The proliferation of imaging tests in number and variety has stimulated an effort to present guidelines directing the best way to work up a particular clinical presentation. This notion has been codified in the elaboration of published appropriateness criteria which seek to offer algorithms purported to reveal the best sequence of tests to reach a diagnosis. Is this approach valid or are these reasons to doubt its credibility or effectiveness?

According to Webster’s New Universal Unabridged Dictionary—Appropriate is defined as suitable or fitting for a particular purpose, person, or occasion. On the surface this is an entirely plausible and simple definition. Yet what constitutes the opposite, i.e., if you do not do what is deemed appropriate, should it be considered to be anti-appropriate or a-appropriate. Are alternatives acceptable or is everything outside the paradigm inappropriate? The American College of Radiology Appropriateness Criteria do not really touch on this question which, in my view, is really crucial to their validity. Can personal preference be accommodated in such a schema without labeling that less than competent or even inimical to patient care? Are extenuating circumstances permissible informants to the formulation of a diagnostic plan? Is no imaging an option depending on the particularities of care? Should such variety be acceptable or will it be so at variance with consensus to thereby put an individual radiologist at risk for a prospective malpractice suit for his/her “deviation” in relation to what is the supposed “right” way. The problem is that appropriateness criteria depend not only on an available roster of tests and the order in which they are performed, but also on many other determinants which makes the uncritical application of the concept often not germane, sometimes mischievous and even ultimately dangerous to one’s reputation [1].

In this part of the discussion, I would like to cite some data which perhaps will render the mist thicker because uncertainty necessarily beclouds even the most sharply defined imaging plan. We must ponder the question; do radiologists really know what is appropriate for the next patient they see, even though there are guidelines that seem to snugly accommodate every patient? Let us consider patients with abdominal pain, an area which I happen to know something about. What has been written to be deemed appropriate or optimal often differs often from what I claim to be a better imaging sequence placing my routine in opposition to a standard paradigm sanctioned by the title of appropriateness.