Overpowering Images

In the past decade, medical imaging has made great advances, and we can now see many parts of the human body with amazing detail. While there has been an exponential increase in medical imaging, there are few data demonstrating improvements in outcome, and imaging that requires ionizing radiation is known to be harmful. Indeed, the Centers for Medicare and Medicaid Services is so concerned about the increased use of advanced imaging that, starting in 2016, there will be requirements for adherence to appropriate use criteria. The “slippery slope” story of Dr Michael Barry et al1 illustrates one of the unintended harms of graphic imaging: dramatic pictures make clinicians (and patients) more likely to want to “do something” instead of considering a more conservative therapy. Their example is of a sports-related orthopedic injury, but in my own field of cardiology we see this same pattern. An “oculostentotic reflex” is when a cardiologist sees a stenosis on coronary angiography and wants to stent it, even if the patient is asymptomatic and would therefore derive no benefit. Barry et al call for more reports and studies of conservative therapy, which would be helpful. We also need to be more cautious about ordering imaging and then feeling that we must “do something” about the images. Their story is another reminder of the importance of treating the patient and not the laboratory test or the image.