High Incidence of Defensive Imaging: JAMA Study

A survey of Pennsylvania physicians in six specialties—emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology—who were determined to be high risk for litigation found that defensive medicine was practiced by nine out of 10 physicians among those who pay the most for liability insurance. Defensive medicine—how physicians change their clinical behavior because of the threat of malpractice lawsuits—and its consequences are key components of the medical malpractice reform debate, especially in Pennsylvania where physicians pay dearly for liability insurance, the authors noted.

Published in the June 1, 2005 issue of the Journal of the American Medical Association , the study’s authors found that 93% (768) of the 824 participating physicians said they practiced defensive medicine. The most common practices in defensive medicine were ordering tests, performing diagnostic procedures, and referring patients for consultation.

Table. Specific Practices of Defensive Medicine Among Physician Specialists. Reprinted with permission: Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005 Jun 1;293(21):2609-17. (Click the image for a larger version.)

In general, the study found that detecting cancer was a major concern for physicians in all six specialties (24%; 157), leading to an increased use of diagnostic imaging, specialist referrals, and invasive procedures.

Imaging was a preferred defensive tool. The authors reported that 43% of those who practiced defensive medicine said they used imaging (CT, MRI, x-ray) as their most recent defensive act, including 63% of ER physicians; 41% of responding general surgeons; 55% of orthopedic surgeons; 58% of neurosurgeons; 36% of radiologists; and 7% of OB/GYNs. An additional 18% of OB/GYNs reported ordering ultrasonography as a defensive act.

Eleven percent (15) of emergency physicians said they were likely to order CT for abdominal symptoms not likely to be acute appendicitis, and 25% (34) were likely to order cranial imaging for minor trauma; 4% (7) of OB/GYNs said they were likely to order ultrasonograms for pregnant and nonpregnant patients; 11% (17) of general surgeons were likely to order confirmatory imaging of appendicitis before operating or declining to operate; 7% (13) of orthopedists and neurosurgeons were likely to order MRI to exclude a tumor diagnosis for spine, bone, and joint symptoms; 17% (26) of radiologists referred patients with ambiguous mammograms for surgical biopsy; and 4% (6) ordered repeat imaging of low-risk abnormalities on chest radiographs.

Technology plays a major role in defensive medicine as well as malpractice liability, the study found. The survey shows that physicians use technology to appease patients, heighten their own self-confidence, or create evidence that they tried to confirm or exclude a particular disease.

X-ray Fluorescence Uncovers Lost Texts

Taking advantage of modern technology, researchers are using multi-spectral imaging and x-ray fluorescence to unlock the hidden text of the Archimedes Palimpsest at the Walters Art Museum, Baltimore.

A multi-spectral processed image of a page from the Archimedes Palimpsest taken by the Rochester Institute of Technology.

The manuscript, bought at auction by an anonymous collector for $2 million in 1998, was donated to the museum for conservation, imaging, and scholarship, says William Noel, head of the Archimedes Palimpsest project at the museum. The collector is fully funding the project.

The 10th-century document contains three treatises by the ancient Greek mathematician Archimedes that “don’t exist anywhere else in the world,” Noel says. The parchment containing the three treatises—Methods of Mechanical Theorems, Stomachion, and On Floating Bodies in the original Greek—was reused in the 13th century for a prayer book.

Using multi-spectral imaging, researchers from the Rochester Institute of Technology, the Boeing Corporation, and Johns Hopkins University have been able to uncover about 80% of the text. By combining the red channel of normal light, or RGB light, with the blue and green channel of ultraviolet fluorescent light, the Archimedes text appeared to be red rather than black, the color used to write the prayer book.

Helping to uncover the remaining 20% of the text, researchers are using x-ray fluorescence to get elemental specific information about a particular page.

“One of the things we know from medieval manuscript recipes and from ink analysis is that the ink in which the Archimedes text was written has a very high proportion of iron,” Noel says.

Using that technique, researchers have found that with the right resolution, the x-rays that fluoresce will show where the iron is on the page.

“The wonderful thing about this is that it enables us to find the iron on a page,” Noel says. “The ink is obscured by gold so we have been able to image through forgeries that were painted over the Archimedes text and over the prayer book text in the 20th century to reveal the Archimedes text underneath.”

The project is due to be completed and open to the public in fall 2008.

ACR Responds to IOM Recommendations

Responding to the recent report “Improving Mammography Quality Standards” by the Institute of Medicine (IOM), the American College of Radiology (ACR) weighed in on several of the report’s recommendations. Congress commissioned the report by IOM in preparation for the reauthorization of the Mammography Quality Standards Act (MQSA) of 1992.

Several of the recommendations IOM made for improving breast imaging quality include:

  1. Revise and standardize the required medical audit component of MQSA.
  2. Facilitate a voluntary advanced medical audit with feedback.
  3. Designate specialized Breast Imaging Centers of Excellence and undertake demonstration projects and evaluations within them.
  4. Make more effective use of breast imaging specialists.
  5. Mandate accreditation for nonmammography breast imaging methods that are routinely used for breast cancer detection and diagnosis, such as ultrasound and MRI.

In a statement, ACR said it is concerned about the impact mandatory practice auditing requirements will have on the breast imaging field.

“While these recommendations for more comprehensive tracking and follow-up likely will improve feedback to the imaging center, the feasibility of implementing this new requirement varies considerably, and may add further disincentive to breast imaging practitioners,” the statement said.

Should the IOM’s recommendations be put into practice, ACR urges that those measures be “feasible, allow for an adequate period of implementation, and do not reduce access for American women to the possible life-saving benefits of screening mammography.”

Industry News

Hologic is in the process of buying the intellectual property and customer lists of Fischer Imaging Corporation as they relate to their mammography business and products, including the rights to their SenoScan digital mammography and MammoTest stereotactic breast biopsy systems. Under the terms of the agreement, Hologic has agreed to a cash purchase price of $32 million…All 28 facilities of Nydic Open MRI of America, Montvale, NJ, have earned the Joint Commission on Accreditation of Healthcare Organizations Gold Seal of Approval for health care quality and safety…The US Air Force’s Air Mobility Command has certified the security of IMPAX PACS version 4.5 by Agfa, Greenville, SC…Medicalis® Corporation, Kitchener, Ontario, Canada, is incorporating the American College of Radiology Appropriateness Criteria™ guidelines into the Percipio” clinical decision support knowledge base…Viewport Medical Systems, San Rafael, Calif, has signed an agreement with iCAD® Inc, Nashua, NH, to sell iCAD’s ClickCAD™ Fee-For-Procedure solution…MedField Billing Solutions, Canfield, Ohio, an affiliate of Nydic Open MRI of America, celebrated the grand opening of its headquarters in June…Cedara Software Corp, Toronto, announced that Cedara B-CAD, a CAD solution for breast ultrasound, has received 510(k) clearance from the US Food and Drug Administration…Siemens Medical Solutions Ultrasound Division announced it has been ranked the Number 1 ultrasound company for revenues in the United States for the fifth consecutive year by the Klein Biomedical Consultants 2004 annual report…AMICAS Inc, Boston, has tied for the overall top score in the KLAS PACS Perception Report in April 2005…Vital Images Inc, Minneapolis, and R2 Technology Inc, Sunnyvale, Calif, have signed a 3-year sales and marketing agreement to jointly sell R2 Technology’s ImageChecker® CT Lung CAD software integrated into Vital Images’ CT lung visualization option…IMPAC Medical Systems, Mountain View, Calif, announced that CentraState Medical Center, Freehold, NJ, is using IMPAC’s treatment management solution to sequence radiation therapy treatments on Varian Medical Systems’ 4D Integrated Treatment Console Clinac®…Siemens, Hoffman Estates, Ill, announced it has formed a new division: Siemens Medical Solutions Molecular Imaging Inc, a provider of PET imaging equipment and services. The company also announced that its Ultrasound Division, Mountain View, Calif, has signed an agreement to acquire Sensant Corp, San Leandro, Calif…ODS Medical, Minneapolis, has announced a partnership with X-Ray Marketing Associates Inc, Romeoville, Ill, to market its digital solutions to radiology facilities…The US Patent and Trademark Office has issued FUJIFILM Medical Systems USA, Stamford, Conn, a patent for Subscription, part of its Synapse® PACS technology.


Richard D. Young

Michael J. Pentecost, MD, FACR, has been appointed chair of the Institute for Health Policy in Radiology of the American College of Radiology. Chairman of radiology at Georgetown University in Washington, DC, since 1996, Pentecost became the director of the Kaiser Permanente radiology practice in the Mid-Atlantic States in April….R2 Technology Inc, Sunnyvale, Calif, has named Shawl B. Lobree as vice president of marketing; Denise Gottfried as vice president, regulatory, clinical, medical and quality; Brad Freeman as vice president of global supply chain, service and information services; and Stephen Geisheker as director of customer service…Richard D. Young, CR coordinator at WestCare Health System, Sylva, NC, has been awarded the $2,000 PACS Administration Scholarship by FUJIFILM Medical Systems USA, Stamford, Conn.