Hot-spotting and Imaging

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Cat VaskoI’ve already fessed up to having a schoolgirl crush on Atul Gawande, surgeon, journalist, RSNA 2010 speaker and, I suspect/hope, fellow bleeding-heart liberal. His most recent article in The New Yorker looks at “hot-spotting,” the practice of providing intensive, personalized care only to the neediest patients as a means of lowering overall health care costs without making impossible demands of clinicians.

Based on Gawande’s past articles, as well as this one, I’m guessing his stance on imaging more closely resembles the radiology industry’s party line than its actual sentiments. This made him a good-on-paper choice for the RSNA conference, but most of the folks I talked to following his lecture felt ambivalent about it. I left feeling inspired; they left feeling chided. And it’s hard not to feel a bit slighted by the following paragraph:

“She suffered from terrible migraines. She took her medicine, but it wasn’t working. When the headaches got bad, she’d go to the emergency room or to urgent care. The doctors would do CT and MRI scans, satisfy themselves that she didn’t have a brain tumor or an aneurysm, give her a narcotic injection to stop the headache temporarily, maybe renew her imipramine prescription, and send her home, only to have her return a couple of weeks later and see whoever the next doctor on duty was.”

Imaging is presented, here, as just another ineffectual tool in a barrage of ineffectual tools, and a high-price one at that. The English major inside me can’t help but notice how CT and MRI are named interchangeably, as if to imply that no particular criteria is being employed as part of their use. CT and MRI are, further, presented as exclusion studies that don’t offer anything useful for this particular patient except confirming that her problem isn’t more serious.

If you read the whole article, which I recommend, it’s clear that hot-spotting is effective, but it represents a decidedly analog approach to medicine. Maybe that’s why Gawande levels the following accusation:

“Medical companies and specialists profiting from the excess of scans and procedures will get squeezed. This will provoke retaliation, counter-campaigns, intense lobbying for Washington to obstruct reform.”

I know what I’d say in imaging’s defense here. What we’re talking about, after all, is focused preventive care, which we all agree is what radiology could be, would be, at its best. So what say you? How would we go about integrating imaging into the hot-spot approach so that both can work to their maximum potential?