Madden likes to listen to both sides of the argument on screening, but ultimately feels that patients and athletes should be involved in the decision making. Embracing a term called “shared decision making,” Madden works toward this in his practice in Longmont, Colorado. Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.
Madden also points out, “I practiced before health care reform (renamed “transformation” to avoid the negative tone) and managed care labeled and is trying to re-brand and monitor much of what quality physicians were already doing. We learn to speak the “modern” language (e.g., SDM) for our practices to survive. To this day our practice has avoided a high volume model that leaves little time for patients. I teach the motto: Would you rather see more patients with less patience, or fewer patients with more patience? Which do you think leads to higher quality care and patient satisfaction? There are ways to do both, yet much of the US healthcare system embraces the former.
In an online forum following the article, Madden explains:
“For a screening test to be effective, it needs be able to reduce morbidity and mortality through early disease detection, AND early disease detection needs to lower risk and not cause harm. That is where it becomes complicated with ECG, especially when entertained universally for athletes.
Even if sudden cardiac death occurs more frequently (incidence) than previously estimated, and even if ECG may be able to identify some of the athletes at risk, the number of athletes that would be needed to be screened (NNS) is still extremely large to prevent a single fatality. And athletes who may never have a problem may face difficult decisions about continuing sport.
If data was statistically significant, the number of athletes in this HIGH RISK subset would still have to be 8500 to identify a single ECG abnormality that may prevent sudden cardiac death. And I say “may” because what we are doing is simply identifying those at risk, but we have no way to know how the disease will behave over time (natural history) or if it would have ever manifested as sudden cardiac death.
Now think of how many asymptomatic athletes you would have to screen with a universal recommendation in the lower risk population where the incidence is 1:40,000!
I know this is a difficult topic to grasp for many, and there is much debate within our own organization about it.
I would offer the there is new data that may support that ECG screening in a select population of high risk athletes (collegiate basketball players) may reduce the risk of sudden cardiac death. But that is a very different issue than universal ECG screening in all asymptomatic athletes, where the incidence of disease is still so low that universal screening will likely yield far more false positives that may cost athletes their careers or mental health because they are disqualified from something they love (that is the harm).
If you look at the numbers – they illustrate the answer to the questions:-even if the higher incidence of SCD in male collegiate basketball players is 1:7000 which some new studies show, ECG would still have to be performed on ~90,000 athletes to reach statistically significant data that would support screening!”
Madden feels it is important for both athletes/patients and physicians to understand what we know and what we don’t know to be able to make meaningful, quality, individualized decisions together.