Is it ever right to order a CT scan before an examination? Patients Need to Know!
DMN: Why is this an important discussion to be having?
RG: Overuse of diagnostic imaging yields no benefit to patients. It can cause more harm than good if incidental findings beget more testing that finds nothing, while exposing patients to risks and the potential for complications. This is the primary reason to be having this discussion.
Also, as a society, we can’t afford to keep doing what we are doing, whether it is unnecessary surgery, tests, procedures, or drugs. Many health insurance plans now have high deductibles, which require people to pay even more out-of-pocket.
DMN: What’s your background and experience with patient safety as it relates to imaging?
RG: I did a deep dive on patient safety when I wrote Wall of Silence, the first book to tell the human story of medical errors, while at the Robert Wood Johnson Foundation. It became clear that errors in medicine too often occur when medically inappropriate tests and treatment are provided. So next, I wrote about overuse in The Treatment Trap and one of the chapters is on diagnostic imaging. The American mind has been marinated to believe that more testing, more doing, is better. It isn’t so. Overuse is a patient safety issue.
DMN: What are some of the main patient safety issues with imaging? Which events stand out to you in particular?
RG: I gave grand rounds at a hospital on the East Coast and an internist candidly talked about a woman who kept coming to the ED complaining of abdominal pain. Each time, she got a CT scan and the results were always inconclusive. Her pain never went away so she kept coming back. After more than 2 years, she had had more than a dozen abdominal CT scans in the same ER. No one noticed. Finally, when the internist saw her for the first time, he checked and counted all the scans that had been done. He diagnosed her correctly as having lead poisoning with a simple blood test.
Diagnostic imaging is no substitute for clinical assessment skills, a competently-performed physical exam, and good clinical judgment. Often, CT scans are ordered before a physician examines a patient.
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I remember a seasoned hospice physician tell how the first inclination of palliative care fellows who came to train at his hospice was to order a CT scan on dying patients. The seasoned physician had to turn off the default button and ask, “So how will the test results change how you care for this patient?” With all the technology at our disposal, it is too easy to lose sight of how to use it so it truly benefits patients.
How do you think these patient safety risks for imaging can best be prevented?
RG: A first step is for hospitals to routinely identify “outlier” cases where repeat patients in the ED have an inordinate number of diagnostic imaging tests.
To prevent double chest CT scans, facilities can institute a “hard stop” when a physician orders a double scan. It would have to be approved before it can be performed.
Hospitals need to ensure that children are given “child size” radiation exposure rather than “adult size.”
DMN: How have campaigns like Image Gently, Image Wisely and Choosing Wisely been helping this effort?
RG: These campaigns have raised awareness about the need to reduce unnecessary imaging and ensure that children receive the right level of radiation exposure. Pediatric specialty hospitals have had success in reducing CT volume. Image Wisely is focused on radiation exposure in adults. For Choosing Wisely, the American College of Radiology identified common clinical scenarios where imaging is overused, such as CT scans for uncomplicated headaches.
DMN: The American Board of Radiology Foundation has been working on a national strategy for safe and appropriate medical imaging. How is this coming along and what do you think any plan should look like?
RG: The Foundation has held a series of conferences to develop the strategy and it has attracted thoughtful people who want to improve patient care. One of the challenges is embedding continuous quality improvement — and the knowledge to undertake it — in the day-to-day work. Professionalism requires not only doing the work but improving it.
A second, bigger challenge is that reducing inappropriate use will cause revenue to drop. The health care system needs to financially reward good care.
DMN: Anything else you would like to add as it relates to patient safety and imaging?
RG: The public has a role to play to ensure appropriate imaging. Patients can ask: Do I really need this test? What are the risks and how do they stack up against the benefits? What if I don’t have it? Can I wait? How might my care change as a result of this test? Is there an alternative?
Rosemary Gibson is a Senior Advisor to The Hastings Center and an editor for JAMA Internal Medicine. She is also principal author of the critically acclaimed book, Wall of Silence, which tells the human story behind the Institute of Medicine report, To Err is Human. She wrote The Treatment Trap, which puts a human face on overtreatment. The Battle Over Health Care: What Obama’s Health Care Reform Means for America’s Future is a nonpartisan analysis of the future state of health care and its impact on the economy. Medicare Meltdown examines the business of Medicare and its impact on the fiscal challenges facing the federal program for older Americans.