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January 22, 2019

Curbing Unnecessary and Wasted Diagnostic Imaging

Author Affiliations
  • 1Department of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota
  • 2Department of Surgery, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
  • 3Stanford Prevention Research Center, Stanford University, Stanford, California
  • 4Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
JAMA. 2019;321(3):245-246. doi:10.1001/jama.2018.20295
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    4 Comments for this article
    Curbing Unnecessary and Wasted Diagnostic Imaging.
    Jim Malone, PhD MA FIPEM FFR(RCSI) | Professor (Emeritus)of Medical Physics, School of Medicine, Trinity CollegeDublin, Dublin D02 NW44, Ireland
    To the Editor,
    The Viewpoint on “Curbing Unnecessary and Wasted Diagnostic Imaging” identifies many of the culprits, some of the bearpits and possible solutions to this unfortunate situation (1).

    While the authors touch on much that is important, they miss two essential elements. They are the legal and the ethical issues involved. Both are underrated and should influence both decisions and behaviour. The legal situation in most countries is based on a set of internationally agreed requirements for radiation protection of patients set by the International Commission on Radiological Protection (ICRP), the International Atomic Energy Agency (IAEA), and the
    World Health Organisation (WHO) (2, 3). These state that all diagnostic radiological procedures must be justified by requiring that the benefits outweigh the harms. Much work has been devoted to trying trying to address this, codify what is required, develop guidelines for good practice, and implement them. There has been some success, in some countries, but much remains to be achieved as Oren et al. observe. Radiological imaging that would fail a test for legal justification is widespread and often taken as acceptable.

    Regarding unnecessary radiology and ethics/moral issues, a good starting point is that radiation is a known carcinogen at high doses, and it is possible, if not probable that this extends to the diagnostic imaging dose range, particularly its upper reaches (e.g. a few CT scans). Given that this is so, unnecessary examinations expose patients to a significant probable risk with zero corresponding benefit. This is surely at variance with the traditional Hippocratic Oath, the current Geneva Declaration on behaviour of physicians, and the general body of wisdom on medical ethics and ethics for radiation protection in medicine (4, 5) Values like non-maleficence, prudence and the dignity/autonomy of the individual are surely violated in such a situation. I agree with Oren et al. that “overuse of imaging equates to haphazard screening of individuals for disease” and worse.

    Yours etc,
    Jim Malone

    1. Oren O, Kebebew E, Ioannidis JPA. Curbing Unnecessary and Wasted Diagnostic Imaging. JAMA. Published online January 07, 2019. doi:10.1001/jama.2018.20295 Accessed 11 Jan 2019.
    2. ICRP 105. Radiological Protection in Medicine. 2007. Ann ICRP. 37(6):1-63.
    3. IAEA. International Atomic Energy Agency. Radiation Protection and Safety of Radiation Sources: International Basic Safety Standards (BSS). General Safety Requirements. Vienna: IAEA. 2014.Also sponsored by WHO. Available at: http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1578_web-57265295.pdf Accessed February 10, 2016.
    4. Cho K, Cantone MC, Kurihara-Saio C, et al. ICRP Publication 138. Ethical foundations of the system of radiological protection. 2018. Ann. ICRP 47(1):1-65.
    5. Malone J, Zolzer F, Meskens G, Skourou C. Ethics for Radiation Protection in Medicine. London and New York: CRC Press for Taylor and Francis. 2019.
    CONFLICT OF INTEREST: Consultant from time to time to World Health Organisation (WHO) and International Atomic Energy Agency (IAEA)
    Missing The Point
    Arnold W. Cohen, MD, Professor of Ob/Gyn | Einstein Healthcare Network
    I believe that the authors and the commenter are both missing an important point. Young doctors, as well as older ones at this time are unable to make a diagnosis without a confirmatory test, either laboratory or radiologic. There is an "intolerance of ambiguity" on the patient's part as well as the legal system we live in. Doctors no longer have the clinical skill (or the time) to take a good history and do a complete physical exam that will result in a differential diagnosis and treatment plan. They order tests to come up with a definitive diagnosis based on testing, not clinical skill.

    As a gynecologist, no woman undergoes surgery without a definitive ultrasound, CT scan or MRI. This is probably good but it has devalued the pelvic exam. Anytime there is a possible problem, a radiologic test is ordered.

    I at one time believed that over utilization could be altered by changing the malpractice system in the United States but at this time, I don't think there is any hope of significantly avoiding the ordering of tests since this is now so ingrained in the practice of medicine, it can't be changed.

    Arnold W. Cohen, MD
    Chairman Emeritus, Einstein Healthcare Network
    Professor of Ob/Gyn, Jefferson Medical College
    No easy solutions, I fear
    Barry Saver, MD, MPH | Swedish Family Medicine Residency Cherry Hill
    Oren et al. have addressed an important, underdiscussed topic – overuse of imaging procedures of low value and the multitude of incidental findings they generate. Unfortunately, I think most of the solutions they propose will not help, with the possible exceptions of emphasis on educating students and clinicians about this issue and masking areas that were not identified as being of concern (though this would likely require review according to some subjective criteria to reduce the chance that a clearly high risk incidentaloma is not ignored).

    Educating the general public is unlikely to have a major effect.
    Patients come to clinicians for their expertise and rarely are in a position to question a test ordered by someone who is supposed to be acting in a fiduciary relationship toward them. Shared decision making is always an easy “solution” to judgment calls, but is far more complicated than most appreciate (1). Radiologists are not trained to discourage unnecessary imaging and their financial incentives typically run in the other direction and the radiology report that does not suggest further imaging for an incidentaloma is rare to nonexistent. As an illustrative anecdote, I inherited a patient with a hepatic incidentaloma on an abdominal ultrasound. The recommended follow-up MRI recommended further imaging to clarify. When the CT scan report recommended further imaging, I called radiology to ask what further imaging they could possibly mean. The radiologist on the phone, reviewing the images, said, “Oh, that’s almost certainly benign I wouldn’t worry about it.” Sigh.

    AI-based image interpretation may give us our best chance at least to minimize follow-up scans of incidentalomas by listing differentials and quantitative probabilities. That will require clinicians and patients to learn to live more explicitly with uncertainty. In some cases, predictive models might be able to indicate the baseline risk of a diagnosis and positive and negative predictive values of the scan make the test very unlikely to be helpful, but that will require far more development and validation than producing probabilities from AI-based interpretation of an imaging procedure.

    It will likely take substantial changes in our culture and reimbursement policies, plus significant developments in AI-based image interpretation and predictive modeling that are incorporated into clinicians’ test-ordering pathways, before a substantial reduction in low-value imaging can be achieved.


    1. Fisher KA, Tan ASL, Matlock DD, Saver B, Mazor KM, Pieterse AH. Keeping the patient in the center: Common challenges in the practice of shared decision making. Patient Educ Couns. 2018 Dec;101(12):2195-2201. doi: 10.1016/j.pec.2018.08.007. Epub 2018 Aug 6. PubMed PMID: 30144968
    Ask a Radiologist About Imaging Stewardship
    Francis Deng, MD | Massachusetts General Hospital, Harvard Medical School
    Oren et al. highlight the intersection of two important issues afflicting radiology: unnecessary referrals and incidental overdiagnoses. The former issue of over-ordering is well-known in radiology and forms the basis of such initiatives as the American College of Radiology (ACR) Appropriateness Criteria, the associated multidisciplinary Choosing Wisely campaigns, and the Medicare requirement to use clinical decision support at the point of care based on appopropriate use criteria in imaging such as ACR Select. Most radiology educators believe their efforts in teaching nonradiology physicians should focus on appropriate ordering rather than image interpretation. Therefore, for example, familiarity with the ACR Appropriateness Criteria are the central learning objective of our medical student clerkship.

    The latter issue of overdiagnosis is also well-known in radiology. It forms the basis of many guidelines from the ACR Incidental Findings Committee and others (eg, the multispecialty Fleischner Society) standardizing the interpretation and management of common incidental findings such as nodules of the thyroid, lung, and adrenals. Most of the solutions the authors propose are also routine in radiology. For example, ensuring that "the quality and focus of the image are adjusted to the level of clinical suspicion" is synonymous with protocolling. When one orders an advanced imaging test (CT, MR, PET and other nuclear medicine), the radiologist must approve the order and select the most appropriate protocol for the clinical question. A renal stone protocol CT already has poor sensitivity for liver lesions due to low radiation dose and absence of intravenous contrast. Similarly, protocolling includes the suggestion of the authors for "the visual projection of only the radiographic fields relevant to the clinical question." In many practices, cardiac and spine CTs already purposefully exclude the full field-of-view images that may incidentally capture other chest or abdominal lesions, even though these areas receive the radiation beam.

    I agree with the authors that "the use of certain modalities could be restricted to cases approved by radiology specialists." The reality is that while radiologists formally have this power today, many are reluctant to exercise it in the face of insistent referring clinicians. The cultural expectation that the radiologist is a gatekeeper is not as strong in the US as in other developed countries in which rationing is more accepted. My hope is that referring clinicians, including the authors of this viewpoint, may consult radiologists more often regarding the appropriate imaging test to perform and the optimal protocol to use. They just might learn something about current radiology practice.