Very soon, our teaching hospital, located in a village in central India, shall use a new computed tomography (CT) equipment for obtaining high-quality radiologic images. The previous CT scanner- it had served us well for 10 years – was living a borrowed life. The hospital, therefore decided to invest into a new CT scanner.
The new CT scanner would surely change the way we make diagnoses, choose therapies and predict disease-related uncertainties. No one can deny that CT scanners- they have entered into a presbyopic age now- have helped us pick the strokes, cancers, infections, inflammations, and degenerations with reasonably good accuracy. Our radiology consultants and residents have every reason to be visibly excited. Then why should I sound a bit skeptical when it is time to celebrate?
For several reasons. I think that the risks, benefits, and costs of CT are often not publicly discussed by the doctors. Patients naively believe that the state of the art technology can reveal almost everything that their doctors wished to see, and once detected, these faults can easily be fixed. We cannot blame patients for such a wishful thinking. The glamour and the glitter of the technology can be very seducing. The images that a CT generates look too good to disbelieve them. The problem is with the healthcare professionals- they make no efforts to correct these wrong impressions. There are three reasons which should make the medical professionals realize that all is not well with the CT. Let me explain them.
First, many patients are being subjected to CT scans for wrong reasons. They need careful history and structured physical examination- and not a CT scan- to either rule in a disorder or exclude it. For example, tension headaches and migraines account for most headaches in primary care, but waiting halls of CT centers are occupied by patients with such headaches, whose cause can be easily and accurately diagnosed by a history alone. Less than 1 percent of patients with severe headaches- and normal neurological exam- have serious brain disorders and therefore, are unlikely to be benefitted by CT scans. And yet, CT head is routinely ordered by doctors as a screening test to confirm or rule out serious brain disorders. Take head injuries, a common reason for referral for a CT scan. A recent BMJ article teaches how to reduce use of CT scans in minor head injuries. Only 1 of 10 patients judged to have mild head injury has a clinically important finding on CT scan, and only 1 of 100 such patients require a neurosurgery. Patients at risk can be easily identified if doctors apply clinical decision rules on them- a task that requires no more than few minutes. And yet, almost every patient, regardless of the severity of head injury undergoes a mandatory CT scan in every hospital where such an equipment exists. Similalry, patients presenting with aching necks and stiff backs- a common problem in primary care- routinely undergo neuroimaging despite substantial evidence that imaging them is unnecessary, and is a waste of time, efforts and money. Researchers have shown that on CT imaging of the lumbar spine, a quarter of healthy people without backache have herniated discs and half the healthy backs have anatomical changes that are reported as significant by the radiologists. When orthopedic surgeons try to fix these findings, they are, according to the New England Journal of Medicine article, actually raping the lumbar spine!
Second, CT scans often discover unexpected –and irrelevant- findings. When patients alarmed by these findings seek medical consultation, doctors do not know how to interpret or address them. Radiologists frequently report asymptomatic healed ischemic infarcts in elderly people, degenerative changes in cervical and lumbar spines and adrenal gland tumors- appropriately called incidentalomas- which not only confuse the doctors, but also frighten the patients. Jerome Groopman quotes Dr. Terry Light in his book, “You can see so many things on an MRI, but nothing that’s clearly responsible for the symptoms. So you begin to go around and around. The hateful part of MRIs – I mean they can be a wonderful technology-but they find abnormalities in everybody. More often than not, I am stuck trying to figure whether the MRI abnormality is responsible for the pain. That is the really hard part.”
Third, CT scans, instead of saving a life, can cut it short. Rebecca Smith-Bindman questions the safety of CT technology in his very readable NEJM article. The author says that patients receive 100 to 500 times more radiation from CT scans than they do from conventional radiography and run a 1 in 50 risk of developing CT-generated cancer— a risk played down by the industry and the medical profession. The irony is that patients with benign headaches, minor head injuries, aching necks and stiff backs- the very people who frequently find their way into CT rooms, are not even aware of these risks- probably because their doctors are either as ignorant or do not have time to explain pluses and minuses. Let the CT specialists count the number of patients who visit their center, after they have prominently displayed this warning at their reception desk: “Of the 100 people examined by our CT scanner, two might eventually develop a CT-induced cancer.” Only patients will brave hearts will submit their heads for CT screening after they read this warning.
Finally, CT equipment is expensive. It costs about 15 million rupees to acquire a decent CT scanner and about 2 million rupees every year to maintain the equipment. My radiologist friend tells me that if they bill Rs. 2000 for a scan, and scan 10 heads, chests or bellies every day, they will have to wait for five years before they recover the cost of a machine- and by then the technology turns obsolete. Because it will be difficult to generate this number by a clean and honest practice, most doctors who own CT equipment promote the technology by inventing new indications for CT scanning, by cleverly placed stories in the newspapers, by lecturing in events organized by equipment manufacturers and social clubs, and by offering commissions to the doctors. “Half the patients who receive CT scans in my clinic,” he says, “do not need this test” but I do not refuse, for, I have to keep referring doctors and patients happy. Even in teaching hospitals, the very institutes where scientific evidence, and not commerse, should guide the use of diagnostic tests, CT scans are ordered indiscriminately and inappropriately. The worth of a radiology department is measured not by the number of unnecessary tests that it could avoid but by the number of CT scans the radiologists did. The more, the better. Hospital managers, morbidly obsessed with numbers and infatuated with technology can harm evidence-based healthcare. And when commerse impacts science, the art of medicine dies a unwept death.
Can we inject a bit of science when we order CT scans? Can we go back to history and physical examination before we hastily scribble a request for a CT scan? Can we invest some time with our patients explaining them that for several common disorders CT scans are not worth the time, money and efforts it takes to generate the images.
An image-shattering task for health professionals!
HI TECH Medicine is what everyone practices nowadays, whatever reason u might attribute it too, CPA or Diagnosis or what we very commonly write in papers, The patient is demanding one!!
To bring a little method the madness is absolutely called for….
In fact, a good start would be what they do here, u can order a CT/MRI without giving a justifying reason to the Radio consultant who then takes a call on whether it is needed or not…
Dearest Sir,
I read that first thing in the morning. As always, your subtle words made me rediscover the ever increasing fashionable dependence of modern medicine on these fascinating technologies. Same is true in the diagnostic laboratories where tests are sometimes ordered either as a part of attractive panel or just because they are available in the market.
The proposed disclaimer “Of the 100 people examined by our CT scanner, two might eventually develop a CT-induced cancer.” was a nice idea!
Best regards,
Sandeep
Unnecessary use of new imaging techniques is sometimes intentional, but mostly due to ignorance, habit developed during training and attraction towards new technologies. Many times it is ordered even when the doctor knows that the findings will not change the course of management.
What makes it worse is, if the patient goes for a second opinion, s/he will definitely be reminded that the previous doctor was not competent enough.
This blog is a good beginning to educate the budding doctors at Sewagram.
Dr. Sudhir Bhave said….
Extremely well written! Makes a lot of scientific (and in true SP style, also linguistic) sense. Wish all referring doctors read this!
Dear Sir
Its true most of us are aware of only one side of coin. Unjudicious and excess use of any thing is bad. I agree with Subodh, blogs are very effective teaching tool for budding doctors.
Ramji
Dear SP, Nice article! Right message for medical fraternity.Commercial approach to medicine, loss of traditional trusted doctor-patient relationship and greed are the root causes. The same is also applicable to pathological tests and all other modern diagnostics.—Vivek Poflee
Dear Sir,
It is indeed a proud feel to add a modern investigatory tool to Sewagram Technosavy team. I remember, you would not allow us to get a X Ray chest done unnecessary for a respiraotory case, just to emphasise the importance of clinical examination. I am sure, you will use the CT scanner with precise indications, without bothering about the recovery of its investment.
We are proud of you sir.
Dr. Arvind Ghongane
Mumbai
Enjoy reading your blogs very much Dr Kalantri. You stated all the reasons for inappropriate use of CT scanning but in India you don't have to practice defensive medicine as much as we have to in the West.
In contrast to India, in the US perhaps the most common reason for ordering a battery of tests by physicians is for medico-legal purposes, to protect themselves from law suits which follow for sure if they miss a major finding like a mass or fail to pick up a finding on exam. Also, we usually follow protocols- for example, dementia evaluation requires a MRI as it helps differentiate vascular causes from Alzheimer’s disease and can differentiate from other dementias. We also need a MRI to figure out how well the findings correlate with the neuropsychiatric testing.
In hospital I see residents often ordering ct scans on patients with confusion or delirium. Delirium is most commonly secondary to medications, infections or electrolyte imbalance.
I recently saw an elderly man, a highly educated and very active person, who was having severe episodic headache post-exercise. He had occasional combativeness and severe weakness during the episodes but with no associated focal neurological deficit. On some of the hospitalization for these episodes he was found to be in atrial fibrillation. He was given a diagnosis of transient ischemic attack (TIA) on every occasion. His quality of life was severely affected and was unable to do some of the activities of daily living and none of the instrumental activities of daily living like driving. His daughter pointed out that the exercise-induced headaches and weakness followed a cyclical pattern. The history gave few differentials- (1) atypical migraines or (2) seizures and (3)x. 4) or? stenosis of a blood vessel in brain. Over a period of six months, he had had six MRI scans, (no MRA) which showed minor vascular changes. He was seen by several physicians, including a neurologist before we saw him. Several other major geriatric problems got caught on assessment but they were just probably separate and in addition to the above (can’t give details as doing so amounts to violation of Health Insurance Portability and Accountability Act (HIPPA). We ordered a CT scan of abdomen that picked one of the differentials ( 3 )confirming an adrenal tumor, blood work is still awaited. Typically unexpected adrenal tumors- incidentalomas- are often picked up on CT abdomen and we don't know what to do with them. Our patient has probable pheochromocytoma. It seems everyone was looking at a wrong site.
But again a careful history taking, listening to patient and family and going back to medical school days of having a differential list would have helped avoid such expensive and repetitive work-up.
It is uncomfortable also to go through an MRI. Also ct scans can cause worsening of renal functions and put a patient in renal failure so the GFR needs to be at least over 40 or a creatinine value under 1.6 mg/ dl in most of our patients to get a contrast. Similarly to get a MRI now also patient needs a creatinine level of under 1.6 mg/dl as gadolinium dye used has been found to be linked to nephrosclerosis of the kidney.
Detailed work ups are important in patients presenting with medically unexplained symptoms, but we need to obtain good history before we order tests.
“The mind cannot comprehend, what it does not perceive” “There is knowledge (storage of information), there is intelligence (being able to retrieve this knowledge), and then there is wisdom (to be able to assimilate the knowledge and use it wisely). The ultimate purpose of education is ultimately to make us wise.” As Swami Vivekanda rightly says “Education is not the amount of information that is put into your brain and runs riot there, undigested all your life. We must have life-building, man-making, character-making, assimilation of ideas.”
Priya Mendiratta MD MPH ,Assistant Professor department of Geriatrics, Donald w Reynolds Center for aging, University of Arkansas for Medical sciences Little Rock AR 72205
Things are clear to everybody, who is practicing that what for we take help of newer technologies(For Diagnosis or else ).But blaming these technologies altogether will be wrong. They very well help us in diagnosis and patient care, even many times above clinical skills. For every thing in present have a good side and a bad side.But good side of this overweigh bad side.
It is true that we do get carried away on just one diagnosis sometimes and blind ourselves to other possibilities. I think part of it may also be over- correction of a bias we naturally feel for medical personnel. I think it is harder to be as objective when we are dealing with colleagues or students. So maybe correcting for that inborn bias can cause as much of an error as the bias itself ? Lots of food for thought, as always.
Do keep up the great work – the teaching and the writing.
Gayatri Iyer