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.