Sunday, March 28, 2010
Tuesday, March 23, 2010
NEJM Article on Radiation Exposure
Click on the above link to get an HTML of a recent New England Journal of Medicine article on radiation exposure from medical radiation. Scroll down in my blog to get a radiologists response.
The War over Imaging
The War over Imaging
Joseph Schoepf, MD
The current contribution in the New England Journal of Medicine is the latest installment of articles in high profile journals that make the case against medical imaging citing concerns over increasing radiation exposure as the authors’ motivation.
It is an indisputable fact that medical imaging is on the rise. Thus, it is inevitable that radiation exposure of our patients, who are part of the general population, is increasing in step with rising imaging utilization. What are the effects on our patients? The authors of this and similar prior contributions cite the theoretical cancer risk from radiation received at medical imaging and act as if this connection was a proven fact. It is not. All estimates of cancer risk from radiation are extrapolations of data collected in WWII atomic bomb survivors. It is highly questionable whether this data can be applied to patients receiving the kind and level of radiation involved with medical imaging. Thus, that radiation from medical imaging causes cancer is a hypothesis, which yet remains to be proven.
More importantly, this, like many similar contributions only focuses on risk. Potential risk cannot be assessed without looking at the benefit side. It would be hard to find a radiologist who would argue that our specialty’s services are of no benefit to patients. However, one does not need to take our word for it. While it is true that the utilization of imaging tests is increasing, we also observe for the first time in history a much cherished decline in mortality from cardiovascular diseases and cancer, the two scourges of our time which are the major focus of medical imaging. It would be hard to argue that our increasing capabilities of applying non-invasive imaging for primary and secondary prevention and therapeutic monitoring are unrelated to this excitingly positive trend. Moreover, an increasing cancer incidence is not observed, which robs the argumentation of imaging’s opponents of its base.
Radiology has been addressing this issue for several years and the Radiology community has long been the proponent of critically evaluating benefit versus risk in deciding whether to use imaging procedures. We have evidence that it is actually not Radiology who is responsible for the sharp increase in imaging utilization but rather the self-referral patterns of other medical specialties who increasingly perform in-office imaging, increasing cost and radiation exposure. However, a national sentiment directed against the use of medical imaging is bound to hurt us. Articles such as this one should serve as a wake-up call for our specialty. The use of radiation to guide patient management and reduce doubt in Medicine is in our name, and we have used radiation for over a century for the betterment of healthcare. It is intriguing, even shocking, that none of the authors of the current contribution is a radiologist, or a medical physicist. We cannot allow other medical specialties to dominate the public discussion on the use of radiation in medical imaging. This is of particular importance in times when the field of healthcare is bound to undergo pivotal transitions. The heavy involvement of the health insurance industry in the preparation of this current contribution and their financial ties to authors of similar prior articles and editorials have received little attention but may make this and similar work seem less altruistic than the authors would like it to appear.
We do not know the biological effects of radiation from medical imaging. Because of this and because of the public fear that is created by articles such as the current one, we owe it to our patients to keep radiation dose as low as reasonably achievable. And we have gone to work on this. Hospital information systems are actively being developed that prospectively identify patients who frequently visit emergency departments with vague complaints in order to prevent unnecessary repeat imaging of such patients. The Image Gently campaign is in full swing in order to ensure that in the patients who we worry about most, our children, radiation dose is kept to a minimum. Technical innovation is rapidly responding to concerns over increased radiation exposure from medical imaging. Particularly in the arena of cardiac CT, which, because of its high visibility and destined disruptive nature in healthcare is abused as a negative poster-child by imaging’s opponents (see the accompanying editorial to the current article), dramatic reductions in radiation exposure are happening as we speak. The below is a striking example, where with the use of 2nd generation dual-source CT cardiac and non-cardiac pathology could be ruled out in a 56 year old woman with acute chest pain, obviating the need for any further workup. The scan was acquired during a single diastole and took only 270 milliseconds with a radiation dose equivalent of 1.3 mSv. Because of the various motivations that drive the current discussion on radiation exposure, this discussion will not go away soon, but with advancing technology and greater focus on the benefits of imaging will increasingly lose its base.
Joseph Schoepf, MD
The current contribution in the New England Journal of Medicine is the latest installment of articles in high profile journals that make the case against medical imaging citing concerns over increasing radiation exposure as the authors’ motivation.
It is an indisputable fact that medical imaging is on the rise. Thus, it is inevitable that radiation exposure of our patients, who are part of the general population, is increasing in step with rising imaging utilization. What are the effects on our patients? The authors of this and similar prior contributions cite the theoretical cancer risk from radiation received at medical imaging and act as if this connection was a proven fact. It is not. All estimates of cancer risk from radiation are extrapolations of data collected in WWII atomic bomb survivors. It is highly questionable whether this data can be applied to patients receiving the kind and level of radiation involved with medical imaging. Thus, that radiation from medical imaging causes cancer is a hypothesis, which yet remains to be proven.
More importantly, this, like many similar contributions only focuses on risk. Potential risk cannot be assessed without looking at the benefit side. It would be hard to find a radiologist who would argue that our specialty’s services are of no benefit to patients. However, one does not need to take our word for it. While it is true that the utilization of imaging tests is increasing, we also observe for the first time in history a much cherished decline in mortality from cardiovascular diseases and cancer, the two scourges of our time which are the major focus of medical imaging. It would be hard to argue that our increasing capabilities of applying non-invasive imaging for primary and secondary prevention and therapeutic monitoring are unrelated to this excitingly positive trend. Moreover, an increasing cancer incidence is not observed, which robs the argumentation of imaging’s opponents of its base.
Radiology has been addressing this issue for several years and the Radiology community has long been the proponent of critically evaluating benefit versus risk in deciding whether to use imaging procedures. We have evidence that it is actually not Radiology who is responsible for the sharp increase in imaging utilization but rather the self-referral patterns of other medical specialties who increasingly perform in-office imaging, increasing cost and radiation exposure. However, a national sentiment directed against the use of medical imaging is bound to hurt us. Articles such as this one should serve as a wake-up call for our specialty. The use of radiation to guide patient management and reduce doubt in Medicine is in our name, and we have used radiation for over a century for the betterment of healthcare. It is intriguing, even shocking, that none of the authors of the current contribution is a radiologist, or a medical physicist. We cannot allow other medical specialties to dominate the public discussion on the use of radiation in medical imaging. This is of particular importance in times when the field of healthcare is bound to undergo pivotal transitions. The heavy involvement of the health insurance industry in the preparation of this current contribution and their financial ties to authors of similar prior articles and editorials have received little attention but may make this and similar work seem less altruistic than the authors would like it to appear.
We do not know the biological effects of radiation from medical imaging. Because of this and because of the public fear that is created by articles such as the current one, we owe it to our patients to keep radiation dose as low as reasonably achievable. And we have gone to work on this. Hospital information systems are actively being developed that prospectively identify patients who frequently visit emergency departments with vague complaints in order to prevent unnecessary repeat imaging of such patients. The Image Gently campaign is in full swing in order to ensure that in the patients who we worry about most, our children, radiation dose is kept to a minimum. Technical innovation is rapidly responding to concerns over increased radiation exposure from medical imaging. Particularly in the arena of cardiac CT, which, because of its high visibility and destined disruptive nature in healthcare is abused as a negative poster-child by imaging’s opponents (see the accompanying editorial to the current article), dramatic reductions in radiation exposure are happening as we speak. The below is a striking example, where with the use of 2nd generation dual-source CT cardiac and non-cardiac pathology could be ruled out in a 56 year old woman with acute chest pain, obviating the need for any further workup. The scan was acquired during a single diastole and took only 270 milliseconds with a radiation dose equivalent of 1.3 mSv. Because of the various motivations that drive the current discussion on radiation exposure, this discussion will not go away soon, but with advancing technology and greater focus on the benefits of imaging will increasingly lose its base.
Friday, March 12, 2010
Sunday, March 7, 2010
Obama at a crossroads
What to make of Mr. Obama after one-year in the WH? As is the usual Democratic approach he tried the Mr. Niceguy comes to Washington and got completely slammed. He tried not making the same mistake of Hiliary and Bill who micromanaged healthcare reform and only now is he realizing that he was too hands-off. He is accused of taking on too much, only because the prior 8-years was so laissez-faire as to allow the current financial calamity unfold. Now the Right calls any attempt at reform "Government Take Over" of medicine (as if the current system is anything but government run just without the tag).
What will be his saving grace is a recovery of jobs data. If he can show that both Wall Street and Main Street benefited from the stimulus and the acts of Treasury then he will be assured of a second term. WS has already recovered much lost ground. Main Street has a ways to go. With 1 in 10 still out of work (and an even greater proportion having stopped looking or underemployed) we all know people who have been affected in one way or another. http://www.bls.gov/news.release/empsit.nr0.htm
What the Right is afraid of is any success on his part at all. Claiming to be the party of Family Values, they would sacrifice the well being of future generations in the name of "free markets". Failing to see what the lack of regulation and control did for the financial industry, they claim that "the markets" will adjust to global warming (if it exists at all). They would propose that private insurers will solve the health care dilemma - just allow purchase of insurance across state lines. They decry a "government takeover" while screaming at the president for attacking Medicare - a textbook form of socialist medicine.
The President will likely adopt some Republican ideas (as he already has) - like purchase of insurance across state lines. Of course the only reply of the Right will be to insist that it is not enough and just a token political move on the part of The White House. And so the game goes on. See who can outlast the other until the next election when the tables get turned and the Democrats are out for vengeance, not allowing any Republican measures to pass.
Just as the Republicans did to get Bush's tax-cuts passed, the Democrats will have to resort to reconciliation to get healthcare through. The only difference being that Bush's tax cuts have made the biggest difference for the highest earners where as healthcare reform will bring benefit to all.
Let's wish the President well in the months ahead - his legacy is in the making.
What will be his saving grace is a recovery of jobs data. If he can show that both Wall Street and Main Street benefited from the stimulus and the acts of Treasury then he will be assured of a second term. WS has already recovered much lost ground. Main Street has a ways to go. With 1 in 10 still out of work (and an even greater proportion having stopped looking or underemployed) we all know people who have been affected in one way or another. http://www.bls.gov/news.release/empsit.nr0.htm
What the Right is afraid of is any success on his part at all. Claiming to be the party of Family Values, they would sacrifice the well being of future generations in the name of "free markets". Failing to see what the lack of regulation and control did for the financial industry, they claim that "the markets" will adjust to global warming (if it exists at all). They would propose that private insurers will solve the health care dilemma - just allow purchase of insurance across state lines. They decry a "government takeover" while screaming at the president for attacking Medicare - a textbook form of socialist medicine.
The President will likely adopt some Republican ideas (as he already has) - like purchase of insurance across state lines. Of course the only reply of the Right will be to insist that it is not enough and just a token political move on the part of The White House. And so the game goes on. See who can outlast the other until the next election when the tables get turned and the Democrats are out for vengeance, not allowing any Republican measures to pass.
Just as the Republicans did to get Bush's tax-cuts passed, the Democrats will have to resort to reconciliation to get healthcare through. The only difference being that Bush's tax cuts have made the biggest difference for the highest earners where as healthcare reform will bring benefit to all.
Let's wish the President well in the months ahead - his legacy is in the making.
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