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The Medical Professionalism 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:

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?

  1. 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.
  2. 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.
  3. 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.
  4. A different payment system must be instituted so physicians and health systems/hospitals are accountable in determining what is necessary and what is wasteful.
  5. 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.

5 Comments to Choosing Wisely: One in a Million

  • January 17, 2014 at 10:57 am | Permalink

    What is the marginal cost of your ekg?To you, to the physician,to the insurer, to “society”exactly how will “we” be paying for it for years to come?

  • Elizabeth's Gravatar Elizabeth
    January 16, 2014 at 1:57 pm | Permalink

    I’m all for reducing preoperative testing as appropriate. Understand, however, that your interaction with that anesthesiologist had nothing to do with his concern for your safety and everything to do with his concern for his malpractice insurance premium. That’s just a fact of life. It’s not a matter of “an ecg [sic] will not prevent an MI;” it’s a matter of being able to demonstrate you (i.e.: the anesthesiologist) did everything a “prudent doctor” would do to make sure the patient wouldn’t suffer any adverse events during surgery. End of story.

    Is it stupid? Yes. What’s the answer? I don’t know.

  • Eric Waffner's Gravatar Eric Waffner
    January 16, 2014 at 11:51 am | Permalink

    I will do you one better. as a practicing Internist I feel medical clearance for cataract surgery is wholly unnecessary unless there is a specific issue that needs to be addressed.
    I have never been asked by a gastroenterologist or colorectal surgeon to clear a patient for a routine colonoscopy and this is probably more cardiovascularly taxing than a cataract surgery.

    a solution would be to bundle the cost of the clearance with the surgery. if the clearance is necessary then the surgeon would request it and it would be deducted from the cost of the proceedure. If it is not necessary then the surgeon would reep the benefit of their efficient care and clear the patient themselves.

  • lee tocchi's Gravatar lee tocchi
    January 15, 2014 at 8:21 pm | Permalink

    If you sign an agreement to sue Choosing wisely if you were to have a cardiac event insead of the anesthesiologist then ok. Just remember there is always a trial attorney in the room with the doctor and patient.
    Your solution #1 has the same flawed logic as Dr. B’s response to your one in a million question. Don’t waste my valuable MOC time with Bayesian theory to battle the one nut insisting on no EKG but use that time to add training to do ACLS when the unavoidable eventual MI does occur with a light general anestheia.

    • Eric Waffner's Gravatar Eric Waffner
      January 16, 2014 at 11:56 am | Permalink

      an ecg will not prevent an MI, nor will a stress test as MIs often occur in small lesions that will not be detected by stress or ecg.
      it is far more likely that a false positive will lead to invasive testing.
      your history is a far greater assessment of cardiovascular risk and I will tell an attorney this any day.

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