With Chest Pain, Defensive Medicine Still the Standard of Care

November 23, 2011

Chest pain admissions and observations are possibly the most ridiculous aspects of internal medicine.

Chest pain admissions and observations are possibly the most ridiculous aspects of internal medicine. Routinely, possibly 40 times daily, ER physicians call internists to admit patients complaining of pain somewhere below the chin and above the pelvis. Because of the fear of litigation and of missing a potentially fatal coronary occlusion, every patient is admitted and evaluated for ischemic chest pain. This usually involves a stress test, and a night’s stay in the hospital.

I may be casting too wide a net, but the majority of ER physicians seem concerned about chest pain occurring while the patient is at rest. But so often, the patient in question had an episode of pain at rest, but meanwhile swims 40 laps daily with no exertional pain. Clearly such a patient’s pain is nonischemic in origin. A simple history (history-taking is an example of cost-effective care!) can identify those patients with exertional chest pain. Exertional chest pain is emotional, physical, and cold-induced typically. If a patient has unimpaired exercise capacity and nonexertional symptoms, there is no reason to admit them for an ischemic chest pain workup. (Often the history is unclear or the patient’s story is confusing, and so it is prudent to err on the side of caution and simply admit the patient and perform the workup - but what I refer to here are the cases of clearly nonexertional chest pain).

The lack of history-taking when it comes to chest pain admissions is noted by every internal medicine physician I know, and is a common complaint we have of ER physicians. Sure, we know that they have a lot of patients to deal with, and would prefer to defer to cardiologists when it comes to chest pain. But in a world where cardiologists are receiving cuts in reimbursements and are not able to wantonly perform invasive procedures (cardiac catheterizations), deferring to them is not the best choice of action. After all, they need business too.

Hospitals need to create a system-based policy on how to evaluate chest pain admissions and observation patients. It begins with a history and physical, possibly bedside echo and chest x-ray, troponin, CPK, and CK-MB measurement. If the patient has stable angina, they need no further inpatient workup. All patients in such situations need lifestyle modification (slowly up-titrated exercise capacity and a plant-based diet). If necessary, a stress test should be performed.

But clinical decision-making should be intelligent and systematic. Unfortunately the reality of the current situation, (symptomatic of the failing medical system) is that defensive medicine (expensive and unnecessary) is the standard of care. Yet outcomes get worse, more money is spent, and people do not heal. The system needs to change.

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