Volume 8  Number 3  August 25, 2011
Second Opinions

Diagnostic Delirium

...Speaking on specialization and the "amputation" of society, each trade and profession "ridden by the routine of... craft. The priest becomes a form; the attorney a statute-book; the mechanic a machine; the sailor a rope of the ship." — (And the doctor a CT scan.)

Emerson in The American Scholar, quoted by Cynthia Ozick in Harper's Magazine

Researchers at the University of Michigan,Yale, and Emory, reviewed 1.3 billion weighted records of emergency visits between 1996 and 2007, 97 million of which included patients who received a CT scan. Using data from the National Center for Health Statistics compiled by the CDC, the study, published online in the journal Annals of Emergency Medicine was a shocker. The authors reported the number of times CT scans were used in emergency rooms between 1996 and 2007. Over this 12-year period the number of CT scans rose 330 percent, or 11 times faster than the rate of ER visits. Just 3.2 percent of emergency patients received CT scans in 1996—13.9 percent of emergency patients received them in 2007! As Dr. Keith Kocher, first author remarked, "This means that in 2007 one in 7 Emergency Department (ED) patients received a CT scan. It also means that about 25 percent of all the CT scans done in the United States are performed in the ED."

According to Dr. Kocher the study "Doesn't provide the reasons why CT use increased over time—but it does make one wonder." I can fill in here, since the study itself provides an insight. CT use increased for all 20 of the most common reasons patients came to the emergency room, and was particularly high for neurologic complaints, flank (side) pain, convulsions, vertigo, headache, abdominal pain and general weakness (sic!). The number of emergency patients receiving CT scans increased primarily among patients with abdominal pain, flank pain, chest pain, and shortness of breath. During the 12 year period rates of CT use rose most dramatically among older adults.

Especially noteworthy were patients complaining of flank pain who had an almost 50% chance of getting a CT scan by the end of the study period. Unfortunately, physicians ordering abdominal or pelvic imaging to look for kidney stones are unaware that CT in this setting is hardly ever warranted–and rarely helpful–when urinalysis, a plain film of the abdomen and the occasional ultrasound will diagnose 95% of cases. This is one more example of intellectual surrender or lack of clinical skills combined with technologic seduction, a dangerous combination I have addressed in my textbook, Effective Medical Imaging: A Signs and Symptoms Approach.

The explosion of medical imaging via CT and MRI goes along with overuse if not misuse of invasive studies such as heart catheterization and upper GI endoscopy (EGD), subjects I have previously discussed. As of 2010, the number of CT scans performed in the United States has increased from three million per year in 1980 to 70 million today.

According to the Organization for Economic Co-operation and Development (OECD), among the 30 countries assessed in 2009, an average of 41.3 MRI exams are performed per 1,000 population. The United States is the top country, with 91.2 MRI scans per 1,000 population, more than double the average in other advanced countries or approximately 28 million studies a year.

Can we Estimate the Cost of Unnecessary Medical Imaging?

Health care experts, Government, insurers, drug and equipment manufacturers, among others, constantly seek answers to rhetorical questions like the above, but are obviously frustrated by the lack of relevant data. Moreover, without making some controversial assumptions about the way medicine is now practiced, one could end up playing dangerous games.

If you care to stay tuned, I will have more to say in my next Newsletter within the week.

Martin F. Sturman, MD, FACP

Copyright 2011, Mathemedics, Inc.

EasyDiagnosis is an automated online service that analyses existing medical symptoms and predicts likely causes and conditions. Click here to find out more about this unique service and click here to try one of our modules for free.