Do We Overuse MRI?

Did I really need to order that magnetic resonance image (MRI)? I have been wondering that a lot lately. Why exactly did I need it? Could I have treated this patient without the benefit of this technology? Is there a benefit for me to have this technology available?

There is no question that having the technology available is an asset. Is the technology required in most cases though? In today’s age of Obamacare, lower reimbursement and the ballooning cost of healthcare for the consumer, what is our responsibility to start questioning the need for these tests? This is of particular interest when we consider these types of things for medicolegal reasons foremost. What do we do and how do we justify our treatment when the tests are against us?

I can confidently say that we are proficient in identifying pathology in the foot and ankle. That is what we do. If someone has pain that centers around the action and course of the posterior tibial tendon, and it does not respond to conservative measures, what information does the MRI really give us? I would imagine most of us, as I do, send our patients for an MRI to try to justify the need for surgical intervention.

“We need to find out whether there is a tear in your tendon.” Isn’t that what we tell them? Is that really the justification we need?

What if the MRI shows no pathology or (gasp) we see the pathology but the radiologist did not identify the tenosynovitis that is so obvious to us? Are we going to tell our patient that there is nothing wrong with them and their pain is not justified? At that point, do we risk potential litigation by telling the patient he or she needs a surgical repair despite a negative MRI result? Then we go ahead and perform the surgery, identify a tear, repair it and discuss it in our dictation. Then if things go sour, the attorney will point out a negative MRI. Should we take an intraoperative photo of the tear and include it in our records to cover ourselves?

This may seem like an extreme situation but I think most of us deal with this often in our practice. It has almost become automatic for us to order a MRI, despite intuitively knowing that regardless of the actual results (in most, not all cases), the course of treatment is virtually assured.

It all revolves and circles back to the issues in medicine as a whole for me. Medical care is expensive. Why? It is the fear of repercussion. I truly think tort reform could be the first step to “healing” the issues, so to speak. If we were not so afraid (legitimately) of getting sued, how much of what we do everyday would change? How much money could “the system” save if we had little (or less) fear of the looming lawsuit that walks in our door with every patient?

I also wonder how much of our time we could save, potentially giving us more time to actually practice our art rather than spending time on the telephone doing peer-to-peer reviews for our patients virtually everyday.

The other factor of course is that our patients “know” more than they used to know. They spend time on the Internet and ask us, “Shouldn’t you get an MRI now?” We all have patients like this but it also seems like those patients are also the ones who complain about how much of their deductible they are still responsible for paying. Sadly, this is a self-fulfilling prophecy.

All that being said, a MRI does have its place. That should be up to the experts, though — the experts being us of course. It would be nice to have an environment in which we should order a test because there are questions we can’t intuitively answer (in most cases), like how deep that tumor infiltrates into the tissues, not because we feel compelled to order a test to cover ourselves.

Do we really need a MRI to tell us the patient has plantar fasciitis?



Jason Morris, DPMsays: August 17, 2012 at 1:42 pm

In my hands, I use an MRI or any other type of advanced diagnostic imagine for two reasons. First, if it will give me information that may change my treatment plan. Second, if it will give me information to plan surgical treatment, such as identifying the extent of a tear or evaluating adjacent tendons if the plan is for a tendon transfer.

Time and time again, I see physicians ordering an MRI as a primary diagnostic tool and a failure to be more detailed in the physical exam. For example, there is no reason to order an MRI for Achilles tendon pain with an intact tenon on physical exam. The MRI will always show increased signal intensity to the tendon, but it doesn't change the treatment plan. I will still be immobilizing it and getting the patient involved in physical therapy as his or her acute pain subsides regardless of what the MRI shows. Symptoms dictate my treatment plan, not MRI findings.

Same thing goes for an MRI in an acute ankle sprain. It may show a tear or attenuation to the lateral ankle ligaments, but those findings have no impact on the treatment. In the vast majority of cases, an MRI is only warranted in an ankle injury that has continued pain for six weeks after injury.

The one constant I see is that the people ordering too many MRIs are the physicians that do not know how to appropriately treat those injuries.

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Dr. Ron Raducanusays: August 18, 2012 at 6:40 pm

Dr. Morris,

I absolutely agree with you.

Interestingly, for the two examples you've given, I will only order an MRI after conservative management has failed and if there is a question of the extent of the injury. Thanks for the reply!

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