Meet our Docs: Cardiologist John Pickrell says taking care of your heart is a team effort
By Kristy Bleizeffer Apr 2, 2014
John Pickrell, M.D., grew up in Salt Lake City and became interested in cardiology while researching beta blockers and heart failure in the 1990s. Then, treating with beta blockers – which block adrenaline from stimulating the heart during heart failure – was very controversial.
“Some doctors thought it was absolutely wrong to treat a weak heart with something that would make it beat slower and not as effective. Eventually, doctors showed that the beta blockers were an important part of treating heart failure. To me that was fascinating, and it was neat to be a part of that,” Pickrell said.
Pickrell now practices at Wyoming Cardiopulmonary Services in Casper and is finishing his tenure as governor to the American College of Cardiology for the state of Wyoming. He recently sat down with The Pulse for our ongoing interview series, Meet Our Docs.
What brought you to Wyoming?
Within cardiology, there are sub-specialties and even sub-sub specialties. One thing I liked about Wyoming, is that it gave you a chance to be more of a general cardiologist. I am an invasive non-interventional cardiologist with a background in noninvasive imaging.
Tell us lay people what that means.
Years ago, most all cardiologists were placing balloons and stents. What they found in cardiology is that what you do often, you do well. The worry was that if everyone was doing a little of something, then they would not get the expertise and a level of proficiency that were needed.
So, in our practice (Wyoming Cardiopulmonary Services), about half of us are interventional cardiologists who are able to put in balloons and stents, and about half of us are not. All of us do heart catheterizations, and we do those fairly often. I trained in invasive, but not interventional, cardiology.
Talk about the cardiology services at Wyoming Medical Center.
It is a collaborative effort. It includes the people on the front lines like primary care providers, nurse practitioners and everyone out there seeing patients. It includes the hospital cath lab nursing team, X-ray technicians, heart surgeons, ICU and ER staffs. We have seven cardiologists at Wyoming Cardiopulmonary, two physician’s assistants and a nurse practitioner.
One of the things that we have that is very good is collaboration with our ER people, EMTs and other physicians in the hospital in treating heart attacks effectively, efficiently and fast. We have a surgery program here and are able to offer most of the breadth of cardiology. We do not do transplants, and we do not do some of the high-end assist devices. We do not have electrophysiology here, but we work with other communities to provide electrophysiology services – the study of the electrical diseases and problems with the heart.
What is the difference between electrical and mechanical functions of the heart?
People say cardiologists are either electricians or plumbers. Plumbers are invasive and interventional cardiologists. A big part of cardiology is dealing with the disease processes of the arteries that feed the heart – the coronary arteries. Coronary artherosclerosis and trying to prevent it, manage it, treat it and then dealing with emergency situations with balloons and stents, or with bypass surgery, that is the plumbing side of cardiology.
There is an electrical side to cardiology where a normal healthy heart starts a heartbeat about once every second or so. About every second you have an electrical impulse that passes through special cells in the heart, almost like it is on wires or a conduction system. That system can get diseased to where either it beats too much, too little, in the wrong spot or does not pass through the heart correctly. Electricians focus on that. The most common thing is atrial fibrillation where the top part of the heart that normally keeps the time stops keeping the time reliably.
So, are you more of a plumber or an electrician?
Again, one thing I like about Wyoming is that I get to be more of a general cardiologist. I get to do some electrical evaluation and treatment, as well as dealing with the other aspects. I still feel like I get to have the best of all the worlds.
Is it unusual in a town our size to have the amount of services that we have?
I think so, but this hospital does not serve just this community. We catch all of central Wyoming. This model does not really exist in too many other places. In fact, we do not even qualify as rural medicine. We are considered “frontier medicine.”
It has to do with our demographics. In Mississippi, if you are more than 30 miles away from a cath lab it is “rural.” Here, distances are more like 150 miles away. A lot of policies are designed for large urban areas where there are multiple hospitals providing the same service saying they are going to weed out the inefficient ones. In Wyoming we have to be all things to everybody. Depending on where you have a car accident or a medical problem, you could be several hours away from help.
This has sort of been one of my soap boxes lately. I think that we have to be careful to preserve our core hospitals in Wyoming. If you beat up the community hospitals too much, to where critical services like trauma are jeopardized, there is really no fallback system. You will have to fly a helicopter from a large trauma hospital like Fort Collins to get you and take you down there for whatever services the community hospitals here cannot provide.
Sort of related to this, the American Heart Association has recognized Wyoming Medical Center for having among the fastest response times to STEMI heart attacks – in the top 10 percent in the country actually. That’s the kind of service you want in your community hospital.
In the past two years, with Dr. Fluture’s help, we have put a lot of emphasis in how proficient we are and how fast we treat a certain type of heart attack, called an ST-elevation myocardial infarction – or STEMI. We have gotten very good results and numbers.
We have made some great improvements in our door-to-balloon time and we expect to keep improving. We consistently deliver good care. We can also go further and measure whether our patients are getting the right types of medicines, the right approaches, and we are showing that they are. We are trying to expand that approach to other types of heart disease – atrial fibrillation, hypertension and other types of heart attack and heart failure. It is very satisfying to know that we provide the same or better quality care than in most of the United States.
We are getting better, and we are getting more sophisticated treatments for advanced heart disease in its different forms. We have very sophisticated pacemakers and defibrillators. We have sophisticated pumps to support very weak hearts.
The best thing is to prevent heart disease from happening in the first place. It does go down to some very basic things: Don’t smoke, manage your blood pressure, know your cholesterol, have a relationship with your care providers and be aggressive with your diabetes. I think one of my kicks lately is we need to make sure we have a healthy community with access to fresh fruits and vegetables, and we are providing healthy eating options for our children. It can be as simple as eating a good healthy diet and exercising daily.
What trends do you see emerging in cardiology practices?
The most interesting trend right now is our practice is still a private practice. Nationwide, most cardiologists work for the hospital. This past year we have started co-managing a cardiovascular service line with Wyoming Medical Center. The goal there is trying to reduce costs by giving the best health care. That is what is consuming a lot of my interest right now. I am the co-manager and medical director for the service line with the hospital. Understanding how health care is delivered and how to deliver it better and less expensively is what interests me right now.
Is this just a trend in cardiology, or is it coming in other specialties as well?
This is throughout medicine. Medicine is delivered in silos and historically there is turf to protect. Trying to make it a more collaborative effort has been a struggle. There is not one model to follow. You have to adapt to what is the best for your region.
What are the advantages for patients?
One of the advantages will be getting more standardized care and care that has been scrutinized to show it gives the best outcome. The cost of medicine is interesting because, sometimes, the cost is born by what is called a third-party payer – whether it is the government or the insurance company. There is a tremendous amount of cost right now in the United States medical care system. It puts a huge financial burden on the whole economy. This goes all the way down to our insurance premiums. I think collectively as a society that we need to reign in the inflation curve that we are on, and then continue to reduce costs.
Medicine is interesting because it is not a transparent price structure. The price providers ask for is not necessarily the price they are going to get paid. They adjust the bill based on what they get paid. Part of the problem also is that you have multiple payers. You have the government that pays at one rate, you have private insurance that pays at another rate, and then you have people who do not pay or cannot pay. You try to get everything to balance out. As a society, I think we’ve struggled with that for a long time. We sort of have socialistic medicine by default, but that is a whole different philosophical matter.
Dr. Pickrell practices at Wyoming Cardiopulmonary Services, 1230 E. First St., in Casper. He is board certified in cardiovascular disease. Wyoming Cardiopulmonary Services clinics in 10 communities including Rawlins, Lander, Thermopolis, Gillette, Buffalo and others. Call (307) 266-3174 for a referral.