You can ‘t always get what you want

Tuesday, January 13, 2009

It may be that Al Horford’s knee ailment may summarize the issues facing the American health care system. The economics of being a high salaried NBA player may dictate a high tech approach to diagnosis. The MRI used to confirm the diagnosis of a bone bruise should cause us to pause for a moment and consider when medical tests should be done, how much they cost and what we should expect of them.

Less than a generation ago, physicians would try to hone their skills in history taking and physical examination so that an elegant diagnosis might be made. Often tests weren’t done because they added little to the process or patient outcome. As technology advanced, doctors were able to peer deeper into the body with CT and MRI. The ability now exists to evaluate joint surfaces, the integrity of muscles and tendons and even look into bone and bone marrow. However, just because that ability exists, doesn’t require it to be used in every situation.

Not so long ago, a patient with a hurt knee would be quizzed about the mechanism of the injury and what other symptoms might be present. If there was swelling, did it occur right away like with a cruciate ligament tear, or did the swelling take a few hours to accumulate like occurs in a meniscus or cartilage tear. Is there popping, giving way or pain while walking steps, again symptoms of cartilage tear. Physical exam would try localize a ligament injury. Was it a collateral or cruciate ligament, a combination of two and was there also a cartilage injury?

But the world has changed and patient expectations have moved from high touch to high tech. A diagnosis may not be acceptable to a patient without an MRI image on a computer screen. The question becomes “what value does a test have if it doesn’t change the course of care”. Al Horford’s MRI may have been done because his team had tens of millions of dollars at risk wit ha knee injury. Were they unwilling to trust the physician or was the physician unwilling to stand by the conviction of his physical exam.

Imagine a patient who presents with a headache and whose story and physical exam are consistent with a migraine. Should a CT scan be done because the patient and family want more reassurance that there is no bleeding or tumor? Is a CT scan enough reassuarance. Perhaps tests should escalate to an MRI or a PET scan. Because a test is available does not mean that it is necessary.

Ultimately, the patient and physician are part of the same team with the same goal, the right diagnosis and a treatment plan. Communication is key. If the patient isn’t happy about the direction of care, then a discussion needs to happen. Similarly, if the doc isn’t comfortable in being pressured for more tests, the rationale for opinions and decisions needs to be made clear.

You can’t always get what you want; you get what you need.

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