What if you are one of the 2 percent?

I’m a member of the ACR (American College of Radiology). One of their recent online postings is entitled: Choosing Wisely.

Number three (of ten things physicians and patients should question) is: “Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.”

In only 2 percent of cases, will it make a difference in management.

Thirteen years ago, I was working on the queue of cases that presented themselves in the department that day. Among many others was the chest X-ray (CXR) that bore the name of a colleague. With others, I played with regularity on his tennis court. He was having elective foot surgery, and this was a preoperative set of films. I am grateful I was having a good day. Or perhaps I paid more attention because his name was familiar.

Regardless, I noticed something in one lung. It was not terribly obvious but didn’t belong there. He was still working at the time and apparently healthy. He met none of the criteria the ACR now indicates are reasonable for preoperative CXR. I called him.

I asked, “Have you had any prior chest X-rays?” (There were none available to me.)

He said, “Yes, but elsewhere.”

“Can we get them for comparative purpose?”

“I’ll see what I can do.”

When those images were procured, the abnormality of concern turned out to be new. Understandably, he wanted to downplay its significance, but I was not so sure. He subsequently had a chest CT scan, and the lesion was real. And something to give a prudent person insomnia.

One of my group colleagues performed FNA, and the lung lesion turned out to be malignant. He subsequently underwent lobectomy and recovered sufficiently to continue practicing, only retiring within the past year.

Unfortunately, he was not cured. More recently, he developed metastases and is now undergoing chemotherapy. But he has had some longevity he might otherwise not have. And was able to continue caring for patients whose lives he may have enriched and see the grandchild he might otherwise not have enjoyed. And participate in those things that make life worth living.

Had he not had the preoperative CXR in conjunction with foot surgery, he might well not have had one until he developed hemoptysis, dyspnea, or chest pain, by which time his cancer might have been inoperable. As it was, it was operable but not cured.

In the end, time is all any of us has.

As has been mentioned by some other writer, we enter this world naked and alone with nothing. Hopefully, we do not leave that way — at least alone. And most of us will have something: friends, family, memories.

So, while I concur with the 2 percent estimate of the ACR of patients in whom a CXR will make a difference, I admit to being conflicted.

How does one put a monetary figure on a few extra years of life?

It is tempting to try to quantify, but what if you are one of the 2 percent?

Meanwhile, I continue to pursue with diligence, because I never know which preoperative CXR I encounter will be among that group.

Samuel M. Chen is a radiologist.

Image credit: Shutterstock.com

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