If a patient presented to the hospital with a serum calcium level of 19 mg/dL, what would you do next? From presentation to management, you may have little time to evaluate if the patient resembles “stones, bones, groans, and psychiatric overtones.” Rather than refining clinical data acquisition and following a step-wise workup, proceeding immediately to imaging could appear most efficient. Although problem-solving and clinical reasoning are critical skills in the practice of medicine, technology appears to offer reprieve to the busy clinician by promising an expeditious answer, particularly for patients with complex presentations.
A middle-aged woman presented to the hospital at the direction of her physician due to a laboratory finding of hypercalcemia; she had no complaints except mild fatigue. When her metabolic panel, otherwise unremarkable, showed a calcium level of 19.3 mg/dL, no time was made to further the history or examination to generate an accurate problem representation. Instead, a series of computed tomography (CT) scans was ordered, including imaging of the head, thorax, abdomen, and pelvis. The extensive imaging incidentally identified an abnormality in the neck suggestive of a parathyroid tumor; only then was a parathyroid hormone (PTH) level obtained. The PTH level, key to the diagnostic workup of hypercalcemia,1 returned markedly elevated at 1,332 pg/mL (reference: 12-88 pg/mL), pointing to hyperparathyroidism, possibly a parathyroid carcinoma, as the underlying cause of her hypercalcemia. Humoral hypercalcemia of malignancy immediately became unlikely. The patient received medical treatment and subsequently underwent surgery, with the finding of a large complex cystic parathyroid mass that proved benign. While the nonspecific and extensive CT imaging identified the potential cause, it was unnecessary. The decision to order the CT series was not the result of a strong reasoning process or a response to a hierarchy of need. By the time the patient’s PTH level was checked, she had been scanned from head to toe.
A 2019 estimate of waste in the US health care system attributed up to 27.9 billion dollars to the domain of low-value screening, testing, or procedures.2 The inappropriate use and overuse of diagnostic tests has been widely recognized as counter to high-value care. The American Board of Internal Medicine Foundation’s Choosing Wisely (CW) campaign3 and Medicare’s imaging Appropriate Use Criteria (AUC) program4 are two quality-improvement initiatives that overlap on the goal of avoiding unnecessary imaging studies.
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-L. Maria Belalcazar, MD, Roshaneh Ali, BA
