# Emergency physicians’ perceptions and optimization strategies for diagnostic imaging overuse in Somalia

## TL;DR

Emergency physicians in Somalia often overuse diagnostic imaging due to fear of missing diagnoses and systemic pressures, and they suggest education and guidelines to reduce unnecessary imaging.

## Contribution

This study identifies the drivers of imaging overuse in Somali emergency departments and proposes strategies to optimize imaging practices.

## Key findings

- Over one-third of physicians reported ordering unnecessary imaging tests daily.
- Fear of missed diagnoses and consultant pressure were the main drivers of overuse.
- Physician education, malpractice reform, and evidence-based guidelines are suggested to reduce overuse.

## Abstract

Overuse of diagnostic imaging in emergency medicine poses significant challenges, particularly in emergency care settings, where imaging practices are often influenced by diagnostic uncertainty and systemic factors. This study explored emergency physicians’ perceptions of unnecessary imaging, the key drivers of overuse, and potential strategies to optimize imaging.

A prospective cross-sectional survey was conducted over a one-month period among emergency physicians working in the Emergency Department (ED) of the Mogadishu Somalia–Turkey Recep Tayyip Erdoğan Training and Research Hospital. A total population sampling approach was used; of the 25 physicians in the department, three were excluded after participating in the pilot phase, leaving 22 eligible participants. Data were collected using a structured, self-administered questionnaire consisting of 26 items across four domains: demographics, perceptions of imaging overuse, drivers of overuse, and optimization strategies. Most attitudinal items used Likert-type scales, and the survey included a single open-ended question asking physicians to identify the most important change their ED could implement to reduce unnecessary imaging. Data were analyzed descriptively using the Statistical Package for the Social Sciences (SPSS) version 24.

Twenty-one emergency physicians participated (81% male, 90.5% aged 20–35 years). All participants worked in a single tertiary teaching hospital. Over one-third (38.1%) reported ordering unnecessary tests daily. Main contributing factors included fear of missed diagnoses (66.7%), consultant pressure (57.1%), malpractice concerns (42.9%), and departmental culture (52.4%). Respondents identified physician education, malpractice reform, and shared decision-making as key strategies to mitigate overuse. Approximately half (47.6%) of the participants self-reported consistently using evidence-based decision rules.

Overuse of imaging in Somali EDs is common and is primarily driven by defensive practices and systemic barriers rather than financial incentives. Physicians expressed strong interest in structured guidelines, educational initiatives, and audit-and-feedback systems to promote rational use of imaging.