Are imaging-cautious ordering physicians a ‘dying breed’?

A Massachusetts-based urologist sparked a conversation on social media Wednesday when wondering whether physicians who are more judicious with imaging orders are a “dying breed.” 

David Canes, MD, who practices at Burlington-based Lahey Hospital, pondered the question on X.com the morning of July 8. By the end of the day, his post had gathered over 115,000 views and 100-plus responses. 

“I'm coming to terms with the fact that I may be part of a dying breed of physicians whose mentors back in the day used to berate them for ordering any scan without being able to clearly articulate what exactly you're looking for and what the pretest probability is,” Canes wrote. “Instead, now CT scans have essentially been continually abused as an extension of the physical exam.”

Canes said all he wants to hear is some articulation around what is wrong with the patient and what a CT scan might achieve. However, he believes “it doesn’t even appear to be necessary anymore to explain what you mean by ‘something bad.’”

“I sound like a grumpy old man, I know, but I think it's a sad state of affairs,” Canes added. “The perverse thing about it is there's no real incentive on the part of any emergency room or hospital system to curtail this kind of behavior because they get paid for every single scan.”

Multiple radiologists and other physicians weighed in on the debate Wednesday. Highly followed radiologist “RJ,” who tweets anonymously under the username @NorthWoods1980, believes cutting back on these unnecessary requests is a lost cause. 

“Honestly, it's a battle you'll never win. The battle you and I need to be fighting is to be properly compensated for these valued and probably frequently abused scans,” RJ wrote. “It's all fine as long as we get properly compensated for each CT scan since one scan/one miss can become a $20 million lawsuit just like in the ER provider missing a dissection or [pulmonary embolism] in that [22-year-old] mother or dad,” they added later. 

Larry Greer, MD, said, while he benefits financially from these orders, he believes reform is unnecessary. Every patient with abdominal pain or shortness of breath does not need a CT scan, he contends. 

“As an ER radiologist, it’s very, very good for my bottom line,” wrote Greer, a retired rad based in Huntsville, Alabama, according to his profile. “However, I do wish a little more thought was put into ordering a total body CT on practically every trauma patient.”

Noah Kaufman, MD, a Denver emergency medicine specialist, said he was previously part of a group of 40 ER docs. He recalls being a 0.5 utilizer of CT on a normal distribution going up to 2x. 

“I was told I should do more CT scans because I was likely more risky,” Kaufman wrote. “But I’ve never had a lawsuit and I had perfectly good outcomes. It’s definitely a huge problem. The hospital loves it.”

“The ER perspective from you is very interesting. Not to generalize because you're clearly the exception, but the ER in general is the biggest offender in this category,” Canes responded. 

Meanwhile, multiple respondents stated their belief that these excess CT orders are necessary in today’s healthcare reality. 

“Yawn. The malpractice environment has radically changed since you started practice. Until someone thanks me for NOT getting a CT scan, I’ll continue doing what I think I need to do to keep patients safe,” wrote Steve Carroll, DO, an emergency medicine specialist based in Philadelphia, adding that this “doesn’t mean to do dumb stuff” like ordering a CT scan for pediatric patient who has already been determined not to have head trauma. 

“I think you’re missing the elephant in the room. Defensive medicine = more scans. That’s a sad state as well,” added John D. Baker, DO, an EM specialist based in South Carolina. 

“I am not missing the elephant. I’m talking about scans that are done for no good reason,” Canes responded. “Here’s another example: Patient goes to ER. Appropriate CT done. 5mm ureteral stone. No indication to intervene. Goes home. Bounces back 2 days later with—whatever. More pain, fever, anything. No repeat CT is needed. And YET … they get one. Without thinking. That isn’t defensive medicine. There’s no suit that could come from not obtaining a scan. Whatever needs to happen next is a clinical decision. Doesn’t matter where the stone is exactly now, or how much hydro, or really anything.”

“My urologists would want another scan,” Baker countered. “An additional scan is path of least resistance. That is not unique to emergency medicine. But I get your point about legality. Unfortunately, the culture of how medicine is practiced is infiltrated by the fear of litigation (to your point that it may not exist).”

Another X.com user, who tweets anonymously under the handle @DrA_001, believes it’s more than just the EM docs driving these unnecessary imaging requests. 

“Patients will hound you until you order the CT despite explaining your rationale extensively. Nurses will send messages suggesting you order one. Other docs will write in their notes that a CT was not ordered. I don’t know … there’s no winning,” Dr. A wrote. 

“Canadian radiologist here with 30+ [years] of experience. I agree with your position,” added another user who tweets under the name Dr. Gawain. “ERs in Canada are all overwhelmed. Everywhere. The ER staff are overwhelmed A primary goal is to get people out of ER ASAP. Imaging is the answer. Unfortunately, this will never be reversed.”

“Responses to this are hilariously polarizing. All the way from ‘Spot on, Dave’ to, essentially and I'm paraphrasing, "You're an a$$hole, Dave,” Canes wrote later. 

The conversation comes amid growing utilization of CT. One study last year published by RSNA noted that U.S. emergency departments’ use of CT has increased substantially since 2013. This uptick was attributed to more scans being administered per patient visit, rather than a rise in overall patient volumes. One single-center analysis last year estimated that about 80% of requests for emergency head CTs are inadequate, while another charted a 90% surge in emergency CT orders since 2015. 

The American College of Radiology and others have pushed for legislation that would require referrers to consult appropriate-use criteria before ordering exams, hoping to curb defensive medicine and radiologist burnout. However, other physician societies have pushed back against the proposal, worried it could take autonomy away from docs.