Would You Like Fries With That MRI?

Have you ever wondered what happens after you obtain a diagnostic medical imaging study? Me, that’s what! Each x-ray, CT, MRI, mammogram, and ultrasound is interpreted by yours truly or one of my dark room brethren—a radiologist.

Crotchety old radiologists, many of whom walked uphill both ways to school, might complain that too many imaging studies are performed today compared to decades past. The entire healthcare economy has grown, but diagnostic imaging disproportionately so. Because of its rapid growth, diagnostic imaging has become a target of healthcare cost-cutting measures by Uncle Sam.

But are these cuts wise? How do efforts to limit diagnostic imaging affect patients? Most critically, what are the reasons driving increased diagnostic imaging, and are they being adequately addressed?

Contributing factors

First let’s explore why diagnostic imaging utilization is on the rise.

• Population demographics: People are living longer lives; math and logic tells us that more imaging studies will be performed, especially on older individuals.
• More reasons to image: New indications for imaging and novel imaging techniques are constantly being researched and implemented.
• Reliance on imaging: Diagnostic imaging has become a key diagnostic tool in modern medicine. To be frank, it has replaced the history and physical examination in many situations. Before CT was invented, for example, it was not uncommon for a surgeon to operate on a patient based on symptoms and physical exam findings. These days, CT can quickly and easily diagnose countless acute conditions, and often aids in surgical planning. Imaging to confirm a diagnosis has become the standard of care for many conditions.
• Incidentalomas: Often a radiologist will discover an abnormal finding unrelated to the reason the study was initially ordered; we call this finding an “incidentaloma,” because it is discovered incidentally (clever, huh?). Most incidentalomas are harmless, benign lesions, but confirm of their benign nature often necessitates repeat imaging at a later time or a different type of imaging study. Thus, we can expect a finite number of additional, “spinoff” imaging studies when incidentalomas are discovered.
• Defensive medicine: In my opinion, this is the most important driver of increased (and sometimes unnecessary) diagnostic medical imaging. Doctors are afraid of getting sued, and order too many tests due to that fear. Unfortunately, defensive medicine has become an implicit—and often explicit—part of training for every medical resident in this country.

Getting defensive

Doctors are trained to make decisions using a risk/benefit analysis. If—in a doctor’s mind—the potential benefits outweigh the risks for a given option, he or she is more likely to choose that option.

In an ideal world, a doctor would only consider risks and benefits to the patient. But in the real world, legal, economic, administrative, and political factors creep into the decision process, and contribute to the practice of defensive medicine.

To illustrate this effect, let us ponder alongside Dr. Defensive as he weighs the risks and benefits of ordering an imaging study.

The decision box

• Benefit of imaging (lower left): The benefit of imaging is clear: make a diagnosis. But the rarer the suspected disease, the less chance this benefit will be realized.
• Risk of imaging (upper left): The risks are small for a single patient and imaging study. Radiation dose from one x-ray or CT scan increases the risk of future cancer development by a minuscule amount. Serious complications—a severe reaction to intravenous contrast, a safety issue during an MRI—are also rare. Financial costs to the patient need also be considered. On the whole, most doctors view the risk of an individual imaging study as low. Extrapolated across large populations, however, these risks become more significant.
• Benefit of not imaging (lower right): Exactly the opposite of the risks of imaging. Similarly, the benefit may seem small for any single imaging study, but becomes more significant with larger patient numbers.
• Risk of not imaging (upper right): AKA lawsuit corner. Medical malpractice lawsuits are as American as guns and apple pie. Depending on specialty, a given doctor has a 75-99% chance of being named in a malpractice lawsuit during his or her career.

I would argue that—based on the interplay of these risks and benefits—doctors decisions are driven toward obtaining imaging studies. In other words:

Fear of missing a diagnosis and getting sued + the (perceived) low risk and large benefit of performing a medical imaging study = a perfect storm of increased imaging utilization.

Stopping the insanity

Is our current level of diagnostic medical imaging a new paradigm, and efforts to slow its growth futile? If so, is this economically sustainable? These are tough questions with no clear-cut answers.

Many folks much smarter than me (and, ahem, Washington bureaucrats) have attempted to address the issue of increased dianostic imaging. Here are few proposed or implemented solutions.

1. Pre-authorization: Insurance companies force doctors to obtain pre-approval from the insurance company for an imaging study. Clearly there is a conflict of interest here: the entity that pays for the imaging study has the ability to deny it. Doctors worry this process wrests patient care decisions from their hands.

2. Decision support software: It is sometimes difficult for radiologists to say “no” to an imaging study request; they are often physically removed from the patient, precluding a direct assessment as to whether or not an imaging study is necessary. Ideally, a radiologist would always advise the ordering doctor as to which imaging study is appropriate; realistically, this is impossible with every patient due to time and efficiency constraints. An alternative solution uses computer programs known as decision support software to guide ordering doctors to the appropriate imaging study.

3. High-deductible health plans: Patients with this type of health insurance tend to share more out-of-pocket cost burden. Unfortunately, this can result in more patients forgoing a necessary imaging study than would have been the case with a traditional, low-deductible heath insurance plan. While it might be cost-effective, I’ll let you draw your own conclusions as to the wisdom of this approach.

4. Tort reform: A tort is a legal term for an act which causes harm and results in a civil legal liability; in other words, it’s why someone gets sued. In medicine, it can progress to a malpractice lawsuit against a doctor for a (real or perceived) mistake which resulted in harm to the patient.

Advocates for medical tort reform propose changes that would—among other things—selectively limit a patient’s ability to file a civil lawsuit and reduce the possible compensation for damages.

• Why tort reform? Certainly some doctors are truly negligent and medical malpractice lawsuits against them are warranted; however, it is impossible to deny that many malpractice lawsuits could be characterized as “frivolous.” (By frivolous, I mean lawsuits which are without legal merit.) On a few occasions, medical malpractice cases have seen compensatory damages in the tens of millions of dollars. These enormous settlements—coupled with countless large ones—rightly petrify many doctors, and impel them to order extra imaging studies for fear of missing something and getting sued.
• Why NOT tort reform? The efficacy of tort reform is controversial. Some argue it may rob patients of their full recourse in cases of true malpractice; others claim that it would do little to diminish the practice of defensive medicine. Patients need to maintain the ability to sue for medical malpractice. But the current medico-legal environment makes suing doctors too easy and without consequences, and is untenable in the long run.
• A middle ground? Every doctor would rather practice evidence-based medicine—with the patient’s best interests in mind—than defensive medicine—with a fear of malpractice lawsuits. Most doctors practice somewhere in the middle. A number of states have taken steps to decrease frivolous lawsuits, such as limiting payouts on “non-economic” (e.g. pain and suffering) damages and requiring qualified medical experts to certify new malpractice claims. Nevertheless, doctors remain vulnerable to frivolous lawsuits and large compensatory damages; more importantly, they feel vulnerable, which affects their decision-making processes.

Final thoughts

I’m trying to stay positive here, folks. But in my opinion, healthcare policy changes enacted to decrease image utilization have been woefully wrong-headed.

One simple solution has been to arbitrarily slash payments made to doctors and hospitals for imaging studies. It’s effective, sure, but a slippery slope. Medicine operates a business, and if payments for services continue to decrease, the affected services will eventually become economically unsustainable.

Attempts to make the ordering of imaging studies more onerous—via pre-authorization and, to a lesser degree, decision support software—have proved frustrating to patients and doctors alike.

Of all the factors contributing to increased diagnostic medical imaging, only one is truly amenable to change via healthcare policy: the practice of defensive medicine. How do we change it? Tort reform. Doctors have been beating this drum for years, but widespread, comprehensive tort reform remains elusive. Whatever “effective” tort reform looks like, it needs to allow doctors to practice medicine without significant fears of being sued. So call your legislators. Just kidding…kind of.

Being a doctor is stressful. If they do a good job, they would appreciate some kind words and a hug, but most of all they would love not to get sued.

Alright, doctors, patients, and lawyers, let me know what you think.