Chest pain in women commonly leads to defensive medicine

The next part of this continuing series. I’m sure that many can relate to this story. A reader writes:

A 30-year old woman comes into her PCP’s office with a complaint of chest pain for the past couple weeks. It is described as sharp and pricking along the left sternal border. It hurts when you press on it and does not radiate. It does not change with position, exertion or food. It lasts hours at a time.

She is otherwise healthy and does not take medications. There is no family history of heart disease. Vital signs are stable and the physical exam is only revealing for reproducible chest tenderness. The EKG and cholesterol panel are normal. We now pick up the conversation:

Doctor
Based on your symptoms, the chest pain is unlikely to be heart-related in origin. Your EKG, blood pressure and cholesterol are normal, and you do not have a family history of heart disease. I believe that your chest pain is musculoskeletal in origin, since this is the most common cause of chest pain.

Patient
I want to be 100% sure this isn’t my heart.

Doctor
Well, there are no absolutes in medicine. But from my experience and your history and physical, I can be reasonably sure that this isn’t cardiac in origin.

Patient
I’m just really nervous. I’ve heard some stories of young adults dropping dead of a heart attack, and I really don’t want that to happen to me. I heard you can run on a treadmill to see if your arteries are blocked.

Doctor
It’s called an exercise stress test. In my opinion, this test will be of low yield in your case.

Patient
What percentage of heart disease does this test pick up?

Doctor
Well, the estimated sensitivity of the test is between 65-70% – meaning that a negative test result will miss about 30-35% of coronary heart disease.

Patient
That doesn’t sound very accurate. Isn’t there anything better?

Doctor
There are stress tests with imaging, like an echocardiogram or nuclear scan, that can push the sensitivity up to 85-90%.

Patient
That sounds good – it would be make me feel a lot better if we went that route. I understand that it’s likely going to be negative, but I just don’t want to be that 1 in a million case where someone like me can have heart disease.

Doctor
Ok, I’ll go ahead and order that test for you – just to be on the safe side.

Cost of ordering an imaging stress test in this low-yield patient: several hundred dollars.

Cost of knowing that there will be zero chance of being sued for this visit: priceless.

Defensive medicine is one of the leading factors in driving up health care costs today. The purpose of this series is to breathe some real-life examples into the numbers, and to provide some insight into how the threat of malpractice litigation pervades medical decision making.

Please e-mail me your stories of “how you practiced defensive medicine today”, and it will be posted anonymously as part of this continuing series.

(Disclaimer: Any pictures shown are not of the patient. All identifying features, including race, age, gender and ethnicity have been modified significantly or fictionalized.)

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