In the on-line version of the New England Journal of Medicine published at www.nejm.org this morning, June 23, 2010, two medical professionals really threw down the gauntlet when it comes to using high-tech medical imaging.
The article, “The Uncritical Use of High-Tech Medical Imaging,” authored by Drs. Bruce J. Hillman, MD and Jeff C. Goldsmith, PhD, site this use as leading to more accurate/less invasive diagnoses but also costs that were until recently “the fastest-growing physician-directed expenditures in the Medicare program, far outstripping general medical inflation.”.
“There is broad agreement that an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.
Unnecessary use has indiscriminately tarred technologies that provide great value to patients and the health care system when used appropriately. Failure to reduce unnecessary use risks inviting policies that could stifle important future innovation.
The factors the authors believe have caused the improper use of the imaging modalities include:
An incomplete evidence-based rationale for imagine
Imaging practice is driven by habit or anecdotal teaching
New imaging technologies are evaluated exhaustively from regulatory perspectives but not from clinical practice standards.
Patients pressure their physicians to refer them for the latest imaging studies (the effect of direct-to-consumer advertising) regardless of the cost, imaging value in determining a diagnosis, well-publicized possible long-term effects of accumulated diagnostic radiation.
This is a litigious world and frankly, lawyers are probably at the root of ordering these imaging studies as well. As this article also states, “Legal actions over failure to diagnose serious abnormalities are common, whereas lawsuits arising from the overuse of testing are exceedingly rare. Like most people, physicians tend to overweight small risks, especially when the consequences may be severe. A recent survey of Massachusetts physicians showed that 28% of diagnostic imaging referrals represent defensive practices.The cost may be compounded by similar fears on the part of physicians interpreting the exams, who may recommend additional imaging studies to reduce their uncertainty.”
At the end of the day though it is how we were trained that makes the difference. I was trained by Gary Jolly, DPM and Gary always said: “Only order a CT or MRI to CONFIRM your diagnosis. Don’t order to MAKE your diagnosis for you.” Amen!
If you are order a CT to make your diagnosis for you, Gary said it was kind of like throwing strands of spaghetti against the kitchen wall to see if any of them would stick. I like that analogy. It has stuck all of these years. I want to know the diagnosis before I take out that order pad so that I may confirm my diagnosis.
Sure there were plenty of times when I was surprised. That is why it is the practice of medical arts. We are never through with the learning process. But our rate had better be in the high 80th or 90th percentile or we aren’t doing justice to our patients.
What I disagree with these authors about though is that I think, with the recent publicity about the cumulative damage of CTs and PET scans, there will be in the future more lawsuits from patients who have received too many of these studies and have cancer later in life. I, for one, don’t want to see my name among the plaintiffs as a physician who went fishing for a diagnosis by ordering multiple scans in hope of chancing upon one.
There was another choice metaphor we had for that:
“The old blind hog finally found an acorn!”
