The Epidemic of Investigations

It used to be very easy.Listen to the patient's chest using that marvellous invention the stethoscope: look at the eyes, tongue, fingernails, and feel the pulse.Sniff, then taste the urine delicately with the tip of the tongue and make the diagnosis.Then Roentgen discovered x-rays, there were ECG's and EEG's and a whole host of other possibilities recently made better, or worse depending on one's philosophy, by computers and electronics.The search for the ultimate accuracy in diagnosis and therapy has become so complex that the alternatives are now quite beyond the capacity of the average physician and the cost is becoming too much for the individual or the insurance or health service responsibie.Can this epidemic be brought under control?There is no doubt that it must, because moving from reasonable diagnostic accuracy to near 100% certainty is so expensive that the business creed of cost-effectiveness is of major importance and already clashing with the physician's ethical wish to do the best for each individual, regardless of income.That last 10% of accuracy often accounts for 90% of the cost and does not necessarily bring an equivalent benefit to the patient.Even in the most advanced countries these financial facts of life cannot be ignored, nor are all diagnostic investigations free from risk.This dilemma exists in every medical specialty but to attempt to discuss every aspect would be to fall victim to the very epidemic which must be recognized and treated.However, 'imaging' provides a good model.Already there is reason to use a more comprehensive phrase than 'x-rays', but before complaining of the difficulty in making the correct choice between ultrasound, radiology, CT scanning, radionuclide or magnetic resonance imaging, with all the possible permutations within each, there is need to pause and widen our perspective.About 70% of the people in the world cannot have the benefit of even the most simple x-ray examination.Their doctors face no investigative puzzle: the probable fracture, the chest complaint, the abdominal pain must be treated on the basis of the clinical examination.And it should be added that in