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
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
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.