Intended for healthcare professionals

Feature Shared Decision Making

Can doctors reduce harmful medical overuse worldwide?

BMJ 2014; 349 doi: (Published 03 July 2014) Cite this as: BMJ 2014;349:g4289

Choosing wisely to make the best use of clinical radiology

Five out of twelve of the “commonly overused interventions” highlighted by the Choosing Wisely campaign [ref 1] involve imaging. Over the last 25 years, 7 editions of the Royal College of Radiologists’ publication iRefer: Making the best use of clinical radiology [ref 2] have been designed to reduce wasteful imaging by asking similar Socratic questions to the Choosing Wisely campaign viz. “Has it been done already? Do I need it? Do I need it now? Is this the best investigation? Have I explained the problem?”

The emphasis has changed from the negative message of doing less to promotion of appropriate imaging, particularly for general practitioners and emergency medicine physicians. Early studies showed improvement in imaging utilisation by a reduction in numbers, typically 20% [refs 3,4]. More recently the RCR National Audit of Appropriate Imaging has shown that CT and MRI investigations conducted at the request of GPs are appropriate in 93-95% of cases [ref 5] largely through the efforts of UK radiologists who vet requests, amending 9-12%. The added benefit in choosing imaging wisely is in the avoidance of further procedures to assess unexpected findings in 2-69% of scans. Few, typically 1-2%, are of any clinical significance [refs 6-10].

The need to include clinical features such as red flags has already been part of the strategy for imaging referral guidance. This will be further strengthened with collaboration between the RCR, the Royal College of General Practitioners and the College of Emergency Medicine for the upcoming 8th edition of RCR guidelines, promoting shared decision making to make the best use of clinical radiology.

1. Hurley R. Can doctors reduce harmful medical overuse worldwide? BMJ 2014;349:g4289
2. Royal College of Radiologists. iRefer: Making the best use of clinical radiology, 7th edition. London: The Royal College of Radiologists, 2012.
3. Oakeshott P, Kerry SM, Williams JE. Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. Br J Gen Pract. 1994 Sep;44(386):427-8.
4. The Royal College of Radiologists Working Party. Influence of Royal College of Radiologists' guidelines on referral from general practice. BMJ. 1993 Jan 9;306(6870):110-1.$=relatedarticles&logdbfrom=pubmed
5. Remedios, Drinkwater K, Warwick R. National Audit of Appropriate Imaging. Clinical Radiology 2014. 10.1016/j.crad.2014.05.109 (in press).
6. Gur RE, Kaltman D. Incidental Findings in Youths Volunteering for Brain MRI Research. AJNR. 2013, doi: 10.3174/ajnr.A3525
7. Cosimo Quattrocchi C, Giona A et al. Extra-spinal incidental findings at lumbar spine MRI in the general population: a large cohort study. Insights into Imaging. June 2013, Volume 4, Issue 3, pp 301-308,
8. HellströmM, Svensson M, Lasson A. Extracolonic and Incidental Findings on CT Colonography (Virtual Colonoscopy). American Journal of Roentgenology. 2004;182: 631-638. 10.2214/ajr.182.3.1820631
9. The Royal College of Radiologists. Management of incidental findings detected during research imaging. London, The Royal College of Radiologists 2011.
10. Morris Z, Whiteley W et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009;339:b3016

Competing interests: No competing interests

08 July 2014
Denis J Remedios
Consultant Radiologist
Giles Maskell, President of the Royal College of Radiologists
Chair of the Royal College of Radiologists' Guidelines Working Party
Department of Radiology, Northwick Park Hospital, Harrow, HA1 3UJ