Issue 26 / 9 July 2012

THERE is a growing mismatch between community demand for health services and our capacity to deliver.

If the media is to believed, our health system is in continuous crisis. Recently one report claimed “tens of thousands” of x-rays were not being looked at by qualified specialists, saying there were concerns that “serious health problems are being overlooked”.

It goes without saying that these troubling backlogs are a symptom of a health care system that does not have the capacity to meet basic expectations the public has about the optimal delivery of patient care.

However, it doesn’t help build public confidence when professionals often disagree about the underlying causes of this crisis, especially where there is an inherent tension between the competing demands of hospital protocols, Medicare requirements, professional training and cost.

Naturally, everyone views backlogs through the prism of their own scope of practice and experience, and this can make reaching a solution all the more difficult.

In the x-ray backlog case, experts cited many possible solutions to address the predicament. The Australian Institute of Radiography suggested training to allow radiographers to provide interim reports in order to assist junior doctors in emergency departments.

While this is laudable, and would no doubt assist the problem in the short-term, the inevitable question of how to continue to meet exacting professional standards must be addressed.

It seems x-ray demand is driven in part by clinical uncertainty, or at least inexperience, and that x-rays are ordered even when clinical indications are absent or driven by the pressure of defensive medicine. There may also be a tendency to overscreen, overdiagnose and overtreat conditions.

For example, why do a presurgical chest x-ray in a patient who is asymptomatic and has normal physical findings including a normal clinical forced expiratory volume (FEV1)? And yet it would be unusual to find a patient scheduled for surgery without the obligatory chest x-ray.

This situation is surely ripe for a study of the utility of conducting routine x-rays of elective surgical patients.

The widespread backlog of x-rays could also be diminished if doctors were comfortable reading the x-rays they have ordered.

Another option could be the development of a technical screening system, which automatically scans x-rays according to predetermined protocols. It should not be difficult for enterprising research and development initiatives to develop a system that will screen x-rays within designated parameters.

This perceived deficiency in x-ray reporting is multilayered and can, in part, be blamed on diagnostic overkill and narrowly focused expertise.

Couple this with the loss of generalists in postgraduate training and the ongoing fragmentation of practice and it is easy to see why the health system appears to be in continual crisis.

Dr Martin Van Der Weyden is Emeritus Editor of the MJA.

Posted 9 July 2012

2 thoughts on “Martin Van Der Weyden: Continual crisis

  1. Bob House says:

    I declare my conflict as a senior radiologist. The concept of computer assisted diagnosis is deceptively attractive. The only current use is in mammography. All analysis of such programs show a great propensity to over diagnose and hence make a bad situation worse; Health Technol Assess 9 (6): iii, 1–58. PMID 15717938. A recent article, in MJA, emphasises the deleterious effect of a false positive diagnosis on the screening population; Med J Aust 2012; 196 (11): 693-695.

  2. TamePhysician says:

    I think it comes down to the expertise that you acquire. It’s a bit sad that surgical registrars can no longer confidently diagnose appendicitis without an abdominal CT, and that emergency registrars aren’t happy to exclude intracranial haemorhage without a radiologist’s ok. Having said that, although I’d back my own interpretation of a chest X-ray against a radiologist, I’d struggle to confidently exclude a subtle fracture on plain film. Isn’t teleradiology meant to sort all this out?!

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