Imaging for the clinician Editorial| Volume 125, ISSUE 4, P321, April 2012

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Imaging Utilization and the Obsessive-compulsive Physician

      Obsessive-compulsive personality disorder (OCPD) can be defined loosely as a dysfunctional repetitive focus on detail and minutiae at the expense of logic and flexibility. There is a distinction, however, between true OCPD and OCP “trait”—which I shall define as a tendency to focus on details and strive for perfection in any given task. It is my opinion that OCP trait is an essential component of any successful physician: minute attention to details integrated into a composite view of the patient is at the root of excellence in diagnosis and therapy. There is, however, not a fine line but rather an entire “meadow” separating the disorder from the trait. And physicians who live in that large space are a major cause of over-utilization of imaging.
      As there are 2 sides to every issue, let us first consider the end user—the clinician who orders imaging studies. Physicians utilize imaging to varying degrees within the same clinical context. There may be a variety of reasons, including differences in experience, knowledge (or lack thereof), institutional bias, patient demands, and all sorts of other contributing factors. But some general behaviors of individual physicians seem quite predictable to me, and personality driven. When I go in to read emergency department (ED) cases at my busy level I trauma center, or other EDs via teleradiology, I can roughly predict what kinds of studies I will or will not see based on who is staffing the ED at that time. I know when I am going to see 4 consecutive negative computed tomography (CT) studies to rule out pulmonary embolism in young patients with no risk factors; often, patients who have had negative similar studies several times before. I know when every bellyache is going to get a CT scan, every pelvic pain an ultrasound, and every extremity top-to-bottom imaging for trauma that is clearly localized to one area. And I know the nights when none of this will happen, based on a different set of emergency physicians. I am not passing judgment. Well, actually I am.
      Flipping the coin, I know radiologists who have never seen a normal CT scan. They dictate 2-page reports describing in excruciating detail every dot in the lung bases, liver, spleen, and kidney; every top normal lymph node is measured, every benign ovarian cyst is described, every hedge is sat upon. To make matters worse, each of these heroic poems ends with recommendations for further imaging to include ultrasound (US) of the pelvis, US of the kidneys, magnetic resonance imaging of the pelvis, CT of the full chest, and repeat studies with additional contrast or thin-section evaluations of specific organs for the “ditzels” described. What is a well-meaning clinician to do with such generally worthless information?
      Hospital leadership has informed me that psychopharmacological interventions can be instituted only by physicians treating these physicians, and not by subspecialists of opposing views. You can't slip anything into their coffee to reduce these sometimes reflexive and mindless behaviors. But it is time that physicians begin to self-regulate. A beginning would be ongoing internal department reviews of clinician ordering patterns and radiologist recommendation patterns, looking for outliers—the low hanging fruit. Pathetic attempts to reduce utilization have been made in the past and are ongoing in some health maintenance organizations, but only with an eye toward reducing overall spending—preserving the bottom line—without any real focus on quality of care and appropriate ordering patterns. I am not aware of any institutional policies that focus on improving quality of care by reducing clinically inappropriate studies, whether generated by compulsive ordering physicians or by obsessive radiologists. If you know of such a formalized program, let me know.
      This month's featured article in the Journal's Imaging for Clinicians Special Section by Prevedello et al illustrates the wide variability in utilization of head CT for atraumatic headache in the ED setting and underscores the need to develop evidence-based systems to reduce or eliminate these costly and inappropriate resource allocations. Read it and think about your own foibles. I am going back to amend some of my radiology reports right now.