Stephan Moll, MD writes… Not everybody with DVT or PE needs the same type of doctor. The best combination is probably to have (a) a health care professional in a formal Warfarin Clinic (Coumadin Clinic) and (b) a physician with special expertise in blood clots (thrombosis). Patients who have been diagnosed and are being followed by a primary care provider or non-thrombosis specialist may ask: “Should I be seeing a specialist?” And if the answer is “yes”, then: “What kind?” These questions are difficult to answer, as the answer depends on the level of comfort and expertise of the primary care provider to manage the various aspects of DVT and PE. The patient and his/her primary care physician should decide together what specialty care is needed. The decision has to take into consideration whether a physician, clinic, or center with special expertise in thrombosis is geographically available. Thrombosis Clinics may also go by the name of “Heart and Vascular Clinic” or something similar. A general concept as to which patients to consider for a referral to a specialized Thrombosis Clinic is here. Additional aspects are discussed below.
A. For Warfarin (Coumadin) Management
- Coumadin Clinic: The patient on warfarin will need a health care professional who will (a) monitor and adjust the warfarin, and (b) make plans how to best interrupt warfarin therapy for dental work and surgeries. This day-to-day warfarin management is often best done through a specialized Coumadin Clinic. Such clinics are frequently run by pharmacists or nurses specialized in and dedicated to warfarin management. A list of clinics in the U.S. can be found here. A physician is typically in charge of the overall Coumadin Clinic operation. This is most often a general internist, family medicine physician, cardiologist, or hematologist. Patients do not necessarily need to see that physician, as long as they are well taken care of by the non-physician Coumadin Clinic provider.
- Non-Coumadin Clinic: Primary care providers or various specialists may also provide warfarin monitoring in their office, without being a dedicated and large-volume specialized warfarin clinic. The more patients on warfarin a clinic follows, the more experienced the staff likely is.
B. For DVT or PE Management
- Thrombosis Clinic: The most comprehensive and most up-to-date care may be provided through a dedicated “Thrombosis Clinic” or Thrombosis Center. Such a clinic may be part of a Thrombosis and Hemostasis Center, i.e. a “Center for Bleeding and Clotting Disorders”. A partial list of such centers in the U.S. can be found here. Thrombosis Clinics are often staffed by hematologists, but may also be run by general internists, vascular medicine specialists, cardiologists or other physicians who have an interest and expertise in blood clots (thrombosis). The role of the specialist in the Thrombosis Clinic is to discuss and help with decisions on:
(a) Diagnosis of DVT and PE
(b) length of therapy with blood thinners
(c) the work-up of the cause of the clot, such as initiation and interpretation of laboratory thrombophilia work-up
(d) enrollment into clinical trials
(e) comprehensive education about clots
(f) switch from warfarin to one of the new blood thinners
(g) choice of safe contraceptive methods and management of possible future pregnancy
(g) appropriate referrals, such as referral to a vascular surgeon, if varicose vein surgery is needed; to vascular interventional radiology, if placement or removal of an IVC filter, or stenting of anatomic abnormalities of the veins, such as May-Thurner syndrome, is needed; to a lung doctor (pulmonologist), if the patient has chronic lung damage from PE, called pulmonary hypertension.
(h) The Thrombosis Clinic can also inform the patient on newly published data that may have an impact on the management of the patient.
Visits in the Thrombosis Clinic may only be a one-time event with subsequent management through the primary care physician, or may lead to every 6-12 months follow-up.
- Primary Care Physician or other: Many primary care physicians also follow patients with DVT or PE. It is difficult to say which patients need to be referred to a specialized Thrombosis Clinic – clearly the complicated or young patient should, but may be any patient with a DVT or PE.
- Hematologist-Oncologist: Even though hematologists (= blood doctors) are often specifically trained in blood clots and clotting disorders, the hematologists-oncologists in private practice are often more oncologists than hematologist, dealing more with cancer than with blood clots. They may be good resources, but are not necessarily so.
- Hematologists, Cardiologists, Vascular Surgeons, Vascular Medicine specialists, General Internists: Any one of these type of physicians may have a special expertise and interest in DVT, PE, anticoagulation, and clotting disorders.
- Finding a local physician specialized in thrombosis and thrombophilia care: The American Society of Hematology offers an index of physicians who have a clinical interest in treating patients with blood clots and clotting disorders. The index can be found here. To use this index, select your location and under the drop-down box for ‘Clinical Interests’, select “Thrombosis and Hemostasis/Blood Clotting”.
C. For Management of Chronic Complications of DVT and PE
- Postthrombotic syndrome (PTS): This term describes the problems that some patients develop after a DVT: chronic leg swelling and pain (more details can be found here and here). Compression stockings are the typical treatment. These can be prescribed by any physician. Occasionally home compression lymphedema pumps are appropriate treatment for PTS, or a procedure through Vascular Surgery or Vascular Radiology to balloon open and possibly stent veins narrowed by clot scar tissue. The referral to these clinics can be made by the primary care provider.
- Wound Clinic: Damage of the leg from a DVT may lead to chronic swelling and pain and, in a few patients, to skin breakdown and open sores (skin ulcers). If skin ulcers develop, the patients should be referred to a specialized Wound Clinic, which is often run by vascular surgeons, sometimes general internists or vascular medicine specialists.
- Pulmonary Clinic: Damage of the lung may result in chronic shortness of breath, referred to as pulmonary hypertension. Such patients should be referred to a pulmonologist, preferably one who runs a Pulmonary Hypertension Clinic.
D. For Testing for and Management of Clotting Disorders (Thrombophilias)
- Thrombosis Clinic: The Thrombosis Clinic physician or hematologist may be the best source of information on testing for thrombophilias. Again, the hematologists-oncologists in private practice may be good resources, but are not necessarily, as they are often more oncologists than hematologists and deal more with cancer than with blood clots and clotting disorders.
Disclosures: I have no financial conflict of interest. I am a hematologist and work in a formal Thrombosis Clinic.
Last updated: May 9th, 2012