Health reform is one thing, but legislators are not physicians

How would you feel if legislators in your state approved a law requiring a specific statement in certain types of radiology reports? What if your state legislators mandated a particular medical imaging procedure for a certain class of patients?

My guess is that many of you would be pretty skeptical. But both of these things happened recently, and as we approach the brave new world of healthcare reform, it’s something you need to pay increasing attention to. As we go through the process of adjusting to this new environment, there will need to be quite a few lines drawn. One of them should be to preserve the physician community as the arbiter of appropriate patient care.

The first requirement was approved last year in Connecticut. Beginning Oct. 1, all mammography reports given to a patient will include information about breast density. When applicable, the report must include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors.”

While it is true that the ACRIN 6666 trial did find there are cancers that can be detected by ultrasound that are not evident on mammography, it’s not a slam dunk that scanning dense-breasted women with ultrasound or MRI will decrease cancer rates. Dr. Daniel Kopans, a professor of radiology at Harvard, argues that the literature on breast density is based on flawed physics (Radiology 2008;246[3]:348-353).

Kopans also contends that breast cancer screening by ultrasound and MRI has not been subjected to randomized controlled trials, so their efficacy for screening is not clear. Given that, the Connecticut breast density law “will lead to unnecessary ultrasound—and possibly MRI—studies that will lead to unnecessary breast biopsies that will lead to increased, unnecessary, trauma to women and cost to society without any proof of benefit,” he said.

The other example comes from Oklahoma this year, and deals with that most contentious of all topics, abortion. Legislators adopted a law requiring that women considering an abortion be given an ultrasound scan. The law requires that a vaginal transducer be used when it provides a clearer image of the fetus, and that the operator describe the fetus in detail, including its dimensions, the presence of cardiac activity, and the presence of external members and internal organs. The law also requires that the screen depicting the ultrasound images be turned toward the woman so she can view them.

The law was vetoed by Gov. Brad Henry, but the veto was promptly overridden. At last report, enforcement was halted pending legal challenges.

In his veto message, Henry said, “State policymakers should never mandate that a citizen be forced to undergo any medical procedure against his or her will, especially when such a procedure could cause physical or mental trauma. To do so amounts to an unconstitutional invasion of privacy.”

No matter how you feel about abortion, you have to wonder how far imaging and its practitioners should be dragged into the debate. And, in both of these instances, there is a larger question about the wisdom of legislators wading into the practice of medicine, as they have clearly done here.

I expect that most patients are more inclined to trust physicians to assure their health than they are an assembly of state legislators. Radiologists and other physicians need to keep this in mind as proposals like those above are introduced.