Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Article Outline

• Copyright

Over the past 40 years, the advent of computed tomography, diagnostic ultrasound, magnetic resonance imaging, positron emission tomography, advanced vascular imaging, and other imaging modalities has transformed modern medicine to a degree previously unimaginable. These advances, in combination with an ever-expanding array of pharmaceuticals and minimally invasive procedures, have led to rapid and accurate diagnoses and equally effective therapies. The resultant highly favorable outcomes have generated an unprecedented faith in medicine in the general population. Every day, the mainstream media reinforce the perception that rapidly accelerating advances in diagnosis and treatment of a wide variety of diseases are occurring before our very eyes and that we are, at the very least, on the cusp of multiple paradigm-shifting discoveries. Every day, the cure for cancer, heart disease, diabetes, etc. is proclaimed to be near. Hand in hand with this, a belief system has evolved that more care means better care.

Reality is never quite as simple as it seems. For all the good that imaging has done, it has come with significant costs: exorbitant financial costs to individual patients and society, and personal health costs to patients through over-diagnosis, over-radiation, and over-treatment.

At issue in any review of the appropriateness of imaging utilization are the various interests of the stakeholders. The primary stakeholders are the patient and the physician. Their motivation to acquire as much information as possible through imaging is laudable but is, in fact, misguided. The core of the dilemma is that our ability to diagnose subtle findings far exceeds our knowledge of what to do with the information: advanced diagnostic studies have led to an epidemic of indeterminate incidental findings that physicians and patients often find at least as troubling as the events that triggered the initial imaging study. In a sense, imaging has become too powerful: it frequently identifies subtle, questionable, unrelated, indeterminate pathology that it cannot characterize any further, leaving both stakeholders up in the air regarding what to do next. This often leads to a vicious cycle of more and more imaging and testing.

The secondary stakeholders are those who pay for this continuously escalating imaging extravaganza. Insurers (both public and private) who bear the direct and indirect costs take an opposite tack: they attempt to restrict access to imaging. Often they do so in an irrational manner unrelated to appropriateness of care and fight to hold the line either for profit or for public monies. Nevertheless, it is essential to understand that ultimately it is not just the insurers but society—each and every one of us—that bears these costs. Insurance premiums (again, private or public), direct and indirect health taxes, restrictions on access to appropriate imaging, and lost revenues to other societal needs directly impact each of us. The problem is simply that as individual consumers, we each want the maximum information possible regarding our health. As a society, we are becoming aware that we can't afford it and shouldn't be made to.

Today marks the inauguration of a new quarterly venue in The American Journal of Medicine, focusing on Diagnostic Imaging and a wide range of imaging issues germane to the practice of clinical internal medicine. We intend to bring you articles outlining appropriate utilization parameters for different modalities and disease entities; clinical research articles identifying the causes, effects, and costs of suboptimal imaging strategies; cost-benefit analyses of various imaging strategies, and global overviews of the economics of imaging in both the hospital and outpatient settings. Our aim is to educate and inform. More importantly, we hope to initiate an earnest dialogue in the internal medicine community about the proper role of various imaging modalities in clinical practice and begin to understand how we can best approach problems that are well known, easily identifiable, but not yet properly addressed.

In this month's issue, we present 2 outstanding and timely articles in the area of imaging utilization, from 2 distinct vantage points. First, in today's Commentary, Dr Stephen Swensen gives a concise general overview of over-utilization and misuse of imaging and provides an innovative and novel proposal for a national, Web-based, support infrastructure to promote effective and properly indicated imaging by all clinical end users. Second, Dr Ivan Ip et al directly approach the specifics of over-utilization by analyzing the parameters of rapidly increasing repeat abdominal imaging, highlighting the complexity of the larger issues by focusing on one small component, and thereby demonstrating the multifactorial approach that will be needed to address all aspects of this seemingly inexorable problem.

We hope you find this new venue informative, engaging, and useful in both clinical and financial health care areas. Most importantly, let us know how we are doing, what types of articles you would like to see in the future, and how we can best address the needs of both the academic and private internal medicine communities in their use of these powerful imaging tools.

Feel free to comment on our blog at http://amjmed.blogspot.com or send us an e-mail. Please address your responses/comments to me at: sternoemail@gmail.com. I will hear you loud and clear.