tell me again why you want an mri?

THINKING ABOUT SPRINGING FOR AN MRI?
CONTROL YOUR EXPECTATIONS

MRI Overuse

Julian Jürgens, Universitätsklinikum Magdeburg

“MRI is unnecessarily overused. In a study of 221 patients who had MRIs, the results showed that only 5.9% actually needed to have an MRI done. The remaining 94.1% of the patients sacrificed their time and money. What’s worse is that the use of MRI for screening isn’t as effective as other methods. MRI can be as dangerous as it is useful.”  Cherry-picked from a June, 2011 guest post by an orthopedic surgeon (“The Angry Orthopod”) on Dr. Kevin Pho’s site, KevinMD.com, called MRI Overuse is Widespread, and Dangerous to Patients

“Quick, operate before the patient gets better.”  An inside joke among Orthopedic Surgeons.

If I were really interested in making obscene amounts of money in healthcare, I would base at least part of my business model on fear, with another significant portion coming from misinformation.  With ADVANCED MEDICAL IMAGING, these two are often blended perfectly together, with just enough “science” to provide one of the cornerstones of the money-making machine that has become modern healthcare.

I’ve already shown you (more than once, HERE, HERE, HERE, and HERE) that MRI’s are overused — frequently way overused.  I’ve also shown you how dangerous that CT SCANS are.  Today, I’m going to show you another of the medical field’s dirty little secrets —- that Advanced Medical Imaging is not even a fraction as effective as you have been led to believe it is.  Today, I want to talk about some of the specific areas where MRI’s are frequently a waste of time and money, as well as a marketing tool to get you to agree to medical procedures you would otherwise never undertake.

MRI & CT ARE UNNECESSARY OR OVERUSED
FOR MANY COMMON PROBLEMS

  • LOW BACK PAIN:  This is the crown jewel of imaging overuse — particularly when you understand the concept of “ASYMPTOMATIC DISC HERNIATIONS“.  A two year old study from JAMA Internal Medicine (Overuse of Magnetic Resonance Imaging) provided some interesting data on this subject.We found evidence of substantial overuse of lumbar spine MRI scans. Over half the requests (55.7%) were either inappropriate (28.5%) or of uncertain value (27.2%).  Family physicians had a lower rate of appropriate MRI ordering for the low back than other specialties. Only 33.9% of their MRI scans were considered appropriate vs 58.1% of those ordered by other specialties. Within the subspecialties, MRI scans ordered by neurologists and orthopedic surgeons were appropriate in less than half of cases.  Lumbar Spine MRIs, only 443 of 1000 requests were considered appropriate.”  There are thousands of similar articles / studies published on this topic, which all too often leads to UNNECESSARY SPINAL SURGERIES.

  • KNEE PAIN:   Interestingly enough, I touched on THIS TOPIC just a few months ago.  But just a few days ago, the Psychiatric Times ran an article by Dr. Allen Frances called Knee Surgery? Think Twice!  Some of the quotes cherry-picked from the article include. “Accumulating evidence now proves that much of arthroscopic (keyhole) knee surgery may be unnecessary because the results are no better than placebo.   This is an especially startling finding because this is the second most common surgical procedure in the world (after cataract surgery).  Every year, about 1 million people undergo this procedure in the US alone. And for most, there is likely no benefit compared with doing nothingMy team decided to repeat the study, but with patients who had only a torn meniscus.  Patients with a torn meniscus seemed more likely to respond to surgery because they didn’t have all the nonspecific damage associated with advanced osteoarthritis.   The 146 volunteer patients all received anesthesia and incisions. Half received actual surgery; the other half got the sham procedure, which was just taking a peek inside the knee, but no trimming. The patients didn’t know which procedure they got—real surgery or sham surgery.  Both groups had equivalent results.

 

  • SHOULDER PAIN:   When I think of shoulder pain, I think of THE STORY told by renowned sports surgeon, James Andrews.  Dr. Andrews did an informal study in his office that involved taking thirty big-league pitchers that were seeing him for things other than their pitching shoulder.  After doing MRI’s on their pitching shoulder (none of the individuals had symptoms), he determined that virtually all of them had “serious abnormalities“.  He concluded that if a surgeon is needing an excuse to do surgery, all you need to do is an MRI.  Debra Beachy published an article in the August 19, 2014 issue of Health Imaging that revealed, Knee and shoulder pain are the most frequent regional musculoskeletal disorders after low-back pain.  Skyrocketing use of MRI for knee and shoulder pain often ignores guidelines and adds millions of dollars to medical costs… I could go on, but you get the picture.

 

  • HEADACHES:  Field leader, Dr. Brian C. Callaghan of the University of Michigan, said the following when he addressed 2013’s annual meeting of the American Neurological Association concerning the guidelines published by the American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS) for using advanced imaging on patients with HEADACHES and MIGRAINES in “uncomplicated cases“.  “Neuroimaging is routinely ordered even in common clinical contexts where current guidelines explicitly recommend against its use…   Though the guidelines exist, physician behaviors remain the same.  The trend since the mid-1990s has been that physicians increasingly kept ordering the tests.”  A year later he published a study in JAMA Network (Headaches and Neuroimaging: High Utilization and Costs Despite Guidelines) concluding that, “Given that headache neuroimaging is common, costly, and likely substantially overused, interventions to curb utilization of these tests have the potential to substantially reduce health care expenditures while improving guideline concordance. Therefore, optimizing headache neuroimaging practices should be a major national priority.”  Of the over 50 million doctor visits for various kinds of headaches looked at in this study, approximately one in eight resulted in a scan. 

 

  • GALL BLADDER PROBLEMS:  Gallstones.  To some degree, most of us have them.  The Journal of the American College of Surgeons published a study (Overuse of Computed Tomography in Patients with Complicated Gallstone Disease) in August of 2011 stating that, “When compared to ultrasound, computed tomography scans (CT) are more expensive, have significant radiation exposure, and have lower sensitivity, specificity, positive, and negative predictive values for patients with gallstone disease.”  Despite this, the study showed that CT continues to be used 41% of the time.

 

  • APPENDICITIS:  This one HITS DARN CLOSE TO HOME.   After stating that 90% of all appendicitis cases could be diagnosed clinically (by patients symptoms — a fact verified by my brother who is an ER doctor) a study published in the December 2008 issue of the Journal of Pediatric Surgery (Diagnosing Acute Appendicitis: Are We Overusing Radiologic Investigations?) concluded that, “It appears that there is an increasing trend in using radiologic investigations for the diagnosis of appendicitis for the past 11 years.   With the association of cancer in later life and early radiation exposure well documented, it would be advisable to avoid the use of CT if possible.”  This statement is even more true today considering that a study was published just over a year ago in the American Journal of Roentgenology.  Their conclusions?  The transition to an ultrasound-first pathway for the imaging workup of acute appendicitis in children occurred without evidence of a corresponding increase in the proportion of patients with complicated appendicitis.”  By the way, if you want to see how dangerous CT really is (it causes CANCER), click on the first link in this bullet point.

 

  • ALMOST ANY PROBLEM BASED IN THE FASCIA:  Because FASCIA is not only the most abundant connective tissue in the body, but the most pain-sensitive as well, there is a huge potential for problems — especially when you consider the fact that IT CANNOT BE IMAGED with standard tests such as MRI or CT.   HERE is a post on Scar Tissue (the microscopic kind), and HERE are all my posts on Fascia, not to mention a post on the fact that a growing number of forward thinking researchers and physicians believe that problems in the Fascia cause or at least contribute to, virtually all NON-GENETIC health problems in existence today (HERE).  Many in the following paragraph would be on this list.
The truth is, all you need to do is Google “MRI or CT overuse unnecessary” along with the specific body part in question, and see what comes up.  You’ll find ample evidence that advanced imaging is being overused not only in the bullet points above, but in any number of other problems as well.  Some of the more common are Abdominal Pain, RIB PAIN, PLANTAR FASCIITIS, TENDINOSIS, BURSITIS, DeQUERVAIN’S SYNDROME, SKULL PAIN, FIBROMYALGIA, Cancer (particularly BREAST CANCER), and any number of “MYSTERY PAINS” (otherwise known as MUPS).  It’s also being severely overused in cases of trauma.  So much for EVIDENCE-BASED MEDICINE.  But then again, this isn’t the only place that physicians are not following their profession’s guidelines (HERE are several posts attesting to this fact).

I asked an out-of-state friend of mine who is a Radiological Technician in a large hospital in another state several questions pertaining to this topic.  Her reply to me was as follows (the link in the quote is mine).  “There are several docs that order MRI or CT every time a trauma comes through the door.  Especially if they are unresponsive or semi-responsive (i.e. they are not able to respond about their pain level and location appropriately).  Particular traumas I’m talking about are the MVA patients that arrive on a backboard.  These individuals get what are commonly referred to as the “Super Seven”.  CT’s of the Brain, C-Spine, T-Spine, L-Spine, Chest, Abdomen, and Pelvis.  How often this is done depends entirely on the ER doctor working at that time.  We usually do several per shift.

A CHANGING PARADIGM

CT Overuse

Beurteilung von radiologischen Aufnahmen

Interestingly enough, the model used for diagnosing and treating the body has changed dramatically over the course of the past decade — much of it due to the patient safety issue known as OVERDIAGNOSIS & OVERTREATMENT.  The old model, which, as you can tell from the earlier quotes, is still in use far to much of the time, essentially says, “we have no real idea what’s causing the problem — so we are going to run more imaging tests.”  This might be justifiable in cases of trauma.  It is not, however, justifiable in most chronic cases, which are by far the majority of the cases that doctors see.  Especially GP’s.

One of the things that I can tell you from being in the profession for the better part of thirty years is that anomalies (variations of normal) are common, and frequently seen with all types of imaging.  And we’ve already seen what happens when we simply blame things on “ARTHRITIS“.   “Oooh, oooh — that looks suspicious; it must be the culprit.  That joint has a bone spur or some frayed tissue.  I’ll send you to a specialist who will discuss surgical options with you.”  What we know is that the majority of issues such as back pain, neck pain, headaches, etc, are caused by DYSFUNCTION AS OPPOSED TO PATHOLOGY.   The problem is that imaging is looking for pathology about 99% of the time, while the doctor is COMPLETELY IGNORING abnormal function (click the link for dozens upon dozens of examples). 

If you are having any sort of health issue, the first thing I would suggest you do is gain a better understanding of INFLAMMATION.  Inflammation is a that word that we’ve all heard about a million times, but in reality, few of us have any real idea what it is, what causes / drives it, or more importantly, how to squelch it without drugs.  Even though this is not how medicine is practiced, we’ve reached a tipping point in healthcare where most involved (doctors and patients) realize that more PAIN PILLS, MUSCLE RELAXERS, ANTI-INFLAMMATORIES, and INJECTIONS are not the answer — even though all to often the band plays on while the charade continues.

If you are looking for some things you can do that involve helping yourself instead of letting the medical profession “try” this and “try” that on you before they recommend specialists, who are invariably going to recommend surgery, you might want to read THIS POST.   I completely get it; nothing is 100% effective.  But this approach will, at the very least, benefit you in innumerable ways —- and it’s not going to make you worse —- something that overused of Advanced Imaging has a penchant for (HERE). 

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