Summary

There has been little research into how doctors work with diagnostic technology and how patients respond Echocardiography (ultrasonic imaging of the heart) is an important non-invasive imaging test which is of great value in the diagnosis of heart disease Like other imaging tests, it is often used to exclude the possibility of disease in the hope of reassuring the patient Clinical experience suggests that there are serious pit­ falls in the use of echocardiography for purposes of reassurance which are also likely to apply  to other imaging investigations

We studied   this  application of echocardiography in  40 patients  using  methods of analysis  which  were largely qualitative-based on  tape-recordings of consultations and of unstructured interviews  with doctors and patients  and a clinical questionnaire involving 40 patients Important problems which emerged were that:

  • Reassurance did not automatically follow the demonstration of a normal  heart In particular, anxious patients  with symptoms  seeking medical care because of worry about the heart generally failed to completely resolve their doubt so that there was some continuing anxiety. Anxiety was frequently provoked  by referral for echocardiography after a heart murmur had been heard in the course of a routine medical consultation or insurance examination. In these patients, doubt and anxiety about  the heart  were frequently  not resolved  entirely by the doctor's explanation that the test had shown  the heart to be normal
  • Such  persistence  of doubt  and  anxiety  after  testing  were  often  not  predictable before referral Although  clear explanation  and  good  doctor-patient communication in  the medical  consultation were factors, there were also 'wild  card  effects' Thus the clinical outcome could be largely determined by random  events involving the test, the patient's personality, family history, medical history or life experience In some cases, it seemed that no amount of explanation could have reassured such a patient once the query had been raised
  • When  the cardiologist  was  confident  that  the heart  was normal,  such  a clinical diagnosis  was  accurate  Given the risk of false positive diagnosis,  of findings  of doubtful significance and the risk of residual doubt and anxiety even when the test result was normal, we concluded  that a consultant's opinion would often be a safer method  of reassurance  than an echocardiogram
  • Doctors sometimes had social as well as technical reasons for ordering the test, such as compliance  with the wish of the referring  doctor or use of the test as a kind of placebo to reinforce patient reassurance

These results have practical implications relating to the use of imaging  investigations in medical  practice, to the education  of students with regard to heart murmurs and to the evaluation of medical technology