Stress Test On Asymptomatic Nursing Home Patients.

Is is possible the the doctor was wrong?  Yes, sometimes physicians just get it wrong.  A reader sent me their experience. 

What an eye opening experience. I had an old man in his 70's experience a nonspecific complaint. What was that complaint? He broke out into a sweat one day while living out his peaceful life at the nursing home. This nondescript complaint in a diabetic resulted in an outpatient arrangement for a cardiac stress test by his physician. However, these plans were aborted when several days later the patient experienced right upper quadrant belly pain that ultimately resulted in a diagnosis of gallstones causing blockage in his bile ducts. The patient was ultimately transferred to the hospital for further evaluation. It just so happens that the transfer was made on the day of the outpatient cardiac stress test. I got a call from the stress lab asking whether I wanted to do the test as an inpatient. I said I didn't know. I would get back to them. So I went to talk to the patient. I asked him if he knew why he was getting the stress test. He didn't know. I asked him if he had any discomfort in his chest. The answer was no. I asked him about jaw and arm pain, shortness of breath, nausea. All negative. I told him I couldn't think of any reason why his doc had ordered the cardiac stress test and that I was going to cancel it. He said, "Thank you. I didn't want to do it anyway."
I couldn't think of a reason either on why this nursing home gentleman without chest pain needed a cardiac stress test. So I called his physician and I asked him. He told me the patient had diaphoresis (sweating) and he was a diabetic and he wanted to evaluate the patient for ischemic heart disease. I told the  doc that I think I had a sound explanation for the sweating (a gallstone attack) and that I was comfortable cancelling the stress test as I felt that the current information explained the episode of sweating. And you know what the doc said to me?  "Make sure you explain the risks to him for not doing it and that it could still be his heart."  If this isn't defensive medicine at it's finest, I don't know what is.

Here's a patient who doesn't want the test and a doctor who is so scared of malpractice that they are willing to do unnecessary and expensive interventions on nursing home patients when alternative explanations clearly explain the science of the situation. With this irrational thought process, one could argue that the patient also needs adrenal vein sampling to rule out a pheochromocytoma. Or perhaps a bone marrow biopsy to exclude leukemia. Why not? If you're going to do unreasonable testing in the setting of rational science based medical decisions, why stop at just the stress test.

Sometimes physicians just get it wrong. Really wrong. At some point physicians will have to take ownership of their medical decisions and make sound evidence based decisions on sound medical principles. If we test every nursing home patient with an episode of sweating with a $2000 cardiac stress test, then we physicians have just established irrational medicine as the standard of care.

We as physicians set the standards. And we have often set the standards which are not based on sound scientific principles. The question is, how do we as a profession change the standards so we practice based on science, not fear?

I for one believe in practicing science based medicine. If I'm going to get sued, I have to believe that science will prevail. A science, I have to believe, most juries would respect. If I practice with sound principles, regardless of irrational standards, I can go to sleep at night knowing I did the right thing, irrespective of nature's plans for the patient.