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Think Before You Scan

I hope every medical student, graduate medical trainee, and practicing physician had a chance to read this article in the New York Times last week.   Several prominent orthopedic surgeons, including Dr James Andrews, were interviewed for the article and engaged in some sobering truth-telling.

The ultra-short sound-bite: American physicians order too many MRI scans. 


 shoulder MRI


If you are a regular reader of Progress Notes, this is not news to you.  Overutilization of health care resources is a common topic here.  There are myriad examples of over-utilization in our health care system, but magnetic resonance imaging stands out.  The United States has the second most MRI scanners per population in the world, and charges more per MRI scan than any other country.  As a single line item in our national health care costs, MRI scans alone cost billions of dollars per year.  There were approximately 14.4 million MRIs performed in the year 2000 alone!  With your average technical fee/reimbursement of roughly $1000 and average interpretation fee/reimbursement around $150, ideally we would use this sophisticated piece of equipment with more care. 

To get back to the NYT article linked above, Dr Andrews worked through a simple (not rigorous) experiment.  Since he has access to elite professional athletes, he decided to submit 31 professional baseball pitchers to MRI scans of their pitching shoulders.  Mind you, none of them were in any pain, and one could argue that they were operating their joints at extreme stress levels on a daily basis.   The results are telling: 90 percent of those pitchers had “abnormal cartilage” and 87 percent had “abnormal” rotator cuffs, despite continuing to pitch without pain.  Dr Andrews quote is priceless: “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,”

As a primary care physician, I don’t order many joint MRIs.  I do my best to diagnose the etiology of joint pain in my patients with a good thorough history and exam.  Often, I can ameliorate discomfort and help people return to functioning with very simple measures.  And nothing pleases me more to see world renowned orthopedic surgeons doing the same, as they describe in the NYT article and through the advocacy of The Society for Patient Centered Orthopedic Surgery (especially DFA’s own Dr Joel Weddington). 

Physicians need to enter the 21st century in a more mindful way.  We have at our disposal amazing technological advances with ever increasing magnet power and computing power leading to images with previously unimagined resolution.  But this creates new dilemmas: what if there is no such thing as a “normal” joint MRI?  What if there is no such thing as a “normal” spine MRI (I certainly have never seen a spine MRI report that used the word “normal”).   Over-use of any technology leads to over-detection of what is very likely expected wear-and-tear of our joints.  This over-detection leads to innumerable surgeries of questionable benefit – look no further than the example of knee arthroscopy.

We need to be mindful of the factors to lead to this over-utilization: do we feel vulnerable to malpractice litigation if we don’t order the scan?  Are we worried about our patient judging us for withholding access to scans?  Are we not taking enough time to collect a thorough history and perform a physical exam?   I implore you: think before you scan.

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