08 February 2011

Flame War? Count me in!

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.

22 comments:

  1. Just wanted to add that I though this was an excellent response.

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  2. Seems to me that the decision to order a CT scan follows a complete ER history and physical, it doesn't negate the need for one. I have yet to meet an ER physician who orders them indiscriminately and when possible, the previous number of CTs is taken into account in making the decision.

    Great response.

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  3. yeah. the comments over there are genius. and happy hosp. still drives me nuts. i feel like i would really enjoy punching him in the face. would that be wrong? yeah, that'd be wrong.....but it would feel soooooo right......

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  4. My gripe, lately, is that the ER docs don't want to do any kind of oral prep, or inject contrast,so they order a r/o kidney stone study on everyone who has abdominal pain and/or flank pain, and hope that it will show whatever pathology is actually there. (Sorry that it takes 90 minutes to 2 hours for the oral to descend through the colon.) Often then, the patient must be scanned a second time after the first scan is not diagnostic for anything but a kidney stone (which they don't have).

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  5. Hi folks--

    They still do VQ scans, on us folks that are allergic to the x-ray contrast.

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  6. My SO has Marfan's, if he shows up in the ER with tearing-aorta-like pain I would sure like someone to shove him into a CT scanner sooner rather than later.

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  7. CT tech--I'm also a CT tech and we do almost everything with IV contrast only. Our ED prides itself on low patient times, so we never ever ever do oral contrast unless the surgeon requests it, which they never do.

    At our hospital the big thing is everyone with a headache must be having a stroke so we end up doing head CT w/o, then COW, and a carotid. And sometimes an US carotid for good measure. Thank God it's only 2 of the ED doctors who have really embraced this mind set....

    Now that I work in a clinic setting, I'm finding just as much "over-utilization" as I saw at the hospital. Do you know how many L-spine CT's are done for LBP? It's completely inappropriate, but since I work for a family practice clinic that owns the scanner, and the radiologists are consultants, it doesn't really matter...

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  8. Working as a CT tech at a Level I trauma center for the last 7 years, I've seen a definite trend towards CT being the imaging of choice for many patients. The ER, sadly, tends to be the major offender when it comes to ordering unecessary exams. My favorite thing to get annoyed about is the patient they order a c-spine CT on to r/o fracture. The patient invariably walks over to my scanner and does not have a collar on. Or, even better, the patient that is flat on a cart WITH a collar on and I tell the nurse and doctor that I need someone to stabilize the patient's neck while we move him to the scanner. I have been told numerous times that they don't really need to come help because they don't actually think the patient has a fracture. It's hard to hear this response and not get the feeling that someone's practicing a little CYA medicine.
    I agree, though, that the increasing number of CTs being done doesn't mean that they are being ordered carelessly. They are a valuable imaging tool and the technology has come so far even in the few years I've been doing it. The radiation isn't a joke, but sometimes the docs don't think about that. I know the ER physician is burdened with the task of "getting answers" and so I can't fault them entirely for picking something that they think will most likely reveal the most information. As with most things, it's the few "over-orderers" that cause the majority of the issues it seems.

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  9. Outstanding. This issue struck a nerve for me and I think you've articulated best why this is largely an artifactual increase in numbers (CT beats VQ, CT beats c-spine XR) and at not just click-happy clinicians.

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  10. The place I think CT's are over utilized is the chronic belly pains that come to the ER weekly. Nonspecific exams, normal blood work. I know of a man that has had 33 CT's of the abdomen in 1 year. Either normal or mild obstructions from constipation from prescription narcotic addiction.

    These people who have chronic belly pain with normal vs, normal labs, and have all ready been worked up several times, there is no point in chasing it again and again. And it delays care for the others in the department, either waiting for a bed or a scan.

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  11. please exchange link with my blog sir

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  12. why are the CT techs complaining? It is job security without bearing the liability of overutilizing or of missing a diagnosis.

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  13. ssmith wrote:
    "Working as a CT tech"
    "The ER, sadly, tends to be the major offender when it comes to ordering unecessary exams."

    Really? On what basis do you make such an uninformed comment like that.

    You're a CT tech. What do you know about "ordering unnecessary scans"?

    If an NP or PA may a crazy comment like that, they would deserve a reprimand - but at least they are clinicians.

    Althogh you may be famililar with NEXUS or Canadian...or may have heard about the "proper" history and physical, you can not apply the C-spine rules and you can not obtain a proper H/P.

    It is completely inappropriate for you to say the 'ER' orders inappropriate scans when you can not evaluate for midline C-spine tenderness or focal neurologic deficit.

    I would argue that is inappropriate for most radiologists to make this comment, and they have gone to medical school and often completed a fair bit of internal medicine training.

    You are a CT tech...stick to what you know. (hint: it is not clinical medicine)

    HH

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  14. Oh, come, on Happy Ho. At least these excellent CT Techs (probably) know what to do with an ambu bag.

    Best.

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  15. Great comments- but what happened to DPL ? Has FAST U/S and abdominal CT made this procedure obsolete ?

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  16. "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."

    WOW.

    Things have changed *a little bit* since the couple of shifts you worked in the 70s my friend. I'd challenge this person to work one shift sorting through the drug seekers, chronic pain-ers, elderly, children, and those with true emergencies at high pace, high liability, and high efficiency. I am proud of the EM profession and how far we've come based in science, research, and specialized training. Ignorant comments like this only set us back.

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  17. Dr. Happy wrote quite the post on this in 2009...;)
    < It doesn't matter how low the probability of having a pulmonary embolism is. When a bad outcome occurs, the probability is 100% that the CT scan should have been done. The unknown medical outcome, which is known only after the fact, drives the process of defensive medicine
    If John Ritter's wife can sue for 67 million dollars because her husband died of a rare aortic dissection that was missed in the emergency room, only a fool would believe that physicians won't order CT scans to protect themselves from perceived negligence. Only a fool would believe physicians won't order CT scans to prevent missing a diagnosis that the American public and the legal community wants you to believe is negligence, no matter how low the probability.


    In America, the standard of care is zero tolerance for failure to diagnose. You can thank the legal driven blame game of American medicine for creating impossible standards which can only be upheld by irrational medicine. Medicine which is practiced in the possible zone instead of the probable zone.


    Here's how I see this playing out in the future. CT scan use will actually increase dramatically because of the legal climate in which we practice. Here's why. CT scans will eventually come with informed consent warning patients of the risk of cancer from CT scan radiation exposure. With informed consent, the rate of CT scans will actually increase as physicians see patient refusal as their way to protect themselves.>
    http://thehappyhospitalist.blogspot.com/2009/12/ct-scan-radiation-exposure-much-worse.html

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  18. Seattle Plastic Surgery --

    Yes, DPL went out in the mid-nineties. When I was in medical school, it was already taught as an outmoded procedure as useful as rotating tourniquets. Which means, of course, that they are still doing them at Harborview, which is taking baby steps into the 1980s only now.

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  19. I agree w/anonymous person @ 8:22...Tons of scans for "nausea and vomiting" in young people (with diffuse abd pain), "sharp pains" in the epigastric area with normal labs, chronic endometriosis, low abd pain with (+) UA, something that sounds like an ovarian cyst that could be worked up with an ultrasound, and things like that.

    We did a head scan on a tween yesterday who had a small bump on her head with no LOC, no nausea, no mental status changes, etc. I'm just like, "The leukemia special, comin' right up..."

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  20. If john ritter's wife can sue...

    Its not just the law suits. Its the lost lives. That's why we practice the way we do. Not that I know anything about the validity of the Ritter suit, nor am I commenting on it here.


    We try to avoid bad outcomes because it means loss of life.

    You do the CT scan on the smoker on birth control not because you think you're going to get sued if you don't. You do it because you don't want her to die of a PE. If you weren't afraid that she might have a PE there would be no need to do the scan. No PE, no lawsuit, scan or not.

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  21. Hi, I'm new here. I would say that I've had enough CT scans to light High Point. However, it took a GI Dr who listened to my complaints of N/V, URQ pain, and abnormal nl liver enzymes after a bad Cholesyctectomy to order "one more" CT scan to discover an enlarged Common Bile Duct. I was already in Liver and Kidney failure by then. Luckily she listened to me and didnt brush off the slightly enlarged common bile duct due to recent surgery. I ended up at Baptist in surgery again with sludge and stones in my Bile duct! Thanks to a surgeon who didnt take the time to do a intraoperative Cholangiogram. He didnt listen to my History of months of URQ pain and done the surgery to satisfy me. Please slow down and listen. I'm in the middle of the road on ordering too many CT scans.

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  22. i think doctors should legally advise patients about the risks of ct scans.
    My doctor did not advice the risks.
    Subsequently I found out it was not necessary in my diagnosis.
    So I have had the scan which was not necessary. This has been very upsetting.

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