Three imaging studies when a single chest x-ray would have sufficed

Linda could not shake the pesky cough and congestion that had settled into her chest. She knew a quick trip to the doctor was the most prudent course of action but this was poor timing on the part of the germs that had inhabited her body. Four months prior, Linda had lost her job and, consequently, her health insurance. Rent, car payment, and student loans loomed large and she knew without having to check her Excel spreadsheet that medical expenses would not fit into her meager budget. A few days later, Linda developed a high fever, shortness of breath, and acute abdominal pain. No longer able to control her symptoms with over-the-counter medications, Linda presented to the emergency department late Tuesday night.

Following a brief physical exam, the emergency room physician ordered a variety of lab tests and diagnostic imaging studies. The studies ordered included: 

• Chest CT with contrast
Indication: shortness of breath, evaluate for pulmonary embolism

• Chest x-ray
Indication: cough

• Abdominal ultrasound
Indication: abdominal pain

As the radiologist on call that night, I first encountered Linda’s case when the order for the chest CT appeared on my queue. The chest CT did not reveal a pulmonary embolus (PE), but did demonstrate consolidation in the right lower lobe of her lung, most suggestive of pneumonia. I cross-referenced this finding with Linda’s lab results and discovered an elevated white blood cell count. These findings, in addition to knowledge of her three-week history of productive cough and fevers, led me to deliver a final impression of the chest CT as “right lower lobe pneumonia, likely infectious.”

Linda’s name appeared a second time on my queue, this time for an ultrasound. I reviewed the images and detected no abnormalities. My interpretation: Unremarkable examination of the abdomen. A few minutes later Linda’s name appeared yet again on my computer screen; this time for a chest radiograph. The chest x-ray revealed a consolidated right lower lobe, similar to the findings noted on the CT performed earlier that night. Impression: Right lower lobe pneumonia.

Linda received three imaging examinations in succession for a common ailment that could easily have been diagnosed by a physical exam and laboratory tests alone. The only imaging examination that was justified at the time of her initial presentation was a chest x-ray, which costs approximately $200. A pulmonary embolism can be a fatal disorder if not detected and treated expeditiously. However, the likelihood of Linda suffering from a pulmonary embolism was quite low given her presenting symptoms. Even the elevated d-dimer, a commonly used blood test to screen for PE, could be accounted for by Linda’s infection and the abdominal pain was likely referred pain from the pneumonia. The chest CT and abdominal ultrasound added $1900 and $800, respectively, to Linda’s final medical bill.

I phoned the ED physician to inquire why he ordered all three studies instead of starting with the more reasonably priced (but just as informative) chest x-ray. He argued that the time pressures faced by his service to evaluate and discharge patients necessitated requesting exams concurrently rather than waiting for results of individual tests. He also lamented the pressure to evaluate for any potentially fatal diagnoses such as pulmonary embolism, however unlikely. I used this opportunity to educate my colleague that Linda’s presenting symptoms did not warrant the multiple studies ordered. A simple chest x-ray would have sufficed.

Unfortunately a culture of defensive medicine exists whereby physicians feel compelled to order numerous and often unnecessary studies to evaluate for unlikely pathologies. The art of the physical exam and utilization of low-cost technology such as radiography are often dismissed in favor of much more costly workups. In a recent article from The New York Times, (“Physician Revives a Dying Art: The Physical,” accessed Oct. 11, 2010) Dr. Abraham Verghese jokes that “a person could show up at the hospital with a finger missing, and doctors would insist on an MRI, a CT scan, and an orthopedic consult to confirm it.” Unfortunately for Linda, her enormous hospital bills are no joking matter.


Dr. Krishnaraj is a clinical fellow in the abdominal imaging and intervention division, department of imaging, at Massachusetts General Hospital/Harvard Medical School. He can be reached at akrishnaraj@partners.org.