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Saturday, April 11, 2009

Take your stupid X-rays!: A patient's choice of treatment

Dr. George Reskakis' story:
It was the first time I had met Cynthia. She was dressed impeccably in a blue suit with an understated brooch on the collar – a woman who clearly took care of herself. So I was surprised when she complained of bad breath.

She just wanted a teeth cleaning. As part of the standard conversation with new patients, I explained the need for a proper evaluation, including X-rays.

She was unequivocal: "X-rays! No way!"

In 28 years in general practice, I have seen the full range of reactions to the dentist’s chair. Personal experience plays a part. So do the stories of friends and family, and "I'd rather have a root canal" jokes. The Internet can give people enough knowledge to be dangerous. A trip to the dentist gives people the motivation to be insistent, even demanding, regarding care that might not be appropriate.

If I do what they want I risk missing something or making poor treatment decisions. If I do what is right, I risk losing a patient who needs help.

I explained that for a dentist seeing a new patient, a thorough exam and a set of good X-rays are the foundation of good care, and that the current guidelines from the American Dental Association suggest that healthy adults without evidence of tooth decay or additional risk factors should have films taken every couple of years.

She had last had dental X-rays three years earlier. We talked for 15 minutes more about X-rays – the modern, digital system, the minimal amount of radiation she would receive, and its quick and painless nature.

I did not want to lose her as a patient, but I could not give in. I told her I couldn't ignore the possibility of underlying disease. I needed X-rays if I was going to treat her.

"Fine," she said finally. "Take your stupid X-rays."

It wasn't until after we completed her treatment (root canals, gum surgery, two posts and two crowns) that Cynthia confided the reason she had fought so hard against X-rays. Her mother had died from cancer that was caused by radiation treatment as a child.

We talked again about radiation, and the difference between diagnostic radiation doses and therapeutic radiation doses. In the early 1950s, I told her, the doses were hundreds of thousands of times what is used today; there was not enough evidence yet of radiation’s harmfulness.

Cynthia came around to the idea that X-rays are a safe and useful medical tool.

Advice to people thinking of having diagnostic tests: Find a doctor who will listen to your concerns and take the time to discuss them with you.

Read a story about a dentist's patient-mindedness.

Thanks to Dr. George Reskakis for his article in the NY Times of November 18, 2008.

1 comment:

Anonymous said...

To make informed choices, a patient still needs to know that there is no low dose threshold for which x-rays are safe. A single ionizing tract of radiation can cause a cancer. The odds may be small, but they are not zero.