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We're all responsible for the rise in unnecessary medical tests

In his latest PopRX column in the online magazine Salon, San Francisco pediatrician and writer Dr. Rahul Parikh discusses how TV medical shows mirror a disturbing trend in medicine: the overuse of medical tests, particularly computed tomography (CT) scans.

A recent episode of “Nurse Jackie,” he says, showed emergency room personnel ordering a CT scan of a boy’s head — not because he needed it (an x-ray would have sufficed for his injury), but because they thought it would be “cool” to let the boy see his brain.

 “The scene is satire,” writes Parikh, “but it demonstrates how easy it is for doctors to run unnecessary tests on their patients. The scene also had uncanny timing. Just after the episode aired, a study came out showing just how often kids in emergency rooms get CT scans. The real-life answer, as suggested by 'Nurse Jackie,' is 'a whole lot more than they need.'"

That study, published earlier this month in the journal Radiology, found an astounding five-fold increase in the number of CT scans performed on children in U.S. emergency rooms between 1995 and 2008: from about 330,000 to almost 1.7 million a year.

Writes Parikh:

And that's a problem, because CTs expose children to higher levels of ionizing radiation than any medical procedure, raising the risk — ever so slightly but very clearly — that some of those kids will develop cancer in their lifetimes. Here's how one pediatric surgeon put it: "CT scans are like mini-Hiroshima bombs, four such scans on a kid are equivalent to the radiation exposure that the survivors were subjected to in 1945."
Statistics suggest that 1 to 2 out of a hundred people who get scanned will get cancer as a result. Kids constitute the highest risk group because they’re young (giving them more time to get cancer) and because their bodies are more sensitive to the radiation that CTs rain on their bodies.

As Parikh points out, there are a variety of reasons why physicians are ordering CT scans at such a rapidily increasing pace: First, physicians are taught to do so; it protects them from misdiagnosing an illness, no matter how unlikely that illness is. Second, CT scans are a big source of profit — for hospitals, imaging centers and physicians who may own a financial stake in such centers. Third, today’s CT scans are fast and easy to do. Physicians no longer have to sedate children for the tests.

But there’s yet another reason why the use of CT scans is skyrocketing: patient pressure. Parikh tells the story of how he resisted a father’s demand that his young daughter, who was complaining of stomach pains, have an emergency room CT scan. The father thought his daughter had appendicitis. Parikh was sure she had a case of food poisoning.

“I practice in the 21st century, a time when patients (or their parents) dislike any ambiguity whatsoever,” he writes. “It's also a time when shows like 'House' and 'ER' and 'Grey's Anatomy' have given even casual viewers a working vocabulary for specialized medical equipment. Patients may not have a sophisticated sense of what a CT scan does, but they know that it's important and advanced, that it has a certain prestige and could give them the best, most unambiguous diagnosis possible.”

So, all of us — patients and providers alike — must take responsibility for the recent upsurge in unnecessary, expensive and potentially dangerous medical tests.

And what can we do to reverse this trend? Writes Parikh:

Most experts agree that overuse needs to be curbed. If it isn't, we could face a future public health problem of rising cancer rates, thanks to our medical overzealousness. It’s akin to our realization that excessive antibiotic prescribing created resistant strands of bacteria. Scientists spent the next 20 years educating doctors and the public about those risks. The message seems to have taken: It’s rare that I get a parent in my practice who demands antibiotics. Many, in fact, now question whether their child needs them at all.
We've fallen off a similar cliff with CT scans. In a 2004 survey 75 percent of radiologists and ER doctors grossly underestimated the radiation dose from a CT scan. Over half the radiologists surveyed and over 90 percent of emergency-room physicians did not believe that CT scans increased the lifetime risk of cancer.
So what do we do? Educating doctors and patients about the risk of CTs is already underway in many places, as is making sure radiologists know how to fine-tune doses of radiation for kids who get CTs so that they’re subjected to less radiation.

More trusting relationships between patients and their primary care doctor would also help, Parikh adds.

You can read his column here.

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