Do We Really Need That CAT Scan?

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.

First, do no harm ... our creed, our command, our imperative. It’s easy to point out those times when a doctor does harm by commission of an act, but what about when we do harm by omission? After all, we get extraordinarily busy sometimes and, out of necessity, sometimes omit things deemed to be "not as important" as other things. If we are honest with ourselves, there are times we fail our patients, and fail miserably.

We are only human, right? How long can we go without sleep, food, or fluid, trying desperately to make it through the "next few patients" before we take a break and tend to our own needs? When we are hungry, thirsty, or just plain grumpy from stress on the job, and life’s events in general, how often do we opt to forgo opportunities to educate and protect our patients?

I think this happens more than any of us want to openly admit. Sometimes it just seems easier to order a test than to spend extra time determining whether there is a better alternative. And then there’s that ever-consuming lawsuit issue. On occasion, most physicians do order tests and procedures to avert a potential lawsuit, even though in our guts we feel the patients don’t really them.

Case in point: the glorious CT scan. Television would have our patients believe that CT scans can diagnose every condition under the sun. No wonder so many ask for them (and sometimes demand them) even for the simplest of symptoms.

Have you ever had a patient who has had 10 or 15 CAT scans in the recent past, all of which were normal, or nearly normal? I have. But after explaining that each scan carries a small but real risk of promoting cancer in the future, that CAT scan that was once so important became rather insignificant. Of course, clinically I did not feel the patient needed yet another scan and after learning about the risks involved, he didn’t either.

Many radiologists – who know the risks better than we do as hospitalists – sometimes feel uncomfortable about the number of CT scans performed. Says Dr. Peter Vandermeer, vice-chair of the department of radiology at Baltimore Washington Medical Center in Glen Burnie, Md.: "We are alternately frustrated and chastened by the fact that we cannot know everything that goes into decision making. It is hard to know if this is the real episode in which a CT will finally help. It will always remain a clinical decision based on immediate circumstances.

"Especially in young patients, we need to be aware that there are small but potentially serious consequences of CT scans. The other side of it is that as radiologists we are always willing to discuss alternate tests, such as ultrasound and MRI, that may be helpful in answering specific, directed questions. CT is great in giving a broad overview of the entire abdomen, but if all you really want to know is if there is hydronephrosis, renal ultrasound may be sufficient."

As a parent, I am particularly concerned about the risk in children. In an article published in The Lancet, researchers reported that 10 years after a first scan for children under the age of 10, there was one excess case of leukemia as well as one additional brain tumor per 10,000 head scans performed (Lancet 2012 June 7 [doi:10.1016/S0140-6736(12)60815-0]).

While a single CT scan does not seem problematic, for that 1 in 10,000 patients who does develop cancer, it is highly problematic. So let us make sure that each scan we order is truly worth the risk to out patients.