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?