To test or not test, that is the TRUE question. Case in point. A 37 year old woman goes the ER, complaining of uncomfortable pressure and some pain in her chest. She has no history of heart disease, high blood pressure, and has a regular menstrual cycle. She describes the pain as sharp, comes and goes, and changes in severity when she changes position. Using today’s diagnostic assessments, with all the medical evidence backing him/her up, the ER doctor most likely will not, and most likely should not send her for more testing (beyond a simple blood test).
Why? Because statistically, this woman has an extremely low chance that she is actually having a heart attack. Further testing exposes her to more radiation, discomfort, stress, and possible medical anxiety.
But, in another case… The other day I had a call from a woman who, in discussing her medical problem about another issue entirely, shared with me that she is 46. Two months ago, she had severe pain in her chest, and went to the ER. Now, I don’t know how she described her pain to the doctor, but a 46 year old woman with no familial or personal history of heart disease, normal blood pressure, is extremely low risk for any heart incident and it would have been reasonable for her to be sent home and perhaps conduct further testing in the community. Yet, for no known reason, the doctor decided to conduct imaging that day, found two blocked arteries, and the woman had two stents inserted the next day, most likely saving her life.
Now what do we do with these two scenarios?
These are the conversations I have with my clients, and potential clients, all the time. Health care systems are run on statistics and are evidence based (we hope). Because that insures that we not be subjected to unnecessary tests, procedures, and interventions, solely due to the provider’s past experiences or personal traumas.
FOR EXAMPLE: years ago, when I was new to this country, I became greatly involved in the then-newish movement to create freestanding birth centers in Israel. Long story, and not our topic, but I sat in a meeting with the then Head of the Ministry of Health and his chief medical officer, a doctor. Who plainly explained to us that home births were dangerous. Why? Because 25 years prior, his wife had a complication during birth, and if she hadn’t been in the hospital, maybe she and the baby could have died.
He was making policy based on a sample size of 1! Based on his gut reaction to a personal situation, and applying it to the now. Which is exactly what we don’t want in a healthcare system.
So, we create diagnostic guidelines, based on large groups of people, being examined over long periods of time, applying statistical analyses and likelihoods. Because that is how effective systems work, to protect the overall population’s health and keep costs down.
So, what do we do about our paradox of the 46-year-old woman, who actually was having a cardiac event, but, based on the guidelines, shouldn’t really have been tested.
Here is where the patient (and family) come in. I found this most recent summary of the diagnostic guidelines for heart events in low-risk groups to be really impressive, and evidence-based.
One article brought in a helpful mnemonic, that although written for doctors, I think should be applied by patients (and their advocates) as well.
C: Chest: Have the patient describe the pain/sensations/discomfort in detail.
H: High Sensitivity: test for troponins in the blood to rule out a cardiac event.
E: Early care: seek out care (going to the ER) early, just in case
S: Shared decision making – meaning TALK to the patient, review the pros and cons of testing, but also take the time to know your patient.
T: Testing – It’s not recommended for low risk patients, and it’s not medically negligent to ‘not test’, despite what many patients think.
Obviously, ER doctors need to be aware of these guidelines, but so do we, as patients and patient supporters. Sometimes there needs to be facilitated conversation between the doctor and patient; it could be because of a language or cultural barrier. Or it could be because of an overcrowded ER, or an overly stoic patient. Despite what many people would have you believe, diagnoses do not happen in a vacuum and often, additional information and observations can be very helpful to decide on next steps.
So what is my take home here?
1) Guidelines are there for a purpose and when used correctly, save many from additional pain, anxiety, and exposure to dangerous chemicals.
2) That being said, nothing replaces patient/doctor or doctor/supporter discussion, and that must be included in the intake process.
3) Not Testing, if the person is categorized as low risk, is not a poor medical judgment, and should always be considered.
4) If you do not feel that the doctor is following the CHEST guidelines, or you feel that the interpretation of the events is wrong, SPEAK UP.
No system is perfect, and no human is perfect, but the combination is what saves us.