The journal Health Affairs just surveyed more than 1,500 patients with employer-provided insurance, including dozens in focus groups and one-on-one interviews.
The “pervasive themes” from respondents, according to the authors, were “more is better, newer is better, you get what you pay for, (and) guidelines limit my doctor’s ability to provide me with the care I need and deserve.”
As I have stated over and over on this blog, true health care reform will encompass improving quality, increasing coverage and perhaps most important (to me) control health care costs. These issues are obviously not mutually exclusive. one can not be changed without controlling the others. Many of the physicians I talk to feel that they have no incentive to control costs… they also feel that if they take the time, and make the effort to control costs via education, that they will suffer financially.
As most of you know I am an orthopedist. Nearly everyone of the patients I see in the office will request or even insist upon an MRI, CT or even an X-ray. Most of these tests are simply not necessary…. and may in fact be *harmful*. I order FAR fewer MRIs than many of my colleagues…. Does that mean the care I offer is any less advanced. Absolutely not!! The literature has proven over and over that we do not need to X-ray every ankle injury, or every low back strain— it has also shown that a quality physical examination by a well trained sports medicine doc will frequently lead to a more accurate diagnosis than an MRI will.
MRIs are useful in many circumstances. They are very useful to confirm a clinical suspicion when diagnosis isn’t clear and surgery might be necessary. They are not needed to tell someone they have an ankle sprain, a rotator cuff strain, low back strain, etc. Is there a good chance the MRI will alter your chosen clinical pathway? If the answer is yes, then an MRI is indicated. Should I MRI your knee if you injured it yesterday and the likelihood of spontaneous resolution is high? Nope. What about someone with back pain after working in the garden all day… again, nope. Most injuries are easy to diagnose by a history and physical exam alone—and most injuries follow a benign course to resolution
I need to spend quite a long time explaining to patients why an MRI isn’t necessary in their particular condition. Most will understand and go along with it. Some will not and will probably not be happy until they get their MRI (usually by another provider).
But this brings up an even more important topic. How many unnecessary MRIs are leading to unnecessary procedures? Do you realize that a substantial number of “NORMAL”, assymptomatic individuals have meniscus (cartilage) tears in their knees, disc hernations in their neck and back, rotator cuff tears and labral tears in their shoulders? Now, suppose your mom or dad goes to the doc complaining of knee pain. Many docs will order an MRI. Based on their age they may have a high likelihood of having a tear (but most *degenerative* tears are not bothersome). So the MRI shows a tear and the patient is sent to an orthopedist who suggests surgery based on the MRI interpretation, despite the fact that the patient has only had pain for a few days and despite the fact that they know many patients with degenerative tears will do very well without surgery. Some tears might require surgery, but that decision will based on much more than simply the MRI reading. So, many MRIs are leading to many unnecessary procedures further increasing the cost of care to the health care system. Physicians have an obligation to improve their patients understanding about a new technology and when the technology could be useful and when the technology might actually be harmful. We also have an obligation to utilize tests when clinically indicated and not simply because you do not want to have a 5 minute discussion with a patient. That time is well spent and can go a long way to diminishing the cost of health care delivery and improving a patients understanding of how the technology is useful.
Improving care, containing costs and educating patients is important to all of us… after all…
We are all patients !!!
This post is not meant as medical advice. Whether or not imaging or other modalities are necessary to treat your condition is between you and your physician.