If you are a regular reader of HealthBlog, I suspect you may already subscribe to THCB, The Health Care Blog. Like most folks in the health industry, I’m a big fan of THCB. It is a “must read” for news and opinion about what’s going on in health and healthcare.
Yesterday, I was attracted to an article in THCB written by Merrill Goozner. In that article, “Research Shows….the Obvious”, Mr. Goozner comments on studies published earlier this week in Health Affairs. One of those studies concludes that providing the public with detailed information about hospital performance on a government website called Hospital Compare has no discernible impact on improving patient outcomes. The other study, which was of greater interest to me, showed that doctors with electronic access to patients’ prior imaging studies wound up ordering more imaging tests than doctors without access to electronic records. That one caught my attention because of my own experience over the last few weeks.
Starting a couple of months ago, I began to have a dull ache in the right lower abdomen and groin area. Being a physician, I ran through my own differential diagnosis; smoldering appendicitis, hernia, diverticulitis, tumor, etc. Like most people tend to do, I waited a while to see if my symptoms would get better. After four weeks of no improvement, I decided it was time to stop the self-diagnosis and see my internist. He reviewed my prior history including results from two colonoscopies over the last ten years, performed an exam, and told me he didn’t find anything remarkable. However, because the symptoms had been persistent over several weeks he suggested that I have an abdominal CT with contrast. Knowing that I had some worldwide travel coming up, I agreed that this was a prudent thing to do.
The CT was scheduled and performed the next day. My doctor called me shortly after the exam and told me the reviewing radiologist hadn’t found anything to explain my right-sided lower abdominal pain, but he was very concerned about a dilated left ureter (the tube between the kidney and bladder). The radiologist strongly suggested that I have a follow-up exam called a CT intravenous pyelogram (IVP). Hearing this, I pushed back a bit since I wasn’t having any urinary symptoms and no left-sided pain. I also had no prior history of kidney stones or infections. However, my doctor expressed concern that we really shouldn’t ignore the dilated ureter. He said it could be an early sign of a stone, bladder tumor or something even worse. He said, “We don’t want to wait until you are doubled over in pain or peeing out blood before we take action on something that might be preventable.” “OK”, I said reluctantly, “Let’s do the IVP.”
Because of my travel schedule about 10 days elapsed between the two exams. When I found time to get the second CT scan it was quickly scheduled and performed. Within a few hours of its completion, my doctor’s nurse called with the results. Everything was perfectly normal. The dilated ureter in the first CT exam was probably just caught in a “dilated phase”. Both left and right ureters were perfectly symmetrical and normal on the IVP.
Of course I was greatly relieved. That is the news I wanted to hear. But I then reflected on the cost associated with those two exams (several thousand dollars) and more importantly, since I am blessed with good health insurance, the radiation exposure I had received from the two CT scans. According to Dr. Donald P. Frush at Duke University Medical Center, a typical abdominal CT comes with a radiation dose of about 10 mSv. That is equivalent to about 100 to 250 chest x-rays. I received two such exams within ten days, or about 20 mSv of radiation exposure. Established scientific data suggest that radiation doses of more than 100 to 200 mSv have a significant association with the risk of developing cancer. And remember, radiation exposure and its risk is cumulative over a lifetime. The bottom line is you really don’t want too many CT scans.
Now, here’s the point I want to make about the availability of a technology like access to electronic images provided by CT scans or data in an electronic medical record and arguments that these technologies increase the cost of care or number of tests that are done. My comment is this. Don’t blame the technology, blame the people (doctors and patients) and systems that encourage and reward its use. The technology is good. Patient care wouldn’t be better if we eliminated technology and electronic records. Patient care would ultimately be much worse. It is how we as doctors, patients, and society decide to use the technology that matters. That is the piece that deserves greater scrutiny. We need to change behaviors and the perverse incentives that reward the bad behaviors and practices and drive up the cost of care and unnecessary testing, not get rid of the technology.
I’m pleased to report that all of my symptoms are now completely gone. I’m just sorry it took two CT scans before I got better.
Bill Crounse, MD Senior Director, Worldwide Health Microsoft