It would appear that I was a much more efficient cardiologist 20 years ago at age 50.  I had my share of the “worried well” — patients with non-cardiac chest pains, benign palpitations, innocent murmurs and normal variation EKGs.  In most cases, a focused cardiac history and physical followed by some words of reassurance resolved the problem.

For those with more serious cardiac problems, a battery of tests such as echocardiograms, stress tests, recorders and cardiac catheterizations frequently led to appropriate diagnosis and treatment.  I would have been able to meet the new metric of the 15-minute cardiac visit easily.

However, 20 years later the problems became more complex and less amenable to simple examination and testing.

“Is Mom’s mental deterioration a side effect of medication, do to her cardiac problems or a sign of dementia?”

“Why is Pop still short of breath after an apparently successful TAVR?”

Balancing my patients’ heart failure symptoms against an increasing creatinine level has been a vexing problem requiring repeated calls to the patients’ nephrologists.   15 minutes is simply not enough to honestly discuss these issues.

What is the metric, RVU or monetary value of a home visit to analyze a shut-in’s pacemaker and perhaps to discuss his or her options of replacing the generator.? How do we value a home visit to turn off the defibrillator of a patient with a co-existing terminal problem?

Fortunately, the RVU metric is irrelevant to me after almost 40 years of practice.  I have my own set of criteria and try my best to follow it.

However, I do worry that the day will come when some practice administrator will notice that my RVUs are an outlier and that a younger differently trained and perhaps differently motivated cardiologist would generate higher RVUs by ordering more tests on my patients.  He might then suggest my time to retire had arrived.

That would be a bitter pill to swallow.

Laurence Lesser is a cardiologist.

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