Oh boy. The usually temperate RCentor over at MedRants has really stepped in it, commenting on a new study which showed that the utilization rate of CT scans doubled between 2001 and 2008. This would be categorized as "not news" and "holy cow you can get published by counting scans?" in my book. But Dr Bob decided to kick over the anthill with his commentary:
It appears that too often CT scanning takes the place of a careful history and physical examination. This can occur when the emergency physician is drowning in patients. But we should care! CT scans when accumulated likely cause cancers. Unnecessary CT scanning contributes to increased health care costs, not just from the cost of the scans, but from the chasing down incidentalomas that often follows a CT scan.
What solutions should we consider? The obvious first solution is to create an appropriate outpatient infrastructure in this country. We need to pay outpatient physicians better and allow them to spend time with patients. The next radical suggestion is that we should modify emergency medicine training. In the late 70s I spent a couple of years working in emergency rooms. My internal medicine training was highly worthwhile. I believe that emergency physicians need more inpatient experiences to better understand the natural history of disease.
My not-at-all-hyperbolic response was: Dr Centor is right! We *do* do too many CTs! I implore you all, lazy careless ED physicians to return to the True Path: Pneumoencephalograms and Peritoneal Lavage for trauma, VQ scans for PE, and a careful history and physical exam for Thoracic Aortic Dissection. (Did YOU check for pulsus paradoxus before ordering that CT? Lazy!)
Or maybe, just maybe, we are ordering more scans because they are USEFUL TOOLS. Yes, we have more access to them, yes, there's a fear of missing something, but really, ER docs are pure diagnosticians at heart. We want to find the answer, and CT can in many cases give it to us, or at least rule out the Bad Things [tm]. Which is truly the central part of our job.
Is there over-utilization? Sure -- I don't think anyone would dispute that. But more utilization does not in itself equate to more over-utilization. Maybe it's appropriate use of the technoilogy. Consider the study cited, which points out that among the greatest increase in use was for neck imaging. Why would that be, in the ER? Probably for non-contrast cervical spines after trauma. During the 8 years studied, there was a real shift in practice patterns in trauma imaging. High-resolution helical CTs became widely available. And multiple studies in multiple centers showed that CT was superior to plain films in detecting cervical spine fractures. So as the technology and the evidence both penetrated the market, there was a seismic shift away from plain films and towards CT scanning to detect the injuries. It wasn't lazy ER docs who were unfamiliar with the natural history (!) of spinal injuries. It was the emergence of a better technology backed by clinical evidence which addressed a common and vexing conundrum relating to a high-risk injury pattern.
I should also point out that ER docs undertook multiple huge multi-center trials to derive decision-making rules to select out patients who needed spinal imaging, in order to limit use of this technology to appropriately risk-stratified patients. There may be a fair question as to how assiduous community ER docs are in following the NEXUS or the Canadian C-spine rules. It's simply incorrect to suggest that the driver in use of this particular scan was failure to adhere to the rules rather than acceptance of the new technology.
There's a similar story regarding the other greatest increase in CT imaging, chest CT scans. During this time frame, CT completely replaced VQ scanning and aortography for PE, TAD, and Aortic trauma. I graduated residency in 2000, and I remember the debates then about whether CT or VQ was better, what quality of scan was needed for good enough images (again, helical scans being relatively new then), and what degree of specialization radiologists needed to interpret a CT pulmonary angiogram. Over time, the balance shifted conclusively towards CT, and now VQ is essentially only performed on patients who cannot take contrast dye. Similarly, aortography used to be the only way to diagnose Thoracic Aortic Dissections, and that's a very invasive screening test for a very uncommon diagnosis. And it's one that docs can most definitely get sued and lose big for missing. So now that better tools are available, we cast wider nets and catch more fish. (I'll also add as an aside that the three dissections I've recently seen on CT were all essentially unsuspected and would have been missed in the VQ era.)
The intimation of Dr Centor's post may not be too far from the truth, I have to admit. I do know docs who shotgun CTs and other tests indiscriminately. I suspect that anyone who works in an ER knows some docs like that. I don't know how to fix that problem within my own practice, let alone across the health care industry, and I don't think that it's possible: it's a personality type. Some docs are hasty, some are ignorant, and some are just really anxious. These high-utilizers will always be with us, whether it's in ordering too many tests or admitting too many patients, or needing too many consults. And we all should be mindful of the need to be selective in ordering studies with ionizing radiation. It is, however, wrong and quite unfair of Dr Bob to smear an entire specialty with the broad brush of "they order too many scans" and "they need to learn the natural history of disease" from the fairly limited bit of data in front of us.
I suspect a flood of irritated ER docs will be letting him know the same thing in his comments.