6 days ago
PCP-Cardiologist Collaboration: How It Works in Real Life
Everyone agrees primary care physicians (PCPs) need to work together with cardiologists when caring for patients with heart disease, diabetes, and sometimes both conditions.
Medscape Medical News asked for examples of PCP-to-cardiologist referrals that were successful — or not. Here are three success stories and one that could have turned out better.
Diabetes, Hypertension, New-Onset Raynaud's…at 97
The patient arriving for a primary care visit had diabetes and a history of hypertension. He was 97 years old. But now, 'his blood pressure was a little low,' recalled Kimberly Petrick, MD, a family medicine physician at Kaiser Permanente, Santa Monica, California, who was his PCP.
'I messaged the cardiologist — we are able to actually text message our cardiologists — and said, 'His blood pressure is a little low. Which ones [medications] would you be OK with me reducing?''
Then, she discovered he had developed Raynaud's, which also needed medication.
After their discussion, Petrick said to the cardiologist: 'I will create follow-up in 1 week, but can we insure he also has follow up with you?'
Kimberly Petrick, MD
The cardiologist agreed. 'It's that collaborative care that makes it so easy and seamless and really reduces that siloed care that isolates cardiology from primary care and a lack of communication and integration,' Petrick said.
Recently, Petrick ran into the man as he arrived for a follow-up blood pressure check in the clinic with a nurse.
'The purple discoloration of his fingers had gotten better. His blood pressure had adjusted beautifully. It was all done with the adjustment of the medication in collaboration with the cardiologist.'
It's crucial for PCPs and cardiologists to be aligned on the big picture, Petrick said. 'It's not just about the heart. That patient has a system of other organs. We need to make sure both of us are looking at that patient as a whole.'
From Cardiac Referral to Rehab
The woman was in her 50s, with long-standing uncontrolled type 2 diabetes and now, new symptoms.
'She had been complaining of intermittent chest pain and shortness of breath,' said Natalie Hamilton, MD, a Denver family medicine physician and senior instructor of family medicine at the University of Colorado Anschutz Medical Campus, Aurora, Colorado. 'She had a family history of heart disease, well, which is something I always ask about. It increases the risk of heart disease and might make me refer sooner.'
She referred this patient to a cardiologist, who performed catheterization and found stents were needed.
Natalie Hamilton, MD
'It seemed like a very fast process,' Hamilton said. 'We got her in quickly, and she's been doing great ever since. From that collaboration, she also got involved in cardiac rehab.'
Then, 'all of a sudden we were controlling her diabetes too well,' Hamilton said. 'So, she was having some low sugars when she was doing rehab. So, we worked together optimizing her cardiac rehab so she could participate while controlling her diabetes in a safe way to prevent further complications.'
One bonus to referrals, she finds, is a better understanding by patients of the importance of managing their health.
'I have many patients with diabetes and heart disease, and I find it can be abstract for patients to understand why it's important to control their diabetes. When they have concurrent heart disease and I feel like a cardiologist would be a good fit for their team, I found that it is very validating for the patient to hear from the cardiologist how important that piece [heart health] is for their diabetes. And it's something people can grasp onto easier. Most people want to protect their heart.'
So that becomes good motivation, she said, for them to start dietary modifications and medications that will help both conditions.
'Don't You All Talk to Each Other?'
Coordination between a PCP in one health system and a cardiologist in another isn't impossible but can be difficult, as Asha Shajahan, MD, a family medicine physician at Corewell Health, Roseville, Michigan, found out with a recent case.
The patient's needs were complicated, she said. He needed a heart transplant and had addiction problems. He was already going to a cardiologist in a different health system, she recalled, so that's who she collaborated with. It was difficult to get records back and forth, and 'it was difficult to keep in touch.'
Asha Shajahan, MD
The patient would come in to see her, Shajahan said, and say that his other doctor wanted him to go off a particular medication — something she would have to verify by reaching out, and it was difficult for her to receive a response.
'I kept trying to get ahold of him but never got to talk to him,' she said of the cardiologist. So she read through all the medical records and the cardiologists' notes when she finally did receive them and went from there with clinical decisions.
For others in a similar situation, she advised: 'Extend your phone number and contact information.' Then, they can respond or get records to you by fax if other methods aren't an option.
Otherwise, others may get the same question Shajahan got, despite all her efforts. 'I remember the patient asking: 'Don't you all talk to each other?''
Tag Teaming for Smoking Cessation
For the past 3 years, the patient had gotten regular reminders from his PCP and his cardiologist about the need to stop smoking.
Recently, the cardiologist, Jennifer Nguyen, MD, who practices at Kaiser Permanente West Los Angeles Medical Center, Los Angeles, reached out to the PCP, using the health system's secure messaging, telling that doctor she had a recent chance to talk to him about smoking cessation and that he seemed open to the idea now. 'And I saw that patient this week in clinic and brought it up again. And because we were able to coordinate and reinforce our messaging, that patient said, 'I did it. I quit.''
Jennifer Nguyen, MD
'It's still early, but monumental.' And the patient was also open to being referred for tobacco cessation counseling. 'That felt like such an achievement,' Nguyen said.
The electronic medical records used at her health system greatly help the PCP-cardiologist collaboration, said Nguyen, who is also an assistant professor of clinical medicine at Kaiser Permanente School of Medicine, Pasadena, California. 'When they leave the primary care office, I can see immediately what was ordered, what the concerns are on the notes; it's all in real time, and I can pick up from there. And that really adds to patients just being able to seamlessly go from the primary care space to the specialty space uninterrupted even though we are physically in different buildings.'
