O cardiology coronary angiography overuse has ranged even >20 which could predispose to un-necessary angioplasties or surgery, both of which have significant morbidity as well as occasional mortality. Another example may be exercise stress test. As a matter of fact 15 of stress tests may be false positive which may lead to needless worry and further testing; often including an invasive angiogram which itself carries a finite morbidity and mortality. With this in background the American College of Cardiology has actually provided a guideline “When initially evaluating Isorhamnetin chemical information patients who are not having cardiac symptoms, don’t perform stress cardiac imaging or advanced noninvasive imaging unless there are markers the patient is at high risk.” As also “Don’t perform stress cardiac imaging or advanced non-invasive imaging as part of routine followups in patients without symptoms of cardiovascular disease.”The reasons for over-utilization of investigations are many and commonly include defensive behavior and fear or uncertainty, lack of experience, the use of protocols and guidelines, “routine” clinical practice, inadequate educational feedback and clinician’s ARQ-092 biological activity unawareness about the cost of examinations.15e18 Another interesting factor responsible for this is increase in patient awareness and patient education with the easy accessibility of ample knowledge over internet and other open sources of information like press, many patients are convinced of requirement of certain tests and emphasize its need to their physicians and the physicians just pander to their request of “self-referral.”7 However more worrying are factors such as inappropriate financially motivated factors, health system factors, industry, and media factors.8 One of the foremost reasons for tendency to excessive investigation is the diminution in the quality of clinical skills or clinical judgment. This again could be partly attributed to the mushrooming of medical colleges across the globe with decrease in the standard of education in the same. This deficiency was lamented long back when Connelly and Steele in their classic article emphasized the need of proper medical education for proper utilization of laboratory tests.9 It cannot be emphasized enough that there is no substitute for a good clinical examination, however, the trend has become to practice evidence based medicine based on radiological and pathological findings rather than skill based medicine. A case in example is use of echocardiography to make a diagnosis of structural heart disease, which unless is accompanied by a careful clinical examination it can often be misleading, even counter-productive and harmful. One is often reminded of PDA closure in duct dependent lesions where cyanosis was clinically missed or case of acute dissection masquerading as pericardial effusion and tamponade (where a simple examination as pulse was not properly done). Thus, each investigation requested should have a proper aim and objective based on the history and a thorough clinical examination of the patient. Clinical examination should be the basis for any diagnostic investigation and not vice versa. It should be well understood that while these investigations help reach a diagnosis but may not necessarily provide diagnosis all the time. Yet another component responsible in the over investigation of simple diseases, is the rise individual rights and empowerment of patients which has led to increase in the number of litigations against.O cardiology coronary angiography overuse has ranged even >20 which could predispose to un-necessary angioplasties or surgery, both of which have significant morbidity as well as occasional mortality. Another example may be exercise stress test. As a matter of fact 15 of stress tests may be false positive which may lead to needless worry and further testing; often including an invasive angiogram which itself carries a finite morbidity and mortality. With this in background the American College of Cardiology has actually provided a guideline “When initially evaluating patients who are not having cardiac symptoms, don’t perform stress cardiac imaging or advanced noninvasive imaging unless there are markers the patient is at high risk.” As also “Don’t perform stress cardiac imaging or advanced non-invasive imaging as part of routine followups in patients without symptoms of cardiovascular disease.”The reasons for over-utilization of investigations are many and commonly include defensive behavior and fear or uncertainty, lack of experience, the use of protocols and guidelines, “routine” clinical practice, inadequate educational feedback and clinician’s unawareness about the cost of examinations.15e18 Another interesting factor responsible for this is increase in patient awareness and patient education with the easy accessibility of ample knowledge over internet and other open sources of information like press, many patients are convinced of requirement of certain tests and emphasize its need to their physicians and the physicians just pander to their request of “self-referral.”7 However more worrying are factors such as inappropriate financially motivated factors, health system factors, industry, and media factors.8 One of the foremost reasons for tendency to excessive investigation is the diminution in the quality of clinical skills or clinical judgment. This again could be partly attributed to the mushrooming of medical colleges across the globe with decrease in the standard of education in the same. This deficiency was lamented long back when Connelly and Steele in their classic article emphasized the need of proper medical education for proper utilization of laboratory tests.9 It cannot be emphasized enough that there is no substitute for a good clinical examination, however, the trend has become to practice evidence based medicine based on radiological and pathological findings rather than skill based medicine. A case in example is use of echocardiography to make a diagnosis of structural heart disease, which unless is accompanied by a careful clinical examination it can often be misleading, even counter-productive and harmful. One is often reminded of PDA closure in duct dependent lesions where cyanosis was clinically missed or case of acute dissection masquerading as pericardial effusion and tamponade (where a simple examination as pulse was not properly done). Thus, each investigation requested should have a proper aim and objective based on the history and a thorough clinical examination of the patient. Clinical examination should be the basis for any diagnostic investigation and not vice versa. It should be well understood that while these investigations help reach a diagnosis but may not necessarily provide diagnosis all the time. Yet another component responsible in the over investigation of simple diseases, is the rise individual rights and empowerment of patients which has led to increase in the number of litigations against.
