Many moons ago, my friend John Villforth, then the director of the Public Health Service’s Bureau of Radiological Health, issued a public pronouncement that 30% of medical x-ray procedures were unnecessary and thus a waste of money and radiation exposure. He got his name in the newspapers and his face on television and vexed a batch of radiologists.
On behalf of the American College of Radiology (ACR), I demanded to know the basis of the assertion. In fact, I already knew that the figure had been cobbled together from a variety of sources and could neither be proved or disproved. About the same time, the ACR was conducting a study of radiologic efficacy with support from another branch of the Public Health Service with an intent of defining the impact of selected imaging studies on decisions made by other physicians about the treatment of their patients.
John Villforth’s comment faded from the public view, but as we contemplated the idea, we became convinced that a third of all x-ray procedures might well be unnecessary. There was the element of self-referral by physicians with their own office x-ray machines and a motive of dollars more than medical efficacy. We also recognized that few radiologists reviewed referral slips to decide whether a requested x-ray procedure could contribute to a final diagnosis of the patient’s clinical symptoms. We knew then and now that seldom do radiologists challenge or reject referrals. And we knew that some of those who did question referrals annoyed their colleagues and risked losing all of their referrals.
I remembered one radiologist telling me that when referrals slackened, he would give a lecture to his hospital medical staff on the dangers of undue radiation exposures. Without fail, referrals would increase after he recited the list of available procedures.
The ACR efficacy study was ahead of its time and eventually ran its course without significant conclusions. The protocol required physicians referring patients for emergency skull x-rays to fill out a form asserting their expectation of clinically useful information from the study. Because a plain skull film did not reveal a subdural hematoma, it was lacking in the assessment of the most important potential effect of a blow to the head. What seemed more significant to the referring doctor was the demand of a stressed mother that her glassy-eyed child get a skull x-ray—and every other procedure known to medical science. Medical malpractice suits were growing, and ruling out a harmful x-ray finding was worthwhile. Just a bit later, computed tomography (CT) scans did show subdural changes and the equation changed.
The proliferation of medical imaging in the past three decades has brought the spending for imaging close to a fifth of all payments to physicians in health insurance programs. Estimates are that radiologists perform most of the imaging procedures in hospitals, but perhaps only about half of those in other health facilities. This proliferation is not limited to basic x-ray studies but now covers CT, magnetic resonance imaging, ultrasound, and even interventional procedures.
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