Editorial: R/O disease

By Stuart E. Mirvis, MD, FACR
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Dr. Mirvis is the Editor-in-Chief of this journal and Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

In a previous editorial, I complained about the lack of credible medical information we receive from referring clinicians on requests for imaging studies ("Why see the patient?" November 2003). In another, I raised concerns about our insatiable need, as imaging specialists, to obtain and provide the latest technology ("Does your CT have a cappuccino maker?" May 2004). These two very real phenomena have merged in a disturbing way and have had a major impact on how clinical medicine and diagnostic imaging interact.

I have noticed that the number of CT scans ordered from our Emergency Department has been increasing steadily. In fact, on many occasions, the number of CT studies performed exceeds the number of radiographic studies. Since the CT scanner is fast, available, close-by, and staffed 24/7, I suppose this should come as no great surprise.

However, in discussing this development with other radiologists on our staff, I realized that this trend is occurring throughout our practice. It seems that the CT scan is becoming the radiograph of the early 21st century. In our department, the volume of CT scans always grows at least 8% to 10% annually, while the number of radiographic studies declines. I am certain this is not at all unique to our institution.

If you are collecting the technical fees for these CT scans, you are a happy camper. If you are actually collecting a professional fee for your interpretations, this is also a good thing. Don't get me wrong, I love CT scans. They are my bread and butter, and offer a fantastic advance in diagnostic accuracy--no question. The information from CT often establishes a definitive diagnosis, guides and shows response to therapy, provides prognostic information, and often saves money in avoiding unneeded treatment, excluding disease, and avoiding more expensive or invasive procedures among other positive contributions.

So what's the problem? Well, more and more of our clinical associates, with our blessings, jump immediately to CT (and sometimes MRI) on the slightest whims. I believe one of their pet phrases is "if you can think of it, order it." Increasingly, I see indications for CT studies that are clearly poorly considered and vague, substitute for a history and physical examination, or are simply not appropriate, if you can imagine such a thing. In ancient days, circa 1979, when I was in medical school (and, yes, we had CT of sorts, with a mouse spinning the anode) we were taught to follow a process: Obtain a history, elicit physical findings, and formulate a differential diagnosis. We would then proceed, in a step-wise fashion, to use whatever skills and studies were available to establish or exclude a diagnosis. Remember all this? If not, consult an elderly internist.

At times, I wanted to rebel against this "inefficient" process and jump right to the test to get the answer (or so I thought). This is like turning right to the last page of a murder mystery and ignoring all the clues that would get you there eventually. The pressure to discharge patients quickly, have "the answer" on morning rounds, and eliminate the cumbersome process of "thinking" pushes us to go right to the high-tech study.

The pendulum has clearly moved too far in this direction. We are using the big guns often without fully taking advantage of the free information readily available. Our younger clinical physicians are losing the "art-part" of medicine in favor of checking boxes to order studies. Lord, please help the young physician out of residency who winds up practicing in rural Mon-tana without CT available 24 hours a day (nothing against Montana). We are increasing our irradiation of the population with poor understanding of the potential long-term consequences. We accept requests for CT (and other advanced imaging technologies) without question, because confronting a referring clinician to question a request or actually saying that a CT "is not indicated" is bordering on professional suicide in the current competitive environment. Interpreting a CT study with no or irrelevant clinical information compounds the over-utilization problem and denigrates the entire effort.

Maybe the next time you see a CT request that essentially says, "rule out disease" or an equivalently nebulous indication, you can take the time to call your clinical colleagues and discuss the matter. Remind them what they wear so proudly around their necks is used for. Perhaps share this editorial. As radiologists, we need to push back just a bit, to promote wise use of the technology, to actually act as a consultant with the patient's best interests, as well as those of the clinical physician, in mind. Otherwise, the radiograph will continue to go the way of the dinosaur, and a CT professional fee will be $7.37, without contrast.

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Editorial: R/O disease.  Appl Radiol. 

March 10, 2005
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