Why Did You Order That Echocardiogram?


  • Peter R. Kowey MD

    Corresponding author
    1. Lankenau Institute for Medical Research, Main Line Health Heart Center, Wynnewood, Pennsylvania; Jefferson Medical College, Philadelphia, Pennsylvania
    • LIMR/MLH Heart Center Lankenau Medical Office Building East 100 Lancaster Avenue, Suite 558 Wynnewood, PA 19096
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The author has no funding, financial relationships, or conflicts of interest to disclose.

When I see patients in my office, a cardiology fellow or internal medicine resident accompanies me. It is a model I copied from my mentor, Dr. Bernard Lown. What better way for a young doctor to learn how to care for patients with complex diseases than by directly observing someone with years of experience?

But when one of our brightest trainees recently asked me the question that forms the title of this editorial, I was struck dumb. I had no intelligible answer. We were evaluating a frightened 19-year-old woman who had blacked out at her sister's wedding a few days before. It was a warm day, she had neglected to have breakfast or lunch, she felt nauseous and sweaty, and while standing at the altar, she collapsed. Bystanders, including an eager medical-student cousin, later described her as “white as a sheet” and “seizing.” They laid her down and put her legs up, managed to find a cold compress, and she came to almost immediately. After a few minutes, she recovered enough for the wedding to conclude. The next day she saw her primary-care doctor.

She had had a few similar episodes in the past, but nothing as severe. Her examination, electrocardiogram, and lab tests from her primary-care doctor were all normal. She was referred to me because of the severity of the event and a family history of heart disease. The latter turned out to be coronary artery disease in a few paternal relatives, although there were 2 sudden deaths that had not been completely sorted out.

The fellow's history, examination, and summation were impeccable. I saw the patient and agreed with the diagnosis of neurocardiogenic syncope, reviewed the situation with the patient and her parents, and advised them how to avoid and treat the problem. The last thing I did was order an echocardiogram—then came the fellow's question.

The answer was simple but painful: I was practicing defensive medicine. “If she has a familial hypertrophic cardiomyopathy or arrhythmogenic right ventricular dysplasia and I don't diagnose it, what do you think would happen to me?” I was embarrassed to admit it, but I had fallen prey to the most miserable excuse for test-ordering. The fellow was kind (or smart) enough not to point out there was nothing to suggest either diagnosis, the pretest probability was abysmally low, and the test would cost the healthcare system at least $500.

And so it is in the United States. Every day, millions of dollars are spent on tests that are either completely or nearly worthless because of the fear of malpractice litigation.1 It is a dirty little secret that has been going on for years, and it is not changing. The amazing part is how authorities and agencies that have been charged with finding ways to cut the cost of healthcare have so atrociously underestimated the frequency of defensive test-ordering.2 The vast majority of doctors in surveys (80% to 90%) say they do it, but few will admit how often, because it runs so counter to the way we would like to practice.3

So why does it happen? Because being named in a malpractice suit is about the worst thing that can happen in a doctor's life.4 It has a devastating psychological impact that only a physician can appreciate. The object of the malpractice game is not to establish that there was an error in medical care, but to prove that the doctor was “negligent.” The complaint is worded to put the doctor in the worst possible light. Phrases such as “willful disregard” and “careless indifference” are used specifically to meet the established legal standard.

The physician-defendant must dedicate time to organizing a defense, taking time away from practice to wrangle over legal details. It takes years for the case to come to trial, while plaintiffs' experts (who frequently are anything but) offer opinions about the doctor's incompetence and utter stupidity. All of this leads up to the dreaded weeks sitting in a courtroom while the complexities of a medical case are explained to a lay judge and jury who, in most cases, have no chance of comprehending the medical nuances.

If it happens to you, you vow it will not happen again; thus the endless rear-end covering, the test-ordering that is rarely appropriate. But that is not all. Doctors who have been traumatized in a malpractice suit treat their patients differently, not only ordering more tests, but also erring on the side of more interventions. Surely, putting in that implantable cardioverter defibrillator or drug-eluting stent in a borderline case is preferable to letting the patient go without.

It would appear obvious that the system is broken, but there is little enthusiasm for fixing it. Caps on pain-and-suffering awards clearly work, but they have been implemented only in a few states, and have even been repealed in some. The federal government refused to make tort reform a part of the new healthcare legislation, except for a few quick fixes.5 Our professional organizations have not fought for us, instead opining that there are bigger fish to fry in healthcare reform. They have chosen to ignore the fact that billions of dollars are spent on needless screenings, diagnostic tests, devices, and procedures that are ordered for the wrong reasons. Relief is not in sight. In fact, a few out-of-touch politicians have declared that the malpractice crisis is over!

It is with all of these thoughts in mind that I wrote a novel called Lethal Rhythm.6 Why a novel? I reasoned that the whining of another physician angry about malpractice would fall on deaf ears. So I chose to tell the story of a good cardiologist who gets caught in a malpractice mess and loses everything. The story seeks to educate the public about the devastating consequences of wrongful malpractice litigation. There is much more to the story in my attempt to capture the public's attention. I also wanted the book to provide a catharsis for doctors who have been through the meat grinder—a vindication, if you will.

By putting this problem into the public domain, I hope that my novel helps to get us back on the path to a solution. We have to convince our legislators and all of the smart people who work in the personal-injury world that the medical malpractice system is broken. That is not to say patients do not deserve to be helped when medical mistakes occur; we just have to stop torturing doctors, the vast majority of whom are good practitioners who really do not want to order more tests or procedures, and who yearn to see their patients get well and stay healthy.

It is time for our profession to rise up and demand meaningful malpractice reform. We owe it to ourselves—and, more important, we owe it to our patients.