Imaging’s Attitude Problem

Medical imaging has an attitude problem. This doesn’t mean that the field won’t continue to grow, Bruce Hillman, MD, professor of radiology and medical imaging and public health services, University of Virginia School of Medicine, said at ACR 2015 but intervention will be required to ensure this growth is appropriate.

“There is a real bias that has developed against medical imaging, even though the days of the really rapid rise of imaging utilization are over,” Hillman said. “But the attitude persist that any increase in imaging needs policies to right side it.”

The field of imaging will grow, Hillman said. It may be a combination of appropriate growth and some one-off aberrant incentives, but growth, he is sure, is imminent.

“Our population is aging and it turns out that our technologies are really wonderful technologies for diagnosis and follow up,” he said.

The bias against medical imaging stems from a poor understanding of what inappropriate imaging is. But the problem has leaks all along the patient care spectrum.

Patients, for example, want more care, he said.

“Baby boomers own 2/3 of the wealth in America, and [they] are willing to spend it on not dying,” Hillman said. He spoke of the ‘moral hazard’ of having health insurance and the danger in the ability to separate the desire to seek care from the need to pay for it.

And then there is the access to information. “The web really does motivate people to seek things out and there is so much misinformation [on the web].”

It’s not just patients who are to blame, though. Physicians, who are more and more often employed by larger health systems with mandates to see patients faster, are using the time crunch to refer their patients to imaging tests, Hillman said.

But the least acceptable inappropriate growth of imaging is bilateral: the fault of referring physicians and radiologists. It’s defensive medical testing.[[{"type":"media","view_mode":"media_crop","fid":"37872","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5544704582618","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3754","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Bruce Hillman, MD","typeof":"foaf:Image"}}]]

“[Physicians] know that hardly anyone gets sued for ordering too many tests,” he said. “The defensiveness part says it all.”

Radiologists also tend to overestimate the risk of malpractice, he said. “We end up with a high false positive rate and every false positive has a high chance of costing more in follow-up testing down the line.”

Hillman also touched on the issue with self-referrers, but noted that this doesn’t really apply to the radiologist.

“So you have this unholy convergence where we have economic motivators, patients who want more exams and third party insurance willing to pay for it, and there is no way around [inappropriate imaging],” he said.

The field of medicine has grown reluctant to limit access to data that’s readily available. Hillman told the story of his first day of medical school, in the dean’s address to the students he spoke of how medicine is about living with uncertainty. Today, Hillman said, physicians have lost the ability to live with uncertainty.

Perhaps to blame is the lack of thought process that goes into ordering imaging. Hillman suggests that imaging works best in the midrange of probabilities, if there is a near certainty or a near impossibility that a patient does or does not have a condition, imaging is not very efficient. There also needs to be an understanding that imaging doesn’t always lead to a correct diagnosis, speaking to the true sensitivity and specificity that varies by reader and the person performing the examination.

Hillman also urged physicians to consider the risks of not performing a test.

“Is something terrible going to happen to the patient, and if so, how quickly”, he asked. “Can we logically wait and see what goes on?”

The risks of inappropriate imaging are worth it, once these considerations have been accounted for, Hillman said.

This change in mentality has to start in medical school, Hillman said. He said that most physicians train in academic medical centers in a high frequency, high acuity environments, but then they take these practices to tertiary care centers.

“We have to fight the educational and cultural issues that brought us to this state,” Hillman said. “We cannot afford inappropriate imaging to the extent we have in the past.”