I Want It Anyway: Radiology’s Conundrum

Saying, “I want it anyway,” the ICU physician insisted that his patient with breast cancer should get an MRI exam to look for lung metastases. My years of experience as a radiologist did not dissuade him; such a test would be a poor way to evaluate his patient’s lungs, even under ideal circumstances (which hers were not). She was on a ventilator, incoherent, and unable to hold her breath, rendering the study a useless waste of time and money. More important, her lungs, just days earlier, had been clear on a chest CT exam—the gold standard for detecting lung nodules. We already knew that she had no lung metastases. Repeating, “I want it anyway,” the ICU physician became emphatic and slightly frantic, desperate for information on why his patient was doing poorly. Unfortunately, that happens sometimes with critically ill patients, and ordering unindicated tests rarely helps. Medical-imaging utilization has increased exponentially in the past few decades, for reasons both good and less so. Radiography, CT, MRI, ultrasound, and nuclear-medicine exams can create incredible visual roadmaps of the human body, dramatically helping us diagnose and treat the sick. We rightfully investigate the benefits of various studies as technology continuously evolves. With trepidation, we sometimes look at costs, biological risk, and the patient experience when tests are performed. Many studies are ordered not because an abnormality is truly expected to be found, but just to make sure that it won’t be. Putting aside that ever-elusive issue of defensive medicine momentarily, can we at least do something about the most blatantly unnecessary tests, which we know will provide virtually no useful information at all? Scope of the Problem This happens daily, and the costs add up: Expensive imaging studies ordered for outpatients often require preauthorization from insurance providers, but preauthorization is rarely required for patients already hospitalized or in an emergency department. For example, a physician might order an ultrasound exam to rule out gallstones for a patient whose gallbladder was removed previously—or for one who already had gallstones diagnosed, using the same study, last month. A question or two—or a look at the medical record (electronic or not)—would be all that’s required to curb this waste. A patient with impaired kidneys has an ultrasound exam to rule out urinary obstruction—but the kidney-stone CT acquired yesterday already showed that there was none. At my hospital practice, unnecessary ultrasounds like these are ordered a couple of times a day, on average. To see how the dollars add up, multiply that by the days in the year, the number of hospitals in the country, and the fee per study. Sometimes, clinicians simultaneously order several studies of the same body part, not waiting to see whether radiography, CT, MRI, PET, or bone-scan results give us the diagnosis (so that the rest of the tests could be avoided). I once saw the CT study of a habitual drug seeker who presented to different emergency departments on a regular basis, complaining of flank pain. Unknown to the emergency-department staff, she would prick her finger and put a drop of blood in her urine specimen, creating evidence that she might have a kidney stone. This allowed her to get a narcotic injection, but with each emergency-department visit, she also automatically had a CT exam to rule out kidney stones. I read her 35th negative CT exam (in our system alone) in five years. She came back every month or two, though, and each time, tests were ordered as reflexively as pulling a hand off a hot stove. There was no review of past records or prior imaging, nor was any thought given to whether this additional test could provide any new information. Ordered tests keep me (and the technologists) employed, but hardly help the patients who do not need the exams. We all pay more taxes or higher insurance premiums as a result, and we certainly don’t do the patients any good—yet if an imaging study (or almost any laboratory test) is ordered in a hospital or emergency department, it usually gets done. One reason for the problem: There is no disincentive to discourage physicians from ordering the tests. The patients’ insurers (if they have any) might deny payment after the fact, if a study is retrospectively deemed unnecessary, leaving patients with the bills. There is usually no real consequence to the physician who ordered the test, however—no cost, no radiation exposure, and no injection risk. If physicians want exams, they usually get them, even if the specialists who know more about radiology try to dissuade or redirect them. This leads to the fundamental issue: To change behavior, we have to know what motivates people. Without disincentives, unnecessary tests will only continue. Like most physicians, I went into medicine because the field is interesting and because it is rewarding to help people get better (or to comfort those who will not). It is also rewarding to work together with colleagues, rather than having adversarial interactions. We learn from each other and from the patients we treat. Most physicians are quite good at what they do, including choosing the tests they order—yet there are times when I would like to see physicians ordering truly unindicated tests feel a consequence just big enough to get their attention. Changes in health care might still be taking shape, but change is coming. Maybe an offending ordering physician will receive a required phone call from a government or insurance-company employee (with no medical training) asking why he or she ordered a study that could not realistically have provided any beneficial information. Perhaps the bad-order police will deduct $5 from a physician’s reimbursement every time a truly unnecessary test is ordered. A system penalizing egregious ordering might be complicated, tedious, and unwelcome for various reasons. Sometimes, though (when I see the worst of the waste), I want it anyway. Cullen Ruff, MD, is associate professor of radiology at Virginia Commonwealth University.