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Editorial |
1 From the Department of Radiology, Fletcher Allen Health Care/MCHV, 111 Colchester Ave, Burlington, VT 05401. Received May 3, 2006; accepted May 5. Address correspondence to the author (e-mail: rsheilman{at}aol.com).
Years ago as the radiology resident on call at a pediatric hospital, I got a frantic, late-night call from my orthopedic counterpart, who asked if I could come to the reading room right away and help him with a case. I was intrigued because orthopedic residents rarely asked for help. On entering the reading room, I was met with an astounding sight. Every view box in the huge room was covered with radiographs. Every bone from head to toe had been filmed in at least two planes, and spinal images included the full 1960s-style scoliosis series, with the patient imaged in forward, backward, right, and left bending positions. I had never seen so many radiographs of one patient obtained at one time before. In front of each panel were piles of other radiographs. The orthopedic resident sheepishly admitted that these older images were the reason he had called. Could I sort the radiographs of skulls, spines, arms, legs, hands, feet, etc, by date so that if his chairman wanted to review them at the next day’s conference they would be organized? When I asked why every bone in the child’s body needed imaging even once, let alone repeatedly, I was told that no orthopedic resident would dare arrive at a conference without "everything," lest the Chairman wonder offhandedly what a particular bone showed. The frantic resident then described what might happen to his own body parts if an idle question by the Chairman went unanswered.
At the time, I was in the final stages of board preparation and knew as much as I was ever to know about absorbed dose and the adverse direct and genetic effects of radiation. Even discounting the old radiographs, I knew that the cumulative, absorbed dose of radiation given to this young child was at a level that no parent would allow had he or she been told the health risk that the team had imposed. Today, it’s unlikely that a fully trained technologist would be willing to take that many radiographs of a child, except perhaps for a life-threatening emergency.
The reason for this trip down memory lane is probably clear to most readers. For those in a state of deep denial, perhaps it should be said that a single examination on a modern computed tomographic (CT) scanner can generate as many images and a radiation burden comparable to the case just described. The shock value of seeing en masse 500 chest radiographs, produced with a dose comparable to that delivered in a single abdominal CT study, has a way of attracting physician and patient attention that spinning a roller ball at a workstation may not.
CT offers remarkable insights into anatomy and pathology, a capability that is now common knowledge to healthcare providers and the public. It allows study of intact tissues in a way that no anatomist, surgeon, or pathologist could ever think of approaching. Before CT, who could have imagined lifting a healthy or a diseased body part out of an intact, living patient and rotating it in space to study its appearance and function? Small wonder that clinicians have come to rely so heavily on CT and are so tempted to use and overuse it.
But alas, it is unmistakable that at the present state of the technology, CT delivers a radiation dose that potentially has serious adverse health consequences. However remarkable the images and however reliant referring doctors (and patients) have become on its use, we simply can no longer pretend that all is well. Routine, and especially repeated, use of CT as occurs in modern medical practice is striking a deal with the devil that we can no longer ignore. Barring a technologic breakthrough, we must spread the news that repeated use of CT to document the course of numerous pathologic conditions, for example, the trip of a calculus down a ureter, will need to be curtailed. Such announcements (eg, that pediatric oncology clinics ought to follow their tumor cases with some other means, rather than CT at every follow-up visit) will be met with dismay and anger. But the facts must be delivered, and the sooner the better.
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