Stop Diagnostic Testing for Old People!

The number one question I am always asked is, “What kind of doctor do you want to be?” I always think to myself, “I just want to be a doctor in the first place,” but that never seems to be a satisfactory answer to people. My answer has changed from internal medicine, to pediatrics, to oncology, and as of late, it is now geriatrics. When I came across this paper about stopping diagnostic tests for older patients after they have had a syncopal episode, I just had to read about it.

During my clinical experience, I probably saw at least three patients a day who endorsed a syncopal episode. This is defined as a sudden loss of consciousness with spontaneous recovery which accounts for 1-3% of ER visits (Mendu et al., 2009). Many, many tests are ordered to determine the etiology of the syncopal episode simply because it’s a phenomenon that could have multiple causes. The most frequent tests ordered are EKGs, telemetry, cardiac enzymes (like troponin), and head CTs, essentially looking only at the heart and the brain (Mendu et al., 2009).

The authors found that these tests were frequently ordered on syncopal patients even though it had a minimal effect on their diagnosis (2009). Part of this is due to the complex and personalized nature of syncope but also because any neurological or cardiac conditions were predetermined from patient history or examination. The most expensive tests were EEGs, head CTs, and cardiac enzymes and these tests were medically useless since it did not contribute to the physician’s diagnosis (Mendu et al., 2009). One study found that cardiac enzymes had little impact on a syncopal diagnosis and another found that a head CT, carotid ultrasound, and EEG all proved to be ineffective in identifying lesions contributing to syncope (Mendu et al., 2009). 

All these diagnostic tests are racking up the medical bill and for what? A diagnosis that doesn’t even provide an answer for patients? I can recall many times when I had a patient’s chief complaint be “syncope” and they would be discharged with the diagnosis “syncope” after receiving an entire syncopal workup. Where is the line between ordering enough tests for an accurate diagnosis and ordering an excessive number of unnecessary tests that will place the patient in debt?

Resources:
Mendu, M. L., McAvay, G., Lampert, R., Stoehr, J., & Tinetti, M. E. (2009). Yield of diagnostic tests in evaluating syncopal episodes in older patients. Archives of internal medicine, 169(14), 1299–1305. doi:10.1001/archinternmed.2009.204