LETTER
Stern but Illuminating Words on Imaging: An Internist Replies To the Editor: As a general internist, I was not happy with Stern’s editorial suggesting that my discretion in ordering radiological studies should be limited by the enforcement of “imaging use policies.”1 Yet, I must admit that his arguments have certain merits. No patient should undergo an expensive and invasive study like computed tomography (CT) pulmonary angiography without a clear evidence-based indication. These scans involve risks: radiation-induced malignancies, contrast reactions, impairment of kidney function, and the discovery of incidental nodules requiring further workup—and potential for further harm. While CT should not be ordered reflexively or without due consideration, there must be a better solution than “restriction of image-ordering privileges” for clinicians whose “diagnostic yield” of positive test results falls below some threshold percentage. Few internists would admit a patient for hematemesis without consulting a gastroenterologist, and fewer would admit a psychotic patient without consulting a psychiatrist. Similarly, we should be able to obtain an urgent clinical consultation from a radiologist before ordering an advanced imaging test to verify that it is best for the patient. When an internist is in the emergency department at night treating a sick patient who might benefit from such expert evaluation, why is the closest available radiologist often located in
some far-away country? Computerized clinical decision support is helpful,2 but there is no substitute for the judgment of an experienced specialist at the patient’s bedside. Unfortunately, radiologists have become distanced from their roles as clinicians. The skills of teleradiologists are considered reliable enough to support life-and-death decisions in real time, and the next logical step may be to economize further by having other teleradiologists verify these reports remotely. Diagnostic radiologists may gain job security by assuming a more hands-on clinical role with patients, because any service that does not require direct patient contact can be outsourced completely. Stern’s admonition to The American Journal of Medicine readers not to “feel entitled to function as isolated, noncommunicating, disconnected cottage-industry prima donnas” also might be applicable to his fellow radiologists. Hospitals could improve the efficiency of imaging use by having a diagnostic radiologist available at all times for clinical consultations, to discuss whether a scan is indicated, and if it is, to help interpret it. It might even be helpful for the consulting radiologist to evaluate the patient in person to get a first-hand impression of the clinical and personal circumstances and to better assist in the important decision of whether and how to image. David L. Keller, MD Torrance, Calif
http://dx.doi.org/10.1016/j.amjmed.2013.11.018
References Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
1. Stern RG. Ordering high-cost medical imaging: a right or a privilege? Am J Med. 2013;126:939-940. 2. Prevedello LM, Raja AS, Ip IK, Sodickson A, Khorasani R. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013;126:975-981.
Stern but Illuminating Words on Imaging: An Internist Replies To the Editor: As a general internist, I was not happy with Stern’s editorial suggesting that my discretion in ordering radiological studies should be limited by the enforcement of “imaging use policies.”1 Yet, I must admit that his arguments have certain merits. No patient should undergo an expensive and invasive study like computed tomography (CT) pulmonary angiography without a clear evidence-based indication. These scans involve risks: radiation-induced malignancies, contrast reactions, impairment of kidney function, and the discovery of incidental nodules requiring further workup—and potential for further harm. While CT should not be ordered reflexively or without due consideration, there must be a better solution than “restriction of image-ordering privileges” for clinicians whose “diagnostic yield” of positive test results falls below some threshold percentage. Few internists would admit a patient for hematemesis without consulting a gastroenterologist, and fewer would admit a psychotic patient without consulting a psychiatrist. Similarly, we should be able to obtain an urgent clinical consultation from a radiologist before ordering an advanced imaging test to verify that it is best for the patient. When an internist is in the emergency department at night treating a sick patient who might benefit from such expert evaluation, why is the closest available radiologist often located in
some far-away country? Computerized clinical decision support is helpful,2 but there is no substitute for the judgment of an experienced specialist at the patient’s bedside. Unfortunately, radiologists have become distanced from their roles as clinicians. The skills of teleradiologists are considered reliable enough to support life-and-death decisions in real time, and the next logical step may be to economize further by having other teleradiologists verify these reports remotely. Diagnostic radiologists may gain job security by assuming a more hands-on clinical role with patients, because any service that does not require direct patient contact can be outsourced completely. Stern’s admonition to The American Journal of Medicine readers not to “feel entitled to function as isolated, noncommunicating, disconnected cottage-industry prima donnas” also might be applicable to his fellow radiologists. Hospitals could improve the efficiency of imaging use by having a diagnostic radiologist available at all times for clinical consultations, to discuss whether a scan is indicated, and if it is, to help interpret it. It might even be helpful for the consulting radiologist to evaluate the patient in person to get a first-hand impression of the clinical and personal circumstances and to better assist in the important decision of whether and how to image. David L. Keller, MD Torrance, Calif
http://dx.doi.org/10.1016/j.amjmed.2013.11.018
References Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
1. Stern RG. Ordering high-cost medical imaging: a right or a privilege? Am J Med. 2013;126:939-940. 2. Prevedello LM, Raja AS, Ip IK, Sodickson A, Khorasani R. Does clinical decision support reduce unwarranted variation in yield of CT pulmonary angiogram? Am J Med. 2013;126:975-981.
