The patient scenario you describe is actually very common. You will actually be seeing a LOT of back pain in the ER, so you (and us all) should be prepared to deal with this.
First, I just want to point out that it is actually reasonable on the part of patients to expect some sort of imaging. Pick random people on the street and ask what they would expect if they were to present to the ER with back pain, and I'll bet a majority of them say "get an x-ray to make sure something isn't broken." In fact, I'll bet that most of us would have said the same thing if we hadn't gone through medical school and residency. So, think of it from the patient's perspective: when you DON'T order any imaging, it is not what they were expecting.
Even so, I don't think you should order a pointless x-ray. I'm just trying to clarify that it is not completely inane that patients expect this.
What you need is an "elegant" way of explaining this to the patient--that is, of "failing" to meet the patient's expectation. I disagree with the speech about "false positives"... It's too confusing for patients, and I've never had success with it. (This is just me, of course--maybe others have found success with it. But, I've never really seen a "satisfied customer" after having that speech.)
The first thing I do is *validate* the patient's concern: I acknowledge the patient's pain and the seriousness of the situation. You will be surprised at how a patient's guard will be lowered once you validate. I generally do this with upset patients in general... For example, I had a patient who was upset that all the previous doctors were "blaming" him for his respiratory infections (due to his smoking), and were discriminating against him because he was a smoker. I immediately fixed the patient-physician encounter by saying, "I can see how it can be frustrating to be discriminated against. I'm sorry you experienced that, etc. etc."
So, validate by acknowledging the patient's pain and the seriousness of the problem. I do this like so: "It seems like you are in a lot of pain. I'm really concerned about that. Back pain can be really debilitating." I've acknowledged the patient's pain and validated his concern.
It's only after this that I say, "This is most likely a muscular spasm, and muscular spasms can be extremely painful." Notice that I AVOIDED saying that "it's *just* a muscle spasm" and I quickly followed it up by saying it is "extremely painful." I also point to where they said their pain was worst (usually paraspinal and muscular), and ask rhetorically: "Your pain was worst here, right? In the muscle?" (Patient nods. What a genius doctor.)
Then, I say: "The problem is that x-rays don't show muscle spasms. They only show bones, not muscles." (I show the patient that I considered x-ray, and then I explain why I'm not ordering it. It's a simple, easy to understand explanation....Not one where you have to take about False Negatives and False Positives, etc.)
Or, if the patient has sciatica: "Based on your description and my clinical exam, it seems that your pain is nerve-related. The problem is that x-rays don't show nerves."
I keep going: "But, if your pain doesn't get better, then I think an MRI might be a good idea. An MRI shows soft tissues, and it doesn't have any radiation either."
Then, I say: "The problem is that I can't order an MRI in the ER.It's an outpatient test." [If it's after hours or a weekend, I also add: "MRI is a big machine, requiring a staff to operate it. Unfortunately, they are at home sleeping right now...unlike us ER doctors." (I'm the good guy.) I'm also trying to explain why their request is unreasonable.] But, I quickly add: "Your primary care doctor, on the other hand, can schedule an MRI appointment for you, so that you don't even have to wait hours to get one." (Most patients don't like to wait... first, I can't wake up staff and bring them to the hospital, and even if I could, would you really want to wait a few hours for that??)
I add what I'll do: "What I'll do is write very explicitly on your discharge instructions that your primary care doctor should consider an MRI if your pain doesn't go away. That way you can hand your discharge instructions to your doctor." (I don't know if this is a jerk move to the PCP, but they punt stuff to us all the time, and I actually *do* think an MRI should be *considered* if pain doesn't resolve in a reasonable amount of time.) More importantly, it is important to put this down from a medico-legal standpoint. That way you're not the guy who said a whopping mass was "just a muscular spasm." Instead, you were the concerned doctor who said, "Even though I think this is likely muscular spasm, if your pain DOESN'T go away, then you should talk to your doctor about getting an MRI, to make sure it's not something worse."
But, I don't want to close by saying I'm not going to do anything. So, I clearly say what *I* will do: "BUT, what I'm going to do is control your pain. I'm going to give you POWERFUL pain killers to BREAK your pain and get you to your primary care doctor." (Even if you prescribe Naproxen, remember: it is a POWERFUL anti-inflammatory pain killer.)
"I'm also going to give you a STRONG muscle relaxant, which should really make you feel better."
"Can I also give you a work note so that you can get a day's rest?" I really want to show that I'm offering multiple things to the patient.
IF even after all of that the patient insisted on an x-ray, I would order it, with the thought that it would rule out big masses. A patient who insists and is angry is more likely to sue if you were to miss a mass. This way, if brought to trial, I can say: "I ordered the test I could order in the ER, and I urged an outpatient MRI as well."
So far, I haven't had any problems with this approach.
My PAs are my employees. It's beyond me why lots of docs out there are willing to supervise PAs without an appropriate bump in their hourly. I figure that's worth $30-50 an hour extra if I'm supervising a PA.
