October 28th, 2010

Drs. Clueless and Apathetic: The State of Imaging Referrals

Editors’ Note: This text has been modified from its original form. Key elements of the case represent a composite of people and events.

On a bright Saturday morning, I was the fellow on duty in the chest pain center. That meant I was responsible for evaluating and stress-testing patients who had been admitted from the ER with an intermediate probability of coronary artery disease. My first patient that morning was Jack — a burly man with course facial hair and a barrel chest.

As I approached Jack’s bedside armed with his chart and personal information, his sleepy eyes opened and he was startled to see me. After he settled, I began my usual routine. I asked him what had brought him to the ER. He said he was a forklift operator and that he’d had an accident. His chest had apparently rammed into the vehicle’s steering wheel. For a week his chest had been causing him pain, which he now wanted to have evaluated. It took but one gentle push on his chest to reveal that this was a case of muscular injury, not cardiac pain. I asked Jack to excuse me while I consulted the referring ER doctor.

I went to the adjoining room and found a doctor swinging from one emergency room bay to the next. With me nearby, she paused to hear about Jack. I gave her his chart, told her that an exercise test was not appropriate, and advised that the patient be discharged. Glancing quickly through the pages, she said, “Well, first of all, this patient was admitted by the previous ER doc and I am not getting involved. Even so, he is 55 and male, and you can’t prove this isn’t CAD. I want a stress test!”

Stunned by the response from this Dr. Clueless, I left to gain higher ground by turning to my attending physician. Initially he seemed annoyed that I had interrupted him, but I relayed the patient’s clinical history anyway. This Dr. Apathetic just shrugged his shoulders and said, “Well, it doesn’t matter. Just do it.”

Out of options, I returned to the patient and began the stress test. Just before Jack got on the treadmill, he asked me whether I thought the test was necessary. I would have liked to respond with an emphatic “No,” but instead I simply relayed the wishes of the emergency room doctor. While watching the wheels on the treadmill and the nuclear imaging camera spin monotonously, I began to think about the process of patient referrals.

I ask you: How often have you taken an inappropriate referral for an echocardiogram, stress test, or invasive imaging and simply completed the test? Have you ever considered these referrals an educational opportunity to discuss issues at hand with referring doctors — clueless, apathetic, or otherwise? When assessing the quality of imaging services, shouldn’t we go beyond images and consider patients like Jack before we place them on the hamster wheel of cardiology?

12 Responses to “Drs. Clueless and Apathetic: The State of Imaging Referrals”

  1. Robin Motz, M.D., Ph.D. says:

    The problem now is that no doctor ever got sued for doing a test, but only for not doing one, and many doctors choose to save time by agreeing to a test the patient requests rather than spending at least 10 minutes explaining to the patient (and possibly another 10 over the telephone to the patient’s spouse) why the test is not indicated.

  2. Danny Talwar, MD says:

    Medico-legal that’s the problem, we need tort reform.

  3. Venkatesan Sangareddi, MD.DM says:


    Kudos to Shanti Bansal for bringing out a live wire issue in cardiology for that matter , in the entire medical field ! Who is to be blamed ?
    The art of medical investigations came into vogue to help the physician at times of difficulty to arrive at a diagnosis . Now modern day investigations has hijacked not only the doctors but also their patients.Why a test is prescribed , what is going to be the impact on the further course of management are rarely addressed( or rather understood )

    Two non academic factors play the game of hell on our patients health.
    1.Perceived fear of litigation and 2.The conflicts of medical commerce.
    Today our young cardiologists are tuned to diagnose a full blown cardiac failure by doing a bedside BNP rather than looking at the necks and legs .We ask our patient with blunt injury chest for a nuclear scan of heart
    How can medical science grow in such a environment for the welfare of mankind . Even , GOD is going to have a tough time to save the medical profession from the current state .

    The important irony is , many developing countries which are so far protected from all these fancy concepts in medicine (Due to lack of affluence ) is just aiming to bring the same to their countries.

    Please allow me to link a realted article form my blog.


  4. Marina Ritsou, Cardiologist says:

    I totally agree with Dr.S.Venkatesan . In my everyday practice in Greece I meet more and more people having done the CT coronary angeiography with absolutely no reason , just “to know ” and some of them have had PTCA after that with no symptoms at all.And above all , they think that this procedure “saved ” them and they recomend it to friends and neiboughrs. And this is happening in a country with so many financial problems .
    Of course, the same happens with stress tests and ultrasound scans and with the classic aggeiography .I have seen a report of a electrophysiology test recomending a 24 hour Holter monitoring.
    I have met a patiend in a very known Cardiology Hospital in Greece , that was going to have an anggeiorgaphy because the last few days, during cough he experienced a pain in the chest.
    Thank you for letting me share my oppinion.
    With best regards.
    Dr. Marina Ritsou
    Athens , Greece

    Competing interests pertaining specifically to this post, comment, or both:
    there are no conflicts of inerest

  5. Charles Roeth, MD says:

    Today’s duality of medicine_ making a living or doing the right thing.

  6. james mcdermott, Electrical Engineering says:

    Competing pressures tempt every scientist to grab the ” steering wheel ” of the Titanic . Until we have more Dr Bansals and Less Dr Clueless and Apathetics , the boat will stay on its slow and disastrous course .
    As my mother , in her infinite jewish wisdom would say , ” how many tests do you need to take before you know you’re doing something wrong ?”
    Dr Motz summed it up appropriately .

    Competing interests pertaining specifically to this post, comment, or both:

  7. Robert Nevin, MD says:

    The Health Council of Canada, Canada’s healthcare watch dog, has published a report entitled: Decisions, Decisions: Family Doctors as Gatekeepers to Prescription Drugs and Diagnostic Imaging in Canada. http://healthcouncilcanada.ca/docs/rpts/2010/HSU/DecisionsHSU_Sept2010.pdf They examine the ordering behavior of family doctors and remark that the reasons for decisions are complex and poorly understood.
    Some of their findings:
    “According to the Canadian association of radiologists, as many as 30% of CT scans and other imaging procedures are inappropriate or contribute no useful information.”
    “A government commissioned literature review in Saskatchewan found that about 30%, and as much as 50%, of imaging exams were not based on sound evidence and were unlikely to contribute diagnostic information proportional to their cost and the radiation exposure for patients.”
    “An Ontario study examined CT and MRI scans done on an outpatient basis and found as much as a 70- fold difference between hospitals in the number of scans ordered for specific problems. Many of the diagnostic scans did not produce clinically useful information. Less than 2% of CTs for headaches found abnormalities to explain the problem and, although 90% of MRIs for back pain found abnormalities, this information was not useful in planning treatments.”
    “In 2006, Dr. Robert Miller, then-president of CAR, noted the following “wasteful use of medical imaging”:
    “Inappropriate ordering is a consequence of pressures put on referring physicians by patients and by an ever increasing workload. Liability and malpractice concerns may drive physicians to order more tests than are needed.””
    Being 60 years old, I have been able to observe that over the past 3 1/2 decades more and more tests are being ordered for more and more trivial reasons. More and more then becomes the new standard of care constituting an inappropriate standard of care creep. This is compounded by the greater number and greater expense of tests now available. The public is aware of the plethora of tests. People talk with their friends who have had various tests and have become less easily convinced of the benignity of their symptoms. They increasingly expect more testing no matter how minor the problem. Extensive high tech equipment, which is the salvation of many, unfortunately also has become a nail in the coffin of our healthcare systems.
    Dr. Danielle Martin, chair of Canadian Doctors for Medicare has said that the next challenge after saving Medicare is to get doctors to stop ordering so many expensive tests and prescribing so many drugs. http://www.thestar.com/opinion/editorialopinion/article/844530–cma-s-welcome-if-belated-change-of-heart-on-medicare
    Another player has entered the fray, rateMDs.com. At least 2 of the 3 negative comments about me are about not ordering enough tests when I have tried to follow Clinical Practice Guidelines. I have found my behavior shifting in the wrong direction because of this.
    Does anyone have any ideas for health policy initiatives to induce more responsible behavior on the part of both patients and physicians?

    Competing interests pertaining specifically to this post, comment, or both:

  8. Micah Eimer, MD says:

    I hate to bring this gripe session to a screeching halt but……

    The only thing we know about the patient is that he is 55 and male. Does he have a history of CAD? Is he a diabetic? Dyslipidemic? Smoker? Family history?

    Obviously the pain he is having is not angina (but I do recall a paper showing that 6% of patients presenting with angina had some sort of reproduceable chest tenderness). But this misses the point.

    It is not uncommon to see a 55 year old man with a family history of CAD and another risk factor or two in the office wanting to know if he is at risk for an event. Would you give him a “screening” stress test? Yes.

    Therefore, before jumping to a dangerous conclusion about the appropriateness of a test you should get the WHOLE story and consider that you may still be doing the right thing for the patient (maybe not in the right setting). Further, if he does have an MI the next day you will never be able to prove that it was “true-true and unrelated” to the admission.

  9. Robert Nevin, MD says:

    Both the US Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf/uspsacad.htm and the American Heart Association http://www.guideline.gov/content.aspx?id=8184 state that there is insufficient evidence to recommend screening for coronary heart disease in asymptomatic adults at intermediate or high risk by stress testing. Some are recommending that this be done for diabetics but there is level 1 evidence http://general-medicine.jwatch.org/cgi/content/full/2009/421/1 that this is not helpful either. Therefore the answer to the question posed above about screening the 55 year old asymptomatic male with family history of CAD and 1 or 2 other risk factors can be No.

  10. This post was written to highlight the growing issue we face as cardiologist – how to deliver quality imaging services. Offering quality means more than imaging it also refers to answering meaningful questions and offering services that will dictate patient care management. We have stepped away from this for several reasons one is financial motivations and second is difficulty in discussing these issues with our referring physicians. If we are to improve quality of imaging services and thereby improve patient care we must evaluate unnecessary testing. Unnecessary testing such as this uses precious health care dollars and puts patients at unnecessary risks. If we are to ask society as a whole to invest in patient care, let us not misplace the that great trust that has been placed upon cardiologist.

  11. Joseph Soler, MD says:

    Inconsistent Histories: A Patient or Physician Problem?

    RM McNamara et al, Medical College of Pennsylvania, Philadelphia asked the same question – University Association for Emergency Medicine, 1988.

    Obtaining an accurate history is critical to the proper care of patients. It was observed that the history elicited from a patient often varied from one physician to the next. Conflicting historical information recorded in patient charts has been cited as a problem in malpractice defense.

    To examine whether this was a real phenomenon, a standardized questionnaire was constructed with a series of questions pertinent to the diagnosis of acute chest pain. Subjects entered had to be alert, fully communicative and clinically stable emergency department patients. Two separate interviewers questioned the patient at least 10 minutes apart. The 13 questions were simple and direct with nine requiring a yes/no answer. 52 patients.

    The overall impression of the probability of cardiac disease was the same between interviews in 28 (54%), paired as no probability/low probability in 5 (10%), low/moderate probability in 15 (29%), and moderate/high probability in 3 (6%). One patient had the separate interviews ranked as low and high probability. In those with proven cardiac disease, 4 of 7 (57%) had a different overall impression.

    Despite the use of a standardized questionnaire, this group of patients often gave conflicting and confusing answers to separate interviewers.

    Our patients learn from the different interviewers what is important, and many times accommodate their answers to different interviewers. In the ER there are many “interviewers” from the EMS personnel, to Triage Nurse, ER Nurse, and multiple physicians. It is very common for patients to alter the history every 10 minutes. This causes much consternation for the poor First Year Resident when the patient changes his history on later questioning by the Attending Physician.

    All of us have seen cases that we could have sworn were nothing, only to discover its severity later on. (a 32 y.o very physically fit policeman sent home by Cardiology without testing “Chest Wall Strain”, and sustained a life-changing MI very shortly thereafter). It is well recognized that 3-5% of acute MIs are sent home from the ER, and 5% of MI patients describe their pain as pleuritic, The bottom line is that the public’s expectation is for “Zero” error for chest pain that could be a “heart attack.”

    Do not suspend clinical judgment. Just be aware that we do not have at this time perfect clinical tools. As a patient told me: “Doc, I know you are right, but a pilot would not be allowed to crash a 747 three percent of the time.” Remember the old Irish proverb: “God grant me the serenity to to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.:

    Competing interests pertaining specifically to this post, comment, or both:

  12. Mark Berry, D.O., M.S. says:

    The problem as I see it, is the inability as physicians to put their “neck out”. This case should not have been referred for a stress test. The ER physician should have been able to realize this concept. How can you defend doing a stress test on someone with blunt chest trama who did not have chest pain prior to the trama. I am sure that it is possible that the patient could have underlying disease but given this clinical senario there is no indication for stress testing. All of the statistics in the world can be quoted as in the post above. Personally, I have never seen a study that correlated the risk of CAD with blunt chest trama. The real problem in this case is that the patient was exposed to unneccessay radiation.

    Competing interests pertaining specifically to this post, comment, or both: