if I talked to our team doctor

I had a question the other day that I had to pause a second or two and figure out how to answer. The question was "If I talked to our team doctor and asked her what she thinks about your screening process, what would she say". It took me a while to think of an answer.

There were three things that I debated talking about. First, not all doctors are qualified to talk about cardiac screening. Having worked with a group of doctors, each has their own specialty. We go to a Pediatrician but I would not trust her reading an ECG. We go to an Orthopedist but I would not trust him with interpreting an Echocardiogram. I go to a Chiropractor and he was smart enough to say that using a stethoscope is something beyond his abilities. Each of these doctors has a specialty and a focus just like every one else in the world. I don't ask my Cardiologist about a pain in my lower back or an ankle injury. He isn't up to date on childhood diseases and immunizations that are needed for middle school.

My first thought was that the doctor that the school has a relationship with is probably an Orthopedist but I didn't want to jump to conclusions. I assumed that they were qualified on cardiac screening and that led me to the next quandary. If they know anything about cardiac screening there are two camps of thought. One group says that simple screening with an ECG will yield about one in two thousand at risk kids. Given that the school has over 23,000 students, that means that there are about 11 kids are potential sudden cardiac death candidates at one of twenty four schools. There is about a fifty-fifty chance that there is one kid has a serious problem in one of the schools and does not know about it. A screening program for all athletes will pick up five or six of these kids assuming a 40% participation in athletics. A doctor who believes in ECG screening would be behind a $15 screening program that hits 80-90% of all student athletes, band members, and ROTC participants.

On the other hand, the American Heart Association is split on this issue. The doctor could fall into the camp that ECG screening catches the worst cases and produces about 10% false positives. To truly catch disease you would need to include Echo screening and the cost of doing that is really expensive. Once they find out that we charge $25 for ECG and Echo screening combined they might recommend the program but admit that not everyone can afford the $25 screening or the $200 doctor visit if something is found.

Either way, everyone agrees that the standard questions posed by the American Heart Association that has been included in the standard physicals is neither comprehensive, effective, or practical. If you answer that you have a family history of cardiac problems you immediately fail your physical and need to see a family physician for a full workup. If you answer that you have fainted or felt dizzy while running you fail your physical. A University of Washington study last fall showed that the majority of doctors don't ask every student the standard questions that are required and the students don't answer the questions correctly because they don't know or don't want to fail the physical.

I did answer the question after about 20 seconds of hesitation as all of these thoughts went through my head. I said that the doctor will either be 100% behind ECG screening and strongly recommend it or hesitate and say that it should include Echo screening. They will also advise that you need to think about what to do with the 5% of the kids that are not categorized as low risk and need a doctor visit. They might also ask how low income kids are going to come up with $25. They should also ask who you are using for screening and what is their history at screening other schools. Fortunately for us, we have faced these questions from other schools and have recommendations on follow up requests as well as eight years of history screening high school athletes.

Hopefully a study in 2012 will show that ECG screening is either effective, a waste of time, or Echo screening is needed to find the leading indicators resulting in sudden cardiac death. Until then, we will continue to have this discussion as well as offer both services to schools that get recommendations that both are needed.