Demystifying Medicine One Month at a Time

Tag: CTs & MRIs

Medical Skepticism, vol. 5

MRI: Irv Fufflik's knee (used with his permission).

Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers’ elbows, shoulders and knees what Andy Warhol was to Campbell’s Soup.

The Times of New York trendspotted the following big medical news: doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it’s the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don’t need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:

  1. The details in an MRI are such that a radiologist almost never interprets a study as “normal.”
  2. The irregularities that make an MRI ‘abnormal’ seldom correlate to physical symptoms (more on this below).
  3. As an example: when a healthy runner goes for a jog, she’ll have evidence of ‘abnormal’ fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.

Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article:

The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc ‘herniations’ and ‘protrusions.’

What do we do with that information? Should we offer the volunteers surgery that they don’t need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don’t demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

Top 5 Unnecessary Health Care Costs

Brand name or generic? $$$ Hmmm

On the WSJ Health blog, there was an informative post about an article from the Archives of Internal Medicine that looked at high physician-caused health care costs.

Here is my response:

_______________

As a general internist concerned about not only the health care of my patients but of our nation, I like to think that I do my part to practice cost-effective medicine.

Jonathan Rockoff’s post about the Archives study listing the “Top 5” unnecessary health care expenditures bears some further analysis.

1. Brand name drugs. I always attempt to prescribe appropriate generic medication. I know it’s equally effective and costs everyone less. The problem is that a) direct-to-consumer marketing makes some patients insist on the brand name, b) some insurance company formularies often offer discounts on more expensive drugs (e.g. Lipitor vs. simvastatin) and c) mea culpa: we often are loath to change something’s that working, especially if a patient takes the medication and is able to get it for a reasonable price.

I will agree that not enough of us give consideration to what our patients can or will pay for medication. Some patients are certainly too shy to question us on this.

2. Bone density scans for women ages 40-64. No reason to order these except in special circumstances, like chronic steroid use or thyroid disease. In our culture of over-medicalization, women are requesting these tests all the time–the bisphosphonate manufacturers (Fosamax, Boniva, etc.) inundate our TV waves with fears about thinning bone, even in normal people. Sadly, it’s easier to placate a patient who wants something (under the guise of building rapport) than it is to spend the time talking them out of an unnecessary test. The stakes are pretty low for a BMD scan–it uses only low level radiation, so the potential harm is small. And in general, we like when our patients are engaged in their health and thinking about prevention.

3 & 4. MRI and CT scans for low back pain. Couldn’t agree more. A complete boondoggle. Try telling that, though, to your patient who can’t function because of their pain. I, for one, would be thrilled to have the Invisible Hand tell me I couldn’t order any more of these. They almost never show anything that’s ‘actionable.’ Even when there’s an abnormality, it’s never clear that what’s found is the source of the pain. People without back pain have abnormalities on lumbar MRIs a third of the time! My only surprise is that the authors calculated a savings of $175 million. I bet it’s closer to a billion on these items.

5. Antibiotics for viral sore throats. Fortunately, we’re making headway in this battle. Parents are learning slowly that antibiotics are not an unalloyed good. There’re side effects (C. diff, anyone?), and an increasing number of resistant bacteria due to our overuse of these medications. Still, like all of the above, when a parent is hell-bent on getting an antibiotic for their kid, if I do the hard work of telling them no, they can often run around the corner to the Minute Clinic and undermine me. And never come back since I’m too difficult.

No one said medicine is easy.

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