One of the issues that struck me during my medical adventure was that of access to diagnosis and treatment. Why was I able to get the diagnosis and the stent when others may not have access to it? I'll defer the more interesting philosophical/theological question of "why" for later. For now, let's just look at the immediate causes.
One factor is clearly proximity to specialists or those skilled in the art. If the doctors giving me the early attention hadn't known the researchers at MGH in this specialty, they wouldn't have referred me there. And if MGH, or a similar center with such skills, had not been conveniently located nearby, I might not have been able to travel to receive such care. This brings into sharp attention the billions of people who do not have reasonable access to skilled care. How is it that some of us have such access but most people don't? Is there a way to disseminate this care more quickly?
Cost--and insurance coverage--are another obvious factor. I was fortunate to have the insurance coverage to cover the costs. The total list price for the procedure exceeds $50,000, as far as I can tell. I don't know how much the insurance company will finally pay or how much I will have to pay. But it is beyond the means of most people to cover it. Access to health insurance is a major issue. Affordability of such insurance may be one of the major challenges of our western society. In other societies such care is often not even available.
A third issue is more nebulous. What symptoms justify the more expensive and often invasive tests to do further diagnostics? For me, the trail was serendipity. A sudden blindspot in my eye led the ophthalmologist to identify an embolism. Had that mini-stroke occurred in any other location than the retina, I may never have noticed it or, if I had, it might never have been identified as an embolism. In searching for the cause of the embolism, my primary care physician requested a TEE, which stands for TransEsophogeal Echocardiogram. Had he not done that, the cardiologist doing the test would not have had a chance to do the PFO leakage test which identified the PFO problem.
As I mentioned in a previous note, the data are subtle and not overwhelmingly convincing that a paradoxical embolism is best treated by PFO closure. Many specialists in the area are still skeptical, pending better studies. It took three months for the team at MGH to decide that my PFO should be closed by inserting an occluder via cardiac catheterization. Had that not happened, I would never have been given an angiogram. There were absolutely no symptoms or test results that would have justified having an angiogram. Yet, with the catheters in place for the occluder, it was an automatic angiogram.
That's when they discovered the nearly complete blockage of the proximal left anterior descending artery. The doctors had no doubt but that in the not too distant future I would have had a severe, and likely fatal, episode of blockage. In the last four weeks, in fact, two of my former colleagues did suffer a fatal cardiac condition that may have been precisely that situation. Each of them had some minor symptoms but nothing that would have justified an angiogram.
All of this goes to show that we have no good systematic way of deciding who deserves a test like an angiogram. It is too invasive and expensive to use as a broad screening tool. Yet, too often there are no symptoms that appear in a timely way.
Who will get the angiograms in the future? We as a society need to think hard how to 1) educate the population on being alert for the relevant symptoms, 2) continue to educate everyone of proper diet and exercise, and 3) aggressively work to disseminate available to the latest medical techniques to as many people in the world as possible. These techniques cannot be reserved solely for the privileged few who live near the medical research centers and have the right insurance.