Thursday, May 27, 2010

Whew! Echo Abnormalties Found!

I have been reading with interest the story from a Harlem (New York) Hospital covered in the New York Times about the discovery that 4000 echocardiograms were "lost" and left unread by a physician.

The outrage! The scandal! The fraud! The malpractice! Man, for newsprint, does it get any better than this?

But if we stop and think about it, unless doctor overreads of the interpretations made by skilled echo techs actually found errors on the initial interpretations made by the echo technicians, it might call into question the need for doctors to view echos that have been pre-screened by the technicians.

Thank goodness this morning that we learned that a few mistakes were found! Thank even more goodness that a nearly-retired renowned cardiologist was more than willing to step up to the plate and reaffirm the outrage:
Having 4,000 tests done and unread is unheard of, and is “unconscionable and unacceptable and malpractice as far as I’m concerned,” Dr. Douglas Zipes, a cardiologist at Indiana University Medical Center, past president of the American College of Cardiology and editor of HeartRhythm, said on Wednesday. “I can’t use more adjectives than that.”
But before we dismiss this case nothing more than pure malpractice, we should ask ourselves if this might not be the health care model for our future.

We are very aware that nurse practitioners and nurse coordinators (whatever those are) have become the new model for health care delivery espoused by Washington to address the primary care crisis in America. After all, now that primary care has been thrown under the bus by our own physician leadership on the Hill to the point where mom-and-pop private practice offices are nearly extinct, we see the evolution to corporately-run health care. And corporately-run health care means shift work. This means working as employees. This means trying to maintain work/life balance. This means health care responsibility for patients can be offloaded on to groups of "health care providers," rather than a physician.

Why should echo technicians be any different in this new shared responsibility model of patient care?

The truth of the matter is that doctors are finding incentives to work like dogs at the expense of their personal lives are dwindling. Pay cuts are constantly threatened. Debt burdens for medical schools ridiculous. The truth of the matter is that we are about to add millions and millions of people to our health care system without increasing the doctor pool. And guess what? In inner city hospitals, the understaffed hospitals had to get resourceful and triage the work volume using technicians instead of doctors. The results were interesting:
Ana Marengo, a spokeswoman for the hospital system, the Health and Hospitals Corporation, said that despite the abnormal results, a cross-check of medical charts had not shown that anyone did not get needed treatment.
Now I know people are ready to pounce on the hospital because insurers, states, and patients PAID for a doctor overread that was never forthcoming. But this is not my point. My point is that creative solutions to an overburdened health care system will require creative non-physician-directed solutions for health care going forward.

If we're not going to insist on more doctors, we'd better study, and study carefully, the incidence of echo misreads (and their severity) in this first creative solution to our looming doctor shortage.

And guess what?

It might just save some money without affecting outcomes. That is, of course, if our liability system could make the same dramatic change.



Tom Farrell said...

"Why should echo technicians be any different in this new shared responsibility model of patient care?" Because in most of the US, echo techs need only a two-year degree to practice, and depending on the employer, they may or may not be required to be credentialed. Regardless, I would not- never, ever- have anyone but a board-certed cardiologist read my echo.

DrWes said...


And yet, our leadership at the AMA seems to feel nurse coordinators (and maybe now technicians) are just fine, thank you.

The reality is, this is what we've signed on for. We can have quality, quantity, or low cost in health care, just not all three. The current health care bill has spoken on which two of these the Aministration wants.

Jay said...


Your pacer and ICD checks may be the next to go.


The Happy Hospitalist said...

I have been told by some technologists that some doctors don't even "read" the echo. They just sign off the report the tech completes.

And then they bill insurance for reading it. It has their signature on it. Why not bill for it, right?

I'm sure it happens more than we think.

Anonymous said...

Typically what percentage of ECHO done by Techinicians are corrected? I know a cardiologist once shared with me that MOST of the echos done by his Tech get transcibed without any corrections(!)

Keith said...


I would argue that we need PHYSICIAN directed creative solutions. Much of our health care mess can be attributed to physicians giving up the management aspect of health care to paid administrators and other non physician personel.

Docs would be in the best postiion I think to cut out the waste and inefficiencies in our health care system, but our current widget model of payment makes innovative and more cost effective solutions unable to thrive. When the time comes, physicians should be taking back the wheel from career buisiness people and leading the charge.

Anonymous said...

It all boils down to how powerful ACC is. ACP is useless and did not stand up for internists, primary care when Nurse practioners and PA's were being touted as the solution. I think ACC will strongly advocate for cardiologists signature(?) so that they can bill.If 4000 echos are read by TECHNICIAN and nothing was missed, what does it tell you ?? Very INTERESTING!!