Imaging Technology and Pandora’s Box

Planners say those who run scanners are not calculating enough about balancing diagnostic yield and cost.

Richard Reece, M.D., “On Having Your Head Examined,” Minnesota Medicine, 1980

A source of extensive and unforeseen troubles or problems.

Definition, Pandora’s Box

Back in 1980, I wrote an editorial in Minnesota Medicine saying CT and MRI would start a radiology revolution despite government protests that these new images cost too much.

How right I was.

Today CT and MRI scans are routine in diagnostic workups, in ER evaluations for trauma, in office visits of back, neck, in joint, abdominal and chest pain evaluations, in insurance evaluations for minor accidents, in questions asked by malpractice lawyers (“Why wasn’t a CT or MRI scan done, doctor?”. And in the minds of health care consumers, who regard images as an integral and necessary part of the treatment regimen.

I once had an elderly man tell me, “You know, I have had four MRIs, and I feel a lot better." Another person, a physician friend of mine, says interns and residents often order imaging studies before taking a history or doing a physical examination.

I thought of this when I read in Massachusett General’s Journal of Computer Assisted Tomography that in a pilot study radiologists now meet directly with patients who had images. The radiologists review that images, answer questions, and explain the implications of incidental findings.

The incidental findings occur in.

• 34% of trauma findings receiving CT scans.

• 31% of patients receiving abdominal CT scans.

• 14% of patients undergoing lung cancer screening.

• 8% of patients receiving imaging for artery disease

These incidental findings can cause problems: neglect for not being mentioned or followed up upon, costly and unnecessary testing causing harm and even death, and exposure to further irradiation or invasive procedures.

Doctor Phillip Young of the Mayo Clinic in the Mayo Clinic Proceedings, noting that incidental findings cropped up in 67% of patients being evaluated before a heart procedure at May and with 10% requiring additional tests, wrote; “It can be a Pandora’s box because when you open it you don’t know what’s going to come out.”

Solutions for closing or at least tightening the lid on Pandora’s box include: meeting directly with patients to explain incidental findings, having radiologists flag incidental findings and then having a radiology team contact the primary care physician to explain the significance of the findings, recommending follow-up testing in four years, having radiologists and primary care physicians share the responsibility for informing patients of incidental findings.