A Game-Changing Statistic: 1 in 250

A Game-Changing Statistic: 1 in 250


Bob Wachter

Although the medical profession has been harming unlucky patients for centuries, the patient safety movement didn’t take flight until 1999, when the Institute of Medicine published its seminal report, To Err is Human. And that report would have ended up as just another doorstop if not for its estimate that 44,000-98,000 Americans each year die from medical mistakes, the equivalent of a jumbo jet crashing each day.

Come to think of it, the quality movement also gelled after the publication of Beth McGlynn’s 2003 NEJM study, which produced its own statistical blockbuster: American medical care comports with evidence-based practice 54% of the time, a number close enough to a coin flip to be unforgettably disturbing.

These two examples demonstrate the unique power of a memorable statistic to catalyze a movement.

Last month, my colleague Rebecca Smith-Bindman, professor of radiology, epidemiology, and ob/gyn at UCSF and one of the nation’s experts in the risks of radiographs, gave Medical Grand Rounds at UCSF. Her talk was brimming with amazing statistics, but this is the one that took my breath away:

A 20-year old woman who gets an abdominal-pelvic CT scan (i.e., just about any young woman coming to the ED with belly pain) has a 1 in 250 chance of getting cancer from that single scan.

Did that fully register? One CAT scan, which until recently most of us ordered with no more restraint than we exhibit when asking the Starbucks barista for a tall latte, will cause cancer in one out of every 250 patients. Two-hundred fifty: that’s the number of students in my college Bio 101 class. Wow.

This is particularly scary given the remarkable increase in the use of this technology. Get this:

  • Three million CT scans were performed in the U.S. in 1980. In 2011, there will be 72 million, an average of 19,500 every day.
  • One in five Americans will receive a CT scan in any given year; some experts suggest that at least one-third of those scans are unnecessary.
  • Between 2000 and 2005, Medicare spending for imaging studies more than doubled, from $6.6 billion to $13.7 billion, twice the rate of growth of physician fees.

And, although none of these examples has quite the impact of the 1-in-250 statistic, there are lots of other scary risk data, such as:

  • The best estimates are that radiation from CT scans causes 29,000 excess cancers each year in the U.S., mostly in women.
  • Researchers estimate that 15,000 people will die from the direct effects of the 72 million CT scans performed in 2007 alone.
  • A 2004 study found that less than 50 percent of radiologists, and 9 percent of ER docs, were aware that CT scans could increase the subsequent risk of cancer.
  • A multiphase abdominal/pelvic CT scan has the same radiation wallop as 500 transcontinental flights, 450 chest radiographs, and 74 mammograms.
  • And those airport body scanners you’ve been so worried about? You’d need to be scanned 200,000 times in order to accumulate the radiation that you get from a single CT scan. I’m a 1K United flyer, but I won’t close in on 200,000 scans for the next couple of centuries.

In her grand rounds, Rebecca walked us through the multiple lines of evidence on the risks of radiation from CT scans, particularly those drawn from studies of Japanese A-bomb survivors and individuals who received radiation for both malignant (i.e., lymphoma) and non-malignant (i.e., acne) disease. All pointed to the conclusion that doses in the range of those delivered by CT scans are fully capable of causing cancer.

Remarkably, with all the attention given to regulating food and drugs, the radiation delivered by CT scanners has gone largely unregulated. (If you ask me, I’d rather receive a precise and predictable dose of radiation than of Vitamin D or Azithromycin.) Rebecca found that CT scanners at four Bay area hospitals delivered radiation doses 66% higher than the usually-quoted doses, and that there were staggering variations (up to 13-fold) among different scanners performing precisely the same test. In her talk, she blamed the lax regulations on radiation physicists, fastidious types who have been reluctant to take a stand on maximum radiation doses since they can’t define those doses precisely.

While I’m sure that’s true, I have to believe that some of the reluctance to blow the whistle can be traced to the usual Medical-Industrial Complex: scanning equipment manufacturers, radiologists, and hospitals who have no particular interest in killing this particular egg-laying goose. If you doubt that these forces are at play, witness the billboards for $1000 total body scans that line Florida’s highways (scans that, when performed in healthy people searching for asymptomatic tumors, undoubtedly cause more cancers than they cure). Even now, despite powerful evidence of the risks, there are some in the radiology community who don’t find the science compelling enough to alter their practice. The parallels to the Global Warming debate are eerie, and troubling.

Even if the risks turn out to be less than we fear, most skeptics now agree that we’re causing a lot of cancers, and that many could be prevented if we took a few sensible steps. Manufacturers, hospitals, and radiology facilities should test the radiation exposure of their scanners, with the goal of decreasing the variation and delivering the minimum dose that creates an acceptable image. Ultrasounds should be substituted for CTs when possible, such as in follow-up of patients with documented kidney stones. There is evidence from Mass General that the use of computerized appropriateness protocols can markedly cut down on the number of CT scans, and thus the cancer risk. And, if we need to obtain the patient’s informed consent before transfusing a unit of blood, we should also do so before ordering a CT scan, since the latter is a far riskier procedure.

But changing culture will be more important, and harder, than changing protocols. We physicians have become so accustomed to saying “Get the scan” that we have turned our brains off. Several months ago, I cared for a woman with a painful lumbar compression fracture of unknown duration. We asked the orthopedic surgery service to see her in consultation, and the resident’s recommendation – made without a hint of self-awareness or irony – was that we obtain both a CT and an MRI. I was dumbfounded. Yes, each test can provide slightly different information, but I don’t believe that both were absolutely necessary; nor did a couple of experts I later spoke with. (We ended up getting the MRI only, which produced all the information we needed.) Somehow, we must find a way to break our reflexive radiographic profligacy.

As we struggle as a nation to “bend the cost curve” and we grapple with the nexus of low yield and expensive medicine (the dreaded “R word”), let us all agree that when we have an issue like this – an overused technology that harms or kills thousands of patients each year – we come together to do the right thing. CT scans can be immensely helpful, even miraculous, at times, but there is no question that the right thing is to Just Say No far more often than we ever have before.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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36 Comments on "A Game-Changing Statistic: 1 in 250"


Thanks for the great article! Technology will take care of what patients need. It is because of the slow economy. When patients needs it most, it cannot offer. Bad!


[…] Wachter, Bob. A Game-Changing Statistic. The Health Care Blog. [Internet]. 2011 February 11 [Accessed 2013 June 10] Available at: http://thehealthcareblog.com/blog/2011/02/11/a-game-changing-statistic-1-in-250/ […]

Feb 16, 2013

My name is MAJ Rob Klingensmith and currently am currently a student at Intermediate Level Education (ILE); Command and General Staff School, Ft. Gordon, GA.

About 8 years ago, I was a fairly new Family Nurse Practitioner. I remember a very nice Radiologist, Ann, who was always willing to discuss films, results, and do a bit of teaching. We had conversation about this particular topic, how much harm is being done by the amount of radiation we expose our patients to when ordering CT films, CXRs, etc. She had mentioned that this topic was beginning to be a big focus in the world of Radiology, and that we are seeing the affect of increased cancers today because of the amount of scans we do.

I never forgot that conversation, and luckily, it was at the beginning of my practice years. I still order CT scans- when I have to. If I’m suspicious of a patient having renal stones, I opt for Ultrasound rather than moving to CT. Or sometimes I will take a gamble and just get a regular flat abdominal series to rule out if there is a stone present or not; although, I’ve had little success over the years of actually seeing stones on flat films because of the lack of sensitivity- usually from overlying obstructive bowel patterns or obesity of the patient- however, taking a chance on one plain film in a non-urgent case I feel is worth it, especially when I can get the film and the results that very same day.

Since I work in Family Practice, the need for stat or asap CT films is rarely indicated, but because of the amount of chief complaints we see for non-specific abdominal pain (along with ruling out renal stones if plain films or US is non-diagnostic), this is probably one of the big reasons we will get CT imaging. But what amazes me, or perhaps concerning, are patients who have a long track history of provider and ER shopping for their undiagnosed abdominal pain (or other problems). Some of these patients have had up to 10 CT studies over the past several years. And now, they sit in your office looking ill for belly pain that is still yet elusive. I think we all have been here, and unfortunately we are still increasingly having to practice defensive medicine; because you do not want to be that one provider who didn’t order the CT scan that would have shown a lower abdominal aorta aneurysm or other urgent problem(and most likely nothing to do with the past several years of abdominal pain).

I certainly don’t know what the answer is, other than trying to be more judicious when having to order imaging studies. And perhaps trying to educate our patients who request (or expect) us to order them CT studies that this is not always the best choice.

MAJ Rob Klingensmith, FNP-BC

Nov 23, 2012

i even have a friend where his cousin died because of doctor’s wrong diagnosis. she gets too many radiation exposure during the time when her body is weak. it leads to cancer…sad, but alot of cases are like this!


If any people die from medical mistake it not intentional.But sometime doctors become so creepy.They don’t provide proper treatment as long as they are not earn enough money from the patient.It can lead a patient to death.I just want to say profession of doctor is not all about business but humanity. They should maintain these humanity to their patient.

Apr 12, 2012

This is an amazing statistic – “44,000-98,000 Americans each year die from medical mistakes, the equivalent of a jumbo jet crashing each day.”

I believe I’ve also read that the pharmaceutical side effects are the #4 cause of death for older adults. Just think of the celebs who have died from prescription drug abuse or overdue or mixing

Apr 10, 2012

This is very informative. Thank you very much.

Feb 11, 2012

i even have a friend where his cousin died because of doctor’s wrong diagnosis. she gets too many radiation exposure during the time when her body is weak. it leads to cancer…sad, but alot of cases are like this!


[…] 1 in 250 […]

Jul 27, 2011

Thanks for the great article. I think that huge proportion of the public are completely uninformed about topics like this which is pretty scary. I guess that when normal everyday people visit their doctor and he/she suggests something like a scan that seems so routine that they just do it without thinking about the consequences…….I think that most people don’t even realize that there are consequences.

May 26, 2011

Technology will keep up with the needs of patients. It is just that in a slow economy the resources are cut just when they are needed the most.

May 20, 2011

As long as lawyers are dictating medical practice, there will always be unneccessary CT scans just because somebody bumped his/her head and went into the ER get into medical school or even enrolled must be made aware of this because too many doctors have accepted the status quo. Thanks for sharing, radiation awareness must be increased.

May 10, 2011

I am glad to know that the airport scanners are not going to make my hair fall out any time soon

Apr 30, 2011

hi ive had 5 ctscan and im only 28 so does this mean im going to get cancer from this

Apr 26, 2011

What are the other options. Sure you have Ultrasound, but is that realistic in this situation. I sure hope technology can keep up with the needs of our patients.