As a university radiologist primarily involved with CAT (Computerized Axial Tomography) scanning, I have had extensive clinical and research experience in studying the use and relevance of the newer imaging modalities. I feel obligated to point out the inaccuracies and inadequacies of Dr. George Crile Jr.'s article, "High-Tech Medicine We Can't Afford" (Outlook, July 31).
Indeed, in examining the impact of new technologies on medical care, life expectancy has risen only 3.3 years over the past two decades. This is despite large increases in health-care spending and technological advances. However, this is really not surprising, in that the most dramatic advances in CAT scanning and ultrasound (the use of sound waves to image the body) have occurred in the last five years. Increased longevity may result, but may not be reflected statistically for years to come.
With the advent of new technologies, it cannot be disputed that the quality of life has improved. The new technologies also often allow diagnoses to be made without the need for "blind" exploratory surgery (i.e., surgery performed with little or no idea of the nature or extent of the disease process). Crile assumes that quality health care and the new imaging techniques are available to all segments of the population. Even in my academic ivory tower, I realize that this is not the case.
The approach to abdominal pain as discussed by Crile is overly simple. It assumes that all diseases that may be found by the new technologies are incurable. Even if this were true, it would not be because of the new imaging techniques, but rather because treatment advances have not kept pace.
Needless to say, there is a wide variety of benign and inflammatory conditions that are treatable, and malignancies that are curable if detected early. To ignore all problems as simply incurable is a fatalistic approach that is neither scientifically nor morally sound.
In just one of many possible examples, nuclear medicine has had a major impact on the treatment of acute cholecystitis (inflammation of the gall bladder usually associated with gallstones). This procedure, called biliary scintigraphy, detects over 90 percent of patients with this serious but highly curable ailment, which produces abdominal pain and other symptoms. Physical examination, however, may detect only 50 percent of patients with this disease, according to both the surgical and radiological literature. Fifty percent is not very good odds, considering the life-threatening complications that can result from the improper diagnosis of cholecystitis.
It is stated in a New England Joural of Medicine article referred to by Crile that overreliance on these new technologies can lead to missed diagnoses at times. This conclusion is barely warranted, however, in the case of CAT scanning. Of some 300 autopsies performed over 20 years, only 36 CAT scans were performed, and these resulted in only one error. While the impact of this error was great on one patient and his family, it is certainly not fair to indict the entire field of CAT scanning on such meager grounds.
Crile has ignored the many advances in percutaneous needle (a long, skinny needly inserted through the skin) biopsies and abscess drainage, which have resulted in less surgery. Dilating blood vessels narrowed by atherosclerosis (hardening of the arteries) can be achieved without surgery. Even the delicate vessels within the heart may be approached this way. Percutaneously draining obstructed bile ducts (which carry bile from the liver to the intestine) has resulted not in prolonging life but improving the quality of life for those terminally ill with pancreatic cancer.
These advances do not come cheap, but they may be a bargain considering the monetary costs, complications and human suffering that result from the alternative--that is, needless surgery.
Discarding the baby with the bath water is a common syndrome these days. While returning to the ethics and scruples of a past medical age is something all physicians can endorse, I would want to be neither a patient nor a physician prior to the development of the newer imaging techniques, which allow for informed and logical treatment.