A recent article in the New England Journal of Medicine touches off another salvo about how nonclinicians have no problems judging the abilities of clinicians in the world of medicine.
The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bells Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan. She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians.
It appears that the case cited may be this one. More information here.
The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80.
The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%.
The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation?
Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it.
In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism?
Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get as much radiation” be a sufficient defense in a medical malpractice trial?
The suggestions are good, but they don’t apply to clinical practice.
In addition, while the FDA does regulate “radiation-emitting electronic products” including diagnostic x-ray equipment, telling patients how many diagnostic radiographic studies they may “safely” obtain is likely an area of mission creep for the agency – akin to regulating how many hours of television people may watch in a day (yes, television receivers emit radiation) or how many hours George Hamilton may spend under his radiation-emitting sunlamp. I’m not so sure that having the FDA limit the number of scans a patient can receive is a good thing.
I also take issue with Dr. Smith-Bindman’s statistics that demonstrate greater than a 1% incidence of developing cancer from a single CT scan. If 1 in 80 patients can get cancer from a single CT scan and almost 80 million CT scans are performed every year, each year we are causing close to 1 million cases of cancer in US citizens. According to the American Cancer Society, it is estimated that 1.5 million total cases of cancer will be diagnosed in the US in 2010. Is our use of CT scans really causing more than half the cases of cancer in the US each year? Even if we cut the incidence in half, causing 500,000 new cases of cancer each year is a hard allegation to substantiate.
While the number of CT scans is allegedly increasing at 10% per year, the number of new cancer cases in the US was 1.22 million in 2000 and is 1.53 million in 2010 – hardly an increase of 10% each year over 10 years. Those increases in new cancer cases also paralleled an increase in the population size – from 281 million in 2000 to 305 million in 2009. On a per capita basis, the incidence of newly diagnosed cancer went from 4.3 per thousand to 5 per thousand during those nine years.
Dr. Bruce Hillman wrote an accompanying article citing how “an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.” As some causes of the unnecessary use of diagnostic imaging he cites patients who “pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.” He also cites defensive medicine, self-referral, medical training programs that ingrain “shotgun” diagnostic testing to confirm diagnoses with the “greatest possible certainty.” He also acknoledges that radiologists also share in the blame for fueling the explosion in diagnostic imaging.
His ideas for changing the system are much more realistic and include tort reform, better physician and medical student education, engagement of radiologists as consultants, and “a change in mindset among physicians.”
I agree with Dr. Hillman on every point except the last one. Physicians have a “mindset” that is created by attorneys and by the public. In most cases, physicians are expected to be perfect or to exhaust all possible testing in finding a diagnosis (I still haven’t had one person who disagrees with me on this point present me with a diagnosis that it is OK to miss). If a diagnosis is missed, the lack of “appropriate” testing that would surely have made the diagnosis is a central theme in the physician’s malpractice trial.
We don’t need to change the physician’s mindset. We need to change the public’s mindset. If less testing is performed, more people will have diseases that won’t be diagnosed … or that won’t be diagnosed early enough. That is an inevitable result of reducing the use of diagnostic radiologic testing. Will the public and the juries sitting in medical malpractice trials accept this fact? Can we say that a 95% possibility you don’t have a deadly disease or severe injury is “good enough” and non-actionable? Until society makes the commitment to lower the bars over which clinical physicians must jump, the incidence of diagnostic imaging – and all the radiation that accompanies it – will go up and not down.
There were many news articles published about this study, including USA Today and Forbes.com.
I didn’t see any clinical physicians interviewed in these articles – only radiologists. That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs. How confident would we be if USA Today encouraged readers to pick up the paper next week when USA Today will have chemical engineers commenting on how mechanical engineers should stress test products more thoroughly? Hey – they’re both engineers, right?
The money quote from Dr. Hillman in a Reuters article really irked me, though:
“We need to convince physicians that a quest for certainty is impossible, costly and is harmful because of indirect diagnoses.”
If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk.
How about this: When the dumb ER doc orders the next total body scan, walk over to the emergency department, examine the patient, and come up with your own diagnosis without using your deadly CT scanner. Get rid of your hindsight bias and make a prospective diagnosis without having the benefit of a “normal” diagnostic test sitting on the computer screen in front of you.
Isn’t as easy as your little news sound bites make it seem, is it?
Want to regulate something to really stop the flow of radiation into patients? How about making the American College of Radiology start regulating the number of diagnostic radiology reports from their members that contain phrases such as “cannot rule out underlying lesion, recommend CT scan for comparison”, and then “CT scan non-diagnostic, recommend bone scan for further clarification”. We could cut down on costs if radiologists would stop recommending “MRI for clinical correlation”, also.
I’m betting that we won’t see too many sound bites about the implications from this radiology report lingo hitting the headlines any time soon.
As a consumer (albeit one who has never had a CT scan) I would like to see patients informed of how much radiation they were getting with a given test. It should be our responsibility as consumers to keep track of cumulative rads and to give truly informed consent for a test when there is time to consider the possibility of another option.
Good point and I agree.
Assuming that we could track cumulative radiation doses, at what point would you consider refusing a test?
I haven’t done the research, so I couldn’t cite doses. But I don’t think it would be a particular threshold so much as one factor of many when deciding whether to have a test done. Clearly there are some circumstances where a CT scan is called for (trauma) and others where maybe another test, or a lower dose, could be substituted with little diagnostic impact.
To answer your question, I would -consider- refusing a CT scan at 0 rads of cumulative dosage. It just depends on the situation.
I guess the larger point is that given our current medical system, consumers must learn to be responsible for our own care; if doctors can inform us about things like radiation doses, that helps us do that.
“I guess the larger point is that given our current medical system, consumers must learn to be responsible for our own care”
I am with you 100%. And I try to go out of my way to help patients like you.
Perhaps all citizens could be given an old-fashioned radiation badge to be turned in quarterly for analysis.
And, Jillian, if you were to refuse that test and were later found to have something more serious, would you then NOT sue Dr. Whitecoat for not thoroughly discussing all the pros and cons of your refusal?
Too many patients do NOT take that responsibility. Short of spending 1 hour away from spending with another ill patient trying to explain EVERY possible outcome, good or bad, of NOT doing a test or doing a less adequate test, Dr. WC can and will be sued for failure to diagnose.
He may not lose the case but that would be another malpractice case on his record, ultimately risking losing his malpractice insurance for having too many suits, lose his job, and lose his license.
“Dr. WC can and will be sued for failure to diagnose.”
Will he? What are the actual odds? When you consider that even WC estimates a billion physician-patient interactions every year, the number of resulting lawsuits (less than 100,000) seems to be pretty small.
First, what’s your source for the 100,000 number?
Second, even if we assume that your 100,000 number is accurate, that means that a physician is sued once for every ten thousand patient interactions.
I see roughly 3,000 patients per year, so that means that I should be sued about 12 times in my career.
Yeah. That sure seems “pretty small” to me.
Good logic.
And we wonder why the cost of medicine is so high in this country.
Tell me what other profession should expect to be sued so much.
My source for the 100,000 number? This article, which actually cites 85,000, but I rounded up for your benefit:
http://faculty.law.miami.edu/mcoombs/documents/Hyman_Silver.pdf
“Second, even if we assume that your 100,000 number is accurate, that means that a physician is sued once for every ten thousand patient interactions.”
Nope, that means a provider is sued, which is not necessarily a physician. I don’t have the breakdown from there, so we’re just guessing.
“I see roughly 3,000 patients per year, so that means that I should be sued about 12 times in my career.”
Not at all, because we’re also not factoring those physicians in who are paying judgment after judgment or hospitals that are sued for the actions of their non-physician staff. You’d have to your insurer for those figures.
“And we wonder why the cost of medicine is so high in this country.”
Do we? I think everyone has figured out that it’s the disconnect between the provider, the patient, and the party paying the bill. I thought that was pretty much settled. Did you really think it was lawsuits after all your decades of “tort reform” hasn’t changed the cost of healthcare? If so, that’s just willful ignorance.
“Tell me what other profession should expect to be sued so much.”
Given that the numbers haven’t been compiled on exactly how often physicians get sued, how would we compare? I guess the insurers of the various professions could. They’d have the numbers.
“I see roughly 3,000 patients per year, so that means that I should be sued about 12 times in my career.”
I know you’ll correct me if I’m wrong, but I don’t think statistics work like that. I don’t think you keep adding. Your percentage chance in any given year doesn’t go up. So if it’s 1 in 10,000 one year, it’s the same the next. Surely someone on here has a statistics background and can clarify.
@Matt: 3k/year times 40 years (age 25 to age 65) equals 120k, divided by 10k gives 12.
…you dumbass.
Again, the statistics aren’t cumulative like that, I don’t believe. I get how he came up with his number, though. Thanks for retyping it, though. I’m sure someone else missed it and appreciates you clarifying.
[coming from a non-statistician who is proffering substantive opinions on statistical matters]
Iiiiii-ron-y … is such a lonely word … everyone is so untrue. I-ron-y is hardly ever heard … and mostly what I hear from you.
Thank you. Thank you very much.
Sometimes I wonder if you read very closely, or if you just scan my posts and pee your pants with excitement and forget to read what they actually say before you start typing.
I said I don’t think that’s how stats work and invited someone with a statistical background to inform us. Clearly, DD is not that.
After all, the average physician does not get sued 12 times in their life. But maybe your one billion figure I was relying on was wrong.
But I’m glad to see you have an IDEA what irony is, even if you didn’t read correctly. Now, try thinking about it before you post. I think you’ll find your quality will go WAY up.
Here’s an interesting thread from a couple years ago that dances around the question but I don’t think answers it directly:
http://forums.studentdoctor.net/showthread.php?t=362583
And if you’re still fussy at me for pointing out your hypocrisy, perhaps this will lighten your mood:
Technically -each patient- would have a .01% chance of suing, assuming the 1-in-10,000 number is accurate. So if we want to estimate how many suits an average doctor could expect over the course of a career, we would indeed divide the total number of patients by 10,000.
No, because the 85000 figure doesn’t take into account claims against entities rather than physicians.
This is an excellent post, and addresses a concern I have had for years. I am subject to kidney stone episodes two or more years apart. I know what the symptoms are, and I know that a couple powerful drugs and an IV will get me relief while I flush them.
When I present myself at the ER, puking and moaning, with blood in my urine, I hope to be able to communicate that I don’t need another CT scan. Unfortunately, once I am zonked out on pain killers, I expect to find myself being wheeled down the hallway to the scan room. I am left with another dose, and a $5,000 bill to pay for that scan. Charged to insurance, of course.
I suppose that the scan is needed to confirm the diagnosis, and to ensure that “something more serious” is not going on.
I agree with you and I usually treat patients with typical kidney stone pain and blood in their urine as kidney stones. If their pain goes away, then I send them home with a urine strainer. I don’t commonly do CT scans with typical kidney stone pain.
So let me ask you a question –
If the scans weren’t covered by insurance and you had to pay a lesser amount – maybe $3000 out of pocket – would you still allow them to do the scans to ensure that something more serious wasn’t going on?
As one of the multitude of uninsured Americans (who is anti-Obamacare, but that’s beside the point), I’m thankful that I have not been in an ER in about 7.5 years. But, God forbid, my kid or husband or I should end up in one, I’d like to know how much is this test going to cost before it is performed on me. Because I don’t want to end up unable to pay my utilities or rent/mortgage because of a CYA test I didn’t need but the doc’s malpractice insurance said he needed to do.
Because contrary to the general consensus, not all of us patients are out looking for a meal-ticket to sue. Some of us are just plain concerned about the broken arm or chest pains or whatever and need to see a doctor NOW (or in 4-5 hours when the pregnancy test seekers and drug seekers make way). But unfortunately there are so many that *aren’t* like us that we have to go through the same CYA crap.
I’d love to be presented with a form that says, “I won’t sue my doctor – no really, I mean it. Sign here.” That would rock! I had that kind of relationship with my doctor when pregnant with my kids – don’t force me to do a bunch of CYA tests/procedures and I won’t sue you if something goes wrong that could have been prevented by said procedure.” Why? Because we trusted each other. And it was great!
Wish all of my patients were more like you.
But unfortunately there are so many that *aren’t* like us that we have to go through the same CYA crap.
No there aren’t. They do “defensive medicine” regardless of whether they think they’ll be sued. In fact, your comment illustrates the one thing that study after study (conducted by physicians) shows would actually reduce their malpractice risk – communicating with their patients.
Unfortunately, the payment system they’re in doesn’t reward them for that. And as normal people trying to maximize their income per hours worked, they don’t waste time doing things that don’t pay.
I typically don’t either unless the pain has been present for longer than 2 weeks of standard treatment at home or presents in a non-classic way.
But my liability carrier and my employer (a large contractor for ER physicians) pressure me to “think of the worst possible cause for the presenting symptoms and rule them out before discharge”. Otherwise, I have to explain in the medical record that I did think about doing the test but list all the reasons I did not DO the test. Which means every visit would be a 200 page novel just so certain other Matts cannot find a flaw in my judgement and sue me for not having 20/20 foresight (only lawyers can have the 20/20 hindsight).
Actually I’m not the one who finds the flaw. It’s another physician. But blame lawyers if it makes you feel better.
“But my liability carrier and my employer (a large contractor for ER physicians) pressure me to “think of the worst possible cause for the presenting symptoms and rule them out before discharge”.”
This is an interesting statement. Because neither your employer nor your liability carrier are making decisions based on the good of the patient. They are making decisions based on maximizing their bottom line. Not saying their goals are bad, just that they aren’t necessarily aligned with the patient’s.
If you’re following their instructions, whose interests are you really working for? Is it the patient you have a duty to?
Matt
I’m afraid you’re a victim of your profession’s success. Once the physicians see “Lawyer” or “Attorney” on the employment/occupation line on the intake form, your goose is cooked … hopefully not literally.
As far as imaging test, why not ultrasound as this plus clinical presentation more often than not reveals the diagnosis.
Given how few victims of malpractice actually recover anything or even get their claim heard, I don’t know that we’ve been particularly successful. I would say the physicians and their liability carriers are the winners when it comes to malpractice.
” That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs.”
I wonder if you ever get the irony in what you type?
Classic Matt-uendo.
Notice how you have no specific examples about clinicians or non-clinicians, just vague accusations.
Stay tuned next week when a plaintiff attorney who is tangentially involved with any type of medical malpractice litigation gives us a detailed analysis of the effect of radiation on genomic expression and then discusses the differential diagnosis of hair loss!
I guess I don’t have to wonder. You don’t get it.
Let me type slower-maybe that will help. You are criticizing others for not understanding or having the background to discuss the things they are criticizing and offering solutions on. Yet you do the same thing every day with regard to the legal system.
Now do you get it?
Of course I get it. You’re just wrong. And I have better luck discussing these type of things with my pet goldfish.
So pedigree is now determinative of one’s knowledge?
How do you know what I do and don’t know about the legal system?
Several good friends of mine are attorneys. What if I bounce questions off of them and respond to you with their answers? Are they all now a bunch of idiots, too?
“So pedigree is now determinative of one’s knowledge”
Didn’t say that. Like you with regard to non-clinicians, I believe people who don’t do the work are unlikely to be qualified to offer solutions.
“How do you know what I do and don’t know about the legal system?”
I can only rely on what you write. Your posts illustrate that you struggle with even the basic criminal/civil distinctions. Not to mention a clear lack of knowledge about the economic aspects of the practice. I don’t know why you find it so offensive to acknowledge that you know little about a field you don’t practice in and that your “solutions” to the problems you perceive may be off base.
“What if I bounce questions off of them and respond to you with their answers?Are they all now a bunch of idiots, too?”
Who said you were an idiot? Not me – I don’t know where you picked up that strawman to rail against. I just said, like you did above, that people who don’t work in a field probably aren’t the best people to be dictating how those who do should do their jobs. When they do, something is “amiss”, as you put it.
I have no idea about the intellect of people who have never commented on here. I’m sure you’re quite an intelligent person, and especially in your field. I just think you don’t know a lot about the law and how it works, so your “solutions” are typically ill considered. Don’t take offense. It’s ok not to know something.
First, your unsubstantiated conclusions and the analogies you attempt to draw are sophomoric. I really hope you do a better job than that in your legal briefs.
Would it make you feel better if I told you that my other job outside of emergency medicine involved the law?
Or is it that unless I’m a lawyer I can’t comment on anything that lawyers should be doing?
Oh, and please do give me one example how I have “struggled with criminal/civil distinctions”.
You can throw all the personal insults you want if that makes you feel better.
Vague allusions to whatever else you do doesn’t really change the quality of your posts on these subjects. Hopefully your understanding and solutions will improve, though. It won’t make me feel any better or worse. This is just idle chatter on the internet, after all.
“Or is it that unless I’m a lawyer I can’t comment on anything that lawyers should be doing?”
Of course not. I would never deny you your First Amendment rights. It is you who wants to limit Constitutional rights.
I’m just saying – as you did with your clinicians comment – that not practicing in an area makes one less likely to understand what the practitioners are doing and one’s criticisms are likely to be off base as a result.
@Matt: I just want to be clear, here, that you’re saying he doesn’t have the background to discuss malpractice litigation because he’s a *doctor* and not a *lawyer*…
No Density, I didn’t say that at all. I fully support his right to discuss whatever he feels inclined to.
One of our radiologists makes definitive statements that frustrate the h&*% out of me. Once sent a pt for a chest CT and the radiologist stated that a PET CT was needed (clinically it was not indicated). I had to do CYA documentation, then referred the guy to pulmonary for bx. He subsequently had VATS and resection of his lung CA without a PET/CT.
A newer performance measure is to assess pts for AAA if they have a hx of tobacco use. Many more pts are getting routine q 6-12 mo CTs for AAA evaluation. Then if they undergo EVAR, they continue to get annual CT scans to reassess the AAA repair/graft. Would be intersting to follow a cohort of these pts and see if they have an increased incidence of CA.
typical garbage.
hey wc, another manhattan hospital closing. should make things in the harlem area “interesting.”
Just curious, but does anyone know how much dosage a typical CT scan delivers?
I ask because I have some experience with radiation and continuous exposure, and would like to correlate the levels.
Thanks
You may find this useful.
http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray
So let me get this straight… radiologists are perfectly within their area of expertise when it comes to regulating a dose of radiation, but when they recommend alternative or additional imaging studies that may be better suited to making a diagnosis, that’s “self-referral”? It seems to me that recommending the better or additional test (often to correct the wrong test originally ordered) is closer to the practice of consultative medicine that Dr. Hillman is recommending. Your point about defensive medicine is spot on… and it applies to radiologists as much as it applies to ER docs, which may color your impression of “radiologist self-referral”. And just how many of these unnecessary scans are being ordered by triage nurses, NPs and PAs out of the ER? In my experience, the ER MD often doesn’t even know the scan has been ordered when I call him with the report.
The authors raised the issue of “self-referral” in the paper. I’m just commenting about why the authors draw a distinction between machines owned by radiologists and those owned by non-radiologists. If the authors are going to cast aspersions that clinicians order tests to make more money at their centers, I can cast just as many aspersions that radiologists recommend additional testing to make more money using the machines that they own – plus they get the fees for reading the additional tests, too.
Regarding non-physicians ordering tests, I’ve had plenty of instances where a patient is signed out to me to follow up on test results and I haven’t had a chance to re-examine the patient before I get a radiology report. In all of the hospitals I have worked in, I have never seen or heard of nurses or PAs ordering CT scans without discussing the matter with the physician first.
If you’re seeing a lot of unnecessary testing being done, why don’t you offer to do a CME talk to the medical staff about the pros and cons of certain testing for the most common issues?
Of course, you can cast all the aspersions you like… but that doesn’t make them true. I’m the first to admit that, as in any field of medicine, there are going to be unscrupulous physicians who put profit before patients. In over 20 years of practicing radiology, (including owning private imaging centers) I can honestly say I have never seen radiologists willfully and knowingly “self-refer” solely for profit. I have seen radiologists, ER physicians and just about everyone else practice CYA medicine and order tests that our dear friend Matt here would hold us accountable for NOT ordering if the patient had a bad outcome. And as far as physician extenders in the ER ordering tests without the imprimatur of the ER physician, I invite you to Southwest Florida to observe.
I have ordered CT’s from the triage desk, but I can honestly say I’ve never done it without interrupting my on duty physician and going over the case with him, and verifying that’s what HE/SHE wants done – I’ve never made that clinical decision to do it on my own – that is definitely out of my scope of practice. In all the years I’ve been in the practice of EM, I haven’t known any of the nurses I’ve worked with to go out on that limb on their own (although I’m sure somewhere, some are). I have, however, seen a steep rise in the number of CT’s that we are doing instead of where we used to get XRay’s. At the hospital I work in, I’m seeing more CT’s of C-spine after MVA and head injuries, as well as scanning the other parts of the spine “because they hurt” after some acute occurrence. I guess the “Gold Standard” has changed – but it looks like it’s also opened another can of worms for us to deal with.
This topic is becoming more and more debated in my peds EM group. It’s to the point that we are probably going to start getting consent before scanning a kid under 18. I already have the ‘risks of radiation’ discussion (and I document it) with parents before obtaining a scan, but there are a lot of people who simply don’t believe the risks or don’t care. They want a test, and sometimes it’s difficult to say no, especially if you’re worried about that 1/10000 diagnosis.
Honestly I think physicians are in a lose-loose situation, and it’s only a matter of time before someone sues us for giving them cancer after an ‘un-needed’ test. You’re liable for missing the diagnosis, and you’re liable for the radiation exposure. Gotta love our society.
One more question. How does anyone know that the scans are the cause of these cancers? Correlation does not equal causation.
Now if you can rule out heredity, medications, occupations, geographical location, and any other possible way that one can contract cancer. Then compare those identical individuals whose only difference is a CT scan, and you may get some meaningful results.
I get that exposure to radiation may increase a risk of cancer. But who is to say how much exposure raises your risk, and by how much?
I lived <150' from an operational reactor for 6 years. 20 years later, no cancer yet. What does that prove? …. nothing.
“Those bastard non-radiologists.” Funny!
Regarding your post ..*sigh*
I am glad to hear you take issue with 1 in 80. Still ..you’re only talking about *one* CT in those stats.
For patients that have had multiple CT’s, etc in a decade … Holy Radiation Batman!
I don’t have any science on this, but I’ll bet the cumulative radiation dose of a patient who has had multiple scans isn’t even in the same galaxy with the cumulative radiation dose from walking around outside every day of your life and going to the beach periodically.
Looking this up on the internet and using resources from Harvard and radiology websites, an abdominal/pelvic CT scan gives a radiation dose of 10 mSv, a routine chest x-ray between 0.02 to 0.2 mSV, and normal background radiation about 0.01 mSv per day. Therefore an abdominal CT scan or cardiac CT angiogram (12 mSv)is equivalent to about three years of normal background exposure. Sunlight’s other danger is UV light, a different matter.
The bottom line is there’s no free luch. Increasing diagnostic precision, the direction society has insisted the medical profession move in for the past century, will entail greater numbers of tests, cost, and radiation exposure. Perhaps greater public awareness of the price to be paid for diagnostic certainty might eventually lead to a better system in the long run. I’m not holding my breath.
I uploaded a Medscape article on the topic here.
Hopefully that helps some.
You are about right for your dose ranges, but note that as the scanners pick up more resolution, the amount of radiation increases.
Coronary stenting, fluoroscopic procedures and thallium scanning all cause even more radiation exposure than CT scans – some as high as 25 mSv.
I generally try to seriously avoid CT’s in young people who are not sick. I order ultrasounds or try to just use clinical judgment. Of course, if they look like crap or I can’t get away with out it, I do it.
I hate that we order so many CYA scans – especially the bogus ones for positive D-dimers who have zero risk for PE. Likewise, minor head trauma.
Of course, I agree with your assessment of the articles permutations though.
Do a quick Gooogle search for lawyers who specialise in CT-induced cancer. I am sure that list will grow – possibly including Matt!
Maybe it will eventually be the same size as those who specialise in missed Cancer because we did not do a CT.
“Maybe it will eventually be the same size as those who specialise in missed Cancer because we did not do a CT.”
How many is that?
1 is 1 too many.
Unfortunately, there’s still no such thing as a free lunch.
An ass-load.
Informing patients about radiation dose is a nice-punding idea, and I do that with some of my patients, but read the article on Forbes.com (June 7th, “Disclosed to Death“) – giving consumers data does not seem to help tem make better decisions. Change should come either from the MDs (but liability reform forst) or from educating the public – hard to do
That’s an interesting article, although the research it discusses deals primarily with huge volumes of information, like in contracts. This issue is with a single piece of information — x number of rads.
Even if you do not expect the consumer to make a rational decision about radiation exposure, you must give him the data so that he can pass it on to the doctor. Until we have some kind of universal health records, the patient is the only one who can keep track of this history.