The flames seem to be finally dying down after a contentious online debate sparked by Dr. Robert Centor, who blogged recently about a study showing increased use of CT scanning in hospital emergency departments, and suggested this is most likely due to the patient load and pressures on emergency-room doctors.
“It appears that too often CT scanning takes the place of a careful history and examination,” he observes. “This can occur when the emergency physician is drowning in patients.”
The ensuing discussion was argumentative – one poster accused Dr. Centor of being “smug” – but it shed some interesting light on an issue that’s far more complicated than it appears on the surface.
The No. 1 cause of excess CT scans is fear of litigation, one physician said. Someone else stated, “We order too many scans because we can.”
In the high-stakes emergency setting, physicians can’t afford to miss a diagnosis because they’ve decided to skip a test, wrote another physician: “My experience doing emergency medicine is that a lot of CT scanning is ordered either to rule out conditions where we are expected to have 100% certainty not to miss (subarachnoid hemorrhages are one example already mentioned), or where the demand for certainty is being driven by the patient or our inpatient colleagues.”
The debate continued in a second post, where one of the key questions became: How do we know patients are receiving too many CT scans, and how do you define “too many”?
So why should the average person care about this issue? There’s no question that imaging technology has aided greatly in diagnosing what’s wrong with the patient. It has helped reduce uncertainty and in many cases eliminated the need for expensive and potentially risky exploratory surgery. But in much of the public discussion, the focus has been on the benefits rather than the down side. We talk about the certainty of diagnosis and less about the incidental findings that can lead to more testing and possible harm to patients. We talk about how beneficial it is to obtain high-definition images of what’s happening inside the body and not so much about the long-term impact of all that radiation exposure.
There are some signs the tide may be turning. The risks vs. the benefits of medical imaging are being discussed more often, especially among health care professionals, in ways that are thoughtful and evidence-based. Consider Dr. Bob Wachter, one of the leading patient safety gurus in the U.S., who blogged recently about the potential harm inherent in CT scanning. “Even if the risks turn out to be less than we fear, most skeptics now agree that we’re causing a lot of cancers, and that many could be prevented if we took a few sensible steps,” he wrote.
Dr. Wachter concludes the medical community needs to “Just Say No more than we ever have before.”
While this is a sound clinical concept, I suspect it’s easier said than done. According to a study published in December in the Annals of Emergency Medicine and conducted with a cross-section of patients who came to the ER with abdominal pain, patients felt more confident about the care they were receiving if a CT scan was part of the medical evaluation. They also underestimated how much radiation is contained in the average CT scan, and many couldn’t accurately recall their previous history of CT scans.
Patients aren’t the only ones contributing to the overuse of CT scans in the United States, but their expectations clearly are among the factors. A little education and awareness by the public certainly wouldn’t hurt and it might even help lead toward a more judicious, restrained use of CT scans.
West Central Tribune photo by Ron Adams