Why So Many X Rays?
Proponents of atomic power and weaponry have long been concerned that indications that small doses of X rays may be harmful would reflect badly on the viability of atomic reactors and the safety of bomb testing. Dr. Stewart’s initial study, for example, was the first major epidemiological indication that low-level fallout could be far more dangerous than the currently accepted limits. In fact, even as late as 1979, during the accident at Three Mile Island, nuclear proponents were arguing that exposure levels from the plant were comparable to a single X ray, and thus safe. But Dr. Stewart’s study, and a host of others, had indicated that even a single X ray could have disastrous effects on an infant in utero and other susceptible members of the community. As Dr. Allan Reiskin, professor of radiology at the University of Connecticut, told a congressional subcommittee in the wake of the accident, "these comparisons are inappropriate because they fail to recognize dramatically different distribution of radiation energies, different dose rates, different types of radiation, and different types of population that are irradiated."55
Another reason for an excess of X rays may be that they add to the income of doctors and medical institutions. X-ray equipment is costly and as the state of the art quickly changes, older but still usable models become obsolete. Doctors who invest thousands of dollars in X-ray machines may well be inclined to use them more than absolutely necessary in an attempt to recoup their investment. Perhaps the technology most vulnerable to this kind of financial consideration is the new "computerized axial tomography scanning" machine—the CT scanner. This device was introduced in 1973 and can perform precise examinations of the brain and, more recently, the whole body. It contains an X-ray tube and an electronic detector situated on a circular track. While rotating, the scanner can take thousands of radiographs in a few minutes and create a computer-processed cross-section view of the patient’s body on a video screen. A visual slice can be taken of any body part.56
The CT scanner can be enormously useful—and also enormously expensive, costing up to $1 million to buy and $500,000 per year to maintain. A body scan can cost $250 (CT radiation therapy can run as high as $36,000 per patient) and by the early 1980s more than two million Americans were undergoing CT examinations each year.57 Unfortunately the radiation doses are not inconsiderable, ranging as high as forty-five hundred millirems for some scans.58
The question must inevitably arise as to whether the machines once bought might be overused for financial reasons. That question has also arisen in the field of dental X rays. The average skin dose per dental X-ray film is about 910 millirems, nearly triple the whole body dose from background radiation. Though the dose to the bone is much lower—four millirems—a full mouth series can involve sixteen or more individual X-ray films and can deliver a substantial dose of radiation to the mouth.59 A 1976 telephone survey of five hundred New York dentists by the New York Public Interest Research Group found that 89 percent of them ordinarily included a full set of full-mouth X rays during a patient’s first visit to the office. Nearly half the dentists repeated X rays of the mouth at least once a year.60 According to radiological health specialist James L. Walker, many dentists "feel that the dental x-ray is a tiny, tiny exposure and it’s not really a hazard."61
Unfortunately, many of the technicians administering dental X rays are no better trained than those working in doctors’ offices. And though lead "bibs" have been recently introduced to protect patients in some dentists’ offices, sensitive organs such as the thyroid, salivary glands, active bone marrow, and lymphatics are still being exposed.
Scatter radiation may also affect other parts of the body, including the gonads, a particularly important problem among children.62
Experts at the 1981 National Council on Health Care Technology Conference on Dental Radiology agreed that dentists rely too much on X rays. Conference participants concluded that X rays should be administered only when clinically indicated, i.e., after the patient’s mouth has been visually examined and there appears to be a definite need for more information.63
Another form of exploratory X ray under scrutiny is the use of chest X rays to find cancers and tuberculosis. As early as 1965 the Public Health Service called for an end to routine chest X rays as a means of detecting tuberculosis. PHS argued that tuberculosis was on the decline and that 95 percent of the people with active TB had been identified without X-ray screening. PHS also learned that chest X-ray units—many of which were mobile, moving around in vans—produced higher levels of exposure than other radiological equipment, and that a large segment of the population was receiving unnecessary amounts of radiation with little return. Nonetheless X-raying of children with mobile units continued essentially unabated until 1972, when the PHS again called for an end to the practice, this time in conjunction with the American College of Radiology and the American College of Chest Physicians.64
Chest X rays remain a part of many routine health physicals and screening programs aimed at finding heart and breathing diseases. Serious questions have been raised by the Medical College of Pennsylvania about their effectiveness in promoting early treatment of lung cancer.65 But in 1977 thirty-seven million chest X rays were performed in hospitals across the country. In February of 1978 President Jimmy Carter approved a directive recommending, among other things, that routine X-ray screening of patients who showed no particular symptoms should be discontinued, except in specific circumstances of high disease risk because of social or economic factors.66
In April of 1979 the Joint Commission on Accreditation of Hospitals announced that it no longer required or recommended routine laboratory or X-ray examination upon admission to the hospital. In February of 1981, as part of the Reagan reductions in domestic expenditures, the federal government saved four million dollars and perhaps numerous lives by eliminating its program of routine chest X rays for some 160,000 government employees in thirty-seven agencies.67
But X rays continue to be prescribed and shot all over America in what Irwin Bross has described as a "mindless" fashion.68 Ironically, one of the chief contributors to this ongoing exposure is the American insurance program. Medical malpractice liability varies from state to state. Numerous insurance companies require an X ray before they will reimburse a patient for treatment. The Social Security Act requires an X ray to be submitted as proof of need for chiropractic treatment.69
Perhaps the worst problem resides in the medical malpractice laws. These vary from state to state, but in general they are a strong incentive to doctors to give numerous X rays far in excess of real medical need, in the hopes of establishing a record with which to defend themselves in case of a lawsuit. This "defensive medicine" can be carried to extremes. Dr. John McClenahan, a Pennsylvania radiologist, describes the syndrome thusly: " If a tennis player suffers elbow pain after a truck scratched the fender of his car, a radiologist will be called on to take pictures of not
only the elbow, but of a shoulder . . . a forearm, a neck, chest and, after the diarrhea ensuing as the result of stress imposed by the accident, of the patient’s entire gastro-intestinal tract."70 Though radiologists and doctors may find such treatment excessive, few would risk losing an expensive lawsuit by refusing to use it. A 1973 survey by the Federal Commission on Medical Malpractice found that more than half the doctors polled admitted to engaging in some form of defensive medicine, and four years later an American Medical Association poll found 75 percent of the doctors contacted were ordering extra X rays to protect themselves from lawsuits.71
55. 1979 X-ray Hearings, p. 10.
56. K. Z. Morgan, "The Need for Radiation Protection," Radiologic Technology 44, No. 6 (1973): 385-395; OTA, Policy Implications of the Computerized Tomography (CT) Scanner (Washington, D.C.: Office of Technology Assessment, August 1978), pp. 15-20.
57. Michael Goldstein, "CT Benefits and Cost in Therapy," Journal of the American Medical Association 244, No. 12 (September 19, 1980).
58. OTA, Policy Implications, p. 39.
59. DHEW, Population Exposure to X rays U.S. 1970 (FDA) Publication 73-8047 (Washington, D.C.: Food and Drug Administration, November 1973), Appendix III; ICRP, Protection of the Patient in X-ray Diagnosis, Publication No. 16 (New York: Pergamon Press, 1970).
60. Deborah Van Brunt, Consumer Perspectives.
61. Susan Lockamy, "X-Rays: Many Tidewater Dentists’ Machines Exceed FDA Levels," Virginian-Pilot, August 20, 1979.
62. S. Julian Gibb, "Radiation Risks in Dental Practice," prepared for the Council on Dental Materials, Instruments, and Equipment, American Dental Association, p. 12; Panati and Hudson, Silent Intruder.
63. Washington Star, July 2, 1981; National Council on Health Care Technology, Conference on Dental Radiology, Arlington, Virginia, June 29-July 1, 1981.
64. Valerie Britain, "Mass Chest X Rays Are on the Way Out," FDA Consumer, February 1973.
65. W. Weiss, et al., "The Philadelphia Pulmonary Neoplasm Research Project, Thwarting Factors in Periodic Lung Cancer," American Review of Respiratory Diseases 3, No. 30 (March 1975): 389-397.
66. Federal Register, February 1, 1978, pp. 4377-4380. Recommendation #3 of "Radiation Protection Guidance to Federal Agencies for Diagnostic X Rays": "Routine or screening examinations in which no prior clinical evaluation of the patient is made, should not be performed unless exception has been made for specified groups of people on the basis of a careful consideration of the magnitude and medical benefit of the diagnostic yield, radiation risk, and economic and social factors. Examples of examinations that would not be routinely performed unless such exception is made are: a) chest and lower back x-ray examinations in routine physical examinations or as a routine requirement for employment; b) tuberculosis screening by chest radiography; c) chest x rays for routine hospital admission of patients under age 20 or lateral chest x rays for patients under age 40 unless a clinical indication of chest disease exists; d) chest radiography in routine prenatal care; e) mammography examinations of women under age 50 who neither exhibit symptoms nor have a personal or strong family history of breast cancer."
67. "X’ing Out Unneeded X Rays," FDA Consumer, April 1981, p. 19.
68. I. D. Bross, "An Action Program to Protect the Public Against the Mindless Use of Diagnostic Radiation and Other Technology," June 17, 1977.
69. 1979 X-ray Hearings, p. 162; U.S. Congress, House Interstate and Foreign Commerce Committee, Subcommittee on Oversight and Investigations, Report on Unnecessary Exposure to Radiation from Medical and Dental X-rays, Committee Print 96-52, August 1980, pp. 3-7.
70. John McClenahan, "A Radiologist’s View of the Efficient Use of Diagnostic Radiation," presented at the Seventh Annual National Conference on Radiation Control, Springfield, Massachusetts, April 27-May 2, 1975, p. 72.
71. Medical Economics, September 30, 1974, p. 75; "Fear of Lawsuits Boosts MD Bills," Buffalo Courier, March 29, 1977.