During my last two weeks on service, whenever we ordered an MRI or a CT, I wondered was this scan necessary and will it really change care? In addition to increasing scrutiny on the perils of unnecessary radiation, the blogosphere was abuzz about this topic (see Bob Centor and Bob Wachter among others). Coincidentally, our grand rounds speaker last week was Dr. Bruce J. Hillman who is the chief of the Journal of the American College of Radiology, and recently coauthored a book on the subject titled the Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care.
Many of Dr. Hillman’s observations were spot on – radiologists hedge – they overcall things due to concerns they will miss something. An overcall is better tolerated than a miss. As a result, many patients are diagnosed with incidentalomas or pseudodisease that could lead to other costly workups and expose them to unnecessary radiation. How can a clinician ‘ignore’ the overcalled incidentaloma in the world of malpractice? Dr. Hillman also spent a lot of time discussing the overreliance on scanning in teaching hospitals. In the busy overworked environment in many hospitals, it is easier to get a scan than do a thorough history and physical exam. (This is assuming that physical exam skills are actually good enough to pick things up).
Unfortunately these days, residents actually have LESS time for history and physical. With duty hours, the chance they actually met a patient on admission and obtained the history is lower. There is also less time to make a decision. With pressure for shorter length of stays coupled with system inefficiencies, if you’re not in the queue the day before for the imaging test du jour, you will add on an extra day just to get the test. Lastly, while fear of litigation does play a role, physicians also worry about backseat quarterbacking and looking bad in front of peers. For example, I often thing to myself, if this patient comes back to the ED with the same complaint, would those physicians think I was crazy for not getting a scan? Because imaging often helps make the right call, the question is when is it appropriate or inappropriate?
This is when radiologists have traditionally come in. When I was a resident, I recall going down to radiology and asking the film clerk to get my films (in fact, being friends with the film clerk was as important as being friends with the nurse). After waiting patiently in line in the dark room for the next available radiologist in the specialty of interest, I ‘presented’ the patient with a one liner and the specific clinical question. The radiologist would then reread the films and discuss the case, often asking for more questions. At the end of this conversation, I often had a plan which usually did not involve another scan.
While technology has replaced our trusty film clerk as our greatest friend, it has also become our worst enemy. Today, I can look at images on the computer, even on the iPads that our residents carry on rounds, and eagerly await the ‘final read’ by the attending. Ordering tests has also become easier. Most of my time as an intern was spent calling down to radiology convincing them I needed the test. That is in sharp contrast to today when orders are just entered electronically with a drop down selection of ‘reasons’ that include ‘r/o pneumonia’ or ‘dyspnea’ (fancy medical term for shortness of breath). No wonder most of the reads come back as “suggest clinical correlation.”
So, how do we fix this? Well, Dr. Hillman highlighted the need to start early in training – essentially to teach students and residents to do this better. So, this past week at a curriculum meeting, I was pleased to learn that one of our expert radiologists would be formally integrating radiology into our third year IM clerkship, including costs of testing and appropriateness of tests. However, we all know this will not change anything if the faculty are pushing for the scans. Professional organizations have recognized this, and started to offer guidelines for practicing physicians. Earlier this month, the American College of Physicians released guidelines calling for internal medicine physicians to minimize scanning for low back pain. The American College of Radiology has released “appropriateness” criteria for a variety of clinical conditions which include the radiation risk for each test. Since faculty may or may not see guidelines, Massachusetts General Hospital has gone one step further, embedding these criteria into the electronic ordering system for radiology testing as a hard stop, which offers suggestions for low yield exams and require that a physician override the system to proceed. Indeed, technology can be a better friend. Perhaps, another solution is to talk to our old friend the radiologist.
-Vineet Arora, MD