In the United States, a quarter of our medical malpractice payments result from missed myocardial infarctions. Therefore, in states with sub-optimal liability environments, emergency physicians are stuck in a quagmire of conflicted interests and fear of litigation if a discharged patient has an MI.
Therefore, a common strategy is to make low-risk chest pain Someone Else’s Problem. And, this article from Archives of Internal Medicine shows the internist evaluating the patient simply makes the same surrender to defensive medicine. In this retrospective cohort, 2,107 admitted patients underwent 1,474 stress tests during their two-year study period. Of those 1,474, 12.5% were abnormal. Of those 184 patients, only 11.6% underwent cardiac catheterization, and a grand total of 9 patients received a revascularization.
So, the authors suggest two salient points:
– 2,107 admissions to yield 9 (supposedly) beneficial interventions – how crazy is that?
– What about the 88.4% of patients with abnormal stress tests that didn’t undergo an invasive test within 30 days – why are we using an evaluation strategy we don’t act on?
The authors think we might be able improve upon this practice pattern.
“Outcomes of Patients Admitted for Observation of Chest Pain”
www.ncbi.nlm.nih.gov/pubmed/22566486