Tuesday, January 1, 2008

Too Much Scanning!!

With all due respect to many of my radiology friends, I came across a great article about the OVERUSE of CT scans in medical practice today. It is in Time and written by a physician (http://www.time.com/time/health/article/0,8599,1698163,00.html).

As most of the physicians who read this blog can attest to, physical exam is all but dead among the new trainees in medicine. Abdominal pain used to incite a thorough physical exam for signs of rebound tenderness, guarding, pitch of the bowel sounds, examination for tenderness at McBurney's point, Rovsing's sign, and percussion throughout the abdomen. Now, abdominal triggers the immediate ordering of a CT scan.

There are so many problems with this new paradigm. First, the art of the physical exam is lost, thus trainees will be ill-prepared to ever practice medicine in a society that does not have the resources of the United States. Secondly, the cost of the unnecessary tests is an additional heavy burden on total health care expenditures, thus driving up insurance premiums even further for many Americans. Third, as Dr. Haig points out in the Time article, the patient is exposed to a hefty dose of radiation, which may result in the development of malignancies over time (remember, several patients receive MULTIPLE CT scans in the course of care, not just one).

And, as a recent Yale med grad, Christoph Lee points out with his recent publication (http://www.ajronline.org/cgi/content/abstract/187/2/282) on a survey of radiology chairmans at US academic medical institutions, radiation risk was explained at only 15% of the 91 sites, and only 9% of sites informed patients of alternatives to CT. At least give the patient all of the information to make an informed decision!! Another sad state of affairs in the gluttonous United States.

1 comment:

Will said...

Steve -- this is an interesting issue...I have a few comments:

The amount of scanning is absurd, there's no doubt. Remember when Howie (or was it Krumholz) would tell us about cardiologists buying their own echo machines and then referring all their own patients to their shiny new machine to keep the thing constantly busy at some ungodly medicare reimbursement rate?!?! I'm sure some of these MDs believe they're doing it in the patients' best interest but still, unforgiveable.

But how do we fix this? Clearly, cases like the one above are easy targets -- Medicare fraud is on everyone's radar now. Some things are more subtle in the reimbursement realm though and Medicare is a little slower to catch stuff like appropriate interval for repeat colonoscopy (we're referring medicare VA patients to a private clinic and almost all come back w/ a five-year return referral regardless of how normal). I don't see how to standardize all this without single payor. But OH! the horror! of having to wait TWO MONTHS for the MRI of your knee that's been bothering you for 5 years.