What Is Good Care, and What Is Bad? and Discussions

I would like to tell you about a fellow named Sal. Don’t worry; I made him up.1 But imagine he is real. Sal is a 60-year-old white male. He is slightly overweight, is borderline diabetic, and smokes half a pack per day. But otherwise Sal is in good health. Aside from minor ailments, Sal has never been very sick. Sal’s doctor periodically advises him to lose weight, take medication for his diabetes, and stop smoking, but Sal has always felt fine. Increasingly, however, Sal feels chest pain when walking up stairs or running to catch the subway. After some nagging, Sal visits his primary care physician. The doctor suspects angina and refers Sal to a cardiologist, who does a variety of tests. The results are not great. Sal has probable heart disease. Cardiac catheterization, a procedure to measure how well blood flows to the heart, is performed. Significant narrowing is detected in one of the arteries supplying blood to Sal’s heart. A heart attack won’t happen next week, but will in the next few years. The cardiologist recommends angioplasty, a procedure to open the clogged artery and insert a mesh tube to keep it open. The procedure is successful, and the artery is reopened. Fortunately, insurance pays the $20,000 bill. The cardiologist sends Sal back to the primary care physician, along with some recommendations: nitrate pills for periods of intensive pain; aspirin and beta blockers as well; more regular use of diabetes medication; absolutely no smoking; switch to non-fat milk instead of whole milk; use salt only in moderation; and exercise regularly. Defining the Health Care Challenge 48