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The Perils of Perfunctory Medicine

I recently took my four-year-old son into the dentist for a teeth cleaning, and the first thing that happened, per usual, is that a technician came into the room and said it was time for X-rays. That’s just a given during a trip to the dentist; has been since I was a kid and had to be dragged to the dentist in chains (just hated getting my teethed cleaned, almost as much as I disliked brushing them, or so I’m told).

This time I was a little leery of doing business as usual. It was the fourth time in the past year my son was going to get a full set of X-rays. A while back he managed to shatter a tooth, which had to be yanked out old school with a pair of pliers and a dental hygienist and me sitting on top of him. That triggered a couple extra trips, and a couple more sets of X-rays to check for complications.

Having been professionally exposed to the current debates swirling around radiation exposure, I told the technician I really didn’t want any done this trip unless the dentist felt they were absolutely necessary. The reaction I got was, sadly, what I’ve come to expect when I’ve piped up about a medical procedure: a roll of the eyes, a bit of a sigh, and the gentle reproof.

“Well, he was exposed to more radiation on the car ride over here than he’s going to get from an X-ray,” the technician told me. “We do these for a reason.”

But wait … that’s not really true, and we both must have known it. Or I hope we both knew it. A full series of intraoral radiographs, like any form of X-ray procedure, results in radiation exposure. While it’s a comparatively small dose, it adds up, and a procedure results in a helluva lot more exposure than a five-block car ride. That I gleaned from a quick check of the American Dental Association site and some other reputable sites, plus a tip to make sure a thyroid collar is used for small children, which wasn’t offered.

Being patronized wasn’t what I was hoping for, so I dug in and told her no X-rays. Before we went any further, the dentist walked in. She told him I was refusing to get the X-rays done, I told him why, and his response was “Makes sense, I don’t need them,” and the situation was settled.

But, wow, it’s really not, is it? It’s not news to the medical profession that there’s a lot of troubling data about the dangers of radiation exposure, at a time when the number of imaging studies being conducted has been on the rise (though that seems to be dipping slightly now). And I stumbled on a particularly touchy debate within the broader issue of radiation exposure.

Last month a study was released that found a possible (I'm always taking medical research with a couple grains of salt) link between dental X-rays and non-malignant meningioma brain tumors. Before I went to the dentist’s office, I had come across a New York Times article about industry concerns over the use of cone-beam CT scans, a razzle dazzle technology that renders cool 3-D images but which causes a great deal more exposure. It is increasingly being used by dentists for standard X-ray procedures, many of whom seem enamored by the cool factor and not overly concerned about medical necessity.

The dentist we go to doesn’t use cone-beam machines, but all in all, I felt I had some reason for concern. To have that concern flippantly dismissed instead of allayed by a trained professional made me suspicious. It pretty much encapsulates why the Internet and the medical professions’ response to treatment questions is eroding trust in the industry.

I as a patient have access to as much medical literature as the chief medical officer at an academic medical center. Of course, I can’t understand 97 percent of it, but I can certainly digest bullet points in executive summaries. And that, plus public debates by industry leaders, should give me enough grounds to raise a question, right?

But no matter, because the technician I dealt with and, at least according to the online chatter, other professionals across the land are plowing ahead anyway because, let’s be perfectly honest, doing X-rays and other of-course-you-need them tests and procedures are an easy and perfunctory way to bump up reimbursement, and  something that patients over the years have been programmed to think are medically necessary.

I couldn’t let our dentist off the hook on this one. After I got my own teeth cleaned and set the kids loose on the receptionist, I asked him why one of his employees would automatically insist on doing X-rays, when he himself was more cautious about firing up the machine.  As I expected, he said it was standard procedure that, because of low risks, no one in the office gave much thought to. Fair enough.

But the industry, in the face of accountable care and ubiquitous information access, is going to have to start thinking really hard about even its most perfunctory treatment decisions.  A rolling of the eyes just isn’t going to cut it anymore, because the medical profession itself, via the Internet, Twitter, Facebook, et al., is telling me so. Thanks to those outlets, the health care industry has the opportunity to be its own worst enemy. 



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