Blog | Thursday, December 15, 2011

Medical Skepticism, vol. 5


Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers' elbows, shoulders and knees what Andy Warhol was to Campbell's Soup.

The New York Times trendspotted the following big medical news: Doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it's the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don't need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:
1) The details in an MRI are such that a radiologist almost never interprets a study as "normal."
2) The irregularities that make an MRI "abnormal" seldom correlate to physical symptoms (more on this below).
3) As an example: when a healthy runner goes for a jog, she'll have evidence of "abnormal" fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.
Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article: "The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90% of them and abnormal rotator cuff tendons in 87%. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI.," Dr. Andrews says."

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc "herniations" and "protrusions."

What do we do with that information? Should we offer the volunteers surgery that they don't need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don't demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.