449
OPINION
Vol. 120
Opinion
•
•
Is This Radiograph Really Necessary? Leo G. Rigler, M.D. While agreeing that overutilization of radiological diagnosis creates an unnecessary increase in both medical costs and patient exposure, the author calls for a more sensible and economical approach to the number of radiographs taken as part of any given study, noting that in many cases the number could be cut in half without any loss of diagnostic efficiency. By limiting the number of views per study, the radiologist would be able to remain in a safe medico-legal situation without reducing his ability to function as a diagnostician. INDEX TERMS:
Economics, medical • Opinions • Radiology and radiologists
Radiology 120:449-450, August 1976
• The increasing costs of medical care, to which roentgen examination is a small contributor, should be a source of great concern to the medical profession. Another kind of cost, radiation exposure-in large part a product of medical and dental procedures-is increasing too and should also be of great concern, especially to radiologists. There is no doubt that some exposure and some monetary costs of medical services are unnecessary; the overutilizatlon of radiological diagnosis cries out for reform. McClenahan (1) and Hall (2) document such excesses in a great variety of situations. Hall has detailed the various radiographic examinations which he believes are either useless or of such little value that they do not merit any drain on our resources. I agree in general with Hall's purpose and certainly with a great many of his specific strictures; however, there are many that I cannot agree with, and I am certain that it would be extremely difficult to obtain a consensus among physicians and radiologists as to which examinations are sufficiently productive to justify their use. The radiologist, however, has relatively little control over the volume of his work. In part this derives from the monopoly position which he and his associates enjoy in the hospital. He is in a poor administrative position to refuse to do certain examinations, as the referring physician has no other recourse. Radiologists do have the opportunity and the duty to educate their colleagues on the place and value of roentgen examinations and to indicate that there may be some slight hazard attending the use of radiations, even in diagnosis. On the whole, however, his influence in reducing overutilization may be relatively small; moreover, it is hampered by the natural disinclination of any specialist to diminish his function in the practice of medicine. Rather, before the radiologist criticizes his colleagues, he should clean his own house: for there is an 1
• area in which the radiologist may control the costs of roentgen examination in terms of both use of personnel and degree of radiation exposure, namely, the number of radiographs made for each specific examination. I believe this number could be reduced appreciably without any loss of diagnostic efficiency. There was a time in the history of roentgen diagnosis when the cost of film represented a great percentage of the expense in any radiology department. Over the past 50 years the unit price of film has increased relatively little, while salaries, equipment, rent, and other expenses have increased five- or tenfold. As a result, the cost of film presently appears to be an insignificant factor in the total outlay of any department. This is a fallacy, for beyond the actual expenditure on film itself, each exposure is costly in terms of technician time, processing time, filing, and storage, but much more so in terms of the radiologist's time. Once a radiograph has been made, regardless of how unnecessary it may be, it must be examined and interpreted; and this may happen several times as the radiographs are reviewed first with the referring physician and then with other consultants and other radiologists. It is here that 'the true monetary cost lies. Furthermore, each exposure adds its moiety to the total radiation effect. In addition to the radiologist's feeling that "films are cheap," there are other factors, such as the competition among radiologists, the fear of malpractice suits, the sheer lack of time to make a discriminating selection of the type of roentgenograms needed, and too much dependence on the technologist. All of these have led to a sharp and sometimes unnecessary increase in the number of radiographs per study. Is it really necessary to make 20 or 25 radiographs for tomograms of the chest when a small nodule or local area is being studied? The exact location of the process in
From the Department of Radiology, UCLA Center for the Health Sciences, Los Angeles, Calif. Accepted for publication in April 1976.
sjh
450
OPINION
conventional studies should permit as few as 5 exposures to give all the information necessary. Excess radiographs often result because the radiologist does not take the time nor make the effort to analyze the situation before the examination is done, leaving this to the technologist: 10 tomographic exposures are often made to determine whether a calcification is present, when one 50-kV exposure centered on the area may reveal it just as well. The unnecessary use of radiographs and exposures is best illustrated in special procedures. During our first experience with angiographic methods, it was necessary to make a large number of radiographs; but with the knowledge we now have, these numbers could be reduced very sharply by properly spaced exposures in most angiographic and neuroradiological procedures. Careful selection would make it possible to do many if not all heart examinations with only 2 radiographs rather than the 4 or even 5 commonly used at present. Are 7 views (or even 9 in some institutions) necessary for each routine examination of the skull? Couldn't we do a good pretomographic mastoid study with less than 7 films? Hall has considered the situation in urology, but even here, given the large number of examinations to be done in each individual case, I believe that the number of views could easily be reduced without any loss. Anyone who did fluoroscopy of the gastrointestinal tract before image amplification and television has no doubt been impressed with the brilliant and sharp images which present fluoroscopic studies produce and may well wonder why radiographs are needed at all, except as a permanent record. Yet many more radiographs are made today than was the case when the fluoroscopic image was indistinct and far less informative. My experience indicates that 12 to 18 films per gastrointestinal examination is not un-
August 1976
common. None of us would advocate a return to the single chest radiograph, 2 views of the sinuses, and so forth, but 9 radiographs for a sinus series or 5 for a routine chest examination seems utterly wasteful. Greater attention on the part of the radiologist to technique, equipment, and the technologist's performance would substantially reduce the very large number of "discards," poor radiographs which range from 5 to 20% of all those made in some large departments. In this situation there is no loss of radiologist time, but the other costs, including excess irradiation, could be reduced. . I would emphasize that both excessive examinations and excessive numbers of radiographs per examination are not especially characteristic of teaching hospitals. These unnecessary exposures occur to an even greater degree in many (not all) voluntary hospitals and private offices. I have mentioned only some of the more obvious examples. I am sure any radiologist could think of many more. I am confident that if we ask ourselves "Is this radiograph really necessary?" we can reduce personnel time and other monetary costs, as well as radiation dose, to a striking degree without eliminating any requested exarnlnation and without reducing our ability to function as diagnosticians. Department of Radiology UCLA Center for the Health Sciences Los Angeles, Calif. 90024
REFERENCES 1. McClenahan JL: Wasted x-rays. Editorial. Pa Mad 72: 107-108, Nov 1969 2. Hall FM: Overutilization of radiological examinations. Opinion. Radiology 120:443-448, August 1976
OPINION
Vol. 120
Opinion
•
•
Is This Radiograph Really Necessary? Leo G. Rigler, M.D. While agreeing that overutilization of radiological diagnosis creates an unnecessary increase in both medical costs and patient exposure, the author calls for a more sensible and economical approach to the number of radiographs taken as part of any given study, noting that in many cases the number could be cut in half without any loss of diagnostic efficiency. By limiting the number of views per study, the radiologist would be able to remain in a safe medico-legal situation without reducing his ability to function as a diagnostician. INDEX TERMS:
Economics, medical • Opinions • Radiology and radiologists
Radiology 120:449-450, August 1976
• The increasing costs of medical care, to which roentgen examination is a small contributor, should be a source of great concern to the medical profession. Another kind of cost, radiation exposure-in large part a product of medical and dental procedures-is increasing too and should also be of great concern, especially to radiologists. There is no doubt that some exposure and some monetary costs of medical services are unnecessary; the overutilizatlon of radiological diagnosis cries out for reform. McClenahan (1) and Hall (2) document such excesses in a great variety of situations. Hall has detailed the various radiographic examinations which he believes are either useless or of such little value that they do not merit any drain on our resources. I agree in general with Hall's purpose and certainly with a great many of his specific strictures; however, there are many that I cannot agree with, and I am certain that it would be extremely difficult to obtain a consensus among physicians and radiologists as to which examinations are sufficiently productive to justify their use. The radiologist, however, has relatively little control over the volume of his work. In part this derives from the monopoly position which he and his associates enjoy in the hospital. He is in a poor administrative position to refuse to do certain examinations, as the referring physician has no other recourse. Radiologists do have the opportunity and the duty to educate their colleagues on the place and value of roentgen examinations and to indicate that there may be some slight hazard attending the use of radiations, even in diagnosis. On the whole, however, his influence in reducing overutilization may be relatively small; moreover, it is hampered by the natural disinclination of any specialist to diminish his function in the practice of medicine. Rather, before the radiologist criticizes his colleagues, he should clean his own house: for there is an 1
• area in which the radiologist may control the costs of roentgen examination in terms of both use of personnel and degree of radiation exposure, namely, the number of radiographs made for each specific examination. I believe this number could be reduced appreciably without any loss of diagnostic efficiency. There was a time in the history of roentgen diagnosis when the cost of film represented a great percentage of the expense in any radiology department. Over the past 50 years the unit price of film has increased relatively little, while salaries, equipment, rent, and other expenses have increased five- or tenfold. As a result, the cost of film presently appears to be an insignificant factor in the total outlay of any department. This is a fallacy, for beyond the actual expenditure on film itself, each exposure is costly in terms of technician time, processing time, filing, and storage, but much more so in terms of the radiologist's time. Once a radiograph has been made, regardless of how unnecessary it may be, it must be examined and interpreted; and this may happen several times as the radiographs are reviewed first with the referring physician and then with other consultants and other radiologists. It is here that 'the true monetary cost lies. Furthermore, each exposure adds its moiety to the total radiation effect. In addition to the radiologist's feeling that "films are cheap," there are other factors, such as the competition among radiologists, the fear of malpractice suits, the sheer lack of time to make a discriminating selection of the type of roentgenograms needed, and too much dependence on the technologist. All of these have led to a sharp and sometimes unnecessary increase in the number of radiographs per study. Is it really necessary to make 20 or 25 radiographs for tomograms of the chest when a small nodule or local area is being studied? The exact location of the process in
From the Department of Radiology, UCLA Center for the Health Sciences, Los Angeles, Calif. Accepted for publication in April 1976.
sjh
450
OPINION
conventional studies should permit as few as 5 exposures to give all the information necessary. Excess radiographs often result because the radiologist does not take the time nor make the effort to analyze the situation before the examination is done, leaving this to the technologist: 10 tomographic exposures are often made to determine whether a calcification is present, when one 50-kV exposure centered on the area may reveal it just as well. The unnecessary use of radiographs and exposures is best illustrated in special procedures. During our first experience with angiographic methods, it was necessary to make a large number of radiographs; but with the knowledge we now have, these numbers could be reduced very sharply by properly spaced exposures in most angiographic and neuroradiological procedures. Careful selection would make it possible to do many if not all heart examinations with only 2 radiographs rather than the 4 or even 5 commonly used at present. Are 7 views (or even 9 in some institutions) necessary for each routine examination of the skull? Couldn't we do a good pretomographic mastoid study with less than 7 films? Hall has considered the situation in urology, but even here, given the large number of examinations to be done in each individual case, I believe that the number of views could easily be reduced without any loss. Anyone who did fluoroscopy of the gastrointestinal tract before image amplification and television has no doubt been impressed with the brilliant and sharp images which present fluoroscopic studies produce and may well wonder why radiographs are needed at all, except as a permanent record. Yet many more radiographs are made today than was the case when the fluoroscopic image was indistinct and far less informative. My experience indicates that 12 to 18 films per gastrointestinal examination is not un-
August 1976
common. None of us would advocate a return to the single chest radiograph, 2 views of the sinuses, and so forth, but 9 radiographs for a sinus series or 5 for a routine chest examination seems utterly wasteful. Greater attention on the part of the radiologist to technique, equipment, and the technologist's performance would substantially reduce the very large number of "discards," poor radiographs which range from 5 to 20% of all those made in some large departments. In this situation there is no loss of radiologist time, but the other costs, including excess irradiation, could be reduced. . I would emphasize that both excessive examinations and excessive numbers of radiographs per examination are not especially characteristic of teaching hospitals. These unnecessary exposures occur to an even greater degree in many (not all) voluntary hospitals and private offices. I have mentioned only some of the more obvious examples. I am sure any radiologist could think of many more. I am confident that if we ask ourselves "Is this radiograph really necessary?" we can reduce personnel time and other monetary costs, as well as radiation dose, to a striking degree without eliminating any requested exarnlnation and without reducing our ability to function as diagnosticians. Department of Radiology UCLA Center for the Health Sciences Los Angeles, Calif. 90024
REFERENCES 1. McClenahan JL: Wasted x-rays. Editorial. Pa Mad 72: 107-108, Nov 1969 2. Hall FM: Overutilization of radiological examinations. Opinion. Radiology 120:443-448, August 1976
