Exactly. Canada has 1-3 of these Machines PER PROVINCE... most large U.S. _Cities— have 6 times this number. SOMEONE has to pay for them, and the Consumer is the one who through Institutionalized Fear has to dig deep to pay for the Hospital's profligate spending. Hence, the unnecessary scans that happen every day in the U.S. ... to pay off "Gee Whiz" Technology that, in the end, profits no-one (save the Medical Institutions and Insurance Companies).

So they check for tumors by giving you one in the future. Sounds like a nice scam for repeat business.

@wonderful, I've always felt it considerable more,maybe 3-4 mil.

"or, even worse, the need to amortize the huge cost of a piece of equipment the practice has purchased." What they do not address is the number of doctors that now are partners in Diagonstic clinics that do MRI's and scans. A huge conflict of interest and another reason why health care in this country is so expensive.

Should we be worried? Hell yes! Nobody likes spikes. They are sharp and pointy, and very painful when used, especially in probing the depths of the human body. I mean simply using the words "Spikes" and "brain" in the same sentence is disturbing.

Therefore, I will state for the record that I am unequivocally opposed to the use of spikes in MRI's and CT scans. Ouch.

Oh relax I'm just kidding. However, I do think that NBC might have used a better choice of words when choosing the headline. Or then again, maybe not. After all, we read the story.

As a practicing physician in the United States, I can honestly say that my reimbursement has never figured into my decision to order one of these tests. Generally speaking, I nor do most physicians get paid for the tests they order. What is/are the main motivating factors are 1. liability, 2. uncertain diagnosis and 3. patient request. You read and hear news every day about physicians being sued for missing diagnosis. Until the system changes and we become less of a sue-happy nation, you're going to see more and more of these pointless CYA (cover your A**) type of tests. The second reason seems self explanitory. The third is such that oftentimes (i work in an inpatient setting) a patient will request/demand said test despite being told of its uselessness. I have been "fired" by patients numerous times because I will not give in and order many of these frivolous tests. We discuss the rising cost of healthcare, and unfortunately I hear very little discussion of one of the primary driving factors... patients.

They told my friend they had to PAY for it somehow!

realityland:

You and the rest of the Doctors in this country are BLOOD SUCKERS. I had minor surgury on my hand 3 years ago $1500.00 bucks done in the office in 30 minutes.... NOW the doctor wants $3500.00 to fix the other hand!!!(same thing)

Doctors are GREEDY PUKES EVERYONE OF THEM!

You're absolutely right, realityland. The general public may think that there is some sort of lucrative financial reason to use these tools, but they're just that - tools. Patients come into my ER insisting on a scan for whatever is ailing them, or they're sent in by their private practice doc. Most times the scan really is not indicated and ends up being negative. Still, it's a great tool and it's far better to have a 5 minute scan and a little radiation to find a head bleed after a fall than to suffer the perilous consequences.

AKRandy - fix your own hand next time. Nobody works for free....

You and the rest of the Doctors in this country are BLOOD SUCKERS. I had minor surgury on my hand 3 years ago $1500.00 bucks done in the office in 30 minutes.... NOW the doctor wants $3500.00 to fix the other hand!!!(same thing)

Doctors are GREEDY PUKES EVERYONE OF THEM!

You need to be blaming the insurance companies, the drug manufacturers and the bloodsucking malpractice lawyers. Doctors cannot cure everything, they can only try. Are you familiar with what the word "Science" means?

@realityland...you have it exactly right. Physicians feel like they MUST order these tests because patients come in to their offices and have an "expectation" of what must be ordered. Gone are the days where we would xray a cervical spine and if abnormal THEN move to MRI...we now order a CT to rule out a fracture and then have an MRI because CT doesn't show spinal cord abnormalities quite so well. Most physicians who do not own their equipment in their office could care less how the technology is paid for. They don't get anything for it. That isn't the issue...it is driven by patients who expect, and unfortunately because physicans are afraid to practice clinical medicine due to sue happy patients...who WIN in many circumstances. If we as a society want change...it will be to cap malpractice suits.

If you want to know where to go to have good quality care done, be sure to look for a site that has ACR accreditation. It at least guarantees that the site had to jump through some hoops for quality at some point and time to get the designation... All free-standing imaging centers must have it now to bill Medicare, but hospitals don't just yet...so if your hospital does have it, they are going above and beyond their requirements and may be better (at least in my opinion) Do not EVER be afraid to ask questions.

Crankenstein...I am a physician. A former professor at UCLA who taught many future physocians. They have lost the ability to do careful history and physicals. Also look at the current issue of "ACP Internist"...page 5. You will see an article that about 2/3rds of recnet premium increases are due to unit payment inflation. Further, physicians in the US make 25-100% more than those in Europe or Canada. Hospital prices are 64% higher than other industrialized countries. Be careful when you tell soemone to fix their own hand next time.

Frank in Sac,

As a former professor at UCLA, you should know:

1) Physicians, not physocians

2) Physicians in the US pay a whole lot more than 25-100% more for med school than those in Europe or Canada. If you want physicians to all be bankrupt from their 200,000-300,000 dollars in school loans, then you are going to have a whole lot less physicians out there. Not going to help the huge physician shortage going on right now.

Perhaps we could adopt the New Zealand approach: Each Emergency Patient can get free/ reduced price care by SIGNING AWAY THEIR "RIGHT" TO SUE!! It would be an interesting study to see if physicians would/could return to clinical decision making. When I started Emergency Medicine at Johns Hopkins, it took a "sign off" by a radiologist or a neurosurgeon to order a CAT Scan. Nowadays the indication for a CT is "belly pain." This is not a regional issue (I was President of both the Hawaii & the Arizona Chapters of the American College of Emergency Physicians) but rather the result of the adversarial nature of "defensive medicine"... to strengthen one's case (as lawsuits are NOT avoidable). "We have met the enemy ... and he is us!" (Pogo)

danny:

Does it make you feel better about yourself to correct an obvious typo? Guess you missed the other one though...idiot!

Unfortunately, oftentimes patients do drive the decision to order unnecessary radiology procedures such as CT scanning, MRI, and even basic x rays, as well as other testing modalities. As a clinician, you explain the reasons they do not need these procedures, however, patients don't want to hear that. They feel as if they are being shortchanged somehow, and they begin to question your abiity as a clinician. When you explain to them that the results of the test will most likely or definately not yield any useful information pertaining to their diagnosis, condition, or symptoms, and will expose them to unnecessary radiation, they still insist on having the test because their friend had it, or their friends suggested it, or they read on WEB MD or google that with their symptoms a CT scan or MRI might be indicated. When the results are reported to them, and the results add no diagnostic value, only then do they understand that the test was unnecessary. Only then will they listen, but then its too late. It's very frustrating as a practicing health care provider when you are faced with this type of patient, for some of us this happens on a daily basis. It's a double edged sword, all the information that is available to our patients, it's great that they want to be a partner with you in their health care, but they don't understand that you can't just type in a few symptoms into a search engine and come up with the answers to their questions. If that were so, no health care provider would have gone to school for the number of years that we did and accumulated so much debt.

I am a radiologist.

I respect Reality land's point of view - that he has never referred a patient with a thought of profit for himself. BUT - He knows, as I know that there are MANY who do. This is because of self referral. As an example - years ago there was a rush of Cardiologists purchasing their own equipment. The rate of referral to their own equipment was about 3 times higher when compared to physicians who referred to centers that they had no ownership interest in. This finding has been repeated many, many times in the literature. As a patient, if your physician has an ownership interest in the site he is referring you to it is very likely that your test is unnecessary. More insidious - now that many cardiologists are employed by the hospitals, they are on production bonuses that reward them for the amount of referrals back to the hospital facilities.

A point of information: if your physician refers you to a radiologist-owned facility, then you can be assured that he is concerned about your welfare. The radiologist gets no compensation for the referral, the referring physician has no conflict of interest in this situation. If the physician is referring you to a facility in which he has an ownership stake, then he is getting paid for the referral, and you should worry that the judgement is not pure.

I have a blog post that goes into the causes of the high cost of medicine that no one sees or writes about. Really, it is quite mysterious to me how the major media do not know about this except to say that they are not in the environment, and do not see what goes on day to day. Also, most of the "analyses" I see are not particularly sophisticated - they read as if they were written by someone who has no familiarity at all with the reality of medical care. That is because they were written by someone with no familiarity at al with the reality of medical care. They can only regurgitate back what they found on a google search.

I also object to the dumbed-down discussion of radiation dose given above. Knowing that a CT scan gives a certain amount of chest x-ray equivalent dose tells you nothing at all. What you want to know is what likelihood is that you will have a problem in the future from it. At least for a single abdominal or chest CT scan, the answer is no detectable risk. When you are getting multiple CT scans in a short period of time, then is the time to worry.

I see the blog address didn't come through, it is:

dr-sardonicus.blogspot.com/search/label/Costs

Odd. After a severe bout of vertigo with vomiting I saw my doctor who ordered a CT scan. The CT scan showed a possible brain tumor and a MRI was ordered. The MRI did not show one. I went to a free standing imaging center and the same doctor read both scans.

After waiting close to two months to get in to see a neuro doctor to have the actual MRI readings explained to me he said that whoever read the CT scan should be slapped. Lol...yes he said slapped...in my mind I'm thinking he should have been fired if the real results weren't anything close to showing a tumor.

I have to think that the CT scan was misread with the intention of having an MRI done for more profit. I will NEVER return to that imaging center.

MRIs are not risky unless you factor in surgery as a result of a finding. As for cost, I pay for all my tests until I reach $3600, so the insurance company is still profiting off me.

What's worse than having an unnecessary test? Not getting a diagnosis and spending $$$ for a shrink.

Aaaahh no.

"Shrinks" are the biggest scam in the medical field.

BW^^^^^My 2 neices who were molested by their softball coach at young ages would beg to differ with you. Kids don't handle things like adults. Hope you've had a good life and that's why you have such a jaded attitude about psychologists.

why is this important? If it finds that cancer that could kill you, you'd pay anything for the test!

How come prices are not discussed. You don't know the price until you get the bill 2 weeks later. Only industry like that.
Also how many of these machines are owned by the your insurance company?

Shouldn't you pay the same amount for the same test as the next guy/gal? U don't!

The cost varies by region and by insurance plan. There is no universal cost. Something could cost me $300 and another person it would be $4000.

How much does it cost ... in 2010 a PET Scan in NC was $4800 ... A CAT/contrast was $1300 for all three areas. My wife had each of these to see 1st where the cancer was and the second (after chemo) to see if it was shrinking. Hers didn't and she passed. she had no insurance.

Insurance companies have a vested interest in using these diagnostic machines??? Quite not! They pay medical claims. They do not profit from the proceedures. They profit by keeping claims paying ratios down. That means the less money they pay out in claims, the higher their profits. That's how United Insurance can pay their CEO over $10 million salary and more than that in stock options. The bottom line is more important to insurance companies than helping patients get an over abundance of medical treatment. The figures quoted for United are actual figures for several years ago.

And doctors do not profit from these diagnostic procedures either--unless they happen to own the diagnostic company. I would say that is not the norm. Many doctors will even ask where you would prefer to have these procedures done, as in closer to your home town.

One more question after getting the PET ... CAT scans and paying that amout of money .. WHY do you also have to pay .. I think it was $250-300 to have someone read the thing ? It's like everyone is a specialist now.

@congoman: With sophisticated radiology procedures such as PET scans, MRI, MRA, CT scanning, the tests do require interpretation by a specialist, in these cases a radiologist. These types of studies are not the same as basic x rays that most health care providers can interpret. God forbid a radiologist did not interpret the test and something is missed. Also, in many states, it is required that any radiology test including basic x ray, the results must be interpreted by a radiologist. It's not a scam that your Dr. is in on to make more money.

Sorry, deepsheet... you've missed the entire point of this Article.

dark, do you think most physicians send people out for testing for the fun of it? There obviously is a complaint or problem that needs diagnosis. I think most of us know that serial x rays are bad, and most MRIs are harmless. Most findings can be differentiated by a good radiologist before a biopsy is performed. And as for cost, a lot of us have high deductibles, so the insurance company still makes a profit.

Umm, I'm not sure where you get your info, but this article talks about increases in the use of these tests. Rationing is not mentioned. The reduction in the use of the tests you mentioned is suggested by research into their effectiveness; it is not a grand conspiracy to trick you into believing they aren't needed before they are rationed by evil death panelists.

jrw617,

Interesting how you chose to politicize this article. I would like you to cite your sources, or else your assertions are garbage. And no, "I heard it on Fox News" doesn't count.

This article simply reports that the number of these scans has increased substantially, not that the "death panels" you probably think are real are causing their use to drop.

The article also reminds us to think before we leap, both patients and doctors, and ask questions before mindlessly receiving or recommending scans.

I would ask you to show me someone who was harmed because "Obama wants to cut back because they cost too much", but you can't, because your opinions have been given to you and you may only be capable of processing base emotions instead of performing valuable and accurate reflection.

Remember, it was congressional conservatives that were in love with the idea of an individual mandate, long before any single-payer or public options were introduced by the current administration. It was only when Obama decided that he would accept this conservative initiative of the individual mandate did the conservatives do a 180 and then start referring to their own pet idea as "socialism" and "communism". Absolutely pathetic.

Step away from the Glen Beck.

Obviously no none who has posted anything here knows anything about Radiology, how the decision to perform a procedure or what results are obtained from them.

The life cycle of medical imaging is changing all the time and the changes from the course of the supposed information this ya hoo got was from 1996 to 2010. 14 years. In 1996 there was a one slice CT scanner that offered light-years less information as to the condition of the patient . Now there are 128 and 356 slice scanners that do the work in 1\1000th of the time and give much better diagnostic information.

I could go on an on about MRI and PET bu,t realize that 14 years in medical improvements is HUGE.

This is a get psyched -up hyped up MSN piece of trash.

Just get over it.

Jane - Yes. Physicians do order tests that aren't needed and are dangerous. They don't order unrelated tests. For example, when a young child comes in after a low impact fall. Do you order a head CT or do you wait and observe? It is a clinical choice...and in my area, most docs do the head CT. Those that are the most likely to do the head CT are at traditional hosipitals. Those that order the fewest (but catch the most) are those a pediatric centers. Some physicians rely on these test because their confortable with their diagnosis...and often because they don't know the risks.

I teach at a medical school. Last week, one of my collegues was discussing the high radiation risks of an MRI while a CT was safe. He had been in practice for 15-20 years. I was concerned.

@Kirstyloo2: There are clinical guidelines based on your patients presenting symptoms, type of fall, surface the patient fell onto, age of patient, medical conditions, medications the patient is on to name a few, that one follows when deciding to order a head CT. The reason many of these tests are ordered is because even though many times the scans are not clinically indicated, the patients want the test, or most often, the ordering health care provider doesn't want to face a frivolous law suit by the patient or their family if anything goes wrong. It's called practicing defensive medicine.

I'm familiar with defensive medicine. And, I can recognized that was what happened when I found the guidelines. That being said, we usually discuss defensive medicine when we discuss costs. This article should make us also recognize that it can cost lives.

I completely agree---goes along with the "specular" pictures being mentioned.

Proof reading needs to be enhanced by the author/editors.

This is why you are a CT tech and not a doctor. Tell me how an xray will help with a patient with a headache. If you want to take responsibility for missing someone's brain tumor, then go to med school. All you have to is load the patient in the scanner, and push a button.

As the parent of a child who had a head CT after a low speed fall...and no evidence of even a bump, I agree. A number of physicians order CTs because they are easy. Even the national organizations say so (see multiple children's low impact head injury studies and guidelines). They also estimated that only 30% of ER physicians knew how significant the risk was of CT for young children and infants in the ER (2009 study).

Then as a parent, refuse the CT scan and stop complaining.

Danny, I agree to a point. Running CT is however quite a bit more advanced than what George Jetson did. But I also agree WHOLE-HEARTEDLY that without a medical degree, a radiographer should not be passing medical judgement. I'm a radiology student (to become a MRI tech), and after taking Anatomy, Physiology, and Medical Terminology, it's taught me a lot, and that I'm only scratching the surface. The reason that doctors want CT scans for a lot of these patients is they are looking for strokes or pre-cursers to a stroke, meningitis, and of course chest scans for cancer, not to mention dangerous subdural bleeding. These are all life-threatening conditions. They are making these decisions off of medical history with risk factors like high blood pressure, cholesterol, age, and smoking to name a few. CT is the best way to get a cephalic (head) angiograph (scan of blood vessels) for strokes, and there are a lot of recent advances in stroke scanning in CT at hospitals like St. Lukes in Kansas City. Where I do my clinical rotations (not St. Lukes, I just job shadowed there) we don't get a medical file, we get an order for a test from a doctor. There is NO WAY we are provided enough information to determine if the test is necessary or not!

I also think, from what I've learned and seen, that PET scan is a better cancer screening for patients on 6 and 12 month scans post-treatment for recurrance. But whatever scan the doctor ordered, it's for a reason.

As for those saying the insurance companies make money off the scans, you know you write the check to the hospital or facility that performed it, not the insurance company, right? That's why most MRIs have to be pre-approved. If you have a $500 deductable and the scan is $1300, then the insurance company PAYS (loses money) on the rest. As far as paying the same as others, different insurance companies have different negotiated prices with the hospitals etc. based on patient volume and the like. Insurance companies pay less than individuals because they contract with hospital A over hospital B across town, funneling more patients to hospital A.

And as for the commenters posting blah blah Obamacare blah blah socialized medicine, this article has to do with NONE OF THAT! This is purely an informative medical piece to help patients understand scan risks more. Go sell crazy somewhere else, we are all stocked up here.

One last thing, the article fails to mention that the "3.9 percent of patients receiving an exposure of more than 50 millisieverts every year" are LONG-TERM SMOKERS that need yearly scans for early detection of lung cancer to minimize the damage. Take from that whatever you will.

if you were a ct tech you would relaize that it is not your call to assertain who "needs" a ct test that is the patients doctors decision. you the suposed ct tech are not a doctor. its that simple. and if you were you know that.

kirstyloo....then if your dr didn't do the scan and something turned up later you would sue his pants off no doubt

Danny and Ponyman - It is called informed consent. It is called communicating to your patient or his/her family what the real risks are. I teach 1st year medical students. I'm a fairly bright person. I didn't know the risks and I wasn't informed of my risks or her options. We weren't talking about a child loosing concousness, a change in behavior, or a visible sign. Since that time, I have done a PubMed literature review and have a decent grasp of the CATCH study as well as the other 3 protocols that have been developed in the US and England. There are protocols to determine if a CT scan is recommended following minor head injury in children, but many physicians aren't following it. My Ped's nurse sent me to the ER. If I had a concern, just go. The ER doctor ordered the test. Both failed my family and daughter.

Patients shouldn't need to be doctors to be safe from their physician. It is the physician's job to protect the patient.

I can handle informed consent and would have waited another hour in ER if it would allow us to skip the test. But again, how would a parent know? Based on your assumption, I should sue the physician for unnecessary treatment and mental distress. I should sue if my daughter isn't brilliant as head radiation has been linked to learning issues. I could also sue, if God forbid, she does develop brain cancer or leukemia...but I guess the doctor was banking on skipping that part of it. Again, where was the legally required informed consent?

I am not at all surprised. We do a lot of things in this country out of fear of litigation. (Seriously, instructions and warnings on a box of TOOTHPICKS?) Why not waste a lot of money on needless medical tests? It's not like it's driving up the cost of our already barely affordable private medical system. Oh, wait...

I guess Robbie missed that the tests can kill people...particularly children.

duditos, if you are absolutely sure that the patient does not need one, then why would you be sued?

because juries sometimes vote out of sympathy, or are misled by lawyers, or as non medical professionals, misunderstand what the test would've shown

Because there was a 1:100, a 1:1000, or a 1:10,000 chance that there was a problem. Medicine is rarely 100% in either direction.

Well, if there is a 1:100 risk, it should be done... that's the same risk for the reasoning behind serial c sections. Now 1:10000 is a little different. Obviously, the jury system of uneducated peers and medically ignorant lawyers is a broken system.

No PET scans do not use MRI's. There are valid points in the article, but it's pretty one sided. First, please mention what the increase in risk of breast cancer is with CT scans. Yes, there is a risk, but it is pretty small. Also, please mention that different types of CT scans have differing cancer risks. Also, there are new low dose CT scanners and scanning protocols that make all the old studies obsolete. It's true that there is too much imaging, but there are better ways to describe the problem, rather than selectively presenting facts to get the most scare out there.

What I also meant to say above was that PET scans do not use MRI. However, you're wrong about PET using "crystals." They use nuclear isotopes to look at metabolic activity or activity of specific chemicals in the body.

mxh--took the words out of my mouth on the "crystals." But I will say that Siemens has a new MRI that scans PET simultaneous for real-time physiology, and I believe that this is what the article is reffering to.

That's cool, but I think the article was referring to PET-CT's, the much more common method.

Yes. There was some risk. The impact (and damage) of the radiation varies depending on where you get it (feet versus head or abdomen).

Actually, it is the physician's job to separate the two not the patients. The responsiblity lies with the physician.

Ah, I see now that you are a physician, Danny, so my earlier post might be "to the choir", but I hope someone else gets some info from it.

And Kirsty, the doctor IS trying to seperate it, by getting A SCAN to be sure! You can't palpate a skull and tell what's going on. If you go to the ER and present with enough symptoms in an EMERGENCY ROOM, then the ER doc is going to treat it like an emergency. Of course the patient has to present, but what's better? Sending 1 out of 5 patients home to die? Or sending 4 out of 5 patients for a scan to make sure?

again kirstyloo2 if it was you they sent home and later something was major you would sue their pants off

Actually kirstyloo2, the ER is not the place for coughs, colds, bumps, bruises, scrapes, etc. It's for **emergencies**. There was a time in this country when people had enough sense to take care of themselves. These days, with our entitled population and regulations like EMTALA, the ER has become nothing more than a medical clinic with a big revolving door.

Uhh, no, we get told by our PCP's to go to the ER because they are too busy seeing patients to fit us in. It's ALWAYS "go to the ER"...don't blame patients for what their doctors tell them to do, hey, they are being compliant just like you want!

I did what I was told to do. I called my daughter's ped. I didn't even get to talk to the doctor. I was told to go the ER if I had any concerns. My daughter fell asleep right after the fall...was it odd...not exactly as it was naptime..but it is a warning sign of potential problems. After we were at the ER, she woke up and acted just fine. She wasn't unhappy and there were no signs and symptoms. I was ready to go home, but the doctor said we could check just to make sure. His biggest downside of the test was preventing her movement not the radiation!

Again, as a relativley new mother, I did what my Ped said. And I'll point out that Ped didn't want the liability either. Months later, I was saddened to find out that other clinics in another area of town give their patients a 1-800 number to see if they need to come in. A friend of mine's daughter fell from a greater height at a younger age. She also fell asleep right afterwards. When she called the 1-800 number, she was told that she didn't need to go to the ER and what signs to look for. I am a compliant parent. I did what I was told.

It is a sad state that it is taking articles on MSN.com to make patients aware of these risks...and the number of physicians/medical personal who still justify the behavior!

PS. Jonathan-Radiology and Danny - Medicine is not about being sure. It is about making the best choices. Unless you knew the medical issues, you can't tell the difference between caution and covering one's liability.

As physicians (if you are) I would recommend that you review the data regarding ER docs understanding of the risks of CT. Most don't know the real risks of the procedures that they order.

Here are a couple of references:

Brenner D, Elliston CD, Hall EJ, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289-96 (the gold standard calculation)

Osmond MH, Terry P. Klassen TP, Wells GA et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010; 182(4): 341-348.

Homer DJ, Lewis RJ, Luerssen TG et al. Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines. Pediatrics 2001;107;983-993

It is interesting that doctors do informed consent regarding potential of death from surgical procedures (e.g., death 1:25,000 for a tonsillectomy). Similar disclosures are critical whenever a risky procedure is recommended, there are other options, and time permits. Estimated risk of lifetime cancer death following head CT at age 1:1500. Estimated risk of lifetime cancer death following abdominal CT in a 1 year old 1:700.

kirsty,

unfortunately, your view is naive. The threat of med mal suits are always on dr's minds. I agree with you it shouldn't be that way, but it is. And I wouldn't blame the doctor or put the onus on him not to consider it

If its a problem, shouldn't the ones who cause it (the lawyers) solve it?

Save your references, we saw them all in med school/residency/fellowship

I teach in a medical school. And no, most of my colleagues aren't familiar with the data...partcular the citations from 2010 or the paper last week that prompted this article (check out Lancet). There is just too much to know. I guess that you're also really up-to-date on why people order these tests? Yes, legal liability is part of it. Another part is it clears the ER. Observation takes time (and is often more expensive) than a quick CT. Parents/patients make demands. But the big one is, physicians don't really know or understand the risks of the tests that they order. My daughter also had some difficulties transitioning to solid food due to texture issues. She had a full workup at CHOP, our local children's hospital. As part of it, they wanted to two routine GI procedures that involved radiation. They did this even though the evidence pointed to sensory issue not a structural problem. When I asked what risks were, her physician (from the #1 ranked children's hospital in the country) didn't know. He suggested that I contact radiology and discuss it with them. He then also indicated that he usually saw one abnormal scan per year (~110 tests/yr) and that it was usually associated with signs and symptoms different than my daughter had. So no, physicians don't know the risk and in some cases they order tests...because they can.

I really do understand that medicine is a tough career; however, data like these would suggest that physicians should be more accountable for their choices. Yes, these tests are very necessary in some cases, questionable in others, and not indicated in others. Will it take legal action against physicians to do their job? If my daughter develops leukemia at age 4, should I go back to sue her ER doc? I don't want to get there on so many levels.

Evidence suggests that approximatley 1 in 6 cancers in 2025 will be induced by the medical procedures and treatments of today. As a physician

Exactly how does a microwave oven cook food? To state there is no danger is incorrect, however that danger is offset by trained professionals using and servicing the equipment. If it isn't maintained properly or inexperienced operators are allowed to use the equipment injuries and fatalities have occurred.

Microwave ovens use microwaves, MRI uses magnets and radiowaves. Big difference. There is danger (i.e. if you have certain types of metal in your body, if someone brings metal near the scanner or if you have kidney failure and receive contrast), but the "exposure" you get from the magnets with MRI's have been shown over and over again to be safe.

So mxh microwave energy isn't RF energy? Been working with this stuff for well over a decade, the magnet doesn't give you exposure to RF energy, the RF transmitter does. I stand by the basis for my original statement, that an MRI is only as safe as the level of training of the operators and service engineers. Don't walk into an MRI room thinking it's a kids magnet, because it isn't and listen to what the tech tells you because if they are trained properly you will be instructed what to do and not do to avoid injury to yourself.

By your logic, visible light is also RF energy. I agree that it's not a "kid's magnet" though.

Good lord, RgusnFl, microwaves and MR's both use radio waves. SO WHAT! Microwave frequency is tuned to the bending and stretching quanta of water, so when water absorbs these, it gains energy and heats. A piece of paper without water won't heat.

MR scanners have the RF tuned to the flip energy of the hydrogen nuclei. NOT to the frequency of the bending quanta of water. There is a very very minor degree of heating in the body, but nothing that is clinically important or even noticeable.

"we no onmany that they are negative before we even do them"

Try "know" first.

I bet you have been fooled on many as well - thought they would be negative, but something life threatening turned out to be there.

What if you are 99% sure that headache is not an intracranial hemorrhage? Guess what, ER doctors see hundreds of headaches a year. That means, eventually you're going to miss a life threatening ruptured aneurysm on a young healthy female with a husband and 4 kids.

Unfortunately, our margain for error is 0. So again, it's very easy to sit there from the CT tech chair and question. Not so easy from the physician side.

..

Estimated lifetime risk of death if you receive a standard head CT at age 1 is 1:1500. The risk for an abdominal CT at the same age is 1:700 (Brenner D, et.a. AJR Am J Roentgenol 2001, Homer DJ, et al Pediatrics 2001, Osmond MH, et al CMAJ 2010). Those are real numbers too. Add to it that most ER physicians don't have a clue about the risks...and it spells problems.

Mortality rate of traumatic subdural hematoma in children - up to 79%

Leading cause of death in children in the United States - Closed head injury

"Estimated lifetime risk of death if you receive a standard head CT at age 1 is 1:1500"

Actually the estimated lifetime risk of death if you receive a standart head CT at age 1 is 1:1. Everyone dies. Good thinking though. Really hammers in your point.

Danny, you're the kind of doctor I'd like to work with, and that I'd hope for if I went to the ER. I like the way you think, good sir!

Ok Danny. It was a lifetime risk of CT induced cancer death. And yes, you knew that. And no, I don't want to be involved with your clinical practice, and hopefully, I wasn't part of your preclinical education. You are/were the type of medical student/resident/physician who will ultimately be a hazard to their patients because they think that they know everything, they are smug, and they don't listen with a thoughtful compassionate ear. Other than that typo issue...refute the data. The lifetime risk of a CT induced cancer death due to a single standard head CT at age 1 is 1:1500. This should be a sobering fact. And yes, if my daughter had any sign of a traumatic subdural hematoma, I would agree with you as it would represent a high suspicion of serious injury. My daughter fell 2.5 feet, cried, and went to sleep. She was difficult to rouse; however, she woke up minutes after arriving at the ER and appeared fine. I apologized for bringing her in and wasting people time. The ER doc said that we should do the test to make sure. In a brief moment, I made a mistake and listened to the professional who failed to do informed consent despite the ER being nearly empty.

I'll point out that the risk for a 1 year old is 1:1500 (treatment induced lifetime cancer deaths) while the risk for an adult undergoing the same test is about 1:100,000 (treatment induced lifetime cancer deaths). 2009 data suggest that 80% of ER docs place the risk closer to 1:100,000 and they don't understand the differential risks for young children.

please post your source. I disagree with that data

Brenner D, Elliston CD, Hall EJ, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289-96

Osmond MH, Terry P. Klassen TP, Wells GA et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010; 182(4): 341-348.

Homer DJ, Lewis RJ, Luerssen TG et al. Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines. Pediatrics 2001;107;983-993

It would be intesting to read the new Lancet article that prompted this whole discussion in the first place.

Kirsty -

Good to have some real discussion on one of these boards with actual information (references) thanks.

I will point out that medicine is transitioning. There is a strong effort to reduce radiation levels when possible. It has not been fast enough for my taste, but it is happening. This has been led primarily by radiologists, and some radiologists are slow to adapt, but also some clinicians are resistant. You cannot imagine the resistance I would get if I cancelled a study due to radiation risk. In fact, I am being sued right now by a young woman who has a breast cancer. One of her contentions, I imagine, will be that we didn't do a mammogram. We resist doing these on young women because of radiation risk, and it may very well cost me a malpractice judgement. There is a possibility I may lose my retirement and house. (remote, but that possibility is there, and I am worried). THIS is what the other side of the argument looks like. (Despite this, I still cancel mammograms on young women when I feel it is not needed, but my criteria for "not needed" are eroding).

There are two points that need to be made: First - estimates of induced cancers are estimates only . No one has ever directly measured an increase in mortality in dose levels we are talking about here. Excess cancers have been observed in populations that have received much, much higher doses. The increases of cancer rates in those populations are statistically real. To get estimates of low dose induced cancers, typically there are many assumptions made. The most important is that the induction rate can be estimated from the high dose induction rate. This is often referred to as the linear-no threshold estimate (LNT). This is controversial. There are real reasons to suspect that this is not correct, and that at some low dose, the relationship between dose and induced cancers breaks down. This means that at very low doses there may not be any induced cancers at all. But, to be conservative, we are acting as if the worst case is the real case. This point gets lost in many discussions of radiation dose.

Second - what the ER docs are concerned about is not so much subdural, but epidural hematomas. The difference is that the bleeding occurs between different layers of the coverings of the brain. Clincally they act very differently. Subdurals are venous, slow oozing bleeds. Epidurals are arterial, rapidly changing bleeds. An epidural patient can look fine, and die literally minutes later. This is what killed Natasha Richardson. From reports, after her head bump skiing she looked fine. She went home and died.

I was trying to convince my ER doc buddy not to order so many head CT's (we have maybe 0.5% of unexpected positive head CT's)— Surely, I said, there must be some way to exclude some of these patients who are unlikely to have the problem. He looked at me and said "the incidence of epidurals is 1 in 10,000. In my career, I will see two. If one of them comes in today, then he will die, and my career is over. I will continue to order the head CT's." I really couldn't think of a good response to this. This conversation capsulizes the problem, not just in head bumps, but in all other areas of medicine.

The whole discussion revolves around the trade off between the risk of missing potentially important disease, versus a theoretical risk of developing cancer. Because this is an unanswerable question, the debate will never be finally solved (perhaps unless another completely safe and completely accurate method is developed - MR isn't very good for acute bleeds).

So you're saying that the CT scans given between diagnosis and passing were not helpful?

Then refuse a CT scan.

Patients have every right to refuse a CT scan.

Here's the thing: If you are worried enough about your symptoms to seek medical attention, and the medical professional suggests a test to further assess what the problem may be, you aren't going to turn it down. That's why you sought medical attention in the first place.

When you pose the question: "I'm relatively sure that your symptoms are not something life threatening, but I can not assure you that 100%. We have further tests, ie CT scans, that have radiation exposure, but can help us determine this isn't something serious. What would you like?"

It has been my experience that the patient says - "Please, I would like the CT scan" every time.

Of course you can refuse a CT scan, but how many would?? Any how many get cancers from the radiation??

Physicians have responsiblity to give informed consent. This means that they need to understand the real risk to the patient. After a bad experience where a physician ordered a head CT for my 1 year old after a low impact fall (no bump, no signs), I always ask about the radiation. When my daughter was offered a barium study and a motility study to see if there was a structural problem, I asked the question how much radiation and what are the risks. He couldn't answer it. All he could say was that he didn't think that she had the structural problem he was testing for and that I could contact the radiology department to see what the risks were. For goodness sakes!

and if she does i'm sure you are going to sue his pants off for not doing the test

Kristy,

This is the funny thing to me. You try to act like such an informed patient with all these great statistics. If you are so "informed" and know all the statistics, then why did you take your 1 year old after a "low impact fall, with no bumps, and no signs" to the ER?

If you were concerned enough to take your child to the ER, how can you fault the ER doctor for being concerned enough to rule out a serious injury with a CT scan?

Wow, great bedside manner, DOCTOR. Pfft...

I am an informed patient and dedicated parent. I am a curricular director who teaches basic science to 260 medical students per year. I'm really easy to educate. I understand risks...heck, I can teach the risks associated with prenatal screening and prenatal genetic diagnosis. I'm also very capable of researching a medical topic and reading the literature.

Physicians need to realize that patients/parents aren't experts. I do know about the risks associated with radiation. What I didn't know is how much radiation is involved in a head CT or how to evaluate the significance of a head injury. Because of my training, I answer questions well, and I don't add or subtract information.

What physicians need to realize is that some people actually do what they are told. When my daughter fell, I did what I was told to do if I was ever concerned...I called my Ped. Without regard, my Ped's nurse told me to go directly to the ER if I had any concerns. As a new, type A mom, I had concerns when she fell asleep...despite it being nap time. She woke up as we entered the ER. We almost left, but my comment to my husband was...well we're here we might as well let them look at her. What harm could it do? Well, we now know the answer. We couldn't find evidence of a bump on her head and everything appeared fine. When started running around and laughing, I apologized for bringing her to the ER because she seemed fine. He still recommended the CT so I figured he knew what he was doing.

Only after doing a lit search did I realize that he practicing defensive medicine. And yes, I live in Philadelphia, an area with very high litigation rates. After the event, I sent him a follow up letter regarding my perceived communication problems with our encounter, the issues of informed consent, and a couple of the papers that I cited earlier because I was struck by how most general ERs are relatively poor at providing ped specific care. I also asked him if his institution was planning on adding pediatric scans to their options because my daughter's report indicated that she had a standard head CT. A pediatric version would have idenfied any major problems and it would have cut her radiation exposure in 1/3 or more. I worked really hard not to make the letter a rant which was hard. I never received a response...which was fine. I just hope that he read it...as there will be another person's child on another day.

What I find really disturbing about this thread is how claimed medical professionals post here and blame the patients/parents or justify a medical practice that The Lancet has questioned. For me, it has really hit a painful nerve both as a parent and as a medical educator.

RE: blaming the patients.

Well - you just have to walk in our shoes a while. For every parent like you - there is one or more who DEMAND the test. You know that you are in the crosshairs of a malpractice attorney. There are patients who come to the doctor who feel blown off and angry if you don't order a high tech imaging procedure. After all - they have paid their insurance premiums and they deserve it, by god.

As an ER doc once told me: Ordering a CT scan is the very cheapest malpractice insurance he can get. Not a sentiment that I am comfortable with, but the society has created this monster. If you don't like it either, vote for a candidate that will enact tort reform.

One other story - bizarre, but entirely true - A physician needed to give a woman a dose of radioactive Iodine to cure her graves disease. Pregnancy test was routine - she refused, making a very loud scene in the waiting room. Iodine given. Next week - she needs a CT scan. Same scene - she gets the CT, and they saw a fetus. So the patient was closely monitored, and when the baby was born, he was given thyroid replacement hormone immediately and he is fine. He was immediately given up for adoption. Two years later, the physician is sued by the mother (who has no relationship with the child now) for malpractice alleging psychological distress.

This is the sort of thing that doesn't encourage, but demands that physicians protect themselves from unbalanced members of the general public that we must deal with and from their attorneys.

Dr. S

If a jury sided with this woman, something is very wrong.



Dr. Sardonicus - I do understand the concept of the crosshairs. I will also point out that there are many well balanced members of society who are getting scooped up in the mix. When national organizations create guidelines that are supported by real data, they should be used or at least discussed.

The Lancet article (June 2012) that prompted this MSN.com article should also be a cautionary word for physicians. There are real negative effects of these tests particularly in children. This should prompt people to practice safely (use the guidelines), clinical researchers to investigate other safer options (e.g, ultrasound), and to search for low radiation options. It was almost inexcusable for a hospital in a main metro area to be doing standard adult CTs on 1 years olds for minor head trauma. They used the same number of cuts for her small head as they would for an adult. They also weren't looking for something small like a small tumor or a stroke. The resolution doesn't need to be as high (the experts conclusion not mine). Doing these things could have cut her dose to 1/4 of what she did receive. It would have taken a bit more time, but wasn't it worth it?

Jenellect -

Oh yes something is very wrong. It has not gone to jury yet, but there is something wrong when this sort of BS can even find an attorney to file the suit. He is obviously trying to use up so much of this physicians time that he will agree to a settlement just to be rid of the nuisance.

There was another suit in Philadelphia some years back in which the woman had a head CT and sued because after the head CT she lost her psychic powers. The jury found against the physician. This was overturned on appeal. But - it cost the physician a lot of money and time to defend.

Funny maybe, sad, but mostly in me it produces anger. You and I all pay for this in the form of higher insurance rates. It is no stretch to say that 30% of all of your medical bills are directly attributable to defensive medicine. And really , if anyone wants to condemn a physician for practicing defensive medicine, don't. The proper target is the legal system, and the society in general that permits this to go on.

Kirsty Loo -

Re appropriateness criteria. My professional organization, the American College of Radiology, has for many years published appropriateness criteria for every exam and every indication for exam. I don't like them. They are way too permissive. Things that are archaic still are blessed by this document. The reason probably is political, they don't want to be too restrictive. So, I think they are pretty much useless, though they are the only criteria that exist.

If you are of a mind to do this, it might be interesting to get your childs head ct and look at the acquisition settings (Kv and mAs), then I might be inclined to schedule a meeting with the medical director to see if these really are the same as used on adults, and if so, why. One informed person like you asking politely for answers really could prompt them to change quickly.

I have a friend (Dr. Steve Birnbaum) whose daughter was injured and in a hospital in Boston. Because he thought she was getting more scans than she should have, he started asking questions, and as a long term result changes were made. He also started, single handedly, changing the way radiology is practiced in the US with regards to radiation protection.

Kirsty loo

Just went back and looked at some scans at our place.

mAs is the number of photons and the kVp is their energy. Number of photons absorbed is essentially the radiation dose and the absorption goes up with lower kVp and higher mAs. So with constant kVp, the dose is proportional to the mAs.

Adult factors are kVp 120 and mAs 230-300.

Pediatric:kVp 120, mAs range 130-230.

these factors are printed on every frame of a CT scan, usually lower left corner. You can call the department and ask them to send you a CD. The CD should be mailed to you, and you can just pop it into your windows computer, and the CD's have embedded image display software that will automatically start up and allow you to view the images. (If you run on Mac's, there is free software called Osirix to do this, and it is actually very good).

No one disputes these tests can save lives, however that doesn't mean billions aren't spent each year for the sole purpose of making money. I think you'd find the doctors who have no interest in any company performing these services or making any fee referring them have far fewer patients given these tests. That's a serious problem with health care costs so high. The last thing we need are tests only being performed for profit.

Of course not. Doctors claiming they are merely providing what the patients want simply isn't true. Many doctors have a vested interest in medical services that do these and make huge returns from these and payments made for referring patients. The fact we have many times the number of these machines in small area's compared to countries with socialized medicine prove most are bought to produce a profit not cover a need.

define and prove "many"

Wilfred

Actually not a provision of any law, just the way it is. The fee charged to you is for 1) technical component - the equipment necessary to do the scan and 2) professional component - the cost for reading what is produced.

If the hospital owns the equipment, then they get the tech fee, if the doc owns it, then he gets it. If an entrepreneur (plain old businessman) owns it, then he gets the tech fee.

Years ago, when the govt was trying to cut costs in their own ham-handed way, they just started cutting payments to physicians. To the point that many physicians became insolvent. But the realized they could buy the equipment and stay solvent, which they did. And your observations that they substantially increase the number of scans they do is absolutely correct, I could go on for pages about this. One doc told me he wasn't concerned about reduction in payments, he said he would just order more scans.

Recently, though the govt made another stupid move. Through the deficit reduction act of 2009, they cut payments to any physician owned imaging center. How they can discriminate against an owner because he has a degree, I don't quite understand, but they did. The cuts were so deep that the centers became insolvent. Rapidly, they were sold to local hospitals and the physicians became employees of the hospitals. Why was this stupid? because now the hospitals own all the imaging in town, and there is no competitive pressure to keep their fees down. What should have been done was this: fees are the same regardless of where performed, but no physician can refer to a facility in which he has an ownership interest. That way, radiologist owned facilities (and radiologists can't really self-refer) and entrepreneur owned centers could be some price competition for the hospitals.