1977, British Journal of Radiology, 50, 299-301
VOLUME 50 NUMBER 593
MAY 1977
The British Journal of Radiology Radiology now The Radiologist's dilemma* The growth in the demand for diagnostic radiology continues throughout the world. In Britain estimates vary, but a growth rate of between 5 and 10% per annum has been reported from many centres, and there is no evidence that a plateau has been reached. It is theoretically possible to meet the demand by increasing resources, and an attempt has been made to do this. According to Raison (1976) the number of diagnostic radiologists increased by 15% between 1967 and 1972, but the workload in the same period rose by 30%, so that the demand exceeded capacity to meet it. At a time when many new and exciting developments are taking place in diagnostic radiology there is anxiety that the increasing workload could result in decreasing quality of radiological work. It is, therefore, opportune to evaluate whether the increase in the use of radiology has been beneficial. Very little is known about how diagnostic radiological procedures influence the subsequent management of the patient. From time to time there is also a need to look at what has become established practice, in order to decide whether it still serves a useful purpose, or whether there should be change or even complete abandonment. A careful history and full clinical examination appear to have been superseded by routine radiological studies and extensive laboratory investigations. In some special situations such as intensive care units the daily ward round is replaced by the daily chest radiograph. Physicians in the U.S.A. have been forced into such practices by medicolegal requirements. Patients demand to be investigated in the mistaken belief that if diseases are diagnosed early enough then all will be well. Unfortunately financial rewards can also play a part in this policy. Every radiologist is acutely aware of the problems of over-usage within his own department, particularly *Reprints from: Prof. K. T. Evans, Department of Diagnostic Radiology, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN.
by accident and emergency units. There is evidence that a good deal of such work is carried out for medico-legal purposes. Radiologists have known for a long time that radiography of the skull in cases of trauma is of little value. Particularly is this so if the examination is carried out on patients who are drunk or unconscious and unable to co-operate. However, irrespective of the severity of the injury, skull radiographs are considered mandatory in such patients if they attend hospitals. Careful studies (Loop and Bell, 1971; Roberts and Shopfner, 1972) have shown that there is no significant correlation between fractures of the skull and symptoms, or between the type of fracture, symptoms and physical findings. From this it is clear that the extent of injury to the intracranial contents is of major importance, and that the presence or absence of a fracture seldom affects treatment. Roberts and Shopfner suggested that skull radiography should be reserved for patients in whom a depressed fracture is suspected, or in location of suspected foreign bodies. Sub-dural haematomata often occur in the absence of a demonstrable skull fracture. Unfortunately some doctors, many lawyers and all patients consider that to detect a skull fracture is of importance. Jones and Roberts (1976) examined the reasons underlying casualty officers' referral for radiographic examination. They found that 44% of all requests were made purely for medico-legal purposes. Concordance between the casualty officer's opinion and the radiologist's report was in the region of 97%. The observed discordance in no way prejudiced the patient's subsequent treatment and management. Pilling (1976) has pointed out that as the profession has made radiology a routine request rather than the consequence of a clinical decision, it has over the years created an accepted procedure. This situation is dearly loved by the legal profession because it is identifiable, and adherence to it is a matter of fact rather than opinion. He argued that the law will ask
299
VOL.
50, No. 593 K. T. Evans
the right questions if the criteria for radiography are changed. It would then be impossible for an expert witness to say that the normal practice would have been to request radiology. Mygind and Vestermark (1974) reviewed 158 children with epilepsy to assess the value of routine radiography of the cranium. In 149 cases the skull radiographs were normal and in nine cases abnormalities were encountered, but in no cases were there changes of diagnostic, therapeutic or prognostic significance. They concluded that routine radiography of the cranium is unnecessary in such children without focal changes and with otherwise normal histories. Some reduction in the workload could be safely achieved according to Bull and Zilkha (1968) if patients with symptoms such as headache and vertigo, but without physical signs, were investigated by a lateral skull radiograph only. Excretion urography is a time consuming and costly examination, and yet the number of requests for this examination is steadily rising. Atkinson and Kellett (1974) commented on the large number of urograms in their patients with hypertension that were completely normal. Following careful analysis of their material they advised that excretion urography in patients with hypertension should be reserved for patients under 40 years of age, or in whom there was a previously recognized renal abnormality. The routine use of chest radiography in apparently healthy people is now being questioned. It is the view of the Department of Health and Social Security that the low incidence of pulmonary tuberculosis found in survey work no longer justifies the general need for mass radiography. Despite considerable opposition the number of mass miniature units has now been reduced. Although the incidence of carcinoma of the bronchus continues to rise there is virtually no evidence that detection of this disease at an earlier stage affects the prognosis favourably. It has become standard practice to request preoperative chest radiographs before patients are given general anaesthetics, irrespective of their age or whether they have signs or symptoms of disease of the chest or cardio-vascular system. Kerr (1974) has suggested that the benefits should be weighed against the risks, and advised against routine pre-operative chest X-rays. He identified certain high risk groups such as patients with respiratory and cardiovascular symptoms, smokers over the age of 50, and immigrants who have not been examined previously. Retrospective and prospective studies of the value of chest radiographs before operation have been reported by Rees et al. (1976). They showed in their
series that no abnormalities of any kind were detected under the age of 20, and there were no significant abnormalities under the age of 30. Furthermore, if in the absence of symptoms, findings on previous chest radiographs had been accepted for pre-operative purposes, 38% of the subjects in this study would have been spared further irradiation. There is general concern regarding the great increase in referrals for examinations such as barium studies, in radiological investigations of the elderly, and lumbar spine radiography in low back pain. A survey of the incidence of abdominal radiography in pregnancy by Carmichael and Berry (1976) revealed that in some major hospital centres up to 34.8% of all pregnancies were subjected to this examination. They suggested that the criteria for radiological examinations in pregnancy need closer scrutiny. Radiologists themselves are not free from blame. Not so long ago clinicians were encouraged to refer patients for radiological examinations. The flood gates are now open and the radiologist is attempting to close them without much success. It is important that the clinical problem should be identified and that the radiological method chosen is the correct one. Hard data must be obtained on the value to the patient of certain aspects of radiology, so that shortcomings can be pointed out. Examples have been described where the yield no longer justifies the expenditure. It may not be possible to change, at a stroke, the habits of a lifetime, but we must now make great efforts to educate medical students and house officers so that only clinically useful radiology is requested. The Royal College of Radiologists, with the support of the Department of Health and Social Security, is about to start on a series of multicentre trials in an attempt to assess the current usage of radiology, and thus to suggest guidelines for radiologists and clinicians. Full consultation with other Royal Colleges and Faculties will be necessary if our efforts are to be successful. Reduction in unnecessary work will give the radiologist time to practise better, more interesting and more productive radiology.
K. T. EVANS REFERENCES
ATKINSON, A. B. and KELLETT, R. J., 1974. Value of intra-
venous urography in investigating hypertension. Journal Royal College of Physicians London, 8, 175-180. BULL, J. W. D. and ZILKHA, K. J., 1968. Rationalizing
requests for X-ray films in neurology. British Medical Journal, 4, 569-570. CARMICHAEL, J. H. E. and BERRY, R. J., 1976. Diagnostic
X-rays in late pregnancy and in the neonate. Lancet, 351352. JONES, G. R. and ROBERTS, C. J., 1976. Preliminary in-
300
vestigation of the utilisation of diagnostic radiology in casualty departments. (Work in progress.)
MAY
1977
Radiology now. The Radiologist's dilemma RAISON, J. C. A., 1976. Medical and legal aspects of the increasing demand for diagnostic radiology. Radiological resources. Proceedings Roval Society Medicine, 69, LOOP, J. W. and BELL, R. S., 1971. The utility and futility of 755-756 radiographic skull examination for trauma. New England REES, A. M., ROBERTS, C. J., BLIGH, A. S., and EVANS, K. T., Journal Medicine, 284,236-239. 1976. Routine pre-operative chest radiography in non MYGIND, K. I. and VESTERMARK, S., 1974. Value of routine cardio-pulmonary surgery. British Medical Journal, 1, radiography of the cranium in children with epilepsy. 1333-1335. Excerpta Medica, 32, 2, Abstract 397. PILLING, H. H., 1976. Medical and legal aspects of the in- ROBERTS, R. and SHOPFNER, C. E., 1972. Plain skull roentgenograms in children with head trauma. American creasing demand for diagnostic radiology. A coroner's Journal Roentgenology, Radium Therapy and Nuclear view of routine radiography. Proceedings Royal Society Medicine, / 74,230-239. Medicine, 69,760-762. KERR, I. H., 1974. The pre-operative chest X-ray. British Journal Anaesthesia, 46, 558-563.
Book review Complications in Diagnostic Radiology. Edited by G. Ansell, Not everyone may wish to read it at once from cover to pp. 509, 1976 (Oxford/London/Edinburgh/Melbourne, cover like a reviewer, but many will want to dip into it to resolve particular problems. It is remarkably complete for Blackwell Scientific Publications), £1800. There is an angiocardiogram of a catheter-perforated this reference function. Has your patient just swallowed a ventricle on the wrapper of this formidable book. It is only cupful of plaster of Paris instead of barium from a misone of many (beautifully printed) pictures to make the labelled container? Stop panicking and look it up in Ansell, radiologist reader wince. At one level the volume might be helped by a good index. taken as a collection of horror stories, painstaking, compreThe volume's sensible approach is illustrated by the hensive and spine-chilling. mention of Murphy's law. This, you remember, has to do However, the book is much more than that. Dr. Ansell is with the natural cussedness of things, with toast always one of 19 contributors, all experts in their fields, and he falling buttered side down. Dr. Ansell's version runs: "If leads us through most of the things which can go wrong in the design of equipment, or the method of performing a radiology. There are 23 chapters. Six deal with angiography procedure, provides scope for a serious error to be made in various territories. All the other current contrast examin- then, sooner or later, someone will inevitably make that ations have a chapter each. Some overlap in the discussion error. Conditions in an X-ray Department provide ample of contrast medium reactions is inevitable with this lay-out, scope for the operation of Murphy's law . . . " We have to but does not intrude on the reader's patience. There are know about hazards in our daily work in order to be able to chapters on anaesthetic, radiation, isotope and ultrasound guard against them. This book helps to do just that, and problems. Electrical and mechanical hazards are not for- must be welcomed, however painful its subject matter. I am gotten. The last chapter reprints Dr. Ansell's "Notes on changing my ways of doing certain procedures after reading Radiological Emergencies", already a firm favourite in wall it. It is to be recommended to departmental libraries everywhere. chart form. THOMAS SHERWOOD. I think this book performs a valuable service in carefully assembling and documenting what we must learn to avoid.
301
VOLUME 50 NUMBER 593
MAY 1977
The British Journal of Radiology Radiology now The Radiologist's dilemma* The growth in the demand for diagnostic radiology continues throughout the world. In Britain estimates vary, but a growth rate of between 5 and 10% per annum has been reported from many centres, and there is no evidence that a plateau has been reached. It is theoretically possible to meet the demand by increasing resources, and an attempt has been made to do this. According to Raison (1976) the number of diagnostic radiologists increased by 15% between 1967 and 1972, but the workload in the same period rose by 30%, so that the demand exceeded capacity to meet it. At a time when many new and exciting developments are taking place in diagnostic radiology there is anxiety that the increasing workload could result in decreasing quality of radiological work. It is, therefore, opportune to evaluate whether the increase in the use of radiology has been beneficial. Very little is known about how diagnostic radiological procedures influence the subsequent management of the patient. From time to time there is also a need to look at what has become established practice, in order to decide whether it still serves a useful purpose, or whether there should be change or even complete abandonment. A careful history and full clinical examination appear to have been superseded by routine radiological studies and extensive laboratory investigations. In some special situations such as intensive care units the daily ward round is replaced by the daily chest radiograph. Physicians in the U.S.A. have been forced into such practices by medicolegal requirements. Patients demand to be investigated in the mistaken belief that if diseases are diagnosed early enough then all will be well. Unfortunately financial rewards can also play a part in this policy. Every radiologist is acutely aware of the problems of over-usage within his own department, particularly *Reprints from: Prof. K. T. Evans, Department of Diagnostic Radiology, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN.
by accident and emergency units. There is evidence that a good deal of such work is carried out for medico-legal purposes. Radiologists have known for a long time that radiography of the skull in cases of trauma is of little value. Particularly is this so if the examination is carried out on patients who are drunk or unconscious and unable to co-operate. However, irrespective of the severity of the injury, skull radiographs are considered mandatory in such patients if they attend hospitals. Careful studies (Loop and Bell, 1971; Roberts and Shopfner, 1972) have shown that there is no significant correlation between fractures of the skull and symptoms, or between the type of fracture, symptoms and physical findings. From this it is clear that the extent of injury to the intracranial contents is of major importance, and that the presence or absence of a fracture seldom affects treatment. Roberts and Shopfner suggested that skull radiography should be reserved for patients in whom a depressed fracture is suspected, or in location of suspected foreign bodies. Sub-dural haematomata often occur in the absence of a demonstrable skull fracture. Unfortunately some doctors, many lawyers and all patients consider that to detect a skull fracture is of importance. Jones and Roberts (1976) examined the reasons underlying casualty officers' referral for radiographic examination. They found that 44% of all requests were made purely for medico-legal purposes. Concordance between the casualty officer's opinion and the radiologist's report was in the region of 97%. The observed discordance in no way prejudiced the patient's subsequent treatment and management. Pilling (1976) has pointed out that as the profession has made radiology a routine request rather than the consequence of a clinical decision, it has over the years created an accepted procedure. This situation is dearly loved by the legal profession because it is identifiable, and adherence to it is a matter of fact rather than opinion. He argued that the law will ask
299
VOL.
50, No. 593 K. T. Evans
the right questions if the criteria for radiography are changed. It would then be impossible for an expert witness to say that the normal practice would have been to request radiology. Mygind and Vestermark (1974) reviewed 158 children with epilepsy to assess the value of routine radiography of the cranium. In 149 cases the skull radiographs were normal and in nine cases abnormalities were encountered, but in no cases were there changes of diagnostic, therapeutic or prognostic significance. They concluded that routine radiography of the cranium is unnecessary in such children without focal changes and with otherwise normal histories. Some reduction in the workload could be safely achieved according to Bull and Zilkha (1968) if patients with symptoms such as headache and vertigo, but without physical signs, were investigated by a lateral skull radiograph only. Excretion urography is a time consuming and costly examination, and yet the number of requests for this examination is steadily rising. Atkinson and Kellett (1974) commented on the large number of urograms in their patients with hypertension that were completely normal. Following careful analysis of their material they advised that excretion urography in patients with hypertension should be reserved for patients under 40 years of age, or in whom there was a previously recognized renal abnormality. The routine use of chest radiography in apparently healthy people is now being questioned. It is the view of the Department of Health and Social Security that the low incidence of pulmonary tuberculosis found in survey work no longer justifies the general need for mass radiography. Despite considerable opposition the number of mass miniature units has now been reduced. Although the incidence of carcinoma of the bronchus continues to rise there is virtually no evidence that detection of this disease at an earlier stage affects the prognosis favourably. It has become standard practice to request preoperative chest radiographs before patients are given general anaesthetics, irrespective of their age or whether they have signs or symptoms of disease of the chest or cardio-vascular system. Kerr (1974) has suggested that the benefits should be weighed against the risks, and advised against routine pre-operative chest X-rays. He identified certain high risk groups such as patients with respiratory and cardiovascular symptoms, smokers over the age of 50, and immigrants who have not been examined previously. Retrospective and prospective studies of the value of chest radiographs before operation have been reported by Rees et al. (1976). They showed in their
series that no abnormalities of any kind were detected under the age of 20, and there were no significant abnormalities under the age of 30. Furthermore, if in the absence of symptoms, findings on previous chest radiographs had been accepted for pre-operative purposes, 38% of the subjects in this study would have been spared further irradiation. There is general concern regarding the great increase in referrals for examinations such as barium studies, in radiological investigations of the elderly, and lumbar spine radiography in low back pain. A survey of the incidence of abdominal radiography in pregnancy by Carmichael and Berry (1976) revealed that in some major hospital centres up to 34.8% of all pregnancies were subjected to this examination. They suggested that the criteria for radiological examinations in pregnancy need closer scrutiny. Radiologists themselves are not free from blame. Not so long ago clinicians were encouraged to refer patients for radiological examinations. The flood gates are now open and the radiologist is attempting to close them without much success. It is important that the clinical problem should be identified and that the radiological method chosen is the correct one. Hard data must be obtained on the value to the patient of certain aspects of radiology, so that shortcomings can be pointed out. Examples have been described where the yield no longer justifies the expenditure. It may not be possible to change, at a stroke, the habits of a lifetime, but we must now make great efforts to educate medical students and house officers so that only clinically useful radiology is requested. The Royal College of Radiologists, with the support of the Department of Health and Social Security, is about to start on a series of multicentre trials in an attempt to assess the current usage of radiology, and thus to suggest guidelines for radiologists and clinicians. Full consultation with other Royal Colleges and Faculties will be necessary if our efforts are to be successful. Reduction in unnecessary work will give the radiologist time to practise better, more interesting and more productive radiology.
K. T. EVANS REFERENCES
ATKINSON, A. B. and KELLETT, R. J., 1974. Value of intra-
venous urography in investigating hypertension. Journal Royal College of Physicians London, 8, 175-180. BULL, J. W. D. and ZILKHA, K. J., 1968. Rationalizing
requests for X-ray films in neurology. British Medical Journal, 4, 569-570. CARMICHAEL, J. H. E. and BERRY, R. J., 1976. Diagnostic
X-rays in late pregnancy and in the neonate. Lancet, 351352. JONES, G. R. and ROBERTS, C. J., 1976. Preliminary in-
300
vestigation of the utilisation of diagnostic radiology in casualty departments. (Work in progress.)
MAY
1977
Radiology now. The Radiologist's dilemma RAISON, J. C. A., 1976. Medical and legal aspects of the increasing demand for diagnostic radiology. Radiological resources. Proceedings Roval Society Medicine, 69, LOOP, J. W. and BELL, R. S., 1971. The utility and futility of 755-756 radiographic skull examination for trauma. New England REES, A. M., ROBERTS, C. J., BLIGH, A. S., and EVANS, K. T., Journal Medicine, 284,236-239. 1976. Routine pre-operative chest radiography in non MYGIND, K. I. and VESTERMARK, S., 1974. Value of routine cardio-pulmonary surgery. British Medical Journal, 1, radiography of the cranium in children with epilepsy. 1333-1335. Excerpta Medica, 32, 2, Abstract 397. PILLING, H. H., 1976. Medical and legal aspects of the in- ROBERTS, R. and SHOPFNER, C. E., 1972. Plain skull roentgenograms in children with head trauma. American creasing demand for diagnostic radiology. A coroner's Journal Roentgenology, Radium Therapy and Nuclear view of routine radiography. Proceedings Royal Society Medicine, / 74,230-239. Medicine, 69,760-762. KERR, I. H., 1974. The pre-operative chest X-ray. British Journal Anaesthesia, 46, 558-563.
Book review Complications in Diagnostic Radiology. Edited by G. Ansell, Not everyone may wish to read it at once from cover to pp. 509, 1976 (Oxford/London/Edinburgh/Melbourne, cover like a reviewer, but many will want to dip into it to resolve particular problems. It is remarkably complete for Blackwell Scientific Publications), £1800. There is an angiocardiogram of a catheter-perforated this reference function. Has your patient just swallowed a ventricle on the wrapper of this formidable book. It is only cupful of plaster of Paris instead of barium from a misone of many (beautifully printed) pictures to make the labelled container? Stop panicking and look it up in Ansell, radiologist reader wince. At one level the volume might be helped by a good index. taken as a collection of horror stories, painstaking, compreThe volume's sensible approach is illustrated by the hensive and spine-chilling. mention of Murphy's law. This, you remember, has to do However, the book is much more than that. Dr. Ansell is with the natural cussedness of things, with toast always one of 19 contributors, all experts in their fields, and he falling buttered side down. Dr. Ansell's version runs: "If leads us through most of the things which can go wrong in the design of equipment, or the method of performing a radiology. There are 23 chapters. Six deal with angiography procedure, provides scope for a serious error to be made in various territories. All the other current contrast examin- then, sooner or later, someone will inevitably make that ations have a chapter each. Some overlap in the discussion error. Conditions in an X-ray Department provide ample of contrast medium reactions is inevitable with this lay-out, scope for the operation of Murphy's law . . . " We have to but does not intrude on the reader's patience. There are know about hazards in our daily work in order to be able to chapters on anaesthetic, radiation, isotope and ultrasound guard against them. This book helps to do just that, and problems. Electrical and mechanical hazards are not for- must be welcomed, however painful its subject matter. I am gotten. The last chapter reprints Dr. Ansell's "Notes on changing my ways of doing certain procedures after reading Radiological Emergencies", already a firm favourite in wall it. It is to be recommended to departmental libraries everywhere. chart form. THOMAS SHERWOOD. I think this book performs a valuable service in carefully assembling and documenting what we must learn to avoid.
301
