Did the radioactive firefighter need that stress test?

Who knew that a having a nuclear stress test might put you at risk for suspicion of terrorism?

No, I am not making this up. A famous medical blogger, known as the Skeptical Scalpel, cited this bizarre news report of a CT firefighter who was stopped by the state police. The unsuspecting public servant was just driving by inconspicuously when a patrol care pulled him over. Yes, in this case, the driver could rightly say he had done nothing wrong.

A sensitive device in the patrol car detected radiation as the motorist drove past. It turns out that the firefighter had undergone a nuclear stress test earlier that day. First off, I had no idea that police had sensitive radiation detectors, and secondly, I did not know that patients who had nuclear stress tests were that hot. (But my lack of knowledge is neither new nor notable.) Let’s move on.

The ever skeptical, Skeptical Scalpel, direct messaged me:

“Did this man need a stress test?”

His post went on to question the rightness of stress testing in non-symptomatic patients. He wondered about the over-testing of American patients and the role such practices play in advancing medical costs. He asked for my opinion. I started to write a comment on his blog, but then I thought it had gone on too long not to share here. (I know; that’s weak.)

Here is my answer:

Dear Skeptic:

Ah…Your question stirs the pot in so many ways. It pokes at the essence of the debate in Medicine today. Has a young man been over-tested, and radiated needlessly? Does this case highlight what ails us so? Does it strengthen the tailwinds of the Choosing Wisely movement?

Allow me some leeway. Let me offer the low-inflammation idealist view and then counter with the cynical take.

The idealist view: ; Many patients with high blood pressure harbor non-specific resting ECG abnormalities. These baseline changes preclude reliable interpretation of the stress ECG. It makes sense, therefore, to add an imaging procedure to the stress ECG–in the name of greater specificity. (You can argue the merits of stress Echo v. stress Nuclear all day. There’s no general agreement. Both tests have their positives and negatives.)

The cynic, on the other hand, would say the patient had a stress nuclear because it’s reimbursed at a higher rate and the cardiologist needs to pay for the camera that he invested capital in.

The right answer here, I’m not sure. I can say that people who persistently take negative outlooks may have a higher risk of stroke.

Hold on there mister blogger.

Why would an asymptomatic patient get any stress test in the first place?

The idealist argues that vocations such as firefighters warrant increased scrutiny and perhaps a nod toward looking for disease more aggressively. It’s why the FAA vigorously screens pilots. Us folks who live under glide slopes appreciate that. Doesn’t this nuanced approach make sense?

Yet the cynic asks where he would find the evidence base supporting this line of reasoning? Doubters of doctors don’t like the answer: we do extra testing in some patients because of clinical judgment and common sense. They take that as code to justify doing more lucrative tests.

On a non-medical note:

Finally, Dr. Skeptic, you left out the whole notion of police using sensitive screening tests on low-risk citizens of a free country. What’s more, you made no note that a citizen who was minding his own business needed a note from a doctor to prove his innocence. I thought such was assumed. (What if his doctor was off on a bike ride?)

That’s all I will say about that.

Of course this man benefited from a stress test. His doctor listened to his symptoms, considered his high-risk job, assessed his physical findings and came to a shared decision in a patient centered model. Together, inside the warm confines of a medical home, the informed patient and enlightened doctor decided that a nuclear stress test was the best means to stratify his risk of heart disease.

Why so negative my friend?

JMM

P.S. I’m a huge fan of the Skeptical Scalpel. He offers great insights into doctoring, thoughtful commentary on social anthropology and frequently jolts fond memories of my surgical rotations. He’s worth adding to your twitter or reader feed.