 2 or 3 clinics a year in our hospital, despite being a world expert living in Vancouver.
I still see him regularly and thank my lucky stars each time. I generally take the 7:30 AM appt and was stunned when his local staff told me they appreciate it because people in our area don’t want to get up that early to see him!!!! For some reason they must be insensitive to the fact that their other choice is a 17-18 hour drive or an arduous 4-5 hours by plane, not to mention that even for those of us with benefits packages, the cost to travel to get the expert care and tests can approach thousands of dollars!
I still make that trip a couple times year, but am so grateful that some of my appointments can be accommodated at home.
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Hello Lauren and thanks so much for this reality check! Many heart patients live with this reality when they are hundreds or even thousands of miles from the nearest specialist.
I admire docs who divide their (very busy) time by providing care in remote under-served areas. I met a physician last month in Vancouver who spends 75% of his practice doing remote tele-medicine in small northern communities and native reserves. The only alternative for such patients before this practice started 18 months ago was to be medi-vac’d down south for anything beyond the basic medical care provided by full-time nurse-practitioners.
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You have addressed a major problem in medical care, Carolyn, and one that most people don’t think about until it hits them in the face.
I have struggled to get appropriate care for a complex of conditions, and I live in one of the world’s doctor-magnets. I can imagine what my odds would be if I lived hours from a major health facility. Yet many relatives and pals discuss retirement in beautiful isolated spots and are entirely unconcerned about access to quality diagnoses and health care. That 3 hour drive (to a regional center with maybe, maybe one of each major specialty) may not seem much to you right now…
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You’re so right, Kathleen. Most of us don’t even think about living near appropriate medical care at all – until it’s too late! I know a number of people who have retired to one of the beautiful Gulf Islands that lie in the Strait of Georgia between here and Vancouver on the mainland. And I also know of some who are now planning to move back to the city as they begin to worry about not being able to get off the island during a medical emergency.
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I experience first hand the shortage of cardiologists and the 3 1/2 hour drive to a medical facility that does heart surgery or intervention.
My first cardiologist when I moved to way upstate NY left his practice between the time of my last visit (Thursday) and the placing of two stents (the following Tuesday)! Four months later, I called my new cardiologist’s office to report what was becoming daily mild chest pain, and was told there were no appointment slots available and that I should go to the ER to be evaluated. This resulted in a four-day hospitalization for “observation” which, in truth, was unnecessary. There were no changes in meds nor any interventions needed.
I was later told by my primary care physician that, had I lived closer to the major distant hospital, I would have immediately been sent to the cardio cath lab. I still feel “iffy” about my current state and wonder if I’m just on the edge of a major event.
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Thanks for sharing your story here, Pauline. The anxiety of waiting for a “major event” is hard on your heart in and of itself. Next time you have an appointment with your new cardiologist, make sure you discuss your angina symptoms and appropriate treatments.
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This is something I never thought about before – how insightful! I should, indeed, hug my cardiologist! I am one of the fortunate ones, as we have several cardiologists in our area as well as excellent cardiac rehab facilities. I have heard that only 25% of cardiac patients actually utilize cardiac rehab, often times because of distance, work, or lack of insurance. This is a sad statistic because cardiac rehab is one of the most valuable tools a heart patient can have. I understand a cardiac rehab app is “in the works.” I can see this making a difference in many lives.
Thank you, Carolyn, for opening my eyes once again.
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Hello Sharon – you and I are so lucky to be in the same boat (living in a community with several cardiologists). I’m sure there is a cardiac rehab app in the works – not quite the same as the in-person support of attending a rehab group, but better than nothing which is, sadly, what far too many heart patients live with now. PS Here’s more on why women don’t attend cardiac rehab even when it’s available compared to our male counterparts.
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This is such an important issue! Thank you for writing about it.
I have seen the difference the lack of access to cardiology and education/rehabilitation services makes within my own family. My brother-in-law and husband have both had cardiac problems within the last year. My husband has had access to all care here in Victoria. My brother-in-law lives 6 hours from the care he requires and has no access to the rehabilitation or education courses. Even follow up visits are a major ordeal. His community is struggling just to keep GP services, let alone specialty care.
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Hi Marilee – imagine being a six-hour drive from the care providers and services that your husband and I simply take for granted as being right around the corner! Makes all the difference in not only our initial treatment but in ongoing support and care.
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Hi Carolyn! I hugged him just last week when I saw him for my Post-Camino visit. He was floored that I completed all 800 km!
JG
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Hi JetGirl – YOU deserve a big hug for your accomplishments! 🙂
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