Demystifying Medicine One Month at a Time

Tag: medical tests

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.

C.T. This

How and when do new medical technologies become the ‘standard of care?’

A recent study showed that the use of CT scans in hospital emergency departments rose sixteen percent between 1995 and 2007.

Looks a bit like a medieval torture doughnut.

The only thing that surprises me about this is that it’s not more.

Way more.

I remember the first time I actually ordered a CT scan on a patient all by myself, in 1997. I remember signing the order in the patient’s hospital chart, and feeling with some trepidation that I had just moved from the sidelines of the medical world into the main arena–the one floored and wallpapered with health care dollars.

Back then, quaint as it seems, we used to really deliberate about ordering tests like CT scans. They were deemed expensive and inconvenient, and in the [paradoxically-named] internist’s armamentarium, it was a sort of holy grail of diagnostics–it lets us see your insides. [Quaint, too, in light of all the hoopla about airport body scanners.]

One of the faculty doctors who trained me had the following shtick that has stuck with me:

“Know what the most expensive thing is in health care?” he would mischievously ask.

MRIs?

Open heart surgery?

ICU care for moribund elders?

“The doctor’s pen,” was the answer, whereupon he’d pull out a Mont Blanc fountain pen and flash it around with panache.

The implication of future wealth coupled with fiduciary-medical responsibility was unmistakable.

Somewhere along the way, our collective reticence at using such “big guns” like CT scans and MRIs have fallen by the wayside. As the technologies have become faster, better, and more detailed, they have become altogether more commonplace, such that they are darn near routine.

In the ER with a headache? You’re likely to get a CT scan. Abdominal pain? Belly CT, you betcha! [I don’t mean to pick on the ER. Come to my office and there’s a good likelihood the same fate awaits.]

Partly it’s the legitimate fear of missing something, of being a bad doctor, and of course the fear of a lawsuit. It’s also partly because patients have come to expect imaging tests because they’ve read about them, seen them on television, had their loved ones go through them. Heck, you can even get your own screening CT scan with no doctor’s order necessary. [Please note the preceding link is just for illustrative purposes, and in no way an endorsement. In fact, I think screening CTs are overall a bad idea. So there. Fodder for a future post…]

Well, we’re through the looking glass now. When everybody gets exposed to the amounts of radiation in a CT scan, bad side effects start getting reported. [These horror stories mostly occurred in the setting of improper use and repeated CT scans, mind you.]

I guess my point is, before asking for/being asked to get a CT scan, ask your doctor to really think through the need for the test “like they did in the old days.”

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