Monday, April 13, 2009

Understanding the CAT Scan Cascade

If we are ever to prevail against the CAT scan cascade, we must understand why these tests are ordered. Here are 7 explanations of why doctors scan their patients. Talk to your own doctor and see if I’ve missed a few. While some physicians have financial conflicts of interest, most order scans for other reasons. This is not a ‘choose the best answer’ multiple choice test. Physicians often have more than one reason to scan you.

The physician orders a scan to follow trivial lesions identified by accident on prior scans.

A patient or the family want a medical test believing that a diagnosis has been missed.

The physician orders a CAT scan hastily, without sufficient thought if it makes medical sense.

The physician has a financial interest in ordering CAT scans.

The physician correctly believes that the scan is medically necessary.

The physician orders a CAT scan defensively for his own legal protection.

The physician orders a scan to bypass a difficult discussion of a patient’s chronic complaints.

I don’t pretend to be a medical saint. I have certainly ordered CAT scans for many of the wrong reasons listed above. Clearly, there should be only 1 reason that a doctor orders a CAT scan on a patient. It’s right there on the list. Can you spot it?


  1. The answer is: The physician correctly believes that the scan is medically necessary.

    The question for the poor little patient is - what do you do if your doctor orders a scan. Of course - he/she is the expert, so the result of not following the order could be life-threatening. How am I to know if a test is necessary or not? And if I do not follow my physician's advice, will he/she continue to treat me?

    Really, the patient has little to no choice in the matter. I have had many CAT scans with, THANK YOU GOD!, no serious findings. But what am I to do?

  2. Congratulations on selecting the correct answer! I understand your dilemma and recognize that patients are not medical professionals. Nevertheless, you can advocate for yourself. If your physician recommends a test or a prescription, ask why. Even though you are not a doctor, make sure that the medical advice makes sense. If it doesn't, then continue the conversation. You may find that these discussions lead to some flexibility in the doctor's recommendation. In addition, if your physician knows that you will be questioning (not challenging) the advice regularly, then he or she may think more carefully before ordering medical testing. This strategy works best when it becomes a widespread practice for all patients.

  3. Ultimately, patients have to become better educated consumers of the health care system. Government cannot set guidlines that are sufficiently individualized to make good decisions on every patient's behalf.

    To use a crude example, I do not know much about cars, and when the mechanic tells me that something is going bad and should be replaced, I can only ask what it is that the part in question does, what are the consequences of replacing it or not replacing it, etc. Of course, the consequences of making a bad medical decision are potentially more serious than those of making a bad car maintenance decision. All of which underscores the importance of (a) having a doctor who is willing to talk to you about the decision-making process, and (b) willingness to take reponsibility for your own medical decisions.

    - Julian Bashir, MD

  4. Excellent comments from Dr. Bashir. Judging from his remarks, he could write his own blog.

  5. I am a doctor and I work in a field where CT scans are very helpful. I like to let patients make their own choices. Here is why you should get a CT. Here are the reasons why not (radiation, costs, incidental findings). I let them choose, and I document thier choice. Its not that big of deal. What I find is that if someone else is paying thier bills (Medicare, Medicaid) or if they dont have insurance, they are more aggressive in pushing for this service. If you give the patient the info, they should choose. but I have to documetn it so when I get sued, its on them. The problem is in the ER when the patient is drunk, on drugs, belligerent, on the ventillator, does not speak english, etc. In the absence of tort reform, they get a CT.

  6. Good post. Being a chiropractor, I routinely ordered x-rays for every one of my patients. Now it is not a common practice for me. Ordering those X-rays did not change the outcomes much. Too many factors to consider. What outcomes does the patient want? Only wants to get out of pain, wants spinal correction, rule out arthritis or some other disease process.

    There's been recent news about Cat Scans causing high levels of radiation to the point where a patient interviewed lost his hair and had sores all over his mouth. Unfortunate but not isolated episode which has triggered investigations at various hospitasl and centers as I'm sure you read or heard about.

    We need more patients asking questions and taking responsibility for THEIR OWN health instead of placing it all on us. They need to get off the couch and go for a walk, learn the basics of preventing most diseases, watch Discovery Health regularly and find a doctor that will welcome your questions and not label you a difficult patient.

    Carlos M. Gonzalez DC

  7. Carlos, I agree with you that patients need to advocate for themselves. After all, it's their health and they should be the primary guardians of it. Thanks for the comment.