Friday, November 14, 2008

Who Knew? History's Important

I am shocked, SHOCKED I tell you, to find that taking a history from a patient is important:
However, almost half of all coronary "events", such as heart attacks, that happened during this period, happened in patients whose ECG results had not shown any sign of problems.

A routine clinical assessment, which involved taking a detailed "history" from the patient, and examining them thoroughly, was almost as good in predicting future heart disease as the exercise ECG.

The researchers concluded that the tests were "of limited value" to doctors faced by patients with no prior heart disease.

Dr Mike Knapton, from the British Heart Foundation said that while early diagnosis of angina was important, the study showed that the best way to achieve that was to talk to the patient.
Who knew?



Anonymous said...

Hi Wes,

Sorry t keep pertering you, but this is one that I think highlights the troubles with medical cost containment.

I am constantly baffled by some of your colleugues who love to do an echocardiogram and stress test (preferably a nuclear stress test where the profit margin is greater) despite no clear evidence that this is of any benefit. I find myself frequently in converstions with patients who are usually men in there 40s or 50s asking if they should have a stress test despite no symptoms and limited if any risk factors. To say you would not reccomend such a test always risks nthe back of your mind the embarassamentof having the patient have an event and then looking very stupid, even though the stress test may not have shown anything.

This hghlights the rediculous nature of our helath care system where I spend my tme explaining to patients why they should not have a stress test to save an insurance company money (by the way, I belong to group of internists who have a diagnostic facility doing MRI, ct, and stress tests, so I am positively incented to say yes when they ask for one) who works very hard to cut my compensation! But doing the right thing for the patient should be the imperative we should abide by, not protecting our asses from malpractice or taking the easier path of saying yes.

So am I wrong when I see cardiologists ordering these tests on every patient who walks through the door like it was part of the initial package of tests every patient gets (much like the lab and EKG we do as internists on all our routine physicals)?

DrWes said...


Like it or not, we all have to practice defensive medicine these days. That being said, the indications for performing an echocardiogram or thallium stress test are varied. Realize that cardiologists are usually sent patients to answer a specific cardiovascular question. Many times, the anaysis and recommendations made are heavily guided by an individual's overall left ventricular function (or ejection fraction). Hence, an echo might be the cheapest way to assess that. New patients in particular are prone to LV wall moton evaluation to assess for coronary disease or reduced left ventricular function.

In the case of the walking well (the asx patient with normal EKG, no to low risk, and no symptoms), I agree with you that there is no reason for a "screening" echocardiogram nor stress test - yet the expectations of individuals, thanks in part to the media and advertisements from hospitals and "screening" facilities adds to the waste seen in health care. Executive physicals are notorious for being fat on procedures and lean on predictive or therapeutic benefit, but every swank hospital seems to have a "concierge" track for these individuals. But hey, it makes them feel good and someone else is paying for it, right?