A CT in a Village

On October 16, 2010, a small wave of excitement swept through our rural teaching hospital in Sevagram. We were preparing to install a new Computed Tomography (CT) scanner—sleek, expensive, and unmistakably modern. The old machine had served us faithfully for almost a decade, but it was now living on borrowed time. The administration, convinced that good radiology was no longer a luxury but a necessity, approved an investment of nearly ₹1.5 crore for a replacement.

Our radiology consultants and residents were euphoric. They had every reason to be.

A CT scanner can change the way a hospital thinks. It can show you a bleed inside the skull when the patient is still talking. It can pick up a small stroke before the limb has fully weakened. It can reveal a hidden abscess, a cancer, a pulmonary embolus, a ruptured appendix—things that would once have remained guesses until the body declared itself too loudly to ignore. In a place like Sevagram, where patients often arrive late and sick, such clarity can feel like a gift.

And yet, while the machine was being wheeled in, calibrated, and admired, I found myself striking a slightly discordant note. I should have been celebrating, but I was uneasy.

Not because I disliked technology. I had spent years trying to drag our hospital into the digital age. But I had also learned that every new machine arrives with two shadows: the cost it demands and the habits it changes. A CT scanner does not merely add capability. It subtly rearranges the culture of clinical decision-making.

The seduction of technology is that it looks clean and certain. The image feels like truth. Patients believe that a “state-of-the-art” scan is a magic lamp: rub it once, and the body’s secrets will appear. We cannot blame them. A CT image looks too precise to doubt.

The problem is us. We rarely take the time to explain what the scan can—and cannot—do. We do not warn them about what it might discover accidentally. We rarely talk about radiation. And we almost never admit that sometimes, the best test is no test at all.

As the new machine hummed to life, I saw three dangers we were failing to discuss.

The Stethoscope Begins to Lose

My first fear was not about the scanner itself, but about what it would replace.

A CT scanner can become a shortcut for thinking. It can tempt us to skip the slow work of listening, examining, and reasoning. When that happens, the stethoscope does not disappear from our necks—but it quietly stops guiding our minds.

Headache is a perfect example. In primary care, most headaches are tension headaches or migraines. They require a careful history, a patient ear, and a sensible neurological examination—not a scan. Yet, the waiting halls of CT centres are crowded with anxious people who have had a headache for three days and have already convinced themselves they have a tumour.

Evidence has been telling us this for years. In patients with severe headaches but a normal neurological examination, serious brain pathology is rare. Still, in many hospitals, the scan is ordered not because the clinician is convinced, but because the clinician is uncertain—and uncertainty feels unbearable in a world that worships images.

The same logic applies to minor head injuries. A study in the BMJ and many later decision rules have shown that only a small fraction of patients with minor head injury need neurosurgical intervention. Most can be safely managed with observation and clinical judgment. Yet, modern hospitals behave as if every bump on the head deserves a scan.

Protocols are useful, but I began to notice something unsettling: in some settings, protocols were replacing physicians. The scan had become a reflex. The request form was filled faster than the history.

Perhaps the most troubling misuse is in back pain. Patients with aching necks and stiff backs are routinely fed into the donut of the CT machine. But research has shown a strange truth: if you scan the lumbar spines of healthy people with no back pain, a significant proportion will show “disc bulges,” “herniations,” and “degenerative changes.”

The scan finds abnormalities in the way a gossiping neighbour finds scandal—everywhere, in everyone.

Once such an image appears, the temptation to “fix” it becomes strong. Orthopaedic surgeons and neurosurgeons are not villains; they are human beings trained to correct visible problems. But when you operate on a picture rather than a person, you risk doing violence to the very spine you hoped to heal. I remember reading an article in the New England Journal of Medicine that described this bluntly: operating on scans can become an assault on the lumbar spine.

In other words, the CT scan can sometimes turn a healthy back into a lifelong patient.

The Curse of the Incidentaloma

The second danger is quieter, but more insidious.

High-resolution imaging discovers things we were never looking for—findings that are technically “abnormal,” but clinically meaningless. Medicine has invented a name for them: incidentalomas.

A healed infarct in an elderly person’s brain. A tiny benign adrenal nodule. Mild degenerative changes in the spine. A cyst in the kidney. A small scar in the lung. The patient feels fine, but the scan produces a new diagnosis—and with it, new fear.

These findings rarely require treatment. But they almost always require explanation, follow-up, repeat imaging, referrals, and a chain of events that can turn a simple complaint into a long pilgrimage through clinics.

Jerome Groopman, in How Doctors Think, quotes Dr. Terry Light on this dilemma:

“The hateful part of MRIs—I mean they can be a wonderful technology—but they find abnormalities in everybody. More often than not, I am stuck trying to figure out whether the MRI abnormality is responsible for the pain. That is the really hard part.”

That line stayed with me because it captured the daily misery of modern medicine: we are not only diagnosing disease; we are managing anxiety created by information.

The incidentaloma is not just a radiological finding. It is a psychological event.

Radiation: The Hidden Price

The third danger is the one we speak about least, perhaps because it is uncomfortable and inconvenient.

A CT scan is not a photograph. It is radiation.

Rebecca Smith-Bindman, writing in the New England Journal of Medicine, questioned the safety of our growing obsession with imaging. She pointed out that patients receive 100 to 500 times more radiation from a CT scan than from a conventional chest X-ray.

The numbers are sobering, but what is worse is how rarely they are communicated.

A patient with a benign headache or a minor backache—exactly the sort of person who crowds imaging centres—is almost never told that the scan itself carries risk. The industry does not highlight it. The referring doctor does not emphasize it. The patient assumes that “a test cannot harm me.”

But it can.

I often wondered what would happen if CT centres were forced to display a prominent sign at the reception desk:

“Warning: Of every 100 people examined by this scanner, two might eventually develop cancer caused by this machine.”

Would people still line up so easily? Or would they pause, ask questions, and demand that their doctor justify the test?

Perhaps that pause would be good for all of us.

The Economics of Diagnosis

And then there is the elephant in the room—money.

A decent CT scanner costs around ₹1.5 crore to buy, and a large sum every year to maintain. A radiologist friend once did the arithmetic for me. If a centre charges ₹2,000 per scan, it needs to scan ten heads, chests, or abdomens every single day for five years just to recover the cost of the machine.

In a clean, honest practice, those numbers are not easy to achieve.

And when numbers become targets, commerce begins to influence science. New “indications” for scanning appear. Newspaper stories get planted. Continuing medical education lectures sponsored by equipment manufacturers quietly glorify early detection. Referring doctors are offered incentives. Patients are frightened into believing that the scan is the only proof of seriousness.

“Half the patients who receive CT scans in my clinic do not need this test,” my friend confessed to me once. “But I do not refuse. I have to keep the referring doctors and the patients happy.”

He did not say it with pride. He said it with resignation.

Even in teaching hospitals like Sevagram, where evidence should rule, we are not immune to such pressures. Managers, often obsessed with balance sheets, measure the worth of a radiology department not by the number of unnecessary tests avoided, but by the volume of scans performed. The more, the better.

When commerce shapes clinical decisions, the art of medicine dies quietly—without a funeral, without a mourner.

A Modest Hope

So, on the day our new CT scanner arrived, my hope was modest.

I hoped we would use it wisely. I hoped we would inject a little science into our ordering habits. I hoped we would return to the bedside—to the history and the physical examination—before scribbling a request form in haste.

Most of all, I hoped we would learn to explain to our patients something that modern medicine rarely says aloud:

Sometimes, the best test is no test.

It is an image-shattering task for health professionals—to shatter the illusion that the image is everything. But if we cannot do it, we will slowly become technicians of technology rather than physicians of people.

And that would be a price far higher than ₹1.5 crore.

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