Environment-Conscious Imaging: Clinicians Must Lead the Change

By Farooq Azam Rathore

Affiliations

1. Department of Rehabilitation Medicine, Quetta Institute of Medical Sciences, Quetta, Pakistan

doi: 10.29271/jcpsp.2025.08.1071

Sir,

I read with interest the editorial by Prof. Saba Sohail on environment-conscious imaging for the substantial environmental impact of radiological investigations.¹ As a clinician with experience in managing musculoskeletal and neurological disorders, I frequently orders a variety of imaging studies. I want to contribute a clinical perspective to this important discussion, particularly within the context of low- and middle-income countries (LMICs), such as Pakistan.

The  Changing  Landscape  of  Imaging  in  Pakistan:

Over the past two decades, there has been a significant increase in the availability and utilisation of advanced imaging modalities such as magnetic resonance imaging (MRI) and computer tomo- graphy (CT) scans in Pakistan. There are now over 100 MRI centres across the country, with the majority concentrated in urban areas, such as Karachi, Lahore, and Islamabad.² This proliferation has made these imaging services more accessible, even in remote regions.

However, this increased accessibility has led to an overuse of imaging trend.³ The most common reasons for the overuse were identified as the need of accuracy of diagnosis, the trend of physicians repeating tests in order to confirm diagnoses, the lack of knowledge about proper usage of radiological advances, and the lack of proper clinical examination.³ This is further complicated by the fact that patients, particularly in private setups, can obtain MRI or CT scans without detailed clinical evaluations or referrals. This practice not only burdens the healthcare system but also contributes to unnecessary environmental degradation.³ In addition, it has been observed that clinicians are very quick to order an advanced radiological investigation without a complete physical examination or writing a detailed referral as to why the investigation is being conducted.

Clinical  Implications  of Unwarranted  Imaging:

The example of low back pain (LBP) is suitable to explain this point. Imaging for back pain is now frequently ordered in Pakistan without clear clinical indications. Lemmers et al.’s systematic review suggested that imaging (x-ray, CT, and MRI) provides no health benefits for low back pain (LBP) patients and is not recommended in clinical practice guidelines.⁴ They also suggested that such imaging may be associated with higher medical costs, increased healthcare utilisation, and more absence from work. Evidence indicates that imaging findings, such as disc bulges or degenerative changes, are common in asymptomatic individuals and even in young people,⁵ and often do not correlate with clinical symptoms.⁶ Despite this, young patients with back pain for less than a week's duration are frequently advised to get an MRI done. For x-rays, they do not even need a referral. This is further complicated when the patients themselves demand an early MRI for back pain, or CT scan brain for headaches or abdo- minal ultrasound for minor gastrointestinal issues.

Economic  Considerations:

The economic burden of the overuse of imaging on patients is considerable in an LMIC such as Pakistan. For example, patients often pay between Rs. 15,000 to Rs. 20,000 for MRI scans at private diagnostic centres due to the unavailability of functional MRI machines in public hospitals.^7,8

The Role of Clinicians in Promoting Sustainable Imaging Practices:

Clinicians play a central role in mitigating the overuse of imaging. Radiologists typically perform imaging studies based on referrals; thus, the responsibility lies with the referring clinicians to judiciously evaluate the necessity of each imaging request. Incorporating environmental considerations into clinical decision-making is essential.

Recommendations  for  Sustainable  Imaging  Practices:

To address this issue, the following action points are proposed:

Education and Training: PMDC and CPSP should integrate modules on the environmental impact of medical imaging into medical curricula and continuing professional development programmes, both at undergraduate and particularly postgraduate training programmes in clinical specialities.

Create Clinical Guidelines: Radiologists and clinicians should collaborate to develop and disseminate contextually relevant and evidence-based guidelines that emphasise the importance of clinical evaluation and the judicious use of imaging.

Perform Audit and Provide Feedback: There is a need to implement regular audits of imaging requests in the radiology departments to identify patterns of overuse and provide feedback to clinicians.

Implement Decision Support Tools: Hospitals should utilise electronic health record systems to incorporate decision- making support tools that prompt clinicians to consider the necessity and environmental impact of imaging studies.

By adopting these measures, clinicians can lead the way in promoting environmentally responsible imaging practices without compromising patient care. This is a collaborative and collective responsibility between the radiologists and clinicians that will help address this issue and benefit the patients and healthcare system in the country.

COMPETING   INTEREST:
The  author  declared  no  conflict  of  interest.

AUTHOR’S   CONTRIBUTION:
FAR: Conception, literature search, first draft, and critical revision.
The  author  approved  the  final  version  of  the  manuscript  to  be  published.

REFERENCES

1. Sohail S. Environment-conscious imaging. J Coll Physi-cians Surg Pak 2025; 35(4):401-2. doi: 10.29271/jcpsp. 2025.04.401.
2. List of MRI Centers in Pakistan. Rentech Digital. 2025 Jan 23. Accessed 17^th April 2025. Available from: httpss://ren techdigital.com/smartscraper/business-report-details/ list-of-mri-centers-in-pakistan.
3. Javed H, Imran M, Nazir QU, Fatima I, Humayun A. Increased trend of unnecessary use of radiological diagnostic modalities in Pakistan: Radiologists perspective. Int J Qual Health Care 2019; 31(9):712-6. doi: 10.1093/intqhc/mzy234.
4. Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: A systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J 2019; 28(5):937-50. doi: 10.1007/s00586-019-05918-1.
5. Takatalo J, Karppinen J, Niinimaki J, Taimela S, Nayha S, Jarvelin MR, et al. Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults. Spine (Phila Pa 1976) 2009; 34(16):1716- 21. doi: 10.1097/BRS.0b013e3181ac5fec.
6. Matsumoto M, Okada E, Toyama Y, Fujiwara H, Momo-shima S, Takahata T. Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. Eur Spine J 2013; 22(4):708-13. doi: 10.1007/ s00586-012-2500-z.
7. PIMS, govt hospitals in twin cities doing without MRI machine. Business Recorder. 2022 Sep 27. Accessed 17^th April 2025. Available from: httpss://www.brecorder.com/ news/40199807/pims-govt-hospitals-in-twin-cities-doing-without-mri-machine.         
8. No MRI facility at Rawalpindi’s public hospitals. The Express Tribune. 2023 Nov 14. Available from: httpss://tribune. com.pk/story/2446268/no-mri-facility-at-rawalpindis-public-hospitals Accessed 17th April 2025.