I call bullshit. I am a radiologist, and I can conservatively say that half my reports have a summary section that reads “Normal”, “Normal for age”, “No acute disease”, “No significant change”, or “No significant abnormality.” This is especially true in the ER.

I may mention the benign adrenal adenoma or hepatic cyst or fibrous cortical defect in the body of the report, mostly to spare myself from getting calls from clinicians who see something on the images and don’t know what it is, but I make a real effort to be definitive in my interpretations. If there’s a lung nodule that has been stable for three or four years, my interpretation will read “Stable lung nodule. No further imaging follow-up is needed.”

When I hedge in a radiology report, it’s because there truly is no way to determine what some vague abnormality really is without further testing. A smudge on a chest X-ray can be a focal pneumonia, atelectasis, or an ill-defined neoplastic mass, among dozens of other possibilities.

You guys on the front lines remember the times I hedge about inconclusive imaging findings, because you have the patient there in front of you with a fairly obvious clinical diagnosis that I am not necessarily privy to. You don’t take notice of the dozens of time per night that I am able to easily dismiss benign findings or artifacts that would otherwise have you scratching your heads for twenty minutes and perhaps over-treating or mis-treating your patients.

100,000 x 2,000 x 52 = $ 10,400,000,000 per year”

OK, but you are missing something pretty important. You probably pulled your numbers out of your butt, but I’ll use them anyway.

The word “almost” is there. Please quantify it. Is “almost” equal to 90%? If so, then the cost is about $20,000 per life saved, right? Seems worth it. OK, maybe “almost” means 99%. Now it is about $200k per life saved. It still seems worth it. You have to get to 99.9% certainty before you reach $2M per life saved. I think it is around the $M mark that people might start debating whether or not it is worth it.

So, based on clinical history, how certain can you be that chest pain is not MI? 99.9% certain?

Canada would be a useful comparison, IF the US had the social safety net of Canada. When physicians want to fully embrace Canadian style healthcare, then what they do with regard to the alleged defensive medicine will be relevant.

We aren’t exactly told “you don’t really need this test, but I want to subject you to its risks, make you pay for it, in order it to protect my own a**”. No we are told “we’d like to order test X to rule out Y” or “we’d like to keep you overnight”. So we think that we are in real danger of Y and since to most of us our lives is more important, we agree to it, even if we have to pay later. Because the way you make it sound, we may die otherwise. If you were to just add the probability of the thing you are trying to rule out “I’d like to order test X tor rule out 1/100000 chance you have Y”, then you could say that you know we actually want the test. Sometimes you even lie – e.g. if someone asks you “would you order the same test on your relative”, you say “yes” even if the real answer is “no”.

You don’t really seem to understand how vulnerable we are when we are in your office or, especially in the ER. The environment can be pretty intimidating to us. Most of us don’t even think that we have an option of questioning “doctor’s orders”. We trust you.

Incidentally, it wouldn’t take even 5 minutes to convey to us that the probability of what you are trying to test for is extremely low. It’ll probably take under 1 minutes. You just don’t want to give us choice because heaven forbid we might refuse. You don’t want us to refuse.

So stop blaming HMOs that many large employers stopped offering anyway. I work for a Fortune 500 company that employs hundreds of thousands of people, and it stopped offering HMOs years ago because they are expensive. Now it is often PPO where we pay deductibles and percentages, so yes cost are important to us. You just think it is perfectly fine to use us as your insurance – take our money to protect you – even those the majority of peole don’t sue.

Huh? Last I checked patients and physicians had a choice where to go for imaging. My hospital-based radiology group competes intensely with surrounding groups for business. If you’re referring to inpatient imaging, then yes, the hospital group has a captive audience, but it’s in outpatient imaging that the money is made.

I’d also like to hear more about how RVUs drive doctors to order more imaging tests. I’m not sure I understand this.

And please stop using the term “fudge factor” – it implies an intent to defraud which is a gross mischaracterization of radiologists who hedge (all of us at one time or another). As the original commenter on this issue stated, this is a manifestation of defensive medicine the purpose of which is to protect from liability – not unlike every other doctor in this country.

It would be an interesting study to see if follow-up recommendations were more prevalent in private practices that earned income per case than in salaried hospital radiologists, similar to how ordering patterns increase for clinicians who have imaging equipment in their office. I honestly don’t know the answer. While I acknowledge that there are unscrupulous radiologists, the vast majority (if not all) of the the radiologists I have worked with including out-patient private practice folks, academics, and hospital-based non-academics share the same disdain for unnecessary imaging (though, obviously to varying degrees). I imagine this would not be the case if radiologists were scrapping for work. The fact of the matter is, radiologists do not need self-referral to keep the money flowing in – referring physicians are happily providing enough work to keep us busy for a long time.

Furthermore, the phrase “possibilities include…” is entirely appropriate in any report. It’s called a differential diagnosis. Look it up. You want more definitive answers, cut the patient open and look yourself.