Dr. Mirvis is the Editor-in-Chief of this journal and a
Professor of Radiology, Diagnostic Imaging Department, University of
Maryland School of Medicine, Baltimore, MD.
The following story will probably sound familiar to most
radiologists. While on call one night, we received a request for pelvic
sonography. At night the Radiology Department is responsible for
emergency pelvic sonography, instead of the OB/GYN department. The
Emergency Medicine (EM) resident described the clinical symptoms, which
did not sound like anything remotely emergent, and the radiology
resident suggested that the patient be scheduled for a complete routine
pelvic sonography the next day. There are a lot of real emergency
imaging procedure requests at night, and given staffing and the need
for rapid interpretation, we try not to do studies that are clearly, in
our opinion, nonemergent.
After making this suggestion, the clinical history changed from mild
lower-abdominal pain to severe abdominal pain and now an ectopic
pregnancy needed to be excluded. Of course, the resident and I were
somewhat surprised and miffed at the sudden change in the history. The
EM resident then insisted that her “attending” wanted the sonography
performed—the “ace-in-the-hole” approach. I strongly encouraged the EM
resident to ask the EM attending to stop by the reading room when an
opportunity arose so we could talk. The EM resident was a bit surprised
as the new academic year had recently begun and she did not realize an
attending radiologist was always covering emergency imaging studies.
About an hour later, the EM attending stopped by the reading room.
He is a great guy, friendly, respectful and knowledgeable. He
apologized for the resident’s style in requesting the study and
admitted that the clinical picture was somewhat murky and that the
presentation was nonurgent. I carefully explained our point of view and
that we were covering many really sick patients. Our technologists were
not available to perform the nonemergent study, so the resident who
would have had to perform the study would have spent an hour away from
his other multiple and varied responsibilities. This would create
delays in many other activities required for other patients who were
indeed quite ill or emergent. I am personally willing to “become” the
resident while they do sonograms, but I am not as efficient nor fast
enough on my own to cover everything (as hard as that may be to
The EM attending seemed to understand and agree. I found out the
next day that the study was requested and performed after another
radiology attending and resident took over coverage.
There are many reasons why we would recommend against a study. Some
studies are technically or medically inappropriate, whether the wrong
modality is chosen to answer the clinical question or if it would lead
to a study that is medically contraindicated. Other reasons for
recommending against imaging are cases when an exam would add no
further information to what has already been established, or when an
exam may be indicated but is done so electively. In several countries I
have visited, when the radiology resident or attending says that a
study is not indicated, the decision is typically respected by the
requesting physician. These are countries that are not limited with
respect to equipment or availability.
It has been my experience that when a nonradiology department
consultant makes a recommendation, either for or against a study or
procedure, usually that advice is followed. Why is it that so often
when the responsible radiologists says “no” it is often dismissed and,
not atypically, leads to quite a battle? Is the radiologist’s opinion
generally faulty? Is it that he is just being lazy? Is it that they do
not have the best interests of the patient at heart? Is it that they
did not examine the patient? Is it that they are not “real doctors?”
I find it odd that our clinical referrers are generally all too
happy to accept our final opinions about what studies demonstrate
diagnostically, just not about an opinion that a certain imaging study
is perhaps not indicated. I believe most radiologists would be fine
with putting a note in the chart concerning their recommendations, but
for some reason, this is seldom sought. There are some referring
physicians that I always say “yes” to. It is too painful a process to
proceed in any other fashion. In most cases, attending-to-attending, I
start by saying the study will be performed if it is their wish, but
that I would like to discuss the circumstances of the decision first.
Most will agree to this, but still want the study. I will not allow any
study where the patient is at reasonable risk for a major complication,
but usually such issues can be resolved to mitigate such risk.
I know the story above resonates with most academic radiologists,
but I do not know how such matters play out in the private setting. I
assume the answer is usually “yes,” except when a given study would put
the patient at unacceptable risk.
I wonder how much the issue of medical malpractice concern
influences the aggressiveness with which some imaging studies are
pursued. Many a resident and attending have given the indication of
just “CMA” (covering my assets) as the actual indication. When looking
at the medical literature I was amazed at how little there was in the
way of research that addresses this issue. Asking the physicians
themselves is worth relatively little as they often will not admit this
behavior. However, when asked about other physicians’ observed behavior
they will indicate that malpractice concern has a definite influence.1
A survey asked physicians if, based on their experience, the fear of
malpractice liability causes physicians to order more tests than they
would normally order just based on their medical judgment alone. On
this survey, 91% answered “yes” and 11% “no.”1 Certainly, from the perspective of an emergency radiologist, this response would be expected.
I do not know how the health care debate will come out, that is, who
will benefit and who will not. There are so many disparate interests
pulling in different directions that it will be a wonder if anything
that is both comprehensive and solves real problems can result.
All I know is that when tort reform was “taken off the table” at the
very start, the ultimate sincerity of the entire effort was suspect. We
will all see how things go. In the meantime I guess it’s better to just
1. Common Good Fear of Litigation Study: The Impact on Medicine.
April 11, 2002. Available at:
http://commongood.org/assets/attachments/68.pdf. Accessed September 8,