Doctoring Health Care Health Care Reform

Saving lives with a 25 dollar painless test…

In the era of expensive and technologically advanced tests like MRI, CT and PET scans, how could a 25 dollar ECG save many lives?  A recent study on the merits of adding a screening ECG to the routine screening of young athletes has created a stir, with many words written in the lay press.

For years, young athletes (ages 14-22) undergo a routine screening physical exam before participation in competitive sports.

Can you remember the long line of equally nervous kids outside the now extinct school nurse’s office?  The old doctor was there, behind the foldable white curtain, and invariably, after listening to the heart would come that dreaded cough test.  Over the many years since I stood outside the school nurse’s office, the rotary phone and eight track tape have become extinct, but not this kabuki dance with the doctor and child.

Fortunately, sudden death in the young athlete is uncommon, but certainly not rare.  With repetitive consistency, tragic stories of sudden death in the young athlete continue to be told.  After reading these stories, a heart rhythm doctor wonders whether the tragedy was preventable.

Briefly stated, as much information is written and available on this topic, the two most common causes of sudden death in the young athlete are…

Hypertrophic cardiomyopathya muscle disease of the heart characterized by thickening of the heart muscle.  Not only can the excess hypertrophy compromise outflow of blood from the heart, it also leads to electrical instability and arrhythmias. This heritable condition may or may not manifest an audible murmur, but more often than not, the ECG is abnormal.

Long QT syndromeThe QT interval measures the time of cardiac relaxation. It is easily measured on an ECG and lengthening of this interval predisposes to sudden death. The QT interval is only measurable on the ECG –it cannot be heard or palpated.

Obviously, the ultimate goal of screening is to identify those athletes with the above (or other less common) predisposing conditions, so as to avoid the catastrophic and unexpected loss of a young person.  How to best accomplish this goal, and at what cost is the question at hand.

Presently, in the US, but not in many European countries, screening is accomplished by the old-fashioned physical exam.  As most clinicians know, the physical exam is woefully inadequate for detecting hypertrophic cardiomyopathy, and the stethoscope is completely incapable of noting the QT interval.  Nonetheless, a physical examination with all the props –white coat, stethoscope, lights etc –can make for good theatre, and as such, often provides a false sense of security to the patient and parents alike.

Adding an ECG seems such a simple thing to do.  ECGs are painless, emit zero radiation, are not implicated in autism, and are easy to do.  They are the only way to see the QT interval, and are much better for detecting cardiomyopathy than the physical exam.  Make no mistake, like any test in medicine, ECGs are not flawless, however, their incremental benefit is clear and obvious.

The previously noted study suggests the ECG would add 89 dollars to the screening exam, but like any economy of scale, surely a “volume” discount is plausible.

Sounds good so far, right?  Not so fast, this is America, and in our healthcare system tests are priced in monopoly-like prices and many forms are required.  Additionally, as I have gleaned from viewing the local newscasts, there are many lawyers who lurk in the background.   Speaking from experience in the “real” world of medicine, when an emotionally charged event like sudden death prevention is the goal, doctors will struggle mightily with tests requiring interpretation.  In ECG reading, unlike lab testing, there is no “H” or “L” on the ECG.  A reader of “squiggles” has to make a call.  In the back of the readers mind, is the fact that a “normal” record does not preclude sudden death.

My former mentor, a very famous doctor of the heart, and now novelist, Dr Douglass Zipes, believes we should mandate ECGs for screening of young athletes, and so do I.  Doing so will save lives, and to do such with a twenty five dollar risk-free inexpensive test exudes elegance.

At the risk of sabotaging an argument with Jim Bunning-like tomfoolery, might I suggest substituting the ECG for the inguinal hernia exam.