Defensive medicine... More tests less suits

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Stim4me

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the wild card is always the Jury. i was fortunate to practice with most of my patients bound to binding arbitration agreements, so if my documentation was good i think i was usually safe. but without binding arbitration the more tests the better. look at it this way - no one has ever been sued for ordering an unnecessary CT scan, even though those CT scans probably eventually kill, maim and make miserable until they die a whole lot of people. and yet a whole lot of people have been sued for not ordering one. //All of that exposure poses serious health threats. Researchers estimate that at least 2 percent of all future cancers in the U.S.—approximately 29,000 cases and 15,000 deaths per year—will stem from CT scans alone. Even some standard X-rays, which expose you to much smaller amounts of radiation, can pose risks if you undergo multiple ones.//http://www.consumerreports.org/cro/...ising-dangers-of-ct-sans-and-x-rays/index.htm
 
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https://www.statnews.com/2015/11/04/doctors-tests-mean-fewer-lawsuits/

I admit I order a lot of tests... No lawsuits after ten years of practice. What does it all mean in the big picture??
It means you have been lucky.

In lawsuits, it IS better to be lucky than "good".

Since you realize you order too many tests... Far be it from me though to suggest you that you need to change your practice patterns. You do what you feel is appropriate for you and your patients.


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It means you have been lucky.

In lawsuits, it IS better to be lucky than "good".

Since you realize you order too many tests... Far be it from me though to suggest you that you need to change your practice patterns. You do what you feel is appropriate for you and your patients.


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Lumbar MRI q 2-3 years for recurrent radics? Or just inject after 2 years with similar radic pattern? Assume no redflags or neurological changes. Daily dilemma...
Today, 70yo lady returns 2.5 years later with same clinical syndrome. No red flags. In an idea medical legal society( i.e. Tribunals) just inject/PT and follow clinically. In the USA today , I get imagining then proceed... Also don't forget the US for incidental renal and pelvic/ovarian cysts. Hence the financial state we are dealing with...
 
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i also always ask what interval change in signs or symptoms, to justify getting another MRI, but i usually come down on not ordering, unless the patient insists.
in those cases and the new evals, many of them literally beg for "a new one". i tell them i will order one after having them engage in PT/home exercise or cognitive therapies or yoga...
 
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At beginning of year order the MRI so deductible is imaging centers problem and they get to chase the patient for $$....
 
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At beginning of year order the MRI so deductible is imaging centers problem and they get to chase the patient for $$....
That's a good point. We typically hold our billing claims for several months so other providers have to deal with the out of pocket headaches...
 
I was wondering if you guys ever do an epidural or any spinal intervention without an MRI? Currently in fellowship, we have been dissuaded to get an MRI unless any red flags arise, but I'm getting the sense this is not the case out in private practice. Forgive my ignorance, but in terms of changing your eventual management of the patient, what new information are you looking for with a new MRI?
 
I was wondering if you guys ever do an epidural or any spinal intervention without an MRI? Currently in fellowship, we have been dissuaded to get an MRI unless any red flags arise, but I'm getting the sense this is not the case out in private practice. Forgive my ignorance, but in terms of changing your eventual management of the patient, what new information are you looking for with a new MRI?
In addition to lowering your lawsuit risk, getting an updated MRI prior to injections saves you patient headaches. If you obtain a lumbar MRI post procedure and there is an infection, new Hnp, mets, your up ****s creek... If you are a new practicing physician i would be extra vigilant the first 5 years of practice...
 
not having any MRI is a huge risk. i am not sure that there is any data that supports that an updated MRI would lower your lawsuit risk. the logical extreme would be to require an MRI before each and every injection...
 
not having any MRI is a huge risk. i am not sure that there is any data that supports that an updated MRI would lower your lawsuit risk. the logical extreme would be to require an MRI before each and every injection...
Some data above referring to overall testing reducing legal risk in general, not clinical outcomes. Personally, an updated MRI has saved me from potential headaches, esp with active or remission cancer patients with stealth spinal cord mets... My biggest misstep was not getting an updated MRI on a prior Brest cancer patient with spinal mets. Her cancer was in "remission" and her MRI a year prior was clear of epidural mets... Rare case though.
 
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Some data above referring to overall testing reducing legal risk in general, not clinical outcomes. Personally, an updated MRI has saved me from potential headaches, esp with active or remission cancer patients with stealth spinal cord mets... My biggest misstep was not getting an updated MRI on a prior Brest cancer patient with spinal mets. Her cancer was in "remission" and her MRI a year prior was clear of epidural mets... Rare case though.

i catch 1-2 cases of undiagnosed malignancies/year. but i do order a lot of MRIs. breast CA, prostate CA, and especially endometrial and renal cancer before metastasis. definitely have saved lives.

i'd argue that getting the MRI actually improves outcomes. cohen would disagree, but there is no doubt in my mind that a focal L4 TFESI will provide better relief than a generic ILESI when you dont know exactly where the pathology is. very difficult to prove b/c there are too many variables, but MRIs are invaluable.
 
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i catch 1-2 cases of undiagnosed malignancies/year. but i do order a lot of MRIs. breast CA, prostate CA, and especially endometrial and renal cancer before metastasis. definitely have saved lives.

i'd argue that getting the MRI actually improves outcomes. cohen would disagree, but there is no doubt in my mind that a focal L4 TFESI will provide better relief than a generic ILESI when you dont know exactly where the pathology is. very difficult to prove b/c there are too many variables, but MRIs are invaluable.
Maybe not if you use Dex...
 
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32 yo female (with infant) presented with axial neck pain for one year. Seen many docs and failed cons measures. No neurological issues. No Red flags except duration of pain. I ordered a cervical MRI and revealed a large c4-6 syrinx. F/u contrast MRI c/w nodular enhancing lesion within syrinx, likely eppendymoma V's astrocytoma V's other malignancy. Pending neurosurgical eval. Patient distraught... Sad day. Get the MRI.
 
32 yo female (with infant) presented with axial neck pain for one year. Seen many docs and failed cons measures. No neurological issues. No Red flags except duration of pain. I ordered a cervical MRI and revealed a large c4-6 syrinx. F/u contrast MRI c/w nodular enhancing lesion within syrinx, likely eppendymoma V's astrocytoma V's other malignancy. Pending neurosurgical eval. Patient distraught... Sad day. Get the MRI.

I would offer Ativan for the situation as time limited dosing. I MRI as much as you do. I hope.
 
I would offer Ativan for the situation as time limited dosing. I MRI as much as you do. I hope.
That's a good point... I'll offer that. I just need her to see Ns asap, not sure what they will do with such a cored-out cervical spine. Literally few millimeters of cord surrounding the syrinx and nodular mass. I gave her restrictions as well.
 
That's a good point... I'll offer that. I just need her to see Ns asap, not sure what they will do with such a cored-out cervical spine. Literally few millimeters of cord surrounding the syrinx and nodular mass. I gave her restrictions as well.

i bet its benign.
 
im curious - are you using this case as a justification for ordering updated MRI scans?

this is clearly a great example of why we should be ordering MRI scans in the first place, when PCPs and other doctors do not want to do so.
 
im curious - are you using this case as a justification for ordering updated MRI scans?

this is clearly a great example of why we should be ordering MRI scans in the first place, when PCPs and other doctors do not want to do so.
Just a case indicating an initial MRI for axial neck symptoms, with no neurological issues, or red flags except chronic pain (i.e. > 6 months). Most physicians would have orders and X-ray and called it a day.
Updated mris are probably over kill like you have indicated, but still may be legally protective and can save headaches if you miss subsequent pathology.
 
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Until we have tort reform for the entire country, I'll be getting MRIs before all procedures, and before writing opioids.
I think this is the sentiment of most proceduralists. And at $800 an MRI, the costs go up significantly...
 
Long term patient. 55 y/o female with grade 1 slip, L4-5, home maker. Oxycontin 20mg bid, Percocet 7.5 bid prn. No increase, no problems in 5 years of care. Seen q3mo. 1 week ago calls crying, pain severe. Order MRI L-spine, neg except synovitis in L4-5 facet at level of spondy. Was washing car day before. Pain no better with doubling Percocet. I say get ESR/CRP/CBC. 3 ER visits in 4 days. Nothing. ESR = 85, CRP = 14 (0-0.5). See her this AM. Pain higher in back than told on phone. Get MRI T-spine. funny on STIR, but no Fx. Add contrast as MRI in office. Osteomyelitis T10-11. Admit to IMS.

MRI saved her life.
 
Long term patient. 55 y/o female with grade 1 slip, L4-5, home maker. Oxycontin 20mg bid, Percocet 7.5 bid prn. No increase, no problems in 5 years of care. Seen q3mo. 1 week ago calls crying, pain severe. Order MRI L-spine, neg except synovitis in L4-5 facet at level of spondy. Was washing car day before. Pain no better with doubling Percocet. I say get ESR/CRP/CBC. 3 ER visits in 4 days. Nothing. ESR = 85, CRP = 14 (0-0.5). See her this AM. Pain higher in back than told on phone. Get MRI T-spine. funny on STIR, but no Fx. Add contrast as MRI in office. Osteomyelitis T10-11. Admit to IMS.

MRI saved her life.

I don't think anyone is questioning a repeat MRI in the above situation. (Different severe pain in a stable patient)

The question is whether a stable pt with no change in symptoms with previous MRI that explains pain needs a repeat MRI every 2-3 yrs prior to injection.

On a side note what are the risk factors for your pt to develop Osteomyelitis?
 
I don't think anyone is questioning a repeat MRI in the above situation. (Different severe pain in a stable patient)

The question is whether a stable pt with no change in symptoms with previous MRI that explains pain needs a repeat MRI every 2-3 yrs prior to injection.

On a side note what are the risk factors for your pt to develop Osteomyelitis?

Kidney stones/possible mild UTI, massive hematuria one month earlier. OR, lip biopsy excision 3 weeks earlier. OR, maybe cut herself on washing car?

No IVDA, No DM, No RA.
 
I think this is the sentiment of most proceduralists. And at $800 an MRI, the costs go up significantly...

It's true, but a modest cost compared to 10 million dollar healthcare CEO salaries and new drugs that cost 10,000 a dose.

I don't feel guilty at all ordering MRIs before all procedures, before writing opioids. And if their symptoms are bad enough to require ongoing specialty care then I update MRI every 2 years.
 
this example is a good case as to why we should order MRI scans.


im not sure it supports whether we should do repeat studies... (thoracic lesions frequently arent visible on lumbar MRIs)


what have you "discovered" with these repeat MRI scans every 2 years, bedrock? what good "catches" can you share?
 
what have you "discovered" with these repeat MRI scans every 2 years, bedrock? what good "catches" can you share?
To be honest, a third of the time of the time it doesn't change what I do, a third of the time it does, and I've helped a pt more as a result, and a third of the time it simply reassures the patient that you are concerned and doing all you can for them.

Additionally since I've been working here in the peoples republic of California, I have come across several insurance companies that won't preauth interventional procedures without an MRI/CT in the preceding two years.
 
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