Subscribe to our blog
Choosing Wisely: One in a Million
The wastefulness of unnecessary EKGs is a subject that has been featured on this blog many times before, both by me and Dr. Stephen Smith, and a topic that has recently been highlighted in multiple Choosing Wisely ® lists.
When I was recently told I needed surgery for cataracts, I was sure I wouldn’t need a third preoperative EKG. The two I had previously were performed prior to the American Academy of Ophthalmology (AAO) and the American Society of Anesthesiologists (ASA) lists of recommendations, which state:
- “Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.” – ASA
- “Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.” – AAO
So when I was forced to get another EKG or abandon the surgery, I wasn’t going to let it lie. I felt empowered and well-informed by the backing of these two world-renowned specialty societies. Before the surgery, the anesthesiologist, Dr. B. (who turned out to be the Director of Anesthesiology) and I had a little chat:
Me: Doctor, why did I need to get an EKG again? I am physically fit, run four days a week and have no heart condition. Surely I can endure the 15 minutes of sedation.
Dr. B: I don’t deal in ‘maybes’. I am here for you and besides, you are considered at risk by being over 60.
Me: But the AAO and ASA both came out with recommendations against preoperative testing including EKGs for procedures like cataract surgery. And JAMA-Internal Medicine recently published a commentary by Lee Fleisher, MD entitled “Preoperative Consultation Before Cataract Surgery: Are We Choosing Wisely or Is This Simply Low-Value Care?”
Dr. B: I do what I feel is best for you and I don’t want this to be the one case goes awry. I don’t let specialty societies dictate what I do in practice.
Me: What if you did a million EKGs on asymptomatic patients who each received a history and physical where primary care physicians listen to all million patients’ hearts and found only one abnormal case? Would you say it was still worth doing?
Dr. B: Absolutely. I don’t like my patients having to risk any odds.
Me: What if we put all that money saved by not doing the tests into something of higher value for patients, would that convince you?
Dr. B: You are the only person I am interested today in serving.
Me: So medicine is about an N of one.
Dr. B: Yes.
I found this to be a sad commentary on the decision-making process of physicians. What can be done to remedy this?
- The physician might benefit from some re-education in Bayesian probabilistic theory and the yields from screening tests and preoperative testing. Maintenance of Certification might be a good pathway. Also, increased awareness of what unnecessary care is doing to the health care system’s overall economic sustainability might help.
- He might enhance his understanding of what goes into evidence-based medicine and what processes were used to develop the Choosing Wisely recommendations. Maybe a conversation with a physician he highly respects might be persuasive.
- Perhaps the hospital should address the individual’s inability to deal with uncertainty in treatment protocols and explore the possibility of a particular event that occurred and thus clouded his decision-making process.
- A different payment system must be instituted so physicians and health systems/hospitals are accountable in determining what is necessary and what is wasteful.
- Better protocols could be developed by physician leadership, a mix of anesthesiologists, ophthalmologists and internists. Once protocols are established, they can be reinforced by clinical decision supports in EMRs.
Unfortunately, Dr. B is not alone in his attitudes and practices. The balance between what is good for the patient and wise resource management has to be an essential competency of the 21st century physician beginning in training and continuing throughout the physician’s career. It must be part of the decision process. Or, we’ll be paying for that “one-in-a-million” case for years to come.
Leave a Reply
Required fields are BOLD