KevinMD Nails It...

[drusso]

http://www.kevinmd.com/blog/2015/04/after-a-verdict-doctors-need-to-be-taught-a-lesson-really.html

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[jonnylingo]

http://www.kevinmd.com/blog/2015/04/after-a-verdict-doctors-need-to-be-taught-a-lesson-really.html

I'm a stickler with MRI ordering. Moreso than my patient like.

But this article brings the debate to light: What are our incentives to order MRI too early vs. timely.

Incentives to order MRI too early:
Patient is happy
Press Gainey goes up
I look smart when I can point to the disc bulge (which is likely NOT causing pain)
I get to bill level 4+
Catch that rare 1:100000 zebra early

Incentive to order MRI when indicated:
Take pride in my work, do the "right" thing
Cost the "system" less
Don't stigmatize patient with "degenerative spine" (aka normal aging spine)


The high road my feel good, but patients may think you're stupid, and may sue. That's the way I see it. Still I'm inclined to stick to my guns, but I'm sticking my neck out there. Is it worth it?

Getting weary of endless patient education regarding MRI/opiates not indicated. Sometimes just want to say "screw it... I'll order MRI, and here's your vicosomaxanax"

 

[hyperalgesia]

I'm so tired of treating "the healthcare system". I just want to treat my patients.

 

[Aether2000]

While Kevin may be theoretically correct, the litigious group of bastards we have to deal with every day care little about Kevin's proper medical protocol. They demand perfection, without any deviation from the usual course of the most expensive tests on first presentation, regardless of what the guidelines say. With the legal system out of control, guidelines and standards of care are useless. Why bother following a standard or well devised guideline when the court system so flippantly disregards such standards and guidelines in order to "award" those that have complications due to their diseases or treatment of disease. We definitely need a different system. I prefer the Canadian med mal system where there is no jury composed of ignorant uneducated misfits that happen to be free that day, but instead a judge honed in jurisprudence orchestrates a no bs trial that takes hours instead of weeks, and with payment of attorney fees by the losing side. This system cuts the number of malpractice suits by 90%.

 

[emd123]

I order imaging early liberally and without remorse. There's no way I will fix the healthcare cost inflation crisis by waiting to order my patients MRIs and X-rays.

Malpractice plaintiffs attorneys will go for your throat if there's a bad outcome and absolutely no jury on planet Earth will accept, "I was trying to save money. Sorry John Doe ended up a quadriplegic from the cervical mass that compressed his spinal cord. After all they are real rare. I know that doesn't help your client, but I hear medical costs only went up 14.9% this year, instead of 15% the year before. Ain't that swell Beaver?"

So....no, no, no. These Choosing Wisely campaigns are nothing more than a dual Trojan horse for malpractice attorneys to get you to cut corners, make errors and feed their industry and the politicians who are trying to accomplish cost containment controls to further their careers.

http://www.choosingwisely.org/doctor-patient-lists/

I've already been falsely accused of malpractice by this toxic and litigious system, had to battle and win. So no. I'm not stupid. My patients all get imaging. If it hurts, I have a picture of it in the chart. If the patient refuses or the insurance refused it, fine. Then that's their circus, their monkey.

 

[deleted682700]

Totally agree with you guys on this, i will do what the patients want, not what the insurance company wants or the CEO wants. This is just getting ridiculous with all these new guidelines. They will retract these as soon as another trial by another drug manufacturer or device manufacturer comes along.

 

[geauxg8rs]

I didn't take an oath to help out blue cross or Medicare

 

[Jitter Bug]

I can usually get around this problem by telling patients when I would be willing to order an MRI.

"Let's just start with physical therapy for now. But if you aren't feeling any better at our 4-6 week recheck, then we can dig a little deeper, and get an MRI, which may help us consider other treatments such as injections that may be helpful."

That works most of the time.

 

[jonnylingo]

Totally agree with you guys on this, i will do what the patients want, not what the insurance company wants or the CEO wants. This is just getting ridiculous with all these new guidelines. They will retract these as soon as another trial by another drug manufacturer or device manufacturer comes along.

The best medicine is NOT what the patient wants.

That's my point. Patients want an MRI for acute LBP, with no red flags. I tell them it's not indicated at this point. They get pissed or worried, or as in the Kevinmd blog case, sued.

By delaying imaging, I'm definitely not thinking of saving Medicare or any filthy insurer a dime. But I am reluctant to kowtow to patients and carpetbomb with xrays/CT and/or MRI if not indicated.

 

[hyperalgesia]

I tell pts when I think it's a waste of time and when it will not change our management. I tell them the chance they get into a car accident on the way to the MRI is greater than the chance an MRI will help them. Also, it is inconvenient and uncomfortable. 90% of my pts accept this. The other 10% get the MRI or they get refused by the payer.

I happily use payer denials to rail against the whole system and will always stand with the pt and never the payer, assuming the request won't medically harm the pt. I don't care if the pt's request is incongruous with a National Healthcare System or MIPS or PQRS or any other census-based metric. Central Planning is the enemy of patient care.

The truth is I would like to see everyone get a full body MRI every year, incidentalomas notwithstanding. But my job is not to screen pts for cancer, I just focus on the presenting problem.

 

[lobelsteve]

I want an mri on everybody. I tell them when it is necessary. I tell them it can be associated with worse recovery just by knowing. I order an mri if they have not had it done recently (if no symptom change in 2 years). If they need it i stress the imoortance. If it is optional they decide if it is worth their copay or cost. No physical risk. I do not own the magnet.

 

[Ducttape]

no obvious physical risk, you mean. the greater risk is that something will be discovered that will be reported and the patient will suffer undue complications due to treatment for something that is clinically insignificant. this is not a theoretical matter, and i have had cases of patients with these incidentalomas who underwent significant surgical intervention for non-malignant conditions. that being said, most people do get testing, but...

i dont order testing on everyone initially. It is infinitely easier to tell patients that insurance requires certain treatments to be performed in order for them to authorize the study. so after you have 6 weeks of PT, 6 weeks of NSAID/muscle relaxants (if appropriate), 6 weeks of conservative self-care, and no obvious red flags, we will see you in follow up and order an MRI. going to 1 session of PT and stating you cant do more is not going through 6 weeks of PT. rarely, someone does get better...

 

[drusso]

Guidelines for the appropriate use of advanced imaging rarely apply to common scenarios seen in specialty care. Order the test. Think like a specialist.