Saurabh Jha, MD

, Schuur and colleagues listed five low value services in the emergency department (ED). Although compilation was not solicited by the American College of Emergency Physicians as part of the Choose Wisely program, it has the ethos of Choose Wisely.

The list was developed by a technical expert panel after multiple iterations. The list is not only wise, but derived from sound methodology. Most importantly, the recommendations are implementable. There is no nebulous advice such as “head CT shouldn’t be performed for uncomplicated headache,” or “always weigh risk and benefits of ionizing radiation.”

The selected low value services cut through the heart of emergency services. A notable example is CT in neck trauma, which is deemed unnecessary when the NEXUS or Canadian cervical spine criteria are not met. These rigorous decision rules guiding imaging in neck injury boast a near 100 percent sensitivity.

Per NEXUS, imaging of the C-spine can be foregone if there is no posterior midline tenderness, the patient is alert and has no distracting injuries.

First, it’s tempting to obtain plain radiographs instead of CT when these rules are not met. This happens because some physicians feel comfortable neither in dismissing the decision rule nor in dismissing imaging.

This is a problem now. Over the years not only have radiologists been accustomed to not reading radiographs of the C-spine as CT has dominated, but there is a wealth of literature that CT is more sensitive for cervical spine fractures. Few radiologists would stick their neck out (no pun intended) for exclusion of C-spine fracture on radiograph. Disclaimers and questionable fractures will abound. One can argue about the appropriateness of this reality, but reality it is nonetheless.

A diagnostic cervical spine examination involves visualization of the junction of C7 and T1. I recall patients who were shuttled repeatedly between the bed and X-ray suite as progressive attempts to get C7/ T1 junction led to incremental success. This is disruptive for the patient.

My advice: if NEXUS criteria are not met and C-spine fracture is not suspected, get nothing; if criteria are met, get a CT. Don’t get a radiograph for the sake of getting something.

The criteria require posterior midline tenderness. Whilst distinction between posterior midline and lateral neck tenderness is not difficult for a clinician, it takes courage to not pursue imaging in someone with lateral neck tenderness, particularly after a rear impact auto-accident that classically leads to “whiplash.”

Then there is the caveat of distracting injury, injuries which cause so much pain that physical examination of the neck is unreliable. Sometimes the distractor is self-evident, e.g. fracture-dislocation of the ankle or a mid-shaft femoral fracture. Mostly it is subjective.

This caveat may nullify the entire decision rule, as neck injury is often part of a constellation of injuries, each of which may arguably “distract.” It will take a disciplined physician to not use the caveat when there is visible injury such as a broken nose.

The alert state is usually unequivocal. One group of patients who are not alert is those who have over consumed alcohol and sustained injuries in the course or as a result. These patients often get CT of the head and C-spine in tandem, as one cannot safely impute their non-alertness to alcohol (understandably) and if there is any possibility of injury, and often there is, their C-spine can no longer be cleared by physical examination.

It takes particular restraint to not follow a head CT for an isolated head injury, such as a direct blow to the pterion, with a C-spine CT. Head CT often reaches C2. It's so easy to continue the helical CT to T1.

Assuming decision rule has a sensitivity of 99.5 percent, one fracture will be missed in 10, 000 patients if prevalence of C-spine fractures are 2 percent. This doesn’t seem high unless you are the patient with the miss, the physician who missed or the ED taken to task by risk management for missing.

Will faithfully following the rules shield a physician from liability if a missed fracture resulted in quadriplegia? One can only speculate but there are no guarantees. “I followed the rules” is not something Greg House would say.

Choosing wisely is an important first step in reducing waste. The second step is more challenging: implementation of the wise choice. The devil is in the detail. That aside, implementation needs physician courage and self-restraint. It needs a cultural change; of the physician, the legal system and society at large.

Articles

Consulting criteria for an imaging study may sound easy, but it requires a cultural change.

Choosing Wisely Takes Courage

 conflict of interest. This can be more revealing than a CT vendor paying for your Hershey Bar.

Let me declare mine. I am an orthodox techno-neutral radiologist nostalgic of the good ol' days when interposed between the clinician's requests and imaging stood the implacable physiognomy of an unflappable radiologist.

Reality is that as inappropriately low the clinical threshold for ordering imaging often is, it is unlikely to re-ascend the heights of the yester years. This is true not just for the US but for the UK where diagnostic medicine is changing and thresholds for requesting CT are falling (UK is US minus ten years on many matters, other than gun ownership).

Reality is that radiologists do not wish to question the referring physician about the appropriateness of the study. Being a nice person is morally (and financially) rewarding, leads to job security and increases the bonuses. Obstructionist radiologists do not score very high on customer satisfaction surveys.

Reality is that payers will manage utilization. If they do not trust that radiologists are able and willing to take this role (they don't) they will hire third party agents: radiology business management associations (RBMAs). But before you draw the crosshairs realize that shooting RBMAs would be like shooting the messenger.

Reality is that radiologists will enhance their value by actively managing utilization of imaging.

Reality is that realities often conflict. I like beer. I do not like being endowed with a triple chin. Conflicting realities.

Let's summarize the realities: imaging is over utilized, it’s over utilized unevenly, it is logistically impossible to run all imaging requests past the radiologist for appropriateness and relevance, utilization 

 be managed, radiologists do not like confronting referring physicians, radiologists that manage utilization will be valuable.

This is tough. It's like trying to displease your mother, mother-in-law, wife and best friend simultaneously.

With these competing realities clinical decision support (CDS) offers an acceptable compromise. National Decision Support, under partnership and guidance of the American College of Radiology, has produced 

The CDS interposes evidence-based appropriateness score between the clinical condition for which imaging is requested and the modality requested.

If the clinician requests MRI of the brain for focal neurological deficit this receives an appropriateness score of nine. This is feedback that the right study has been requested for the right indication.

If the clinician requests CT for suspected infection of the ankle in a diabetic ankle the appropriateness score flashes one. This is feedback that the wrong study is being considered. This is particularly important in the emergency department where a CT may be ordered not because it is helpful but because it is there.

Understand that presently no feedback is being offered to clinicians whatsoever. Note two things taking place with CDS. First, the feedback. Second, the documentation. Record is made of good ordering, bad ordering or, most pleasing of all, conversion of bad ordering to good ordering.

Or, evidence of the right test to order, evidence that right tests are ordered and evidence that wrong tests are ordered. Evidence, evidence, evidence.

Data are important. The radiologist can approach the boundlessly affable Dr. Hormesis, who has taken the "beneficial effects of low dose radiation" to heart and wishes to apply this paradigm to his patients, and say "positivity for CT angiograms that you order is 0.1 percent, the national mean is 20 times higher. What gives?"

In the old payment model Dr. Hormesis would be Chairman-preferred frequent flyer, on the golf course with the CEO of the radiology practice. In emerging capitated payment models, Dr. Hormesis's over utilization of imaging for Peter affects both Peter (less in the bundle for Peter) and Paul. He has support neither of Peter nor Paul.

Will feedback change the culture of ordering? May be. May be not. But gains will be realized at the margins. And progress must start at the margin and work centripetally.

ACR Select is an adjunct to utilization management. It is not intended to, indeed it cannot, replace a radiologist's conversation with the clinician. It is intended to generate those clinical scenarios that most merit discussion so that these discussions are appropriate, valuable and not intrusive.

The success of ACR Select depends on radiologists for many reasons. Their willingness to learn the system. Their willingness to teach clinicians about the system. Their willingness to collect and act on the data generated by the system.

The CDS will strengthen with iteration. Iteration needs adoption, unconditional widespread adoption. Healthcare domains vary. Healthcare practitioners vary. Any attempt to fit all with one size is bound to fail. However, if radiologists work with their local CMIO they can temper the nuances, so that the CDS is adjusted for the thrifty electrophysiologist differently from Dr. Hormesis.

This a two way street. Consider, for example, that several physicians are ordering a test for a certain diagnostic condition that consistently receives poor appropriateness score. There are several interpretations. First, that the clinicians need education. Second, the appropriateness for that indication needs to be revisited. Third, this represents an area of need where research dollars can be allocated to find better tests.

The gulf between radiologists and clinical context is large but not unbridgeable. In order to re-capture relevance radiologists must offer consultative services. We will find in ACR Select a useful tool. But it will only help us if we wish to be helped.

Imaging is over utilized, and utilization will be managed. Clinical decision support is the best compromise, and ACR Select is the answer. Here’s why.

Radiologists: Time to Aggressively Adopt ACR Select

dwindling job opportunities for radiology residents

, if the comments in the discussion forum at AuntMinnie.com are anything to go by, is similar in kind to the panic in the financial world when Enron became bankrupt. Some radiology residents have even threatened to short sell radiology, i.e. to change to a residency in dermatology or family practice.

If you entered radiology for the money, then it is fair to say that in the current labor market and for the foreseeable, indeed indefinite future, you are likely to be disappointed. Like William Sutton, you need to find another bank, or just a bank.

If you entered the profession for the love of the gray scale, for flirting dangerously with fractions as you decide between a moderate and severe facet joint narrowing, an unconditional love regardless of the reimbursement (within reasonable interval), then it is worth seeing out the storm before changing careers to psychiatry, radiation oncology or financial analysis.

Imaging might reduce at the margins but large scale reductions are improbable. It is unlikely that emergency physicians will overnight or ever rediscover Mc Burney’s point or Rovsing’s sign. The clinical “horse” has well and truly bolted the stable. Society is unlikely to get less risk averse with time and rediscover its frontier spirit, the removal of the ban on carrying knives aboard the plane by the TSA notwithstanding.

So fret not trainees. D-dimers will still be ordered and CT to rule out sub-segmental pulmonary emboli will still be performed to mop up the false positives. The referring physicians will demand imaging. The patients will not object.  People are living longer and 85 is the new 65 (no that is not a subtle dog whistle to increase the age for eligibility for Medicare).

The value of radiologists has only just begun. If you don’t believe me, orchestrate a PACS and RIS shutdown and watch the pandemonium in the emergency department. (Actually don’t do it; just take my word for it). Fed with a long term diet of rapid turnaround time it is unlikely medical decision making will suddenly germinate without the input of the radiologist.

Uncertainty. The forthcoming integrated payment model, or bundled payment, so that everyone fights for the same needle in the bundled haystack, has created uncertainty. Groups do not know how much harder they will have to work to make the same ends given the unknown reduction in reimbursement. This is status quo bias. However, there is a limit to how much harder a radiologist can work. And at some point the groups will have to hire, albeit at lower salaries.

And with any luck, many radiologists (peri-80) will start retiring. There are reasons to believe that this process will be non-linear, i.e. there will be an exodus. The increasing burden of paperwork (checklists, quality metrics, mindless documentation of utter clinical irrelevance for bean counters), coupled with dwindling reimbursements and out-of-hours coverage will create a perfect storm. All it would need is a high school reunion or residency reunion for the senior radiologists to decide en masse to retire en masse and enjoy their well-earned timeshares.

So what’s the bad news? The bad news is that we are likely to working a lot harder for a lot less with more paperwork to fill than the CIA. So my advice is: Hang in there, read Seneca (he was a stoic), develop a hobby for the weekends, and don’t ask orthopedic surgeons what kind of car they drive.

Saurabh Jha, MD, MRCS, MS is assistant professor of radiology and cardiovascular imaging at the Hospital of the University of Pennsylvania and a member of the 

Fret not, radiology trainees. Despite the uncertainty of the market right now, the value of radiologists has only just begun.

Saurabh Jha, MD

Articles

Choosing Wisely Takes Courage

Radiologists: Time to Aggressively Adopt ACR Select

Radiology Job Market Will Improve, Eventually