Development of medical imaging technologies is the best way to advance clinical diagnostic accuracy and there is no such thing as VOMIT

Abstract

We recently published a commentary on the impact of blood biomarkers in clinical decision-making. In this issue we shift to a similar contemporary debate surrounding over-reliance on imaging technologies to make diagnoses, often without a clinical rationale other than to rule out pathology. This strategy is not without harm to patients as illustrated by both of our experienced contributors. The place and responsibility for missed or irrelevant diagnoses following imaging will often rest on little more than inept clinical targeting, although as McCoubrie points out, the skilled radiologist may have some role in tempering everything from overzealous interpretation to simple error. Given that many techniques are based on (albeit falling) X-ray exposure and involve vastly expensive (and routinely redundant) technologies operating almost continuously, the role of skilled radiological input is more essential than ever for reducing VOMIT. Can we control inadequate imaging request strategies?KeywoRdS Clinical decision-making, medical imaging, 'rule-out' testing, incidentalomas, radiation dose, demise of bedside medicine deClARATion of inTeReSTS No conflicts of interest declared.VOMIT is overstated, preventable and flawed Victim of medical imaging technology isn't a particularly new idea; the term 'incidentaloma' was coined 30 years ago.3 Since this original description of increasingly found incidental adrenal lesions, it has emerged that if one looks closely enough, most organs commonly contain benign masses that are often difficult to distinguish from early malignancies. The principles underlying VOMIT are now considered beyond question. The increasing accuracy brought by advances in imaging technology brings an inevitable flurry of incidental findings. It is a hegemonic assumption that 'red herrings' are an inevitable part of modern medicine. It logically follows that the more modern the imaging technology, the more VOMIT it will produce. Increased availability of modern scanners will merely result in more VOMIT. The ultimate extrapolation of this argument is that expansion of radiological imaging services will not produce population health gains; expansion should be therefore resisted. There are many reasons why this is wrong. In truth, VOMIT is a flawed principle.Why is it flawed? First, incidental isn't always trivial. Second, VOMIT is overstated but not intrinsic to scanning, just usually down to poorly performing radiologists. Third, I will contend the rise in incidental findings is due to defensive medicine driving increasing scanning rates. inCidenTAl iSn'T AlwAyS TRiviAlIt is often forgotten that some 'incidental' findings are not innocuous. For example:• Unexpected malignancies are commonly identified.In a large series of nearly 11,000 patients undergoing bowel cancer screening with computed tomography (CT) colonography (Figure 1), 4 unexpected extracolonic malignancies were discovered in 0.6% of patients. Interestingly, this is over double the rate of colonic malignancies in their series.• Serendipi...

Did medical doctors who order abdominal CT scans during on-call hours truly become worse at clinical reasoning? Yes, they did

“…Although medical imaging is generally considered beneficial to patients, a part of its increase has been attributed to overutilization [3]. Anecdotal data indicate that clinicians request more and more imaging simply because it is available, and to rule out disease rather than to confirm disease that is most likely based on probabilistic hypothetico-deductive reasoning [4][5][6]. Based on these anecdotal data and our own experience, it is hypothesized that the clinical reasoning quality of physicians who request medical imaging has deteriorated over the years.…”

Incidental imaging findings referred to a specialized sarcoma center: Frequency, determinants, and downstream healthcare costs

“…This may be accomplished by avoiding or minimizing the use of imaging when the probability of disease is very low (also known as the "rule out scan") and applying probabilistic hypothetico-deductive reasoning before requesting imaging. 20 Furthermore, patients may have to be informed about the possibility and potential consequences of detecting an incidentaloma, and provide consent before imaging is done. 21 On another note, in their communication to referring clinicians, radiologists may assign less clinical relevance to some incidental findings whose nature is most likely indolent, such as atypical cartilaginous tumors.…”

On-call abdominal ultrasonography: the rate of negative examinations and incidentalomas in a European tertiary care center

“…According to clinical experience and anecdotal evidence, the number of imaging examinations that are requested to rule out disease, a practice that is considered to be reflective of defensive medicine, has been and keeps on increasing [15][16][17]. In an attempt to exercise greater restraint in the use of imaging, a call has been made to establish benchmarks for the acceptable proportion of negative studies [16].…”