Sunday, April 2, 2017

MRI's Are Good, But Are They Good For You?




So, after putting your bike on the rack on the car after today's ride, you accidentally step back off the curb and roll your ankle. This is pain, big time pain, as you reflexively flop around on the pavement in agony. As the intensity slowly dissipates, and your bike buddies encourage you to get up if you can and get out of the traffic, you find that you can hardly walk on it and wonder now what? If this is serious, everything's going to change from your scheduled track work out tomorrow to the trip to Disney World next week (you hope not that one, the kids have been looking forward to this for weeks.)

When you get home, you visit you favorite tri forum, post the injury looking for direction from the knowledgeable, but often anonymous (and not so knowledgeable) audience.  The call for an MRI or two, the foot and the ankle, to "see what's going on in there" is heard more than once.

Some time later, rroof (a noted Sports Podiatrist from Cincinnati - and not anonymous) posts, "uh, well maybe you need an examination and a diagnosis first, perhaps an x-ray if indicated." Of course he's right.


This scenario plays out every day on tri forums, in athlete to coach communications, and simple every day life. Those of us in medicine get pushed every day to "take a look" with an MRI when a more appropriate course, and perhaps a less aggressive course, is correct. (MRI - nuclear magnetic resonance - produces images of the molecules that make up a substance, especially the soft tissues of the human body. Magnetic resonance imaging is used in medicine to diagnose disorders of body structures that do not show up well on x-rays.*) Noted researcher Jennifer Hodges has found that, "If they're not the ones paying for the examination, they'll be much more likely to request that it be performed."

Jack Wennberg of Dartmouth’s Center for the Evaluative Clinical Sciences is often quoted as having said: "…up to one-third of the over $2 trillion that we now spend annually on health care is squandered on unnecessary hospitalizations; unneeded and often redundant tests; unproven treatments; over-priced, cutting edge drugs; devices no better than the less expensive products they replaced; and end-of-life care that brings neither comfort, care, nor cure."

It's also interesting to note that this is not just a patient driven phenomenon. In a recent study in the Orthopedic literature, it was found that with physician owned MRI scanners, there was a higher likelihood that a study would be ordered than if the doctor had no financial interest in the unit. Makes you think doesn't it. And these are my peers.



The take home lesson here is that, with MRI examinations that are sometimes billed at over $3000 each (thus the consideration of an ankle MRI, and foot MRI as suggested above, could be billed in excess of $6,000,) some measure of restraint is needed. "Fiscal restraint on the part of both parties," says Hodges. If there's a diagnostic unknown between the doctor and the patient, ask the question, "Would my treatment be changed/enhanced with an MRI? Would we use the information from the scan, positive or negative, to make a decision in my care?" If the answer's no, or perhaps not right now, maybe another treatment entity is appropriate at this time.  Plus, the time you'd be using in the scanner may be used by someone who's really sick or injured and needs it badly.


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