Author + information
- Tiziano Scarabelli, MD, PhD∗ ()
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Tiziano Scarabelli, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, New York 10029-6574.
Recently, technological advancements have made available to physicians novel instrumental methodologies, which have revolutionized the diagnosis of cardiac disease. In addition to ensuring a more defined resolution of cardiovascular imaging, modalities such as echocardiography, myocardial perfusion imaging, cardiac computed tomography angiography, magnetic resonance imaging, and positron emission tomography, also provide morphological and functional information, which are instrumental in formulating a diagnosis. A fortiori, color-coded Doppler echocardiography, a noninvasive technique that is reliable, innocuous, and easily executable even in its transesophageal application, has become a “diagnostic garrison” routinely used in diagnosis and follow-up of almost all heart conditions (1). However, as young cardiologists, we cannot only rely on these tools to inform our clinical decision making. Although young cardiologists have to embrace the benefits of such instrumental methodologies, I would recommend caution against their unreasonable and unconditional use. Cardiac auscultation, when combined with bedside examination, is not only simple and cost-effective, but also indispensable to provide the physician with the necessary baseline knowledge suitable to select and direct, if clinically indicated, further testing and procedures. The information offered by physical findings come first and cannot be totally replaced by alternative technological methods. Listening to the heart carefully and meaningfully is the conditio sine qua non of a proficient and balanced cardiology practice.
Risks of Techno-Dependency
Technology should serve as a sort of extension of the physician’s senses. In this vision, “machines” must be subservient to the clinician and not take his or her place. Their role is to confirm or refute the validity of a clinical suspicion and not make a diagnosis ex novo creating sometimes a condition of “instrumental illness,” which, although clinically negligible, is still a reason of concern for the patient. This phenomenon of techno-dependency, paradoxically, seems to be encouraged by training institutions with inevitable repercussions on the education of their students. Three-fourths of the internal medicine programs and two-thirds of the U.S. cardiology programs do not offer structured teaching of cardiac auscultation (2). Evidently, listening to the heart is believed to be important, but certainly less central than newer technological means. The ability to understand the “whispers” of the heart does not come as a gift. It is both a skill and an art with a steep learning curve, whose proficient practice requires not only theoretical knowledge, but also systematic bedside teaching. Cardiology fellows taught to use the probe instead of the stethoscope with the blessing of their institution are increasingly susceptible to the risk of becoming technocratic physicians, which entails “doing the right thing” without necessarily “doing the thing right.”
However, I am not writing with the wounded pride of a clinician to bemoan a gradual decline in my authority, but instead, with the intimate conviction that the indiscriminate use of instrumental diagnostics has a serious impact on health care quality and cost. It is disconcerting to see training cardiologists with an abundant knowledge of technical details showing embarrassment in the presence of a heart murmur or an extra cardiac sound, to the extent that he or she is unable to make a diagnosis based on clinical information derived from history and physical assessment. Cardiologists of this extraction, who developed strong technical skills during their training but kept themselves untangled from clinical dexterity, may feel uncomfortable when asked to handle clinical issues without the support of instrumental tests. Between the occurrence of the clinical problem and the actual reading of the ordered tests, there is a latency period during which a cardiologist must necessarily be a clinician and cope with the emergent situation, resorting first to a thoughtful assessment of clinical findings, especially those auscultatory, collected at the bedside during cardiopulmonary examination. When unable to interpret meaningfully clinical findings, a physician can be tempted to use instrumental tests as a “diagnostic crutch” to bridge a gap of knowledge. Such a decision can delay an important pharmacological intervention or result in inadequate interventions under the pressure of a medical emergency, with unpredictable consequences. Cardiac auscultation is not the academic virtuosity or the educational “amarcord” of démodé cardiologists grown at the primordial school of stethoscope, electrocardiogram, and chest x-ray, but is, instead, the simpler way to take to ensure the quality and appropriateness of health care.
Beneath the Surface of Diagnostic Overshooting
The indiscriminate use of instrumental diagnostics also contributes to the misuse of the economic resources earmarked for health care, leading inevitably to the so-called “diagnostic consumerism,” a trendy, multifactorial phenomenon that is rampant in many branches of medicine, at the base of which are, among other things, the necessity of diagnostic absolutism, medico-legal issues, as well as an overwhelming desire to reassure and please patients. The search for utmost diagnostic inclusivity inevitably results in the spasmodic request of numerous, redundant instrumental investigations. Uncertainty, convenience, lack of confidence, and fear of legal liability are some of the most prominent reasons propelling physicians to pursue this diagnostic escalation. Specifically to avoid accountability, physicians may resort to “diagnostic stunts” to prove beyond any doubt that they have acted properly in an effort to document both the likely and the far-fetched. In this situation, a physician can use aberrant diagnostic tests to communicate to patients, especially if they are fearful and demanding, proving incontrovertibly that they are in good health. This approach, however, is doomed to cease. Unnecessary diagnostic tests contribute to the rapidly growing health care costs, which are driving the health insurance system to collapse.
The Simplest Prerequisite for a Healthier Health Care
The new generation of cardiologists will have to keep this in mind and strive to dramatically reduce the number of redundant instrumental tests, maximizing the degree of information provided by physical examination. A wiser and more selective use of diagnostic tests based on clinical findings would spare asymptomatic patients with a benign cardiac auscultation from unnecessary tests and would reduce the waiting time for those patients whose physical findings are clearly evocative or suspicious of cardiac disease. The reduction of diagnostic consumerism is also expected by U.S. patients, who have moved from a condition of supine acceptance of instrumental examinations to an unpleasant condition of active participation in health care costs. Hence, the appropriate and cost-effective utilization of instrumental tests also is justified by the ethical need to protect the patients’ rights by sparing them the potential harm and cost of unnecessary investigations. In conclusion, the abuse of technology aimed at diagnosis, hiding alarming consequences behind the apparent innocuous trendy phenomenon, should be minimized first by a systematic recourse of the physician to a comprehensive and meticulous physical examination. Indulging the temptation to leave the diagnosis to “machines” does not mean just bowing to technological development, and thereby alienating some of the clinical duties that vocationally should belong with the physician, but it also means contributing to the malfunction of the health care system. Based on a recent report by The Commonwealth Fund, the U.S. health care system underperforms comparatively to other countries, despite being the most expensive in the world (3). Although the disservice of our health care system is extremely complex and multifactorial, it is expected that some degree of improvement could derive from a wiser investment of financial resources earmarked for health care; this includes the misuse of the working time of “instrumental physicians” who, as a result of inadequate requests, may be forced to overinvestigate the healthy at the expense of the very sick patients.
- American College of Cardiology Foundation
- Wiley B.,
- Mohanty B.
- ↵Davis K, Stremikis K, Squires D, Schoen C. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2014 Update, The Commonwealth Fund, June 2014.