getting the call wrong

Tuesday, September 27, 2016

One wonders why anybody would aspire to be a referee. It is a thankless job that somebody has to do, especially in the amateur ranks. There is some glamour in being on the field, ice or court as the best players in the world perform, and in that regard professional referees and umpires are also the best at what they do. Less glamourous are the little league umpires or soccer referees who suffer just as much scorn ads the pros. But it’s the beginning of the week and fans, especially those of the losing team, are vocal in blaming officiating as the cause of their favorite team’s demise.

There are very few sports that have black and white results. Racing against the clock provides an arbitrary score but most team sports are at the mercy of the officials. The same is true in medicine. One would think that doctors could agree on the results of an X-ray, blood test or EKG, but one might be wrong. Black and white don’t often exist in medicine and even grey is often in dispute. Not that one shouldn’t trust test results, but they are just one part of a patient’s evaluation and need to be taken into context.

Radiology

cxr

Let’s consider the basic X-ray. The radiologist can take as long as needed to interpret the images, but the in box is always being filled with new cases to read and there is a time crunch. It’s no different than instant replay; the referees could take forever to review play to the detriment of the game and the enjoyment of the fan. Many studies have looked at the radiology miss rate and it tends to be about 3-5%. Interestingly, that percent stays about the same whether the radiologist quickly looks at the film or whether inordinate amount of time is spent reviewing the images. One study reviewed chest X-rays and defined visual dwell as spending too much time on one specific part of the film. Those who spent too much time had the same error rate as the radiologist who spent less than 4 seconds reading an X-ray. The researchers’ conclusion: “Common experience in radiology suggests that many errors are of little or no significance to the patient, and some significant errors remain undiscovered.”

 

Cardiology

echo

Like radiologists, cardiologists (heart specialists) often interpret tests without physically seeing and touching the patient. Presumably, a test result is a test result, but just like fans from opposing teams who can’t agree on what constitutes a catch in the NFL, cardiologists reading the same test may come to different conclusions. Echocardiograms are ultrasounds of the heart that help diagnose structural abnormalities. Add exercise (or inject a chemical to get the heart to do more work and the echo can help diagnose narrowing of the coronary arteries. Researchers had two or more cardiologists review echocardiograms and compared their interpretations. In patients with normal hearts and those with bad heart disease, the docs agreed. But is patients with intermediate disease, cardiologists could only agree 75% of the time.

For most patients, diagnosis and treatment involves being touched by a health care provider and test results are put in perspective. Clinical situation and tests have to make sense together and the art of medicine involves interpreting the situation. There may not be a wrong, just a gray shade of not right. This perhaps does not satisfy the Monday morning quarterback since everybody, including medical people strive for perfect. But in the imprecise world that is medicine, black and white don’t routinely exist.

Radiology Quality Institute. White Paper: Diagnostic Accuracy in Radiology 2012

Brady A, etal. Discrepancy and Error in Radiology. Ulster Med J. 2012 81(1).

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hypertrophic cardiomyopathy

Tuesday, March 10, 2015

Anniversaries allow memories to be rekindled and sometimes, introspection regarding what might have been. Perhaps 25 years after the sudden death of Hank Gathers allows another look at the philosophy behind how society decides to spend its resources and how much it’s willing to invest.

Hank Gathers was an elite basketball player for Loyola Marymount University and during a game collapsed and died, the victim of hypertrophic cardiomyopathy, ventricular fibrillation and sudden death. The anniversary of his death has reopened the ongoing discussion of how we screen athletes and potentially prevent future tragedies but the decision making is murky at best.

Hypertrophic cardiomyopathy, or HCM, is a genetic disorder, where part of the heart muscle becomes thickened and may affect the ability of the heart to pump block to the rest of the body. It can affect the function of heart valves but perhaps the most frightening problem is the potential to develop life threatening heart rhythms, ventricular fibrillation and ventricular tachycardia, that cause sudden death. HCM is the most common cause of sudden death in young adults. Abnormal muscle fibers potentially conduct the heart’s electricity abnormally and the “short-circuiting” may cause the fatal heart rhythm.

HCM is relatively uncommon, occurring in about 1 in 500 people. The severity of disease depends upon where the muscle thickening occurs within the heart and how abnormally thick that the muscle becomes. Most people are unaware that they have the disease and have normal life expectancy. For those with significant disease, between 10-20% of those with HCM, aggressive exercise can precipitate symptoms including fainting (syncope) shortness of breath, chest pain and the big deal…sudden death.

The question becomes, how we screen people to find HCM, especially in athletes and hopefully prevent sudden death. History and physical examination is not great at finding the disease, but can find those at potential risk, especially if there is a family history of HCM or sudden death, OR if there is a history of fainting, lightheadedness or palpitations with the patient feeling a rapid heartbeat. Examining the heart, listening for abnormal sounds or murmurs, might give a clue that HCM is a potential. An EKG (electrocardiogram) may or may not be abnormal and is not a great screening exam, missing up to 30% of those with HCM. Echocardiogram, an ultrasound of the heart, is very good at finding abnormal heart muscle structures and is the ‘gold’ standard for finding HCM.

The American Heart Association and the American College of Cardiology are at odds with their European counterparts when it comes to screening. The Americans felt that using technology would be unsuccessful. In the 1970s, the Italians mandated full screening as a condition of sports participation for all competitive athletes. This includes full history and physical exam and EKG plus echocardiogram for those to be high risk. The proponents of the Italian model, including the European Cardiology Consortium, the International Olympic Committee and FIFA, the international soccer organization, point to studies where there is a 90 percent reduction in HCM sudden death from about 10 deaths per year to one death per year in the past 25 years.

With that background, consider the US situation. There are 8 million students that participate in high school athletics every year. The expected sudden death rate for HCM in the general population is about 1 in 200,000. This statistics seems to fit the 10-25 deaths per year that are reported. In the freshman class of 2 million, HCM would be expected to affect 4,000 student athletes and without any screening, 10 deaths would be expected per year if no screening procedures were in place. If the Italian model was in place, 9 lives might be saved.

The participation physical examination is often a distraction and inconvenience for students and parents alike. Often, a form gets signed without much more than a cursory provider visit and it is seen as not important. However, there is little infrastructure in place to perform 2 million physical exams and EKGs. Aside from the cost of the visit and the EKG, there may be a lack of medical personnel who are trained to ask the right history questions or to look for the signs of HCM on physical examination. The EKG changes may be subtle. For those whose risk factors would suggest the need for an echocardiogram, there are many parts of the US, where the cardiologist, technologist and machine are not readily available.

Mandating heart evaluations before allowing students to participate in athletics may cause those living in medically underserved areas to be divorced from organized sports. What societal consequence exists for a less active adolescent population? HCM may be progressive and affects those of all ages. Taking the screening requirements past high school, should YMCAs, and health clubs require cardiac screening exams before allowing membership? And for those who work in trades and professions that require manual labor and exertion, should there be screening?

Society has opportunity to choose its priorities. Great time, effort and resources are spent to prevent even one plane crash. Less effort is made to outlaw smoking or aggressively diminish drunk driving rates. The question becomes, how much should society care. Even with the most aggressive screening policies found in Italy, there are still athlete deaths due to HCM.

So how much are 9 lives worth?

 

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