Re: Have you had any problems with diagnostic test ordering?
Jeff brings our attention to this article which I don't dispute instinctively. I would guess that various specialties (podiatry, orthopedics, general surgery, etc.) probably have good medical basis to proceed with CAT/MRI studies. The only debate I have a times with insurers if I am able to obtain IV contrast with my studies at times. There is the debate to have!! Try explaining to a "nurse" I need to use contrast to rule out recurrent neuroma from scar tissue on a T2 Image....you can hear the crickets in the background....LOL.
I think the reason why primary doctors or general internists tend to overutilize these services are due to many reasons. The main reason is due to litigenous/tort considerations of "failure to diagnose." Other reasons may include referral to physician-owned facilities (in my view, one should advise a patient of such an interest the practitioner may have and provide a list of facilities that the patient may select from....besides yours...LOL). Another reason for this over-referral of CAT/MRIs, is that I feel physicians are so "overworked" that they refer also to defer workload they may have seen in the past few years. There is no time to take that Xray....give a script for the MRI/CAT scan. There are currently approximately 24 medicals schools opening in the United States to meet the demand for physician shortages. Whether these students pick internal/family medicine over plastics/dermatology is a subject for debate another day.
Another main reason is the patient themself. How many of us encounter a patient who may be insistent on an MRI/CAT scan. I am somewhat bemused at this thought currently. I have a 90 year old patient in the hospital with a cellulitis/ulceration over the dorsal aspect of the second toe, right foot which is dorsally subluxed at the MTP joint. She was admitted and treated to the point that 4 days post-admittance her ulceration is nearly completely healed along with complete resolution of her cellulitis. Comparative radiographs reveal no evidence of osteomyelitis. She related pain with her right knee for one month. She wanted an MRI!!!! Radiographs reveal extensive degenerative joint disease without evidence of subluxation/dislocation, fracture or infectious process. Every time I see the patient, she and her daughter continue to ask for an MRI. I have explained the two knee radiograh studies yielded a diagnosis of osteoarthritis. The patient continues with her daughter to insist on an MRI!!!!....FINALLY, I stated to them "and what would you gain from an MRI study?" Are you at 90 y/o with CHF, HTN, resolving cellulitis/ulceration and PVD going to undergo a knee replacement (arthroscopy would fail in this case, in my opinion.) Finally, the light bulb went off!!! I explained that PT with consultation and treatment by a rheumatologist would be more appropriate. These explanations were provided by the orthopedic consultant and the medical physician also!! My point is, that physicians often feel badgered by patients for these tests.
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