Appropriate Imaging

The five reasons for excessive imaging are lack of standards for a diagnostic work-up, lack of systems of care, improvements in the technology, defensive medicine, and the ownership of diagnostic facilities and equipment by physicians who refer their patients to themselves. We certainly would not want to limit improvements in the technology and organizing systems of care will take a while. The risk of reducing imaging volume by prohibiting doctors from performing in-office imaging of their own patients is that patients would be deprived of services that often improve their care along with services that do not. For instance, it is very common to need an x-ray in order to make a treatment decision for a patient that is in your clinic. To require the patient to go to a remote facility and obtain the x-ray and then return to the clinic only delays care.

A better approach is to first determine an appropriate indication is for an MRI or CT scan. For instance, CT scans of the brain are routinely ordered on any patient who suffered a concussion. A concussion is a brief loss of consciousness after a blow to the head. Patients are usually unconscious for a few minutes and then return to their normal state. In all my years of practice, I do not recall a CT scan changing the management of any patient who had fully recovered from a concussion. They are almost always normal in this circumstance. However, in the remote possibility that such a patient later developed a hemorrhage or a complication of the injury such as a seizure, we would have been in a legally indefensible position had we not ordered the study, even if it would have made no difference in either the outcome or the management of the patient.

An approach to this problem is to review the results of 1000 CT scans performed for concussions. If the studies proved to make no difference in management and detect nothing that would not have otherwise been detectable, then the standard could be not to order a CT scan for a patient with a concussion. One might even refuse to pay for such scans unless there were extenuating circumstances. However, doctors that complied with the new standard would have to be immune to suits for failure to diagnose if they followed diagnostic standards.

The three-fold approach to reducing excessive imaging is:

1. To develop agreed-upon standards for imaging
2. To only pay for a standard work-up unless a doctor certified that the patient’s needs fell outside the standards (no more than 10 percent of patients)
3. Provide immunity from medical malpractice suits for failure to diagnose for doctors who follow standards.

The net result would be fewer and more appropriate images and fewer medical malpractice suits. The method would not interfere with doctors’ ability to image their patients in their offices. The cost would be the trouble of a physician requesting an exemption from diagnostic standards for patients who required a more detailed work-up than usual.