MEDICAL IMAGING PROBLEMS: Better--and better access to--scanning technology lets doctors hunt for rare and serious internal injuries, but is it worth exposing so many patients to radiation to find the rare cases?
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As medical imaging technology has increased in sophistication and accessibility over the past decade, it is little wonder that the number of scans has also been on the rise.
Conflicting reports have emerged about whether these additional tests are having a commensurate impact on diagnosis—and cure—rates. In fact, a new study shows that for life-threatening injuries, a threefold increase in the number of computed tomography (CT) and magnetic resonance imaging (MRI) scans in emergency rooms has not resulted in an improvement in useful diagnosis.
On the ground, in hospital wards, however, doctors know that the scans can quickly help them see things that other tests cannot. "These CAT scans are way better than the x-rays," says Frederick Korley, an assistant professor of emergency medicine at Johns Hopkins University School of Medicine and co-author of the new study. New CT scans can offer rapid and detailed information about a patient that extensive x-rays, physical examination and observation are often hard-pressed and slower to reveal.
Although Korley and his colleagues had expected to find an increase in the use of these advanced imaging scans in 2007 than in 1998, "the increase was definitely more than we had anticipated," he says. Their study, which was published online October 5 in JAMA The Journal of the American Medical Association, analyzed nationwide hospital data sampled 65,376 injury-related emergency room (ER) visits between 1998 and 2007.
The researchers found that in 1998 a person admitted to an emergency department with an injury had about a 6 percent chance of having a CT or MRI scan. In 2007 that number had jumped to 15 percent. Life-threatening conditions were uncovered by these scans in 1.7 percent of the sampled 1998 ER visits and about two percent of those sampled in 2007. The most dramatic usage increase occurred between 2003 and 2007, during which time the percentage of injured patients who received CT or MRI scans almost doubled.
"It is concerning," Korley says of the trend, but simply based on their analysis, he says, it is not clear that the current imaging rate constitutes "an overuse" of the technology.
Other researchers who have been following and working in the field were not surprised by the study's results. Joshua Broder, an associate professor of emergency medicine at the Duke University Medical Center who was not involved in the new research, is also "worried about the trend," he says.
Many observers, he notes, see these large increases in diagnostic imaging and say, "'What the heck are these people doing? They're just scanning everybody,'" Broder notes. But the view from the inside is much more complicated.
Doctors' dilemmas
When an emergency physician faces a patient with severe and possibly life-threatening injuries, that doctor often needs to make speedy decisions about what tests to order.
"Not every single person needs a test," Korley says of the scans. But with scaling back on detailed imaging tests "will come a potential small miss rate."
Some severe injuries, such as a crushed aorta, will likely be missed by x-rays and physical examinations. Although many of these instances, including aortic injuries, are rare, trauma patients who have them—usually as a result of a rapid deceleration injury, such as car crash or large fall—face a high chance of dying if the condition is not rapidly diagnosed. And just the possibility of discovering such an otherwise hard-to-find but severe internal injury, Broder says, is often enough to prompt a physician to order scans.
"One of the main motivators for doing all those scans is to hunt for that needle in the haystack," he says. "No physician wants their patient to die because they didn't find an injury." And aside from ethical and moral concerns, he notes, underdiagnosis is "a significant source of liability."
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10 Comments
Add CommentAnd aside from ethical and moral concerns, he notes, underdiagnosis is "a significant source of liability."
Reply | Report Abuse | Link to thisBINGO!!! Ladies and Gents... we have our winner.
Yup... shotgun testing is "defensive medicine" at it's worst. It's medical liability ("CALL 1-800-BAD DRUG") and all of its ugly ramifications driving this train of excess testing, procedures & specialty consults... and (duh) skyrocketing costs.
"Life-threatening conditions were uncovered by these scans in 1.7 percent of the sampled 1998 ER visits and about two percent of those sampled in 2007." According to my math, that's almost an 18% increase in diagnosing Life-threatening conditions. That's great! I say buy more MRI's. Just cut the size of the military in half to offset it.
Reply | Report Abuse | Link to thisI have one Kidney and it had been years since I had a full checkup, in fact so long ago all the records were gone, so my doctor and I decided it would be a good time to have the status of my internal workings checked by one of these. We didn't expect anything and hoped we wouldn't find anything wrong which we didn't however this gave us a base line on my present condition in case something does happen in the future. The point is not all test are to find something but to just see what is. This leads me to believe that the reason such articles are being released recently is because the government and insurers are looking at how they can cut expenses by not allowing test on these machines based on the idea that they don't find anything. By the way I paid cash for my test because my insurance doesn't cover doctors visits.
Reply | Report Abuse | Link to thisDefensive medicine is just a component. Doctors also succumb to marketing efforts by pharma and medical suppliers. Of course one of the marketing goals of medical companies *is* to raise the specter of malpractice. If doctors don't use their inevitably amazing and new product, a product on the cutting edge of technology, their medical competence might be questioned. Perhaps more rigorous FDA approval standards and oversight might limit such needless overuse of products if such product limitations were more thoroughly discovered before they were actually employed in ordinary practice.
Reply | Report Abuse | Link to thisAlso, actual malpractice costs are not that great relative to the overall cost of health care. What is great is the fear of malpractice suits. The whole notion of limiting awards as a remedy to defensive medicine will have little bearing on doctors' irrational fears, which frankly will likely always supercede rationality on the matter. The insurance industry routinely sends out trial lawyers in seminars to stoke such fear in doctors to keep them running scared (presumably to limit their own costs down the line). That fear mongering will not stop with tort reform.
Many frivolous claims come from patients seeking retribution for a doctor sending delinquent unpaid bills to collections. That may not be the claimed basis of a suit, but it's usually the discovered basis. Unless such suits can be curbed prior to the disruption of a doctor's life, tort reform won't change much. Exposure to the legal system even if you are a sure winner is still a waste of time. The problem is a system that forces people at every step of the treatment process to weigh the weight of their life by the money they make. People natually get touchy when others start messing with the most basic necessities of life.
I occasionally volunteer in a free clinic. Malpractice claims and rates are essentially non-existent in such facilities. People simply do not sue for frivolous reasons when money is not an up front issue in treatment. Period. Overtreatment is driven by fear (defensive medicine), greed, or both. Both medical ethics and patient expectations demand medically consistent and equal treatment regardless of their ability to pay. Lawsuits will decline automatically as a health care system sheds its role as avaricious money-collector.
Please remember also, hospitals make a lot of money with MRI and CT scans. The motivation to overuse diagnostic tests is not always simply defensive. Defensive medicine makes a great cover for profiteering.
Reply | Report Abuse | Link to thisI have also noticed a large number of research papers I think stretching a point to draw conclusions from fMRI scans. I have to wonder if these also are not produced by organizational projects to justify their investment in or budget for scanning technology...
Reply | Report Abuse | Link to thisWhen I first heard of scanning computed tomography, decades ago in a Scientific American article, one of the points made was that it actually submitted the patient to less X-Ray radiation than traditional X-Rays. Has something changed since then?
Reply | Report Abuse | Link to thisThis article displays a fundamental lack of understanding, CT scans are certainly associated with high doses of radiation , the same sort that is used to treat cancers but can also cause them . In contrast, MR scans are not as there is no ionizing radiation , there is currently no known adverse biological effects of MRIs (but watch out for bits of ferromagnetic material which can cause damage by migrating through tissue such as metal splinters in the eye) I would happily undergo a regular total body MR but would think long and hard about undergoing CT scan. Failure to distinguish between the two techniques is confusing for the non medic reading this article.
Reply | Report Abuse | Link to thisDitto Rajesh.
Reply | Report Abuse | Link to thisThis article is highly misleading about the risks associated with MRI and 'radiation exposure'. Clinical MRI scanners operate using radiofrequency EM radiation and are regulated in much the same way as cellular phones. Of course, there are other (small) risks associated with a strong magnetic field and contrast agents, but these aren't discussed in the article.
Rajeshmunglani is right. MRI and CT should not be lumped together in this piece, which displays surprising lack of understanding for an author in a scientific publication. MRI do not emit ionizing radiation. That is the kind of radiation that creates reactive chemical species that can attack chemical bonds, break DNA and RNA molecules, and potentially cause cancer. MRI uses magnetic fields, not ionizing radiation.
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