To Avoid Stress Test Lawsuits, Proceed With ‘Introspection’

Noninvasive stress tests orders are common; falls and adenosine reactions rare. Still, pausing to consider appropriateness is key.

To Avoid Stress Test Lawsuits, Proceed With ‘Introspection’

Many medical professional liability (MPL) claims following noninvasive stress testing might be avoided through careful review of appropriateness, communication, and urgency of these tests, according to the authors of a new study.

For most cardiologists, the question is not if but when they might face such a claim, given the procedure-heavy nature of the field.

More “introspection” before going ahead with a stress test requested by a referring physician, or ordering one themselves, might help ward off legal complaints, said lead author David M. Dudzinski, MD, JD (Massachusetts General Hospital, Boston). “A lot of times there is inertia [when] a test is ordered,” he told TCTMD. Patients typically get referred for a stress test by a noncardiologist, “then they're supposed to go and get the test. . . . I think we feel sometimes that we shouldn't disrupt that. But we need to really think about what's best for this individual patient holistically.”

He advised focusing on questions such as: “With the information I have at hand, am I doing the right thing for this patient? Am I answering a particular clinical question with the right answer? Am I minimizing risk, or is the risk that I'm going to engender justified? Have I got all the information I absolutely need before I make this decision?”

Fourteen Claims

For the study, which was published online as a research letter last week in JACC: Cardiovascular Imaging, Dudzinski and colleagues looked for stress test-related claims from a large, physician-owned national MPL insurer between 2007 and 2023.

Their data set represents 5% of US cardiologists, according to Dudzinski. During the 25,567 cardiologist-years of coverage, they identified 14 MPL claims, of which seven involved allegations about treadmill injuries, three were related to adenosine use, and four regarded follow-up and management. Six claims involved a patient death and another six entailed orthopedic injuries. Just half of the claims were concluded in favor of the cardiologist.

The scenarios of each claim varied, but several centered on patients who did not primarily speak English and some were for patients with preexisting orthopedic issues using a treadmill. Many patients fell off the treadmill, and others had breathing-related issues following adenosine administration.

“We can use data sets like this as a real-world assay of our health system and our practices to assess quality and process gaps,” Dudzinski said, adding that this represents the first look into MPL claims related to noninvasive stress tests.

“It’s incumbent on all of us who are going to run a diagnostic test [to know that], while generally safe, it does have some risks,” he said, adding that he has been known to cancel ordered tests after reviewing a patient’s history.

This can be hard, though, Dudzinski acknowledged. “Laboratories are built for productivity and a certain amount of throughput per day and tests per day, and other downstream things like surgery or discharge may hinge on the result of getting a stress test result,” he continued. Still, “we may have a hundred stress tests a day, but for this patient, their stress test is the most important.”

Practical Advice

Vinay Kini, MD (Weill Cornell Medical College, New York, NY), who commented on the findings for TCTMD, said his first takeaway is that these claims are “pretty rare.”

That said, the claims identified in this series offer several lessons to cardiologists on ways not merely to avoid legal action but to improve care, he said. Those include ensuring appropriateness of the test overall and of treadmill or pharmacologic use, specifically, as well as “making sure that we convey the results of stress tests to patients and referring providers in a timely manner to make sure that results are followed up on appropriately,” Kini specified.

In practical terms, this means explaining to patients how to safely get on and off the treadmill and what to do if they need to stop suddenly, Kini said. For the adenosine component, he added, this means “making sure that, for example, patients aren't actively wheezing, don't have a strong history of asthma, and don't have any known contraindications to those medications.”

He continued: “Cardiologists don't need to practice so-called defensive medicine where we're doing things for the sake of not being sued, but I think that the study really nicely shows that we just need to be . . . practicing good and safe medicine for our patients.”

“You're never going to get risk down to zero,” said Bernard Black, JD (Northwestern University, Chicago, IL), who commented on the findings for TCTMD. “There are a lot of stress tests in the world. Most of them go fine. A few of them are going to go wrong.”

What to do about that depends on the “total denominator” of incidents, but that is difficult to know as many of these patients may never file claims, Black said.

Because of that and the “heterogeneity of environments in which diagnostic tests are delivered,” Dudzinski said, “it's really hard, I think, for any one person to be prescriptive and say what should be done across all environments.” System-wide protocols could potentially help reduce these sorts of claims, but it starts with the individual, he said.

In general, Kini acknowledged, “it's a very hard thing to study, which is why I think we don't know a lot about this.” He highlighted the fact that physicians are often fearful to even discuss these events for a variety of reasons, noting, “There's some embarrassment when these things happen.”

But “the fact that we did see a signal does, I think, provide some information for laboratories to evaluate their own procedures and assess, could any of these things have happened in my laboratory?” Dudzinski concluded, adding that this might be an area where artificial intelligence could be applied to identify patients who might not be suitable for noninvasive stress tests in the future.

  • Dudzinski, Kini, and Black report no relevant conflicts of interest.