Rethinking testing for pulmonary embolism: less is more.

Since Virchow’s first description of pulmonary embolism, experts and clinicians have struggled with the diagnosis and treatment of this common condition. In Virchow’s time, the absence of diagnostic tests made pulmonary embolism a late diagnosis, one suspected just before death and often confirmed on autopsy. Today, pulmonary angiography, ventilation: perfusion nucleotide scanning, and most recently, computed tomographic (CT) pulmonary angiography have dramatically changed this. We now regularly diagnose pulmonary embolisms so different, both clinically and anatomically, from those described by Virchow that we must ask ourselves whether the 2 conditions are clinically distinct. In the modern era, pulmonary embolisms that were routinely missed are now the predominant type diagnosed, and overtesting to detect these events is rampant. Numerous contemporary studies have attempted to reduce testing for pulmonary embolism; however, the medical effect and root causes of this problem have not been widely examined.