X-rays and public money
John Rowan Wilson
If Sir Keith Joseph is really going to introduce cost-effectiveness into the Health Service, he might do worse than turn his attention to one of the more flagrant wastes of money in the administration of our hospitals: the taking of useless and unnecessary X-rays. Every now and then there is an outburst of anxiety on this subject from the medical profession. Somebody publishes an article containing alarming statistics about the number of expensive X-rays ordered which end up by showing no lesion whatever. Voices are raised at meetings of radiologists or orthopaedic surgeons. A correspondence flares up in the columns of the British Medical Journal. Then it all dies away again. The problem remains.
It is not a problem peculiar to a free Health Service. It occurs in an even more serious form in the free-enterprise system of the US. It is not new: it has been present in some degree or another ever since X-rays were invented. But for a variety of reasons it has become much more acute in recent years.
Most unnecessary X-rays are ordered in the casualty department, by the youngest and most junior members of the hospital staff. They may be ordered simply from lack of experience: because the casualty officer lacks confidence in the accuracy of his clinical examination, he tends to support it with some outside method of confirmation. Also, because of the way casualty departments are staffed, he is on his own, and has nobody to turn to for advice. He is afraid that if he makes a mistake he will be criticised by the consultant who sees the patient at a later stage. He is less likely to be attacked for being too careful than for not being careful enough, so he plays it safe.
He may also be intimidated by the patient or those who accompany the patient. A father strides into the department, bringing with him his small son, aged three.. The lad is tearful but otherwise apparently unharmed. He fell out of a tree on to his head. Father thinks he was unconscious for a few seconds, but doesn't really know. What he does know is that he would like the boy X-rayed. When the casualty officer suggests that it is unnecessary, the father becomes indignant. He has travelled half an hour on a bus to get to hospital and spent another half-hour in the hospital getting his papers and waiting in a queue to see the doctor. Is he to be sent home with nothing more than empty words of reassurance? The casualty officer is harassed and overworked, and doesn't feel in the least like an argument. He is new to the job, new to the area, and most probably nowadays even new to the country. He orders an X-ray.
Skull X-rays, carried out in circumstances like these, are one of the most wasteful forms of investigation known to man. Even in the very unlikely event of a fracture being shown, it is hardly ever of clinical significance. Symptoms and signs are what count in diagnosing the severity of a head injury, but it is extremely difficult to explain this to a man with a three-year-old son who has just fallen out of a tree. The fact is that the public believes in X-rays. They are, like the sacraments of the Catholic Church, "an outward and visible sign of a secret and invisible grace." You might as well try to argue about Holy Communion.
It isn't only skulls. It's ankles, ribs, backs, pelvises, feet, anything you like. The patient gets a bang on the affected part, or feels a pain in it, and he wants the complete check-over, to make sure nothing is wrong. Even when he has had one negative X-ray, the matter may not end there. The pain persists. The doctor is uneasily conscious that very occasionally a small fracture may not show up on the first film. So he takes another set, a week later, just to be sure.
He feels he has to cover himself against the outside chance. He is afraid, not simply of the patient or his seniors, but of the law. The courts care nothing at all for the cost of the Health Service and share the public belief in the sacramental quality of X-ray films. If anything goes wrong with a patient, the omission of an X-ray investigation gives the plaintiff's lawyer a strong peg on which to hang a suit for professional negligence. Even if the doctor ends up by winning the case, it will certainly poison his life for several years and put a question mark against his judgement for the rest of his professional career. And this hazard can easily be avoided, at no cost to anyone but the taxpayer, by putting his signature to a form and scribbling "Please X-ray skull. Fracture."
When I was a casualty officer I wasted hundreds of pounds of public money every year in this fashion. I am told that the recent publicity about casualty departments, together with some heavy awards for damages, have increased the wastage rate enormously. It is an unfortunate fact that every measure taken to protect the public from negligence leads to an increase in Health Service costs, as the doctors in turn try to protect themselves from attack. The only possible answer to this seems to be a'much more realistic understanding bY the courts of when an X-ray may be reasonably omitted. Perhaps this is something that the doctors and the lawyers ought to get together about.
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