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Disturbing trends in the heart rhythm clinic — New post up over at

What follows is a short intro to my latest column on | Medscape Cardiology.


The title of the piece is Three Concerning Trends in the Electrophysiology Clinic. I worked on the 750-word piece the entire week. It was hard to get the tone just right. This is because the trends do not reflect well on us–caregivers in the US healthcare system.

These are changing times for cardiology. In my city of 1-million people, cardiologists are now employed by three major healthcare behemoths. Most, but not yet all, of my referrals come solely because I am part of behemoth A. Doctors in my corporation have no choice. They have to send patients to me. Likewise, referral relationships I had formed with caregivers over years were shattered when we were employed by different corporations.

Earning referrals based on merit is essentially dead. That’s not a complaint; it’s a fact. A doctor in behemoth corporation B may send his mother to me, but his patients are going to the electrophysiologist in his corporation. I may have done 800 solo AF ablations but if your cardiologist is in behemoth B, and his electrophysiologist has done 50 AF ablations, you know where you are going. Heck, what am I thinking, all board-certified doctors perform equally, right?

To put it bluntly, this sucks. Cardiologists are a competitive lot. Knowing that your skills, real skills, not box-checking and compliance skills, don’t matter anymore is a joy-killer.

The good news is that, at least for now, some patients–especially those with means–still have a choice.

So one of the trends I am seeing involves patients seeking me out as a second or third opinion. This is new. I used to get an occasional second opinion, maybe one a month, but now I am seeing these types of consults almost daily.

The two other patterns I discuss pertain to how healthcare is delivered in this country. I use heart-rhythm examples, but the patterns extend to all of medical care.

Here is the lead paragraph:

The essence of electrophysiology is pattern recognition. I like to say heart-rhythm doctors are trained observers. What follows are three changing patterns I’ve noticed in my office practice. I write of these patterns because fixing things in medicine first requires seeing the problem.

I hope you want to read more.

If you do, and you don’t mind giving | Medscape Cardiology your email, here is the title and link to the column:

Three Concerning Trends in the Electrophysiology Clinic


13 replies on “Disturbing trends in the heart rhythm clinic — New post up over at”

Wow, your 3 concerning trends are so spot on. I was going to say that “too much testing, too little communication” was the most important, but “creating unnecessary fear”, and “managing the patient, not the disease” are just as important. This is one of your best posts. Direct, spot on, to the point. I was just reading an older article at

called “What patients want and need to know about atrial fibrillation” that meshes nicely with what you wrote.

Excellent post. As a patient of very limited means, my options are even narrower: a dwindling pipeline of competent, patient-centered providers, a tight-fisted state program that is conducted with the managed-care “evidence-based” model, poor quality affiliate hospitals, and outdated equipment/methodologies. Add in fear-based medicine, and people wonder why I’m terrified to have paroxysmal AF. Terrified because of the trends toward aggressive/potentially dangerous treatment, and terrified because of lack of access to calmer, more patient-centered providers. I really want to regain my life, but I know the medical system of which I’m assigned won’t be of much help.

For some reason I thought that the Medscape article was going to be more in keeping with the issue that you addressed above. I had wondered how the new trends in Health Care Centers, or Homes or whatever was working on the other side. Living in a city of over abundant healthcare choices, finding a really good doctor in almost any system isn’t really a problem. And I can see a great advantage to having all doctors in one system. They all have visibility into health care records of the patient. I like that my endocrinologist, nephrologist and cardiologist can all see the same records. I might be wrong, but it seems like the over all knowledge of what is going on is an advantage for getting better treatment. I was sick a long time before these alliances formed and I have doctors spread over 4 of the 5 major ones in this city. I look at it and think that I wish that they were all in the same system. Still, many of my doctors I have been seeing for 10 years or more. I am not willing to change doctors to accomplish that advantage.

Lisa: The part where it meshes is with communication, considering the patient (their perceptions), and getting patients to understand what they can control. Different approach to the same subject. But it fits.

THANK YOU John for this excellent post – with the 2-pager in Medscape being highly recommended. I am going to add reference to this post (and the Medscape article) to my recommended reading for the Arrhythmia Management Talk I’ll soon be giving to a primary care audience! An informed, dedicated primary care clinician may be the optimal (as well as most cost-effective) provider for seeing the patient with a benign arrhythmia.

Dr. John,
I am a patient that, between cardiologists & electrophysiologists, has had 2nd, 3rd & 4th opinions. Let me tell you, from a layperson’s perspective, why. The first cardiologist diagnosed Afibs and put me on Flecainide. I had a reaction to that medicine (I know, “That never happens”). That doc wouldn’t acknowledge the possibility, so I sought a second Cardio. He said what he was reading didn’t say Afib, so he sent me to an Electro. I had barely sat down & he was talking about ablation. He must have needed to make a payment on that boat he just bought. I wasn’t yet ready to commit, so he grudgingly prescribed some pills. After I left his office, I had a question about those particular meds – never heard back from him. I didn’t take them. So, I took myself to another Electro. He said he didn’t think it was Afib, but to be sure, he’d want to do some invasive testing. I again hesitated, so he recommended some different meds from last guy. Let me say, from all these learned people, no one could or would take the time to learn about me. They wanted to treat the symptoms, not try to determine why I was having these problems. When I asked if it could be related to the possiblity that maybe, since I had just turned 50, my hormones (menopause) might be involved – I was looked at like I had grown not one, but two heads. Treat the whole body like it actually works together? Forget about it! Lets compartmentalize & potentially do more harm!
So, I believe part of seeing the problems in medicine might begin by actually seeing the patient – the whole patient. I suspect with our healthcare system/crisis the way it is, I will see a unicorn in my backyard first.

It must be the same unicorn I will see in my backyard. Although I didn’t consult as many docs as you have, rest assured you’re not alone. The cardio I was referred to (my plan doesn’t allow for selection of Drs..we are assigned to whomever has an opening, regardless of their skill level or quality) looked at me like I was insane when I brought up the correlation between hormone shifts and irregular rhythm. I didn’t buy his answer (or lack thereof), so I hit the journals and found some interesting research highlighting the possibility of increased SVT episodes in perimenopausal and menopausal women. The doc was rude, dismissive and snarky when I really tried to engage him in some honest conversation. And yes, there is economic incentive for some docs to do procedures/rx meds. Not at home so I can’t find the links to the articles I read re: hormonal shifts and heart rhythm, but a focused Google search will strike the mother lode.

I think when enough patients are fed up and begin to educate themselves and ultimately seek help outside of our healthcare system will medical schools begin to train future docs to take into consideration the whole person. The expensive concierge docs already take that approach, but it’s time that docs who treat us Regular Folk take the same approach. It’s like dodging landmines out there!

Take care!

Thank you! I will do that Goole search and continue educating myself.
When it comes to my health and the health of my family, it seems we are the only ones attempting to “do no harm.”

@Jeannine: you’re welcome! Google responsibly, of course, but as mentioned before, I have hit the mother lode. Mayo Clinic has an article online about the possible correlation between hormonal shifts and changes in heart rhythm, and you’ll also come across assorted forum postings. The latter aren’t “hard data” by any means, but it does help to know there are other women like us with the same questions. My heart was as quiet as could be until about a year and a half ago. I’m charting my hormonal symptoms and heart rhythm stuff to see if there is any pattern, and viola! there is! What would help is a great doc who would work in partnership with me and who would “take their foot off the gas” in terms of aggressive treatment.

It does feel like we are the part of the equation that practices “first, do no harm.” Very, very sad commentary on the state of our “health care” system. I wish my money spoke loudly enough to find a good doctor who practices “slow medicine” but unfortunately it doesn’t. The corporate approach that Dr. Mandrola writes about will only worsen the problem as time goes by.

The day I find a doc that likes an educated patient, and who practices slow medicine will be the day I go into afib from the shock of it all 😉

If I had listened to the docs (two of which were Mayo docs – they must not have read the online articles). I suspect I would have a lot more problems now then when this whole saga began! After the reaction to Flecainide, I never took any of the meds that were prescribed. And I didn’t allow them to do any invasive testing. I slowly started feeling better. I had some hormone testing & was told a few levels were very low. I was prescribed a bioidentical hormone cream. Because I had begun feeling better – fewer Afibs – I was afraid to change anything. So, I didn’t use the cream either. I went to see a Naturopath. She spent 2 hours (you read that right) going over my history and what had been happening to me this past year. I don’t know yet if the changes that she has recommended will help or not. Too soon to tell. Every day I wonder if the flutters, racing, drop-outs will begin again in earnest. All I know for sure is that I now have a whole lot of medical debt and most of the answers have come from my own research. The small amount of trust in the medical community that I had is gone. I’m not sure what docs are learning in medical school except how to get nice lunches from pharm reps. And I don’t believe the ones that go to conventions/seminars are learning how to buck the very poor system.

Dr. John M,

I watched your presentation on evidence-based statistics that women are being undertreated and far more palliatively treated than males. Thank you for putting that out there…and for your journalistic eye that caught this in the first place. Very courageous of you.

We can rest assured you won’t be sneering at women in cardiac distress in your doctor narratives. Examples: when reporting deep clenching chest pains. ‘magical, mythical thinking’….”maybe your breasts are just vibrating’….”advised past life regression therapy’. Who is teaching male physicians this in the 21st century? Who is pushing male physicians to route women right back out the door, sans cardiac referrals or testing of any kind? Just this bizarre ‘stance’.

Backing your push back on current healthcare models. Thank you!

My husband went back into persistent AF some months ago. I mentioned that he had suffered a malpractice cascade that left him with an unnecessary pacemaker, plus two unnecessary ablations for an iatrogenic arrhythmia. Unfortunately, he was fired by his last electro – who should have been grateful not to be sued – for not wanting to submit to further cut-burn-and-poison approaches to AF or constant rent-seeking follow-ups of the turned-down device. (This guy refused to accept published data regarding, among other things, the equivalency of rate and rhythm control.)

My husband is not yet getting ideal rate control from what his GP is giving him and has some symptoms, and once or twice suggested seeking a cardioversion. However, we fear the possibility that this could reset the pacemaker to start pacing, or that it might cause another lead dislodgement, of which the first he suffered nearly killed him. We were told future ablations could cause lead dislodgement – ironically, this was used to coerce him into getting one that had no possible benefit – and we can’t assume that if that happened, he would be granted a late explantation from a brand-new Ologist who had no legal responsibility and might well share the “thin white line” mentality.

So I’ve encouraged my husband, whenever he has mentioned possible procedures, to stick to rate control, try harder to lose weight, and just accept living with permanent AF if future alternative approaches don’t stop it. I wish I could help him to get a cardioversion or even an ablation for his real arrhythmia, the amount of damage and radiation he’s already needlessly received notwithstanding. But it is impossible for us to trust that he wouldn’t suffer even more devastating harm, or that the specialist he chose would even attempt to alleviate that harm. I think I’d trust Dr. John with my husband’s life, but he doesn’t live here, and after seeing some combination of incompetence, ignorance of literature, outright lies, and brutal coercion from every single one of eight specialists and trainees my husband encountered during his illness, the odds that any randomly selected specialist in this town would be honest, conservative and open-minded seem … small. Say NO to unnecessary devices, and your chance of being free to pursue desirable treatment for real problems later will be much greater.

The truth about referral patterns and hospital systems is important for patients to understand. Trust has always been a key ingredient in a Doctor-Patient relationship, and referrals based on anything but a Doctor’s opinion of what is in the patients best interest can’t help.

The deeper problem with an in-system referral bias is that we take our best diagnostic and procedural talent and split it into 2 or 3 separate groups. When it comes to tricky problems and difficult cases, we should insist on seamless cooperation between the best specialists – wherever they might be.

Does anyone really think healthcare functions better when we take half (or a third) of our talent and tell them to never work with the other half (or 2/3rds) of their colleagues? No one could defend that with a straight face.

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