Reducing Low-Value Imaging: Choosing Wisely in General Practice

Low-value imaging is a study that is unlikely to change management, improve outcomes, or answer a question that matters - and Australian general practice generates a substantial share of it, usually with good intentions.

The costs are not only financial. Unnecessary X-rays and CTs add radiation exposure. Scans of asymptomatic-equivalent regions generate incidental findings that trigger cascades of follow-up imaging, specialist referrals and patient anxiety. Reports describing age-normal degenerative change can entrench a patient's belief that their body is damaged, worsening function in conditions such as chronic back pain. And every low-value study occupies an appointment slot another patient needed.

Choosing Wisely Australia, in partnership with the RACGP, RANZCR and other colleges, publishes specific recommendations on tests to avoid. This guide covers the presentations where those recommendations most often collide with patient expectations in general practice - and how to navigate that collision well.

A handful of requests account for much of the low-value imaging that flows out of GP consulting rooms:

• Lumbar spine imaging for acute non-specific low back pain without red flags - the highest-volume example, addressed in detail in our low back pain imaging guide • Knee X-ray in established or clinically evident osteoarthritis where the result will not change management - the diagnosis is clinical, and radiographic severity correlates poorly with symptoms • Neuroimaging for uncomplicated primary headache - tension-type headache or migraine meeting criteria, with a normal neurological examination and no red flags • Repeat ultrasound for previously characterised simple cysts or stable findings without a defined surveillance indication • Follow-up imaging "for reassurance" where the original report recommended none

The common pattern: the test feels responsive to the patient's concern, but no realistic result would alter the plan. That question - "what would I do differently based on the result?" - is the most reliable filter.

Naming the drivers makes them easier to resist:

• Perceived patient expectation - GPs frequently overestimate how strongly patients want a scan; what most patients want is to be taken seriously and to understand what is happening • Time pressure - a referral form is faster than a careful explanation, at least in the moment • Diagnostic anxiety and defensive practice - the fear of the rare missed diagnosis, even when validated red-flag frameworks make the presentation genuinely low risk • The reassurance hypothesis - the intuition that a normal scan will settle a worried patient; evidence consistently shows the reassurance effect is small and short-lived, while incidental findings frequently generate new worry • Habit and departmental momentum - "we always X-ray these"

None of these makes a clinician negligent - they make them human. But the reassurance point deserves emphasis: imaging is a poor anxiolytic, and a structured explanation with safety-netting outperforms it.

The skill is declining the test without appearing to decline the patient. Elements that work:

• Validate before you educate - "That pain is clearly really affecting you, and I want to get this right" comes before any discussion of guidelines • Explain what the scan would show - "At your age, a knee X-ray will almost certainly show some arthritis, and we're treating that already. It wouldn't change what we do next." • Replace, don't just remove - pair the declined test with a concrete alternative: a management plan, a physiotherapy referral, a review date • Safety-net explicitly - "If you develop X, Y or Z, that changes things and I'd want to see you straight away" • Leave the door open - "If this isn't tracking the way we expect by our review, imaging is back on the table"

A declined scan with a plan and a review date is rarely experienced as dismissal. A declined scan with nothing in its place almost always is.

For patients who remain unconvinced, shared decision-making beats repetition. A workable structure for a two-minute conversation:

• Ask what they're worried the scan might find - the answer is often specific ("my father had cancer in his spine") and addressable directly • Lay out benefit and harm in plain terms - the low likelihood of a finding that changes treatment, against radiation where relevant, the strong chance of incidental findings needing further tests, and cost • Use natural frequencies rather than percentages - "of a hundred people with your presentation, the scan changes the plan for very few" • Invite the decision - many patients, hearing it framed this way, choose against the scan themselves; a patient who still strongly prefers imaging after a genuine discussion is making an informed choice, which is a different thing from low-value care by default

Document the discussion either way. Choosing Wisely Australia publishes patient-facing resources and question prompts that support exactly these conversations.

Individual willpower fades under time pressure; systems persist. Practices that sustainably reduce low-value imaging tend to share a few habits:

• Agreed practice positions on the high-volume scenarios - acute low back pain, uncomplicated headache, knee osteoarthritis - so patients hear a consistent message from every GP • Patient information leaflets or waiting-room material that pre-frame the conversation before it happens • A norm of writing the clinical question on every referral - the act of articulating what the scan is for filters out requests that don't have an answer • Peer discussion of audit or feedback data where available • Using review appointments, rather than imaging, as the default response to diagnostic uncertainty in low-risk presentations

None of this is about rationing - indicated imaging should be ordered promptly and without apology. It is about reserving imaging for the questions it can actually answer. Consult current Choosing Wisely Australia and RACGP recommendations for the specific, updated list.