Want versus Need in Radiology

About a decade ago, I was covering a typical callshift at a level-1 trauma center. One of the requisitions for imaging caught my eye. Hastily scrawled in the space for a clinical history was the unilluminating statement: “Patient needs CT.”

Although a number of queries came to my mind (How am I supposed to know what’s going on with the patient? Does the clinician need re-education as to what a clinical history is? Would I get hassled if I dictated a report without any clinical background?), I also found myself a little hung up on the choice of words.

The patient didn’t “need” the CT. Unless he was suffering from a deficiency of radiation or contrast, the scan itself was not going to satisfy any biological requirements. If anyone “needed” the scan, it was the clinician, who presumably felt that the scan was needed to diagnose and treat the patient.

Even so, based on the eagerness of that ER to scan everyone and everything that came in the door, it was entirely possible that the clinician didn’t really need the scan, either; A more apt statement might be that he wanted it. To speed the patient’s workup, to diminish the clinician’s liability, whatever.

During the subsequent 10 to 12 years, I’ve seen more than a few scripts on which other docs have written of their patients’ “need” for imaging. Fortunately, most of those contain other words that are more useful to me: “Patient with abdominal pain - he needs an ultrasound,” for instance.

I still wonder why the referrer bothers to write “need,” unless that one word somehow proves the all-important “medical necessity” which paper-pushers in the insurance companies have the power to determine.

The line between “need” and “want” has gotten very blurry in our society. Notwithstanding ominous rumblings about tidal waves of governmental debt and imminent inability to keep civilization functioning, people have very strong notions about what they need. Healthcare showcases this, whenever the topic of reform comes up. “People need healthcare,” some insist. Then, as if it logically follows, “They have a right to it.”

This implies that everyone should have it, even if some pay nothing while others bear the cost. Or that the providers of healthcare should operate at a loss in order to provide free (or “affordable”) service.

But don’t providers have needs, too, like staying in business? Apparently some folks’ needs trump others. Especially if you’re willing to subjectively decide that the winners had needs, while the losers merely had wants. Example: Patient needs a cardiac cath, but the cardiologist wants to be paid fairly for his work (not to mention the malpractice liability he takes on by doing the case). The doc can very easily look like a villain for wanting his payment, even though he did the case without hesitation and waited six months before sending a letter reminding the patient that he still hasn’t paid his bill.

The harsh truth is that wanting something very badly is not the same as needing it. We don’t actually need all that much - food, water, shelter, and breathable air pretty much cover it. Even then, one only needs those in order to live, and I suppose someone eager to debate moral philosophy could argue whether that’s truly a need since everybody dies sooner or later.

Just about every other need people claim is associated with an unspoken predicate. A patient balking at a $10 copay, if asked how she manages to afford her cutting-edge smartphone with its pricey unlimited data-plan, might say she needs it for her job - but civilization limped along without cellphones until just a couple of decades ago. Upon inspection, you’d likely find that she uses her device to play games and text-message with friends throughout the day. Knowingly or not, some of her “need” is for a trendy toy that keeps her entertained.

A 5-year-old child might just as stridently insist that he needs to watch his favorite cartoon. Frustrating this perceived need may provoke a tantrum. Hopefully, he unlearns this kind of thinking as his parents properly raise him. Perhaps that’s not happening for enough of our populace during their formative years. It could explain why we seem to have more overly-needy adults than we once did.