Applied Radiology

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

As radiologists, we all want to provide the best care for our patients. This means, among other things, that we provide an accurate and timely interpretation of appropriate imaging studies. It also means that we interact with referring physicians to help select the most useful, accurate, safe, and cost-efficient imaging to verify or refute a diagnosis.

In today's medical environment, radiologists perform an abundant number of studies, both appropriate and not appropriate (not the best clinical choice or simply not indicated at all). In the U.S., the equipment is generally readily available to perform most high-tech imaging studies, interpret them, and provide final reports rapidly. If there is any doubt about the diagnosis after the clinical assessment and lab work, imaging is often obtained to confirm, exclude, or offer alternative diagnoses. Unfortunately, there are almost always some doubts about the diagnosis. Many presenting symptoms can be caused by myriad etiologies-some benign, some distinctly not. The very low threshold for requesting imaging stems from a combination of a litigious medicolegal environment, the accuracy of imaging information, and the ready availability of studies.

With subspeciality radiology expertise, appropriateness guidelines for imaging have been developed for many clinical presentations. ¹ I doubt that many radiologists are familiar with, use, or promote them. They may, in the future, be incorporated into computer-based order entry systems for radiologic studies.

Many of us have also experienced occasional encounters with referring physicians in which we offer an opinion that a certain test is inappropriate for the clinical indication (assuming one is provided). I hope that your suggestion is at least considered. On the other hand, you may hear, depending on your relationship with the referrer, that "you are not taking care of the patient," or "have you examined my patient?" Of course, you are taking care of both the patient and referring physician. Our judgments about the use of certain imaging studies are based on the distillation of the history, physical examination, and lab work provided to us (or not) by the referring physician. We trust his/her medical judgment to form our opinion about whether a certain test is appropriate. We would expect them to trust us in our area of expertise.

As a specialty of medicine, we profess-at least at meetings and in the literature-that many imaging studies are not appropriate to the clinical issue. A large number of studies (particularly in the ER) are requested based on minimal symptoms and produce a very high rate of negative results. Indeed, a very wide net is cast to catch very few fish. Often, we know (as does the requesting physician) that the study is performed to protect the collective gluteus maximus.

Let's postulate that a group of physicians in a hospital, including radiologists, could sit down and, based on current recommendations in the literature and published guidelines from specialty organizations, determine which imaging studies were appropriate, in which order, to work-up common clinical presentations. This group could meet twice a year to observe the effects/results of their local guidelines and to digest any new literature that might be relevant to their approaches. This is no panacea, since many clinical presentations are complex and difficult to resolve into neat categories. While cookbook approaches to medical decision making have their limitations, they have certainly become a mainstay of practice today.

Let's further assume that a patient presents with a complaint that fits into a clinical scenario covered by the institution's imaging guidelines and they are followed to the letter. Still the patient's medical outcome is suboptimal, and a lawsuit is filed. Is it likely that a physician following documented guidelines who did not order a "nonindicated" study (based on the majority of the literature) would be guilty of malpractice? It would seem to be very unlikely.

Such an approach should decrease the number of unnecessary imaging studies, now often obtained as a reflex, and allow for more appropriate study selection. Physicians would feel less compelled to "unload the shotgun" of tests in the search for diagnostic certainty. This concept runs quite contrary to the current use of and literal addiction to diagnostic imaging.

Perhaps, the potential for a real decrease in imaging studies and its impact on income is a powerful disincentive to move in the proposed direction. Perhaps, diagnostic doubt is not something today's direct patient care physicians are willing to tolerate. At least we should make use of contemporary, well-founded imaging guidelines. It is in the best interest of patients and ourselves. There are undoubtedly far more draconian and clinically insensitive ways to limit the volume of diagnostic imaging, which contributes to a rapidly rising national medical bill. ²

1. Blackmore CC, Medina LS. Evidence-based radiology and the ACR Appropriateness Criteria(R).J Am Coll Radiol.2006;3:505-509.
2. Rothenberg BM, Korn A. The opportunities and challenges posed by the rapid growth of diagnostic imaging. J Am Coll Radiol.2005;2:407-410.