ER docs question relevance of consultations with radiologists for patients with abdominal pain

May 3, 2007

College-based urgent care physicians and community-based emergency room physicians do not feel compelled to consult with radiologists about patients with abdominal pain, according to results of an e-mail survey presented at the Association of University Radiologists meeting in April.

College-based urgent care physicians and community-based emergency room physicians do not feel compelled to consult with radiologists about patients with abdominal pain, according to results of an e-mail survey presented at the Association of University Radiologists meeting in April.

The American College of Radiology appropriateness criteria recommend consultation and collaboration between referring physicians and radiologists to achieve effective results. Yet the survey found that neither group of physicians acknowledged the need for radiologist consultation in presentations that suggested appendicitis.

"We congratulate ourselves because we have a mechanism, the appropriateness criteria. But what good is it if it's not being used effectively?" said lead author Dr. Stephen R. Baker, radiology chair at the University of Medicine and Dentistry of New Jersey.

Diagnostic Imaging interviewed Baker after the meeting.

Using the membership lists of the American College of Emergency Physicians and the American College Health Association, researchers sent surveys to 3000 ER physicians, receiving 624 responses, and to 2435 college physicians, receiving 577 responses.

Both groups were asked if they would order a CT for a 21-year-old male or female with:

  • right lower quadrant pain, tenderness, fever, and elevated white blood count that strongly suggested appendicitis; or

  • more generalized symptoms involving nonlocalized abdominal pain for one day with no fever and normal white blood count.

About three quarters of respondents from each group recommended CT for patients who had the first set of symptoms. But when considering the second set, ER physicians were three times more likely than college physicians (35% versus 11%) to request a CT scan for men or women with generalized abdominal pain. The findings were statistically significant.

The survey also asked physicians to assess factors that influence ordering practices. Both groups considered a physical exam to be very important (3.88 and 3.90 on a scale of 1 to 4), but they placed little significance on the relationship with the radiologist (1.63 and 1.72).

"We as radiologists are not doing enough to get involved at the front end of the procedure, which would allow us to take more control over utilization," Baker said. "The fact that one third of patients with generalized symptoms would have received a CT scan had they gone to the emergency room suggests that ER physicians are out of control."

He noted that the indiscriminate use of CT scans for young patients with abdominal pain exposes them to potentially unnecessary radiation, which could, in time, become carcinogenic.

Several factors could contribute to the discrepancy in ordering patterns between college physicians and ER doctors, Baker said. College physicians might be hesitant to order a CT scan because a scanner may not be readily available and reimbursement may not be guaranteed.

In the ER, it's a whole different picture.

"If there is a scanner, it will get used," Baker said.

For more from the Diagnostic Imaging archives:

Panel recommends major changes in ACR policy governing patient radiation exposure

Soaring ER CT use stirs appropriateness concerns

Protocols for pregnant patients increase safety

64-slice CT transforms emergency radiology