Help me trick my Doctor and HMO . . .

Factual Questions
1

Well, not really trick her, but someone please let me know what are the buttons to press which will get me referred to a specialist without waiting for 6 months and 4 more appointments with the PCP.

At issue: my heart. I’d like to get an expert (Cardiologist) opinion of my heart health and get a better idea of prevention, need for cholesterol reducing drugs now instead of later, etc.

It took over a year and 5 appointments with my primary care physician to finally get to see and ENT specialist about my sinus congestion, so I’d like to know what symptoms or issues to be sure to tell the doc about (or exaggerate if necessary) to get into see the specialist.

My health status, so far: “high” cholesterol level, tested a few years ago (at 230-240 range), but not tested at the HDL-LDL(??) level. Family history of high cholesterol, grandfather dead of a heart attack, uncle dead of a heart attack, father currently with coronary artery disease possibly needing open heart surgery. I’m a little too sedentary in that I don’t really exercise aerobically at all, although I do play a little basketball, splash around in the pool, chase my toddler. I’m male, age 34, 205 lbs (probably about 20 lbs overweight for a 6 footer). I don’t smoke, but I do eat too much red meat, cheese, eggs, and fatty foods. I do get a little too out of breath and/or a little dizzy when I do something (like 1-on-1 basketball) too long. Fairly stressful job, sometimes with many concurrent deadlines.

I’m pretty sure that without any current symptoms (i.e. chest pains) she won’t be willing to refer me on to the Cardiologist because I’m too young. I’m guessing I’m probably moderate-to-high risk for heart disease down the road, but I’d like to get an expert opinion and find out what some of my options are with regard to my heart health now and prevention ideas.

So, what symptoms and aspects should I be sure to address with my PCP?

BTW, you can’t generally self-refer to a cardiologist, and I don’t want to pay $$$$ for testing if that cardiologist wants tests done without first going through the PCP (if I could somehow get in on my own). I don’t believe my PCP-HMO has my LONG-TERM health in mind, so I doubt they would be willing to automatically refer me on to the specialist because it would cost them NOW.

2

Go to an emergency room, & complain of chest pains.

Simple.

Even if there is no problem, you should be able to insist on a cardiologist after that.

3

My recipe for figuring out which of my patients is at risk for heart disease (if they are not symptomatic)is a good risk assessment, which your primary care doc should be able to do. Key data here includes:
Fasting lipids, including total cholesterol, triglycerides, HDL and LDL level.
Fasting blood glucose.
Blood pressure.
Family history, looking especially for premature heart disease. Granny dying of an MI at 93 don’t count.
Nicotine, alcohol and other drug use status.
Basic metabolic index.
Current exercise regimen assessment.
Current diet assessment.
Probably an EKG.

If enough abnormalities show up there, then a stress test.

If these indicators point towards a suspicion of heart disease, then I refer to cardiology.

If not, then we discuss risk reduction, and repeat the assessment as necessary over time.

Qadgop, MD

PS, thanks a lot, Bosda for tying up resources in the ER with fake chest pains, and driving up healthcare costs.

4

Faking it in the ER is something I’d never do. I’d hate to think someone else didn’t get the emergent care they needed because I told the doc that I was having a heart attack and they worked on me first!

So, Qadgop, MD, do you think a person in my situation should ask for an assessment like you described? Should I demand if she says “No, it isn’t necessary”?

5

I’d just ask her straight up for a cardiac risk assessment, and go ahead and cover the points I raised. If she’s not willing to listen to you and discuss these points, then you don’t necessary need a cardiologist, but you do need a different primary care doctor. She may not do exactly as I would do, but she should certainly hit on most of the things I talked about. She may do much more. But ask, and don’t be afraid to ask specifically. It’s your body and your health care.

6

My PCP recognized I had elevated cholesterol 10 years ago but because I didn’t have a history in my family of stroke or heart attacks he tried lots of different things before he finally put me on Pravachol. First we tried diet… then diet and exercise… then extreme no-fat diet… then Niacin which make you get flushes… and finally Pravachol which seemed to do the trick. Keep hounding your PCP until they pay attention and if you don’t get satisfaction get a new PCP!

7

Is changing to a “traditional” (i.e., non-HMO) medical plan a viable option? Some of my coworkers have opted for the HMO, and while they have lower co-payments, it was REALLY nice just being able to walk into the **oligist with my Blue Cross card in hand instead of a doctor referral.

8

Instead of or in addition to seeing a cardiologist, you might research the issue yourself. All kinds of information is available on the internet. Personally, I would do this for several reasons:

(1) Some doctors are not up on the latest research;

(2) Internet research will let you gather differing opinions; and

(3) You will put a lot more time and care into the project than your doctor.