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A Case For Earlier Access To Advanced Imaging

There is a prevailing sentiment in the pain medicine community that advanced imaging techniques like MRIs are overutilized. While I tend to agree that given the current set of constraints dictated by the health care system that MRIs are overprescribed, this acknowledgement need not justify the demonization of anatomical/structural considerations that is beginning to pervade pain management as a field. I’ve been very critical of the manner in which painful conditions are reduced in medicine to single anatomical sites. That said, an MRI just provides information and with the right diagnostic and conceptual framework, more information is generally helpful, especially something that visually depicts the site of one’s pain.

Currently, the biggest barrier to MRI access is cost. MRIs are absurdly expensive because unlike any other service-related industry, the service providers in medicine generally don’t compete on price. We’ve equated health care with health insurance so we have this illusion that healthcare is “free”. But it’s not free. Employers get a tax break for providing employees with health insurance. Health care benefits are taxed less than the additional salary employees would be making otherwise. It is possible that the extra salary employees would be making if not for their employer’s health insurance-related tax break would go much further in a medical system where market forces operated more freely. Under the current scheme in the United States, overtreatment (to include ordering an MRI “prematurely”) drives up everyone’s health care costs and insurance premiums because it’s an interdependent system. Not only is healthcare not free but we’re all affected by the choices medical providers make on behalf of other consumers of medical services. Consequently, in a dysfunctional system with no price transparency, MRIs should be ordered very judiciously.

Additionally, even when somebody “needs” an MRI, he/she will rarely receive one during the initial encounter with a medical provider. Billing and administrative incentives are such that multiple appointments are typically required to receive a definitive diagnosis for many conditions. Overspecialization plays a role here too as it is often unclear which provider is ultimately accountable for a particular case. MRIs are too expensive, even if we don’t see the cost. As technology evolves, however, the cost of MRIs will necessarily decrease even if the health care system remains its dysfunctional self. Artificial intelligence will allow for rapid and accurate interpretation that syncs in real time to our smartphones if overly restrictive confidentiality laws don’t interfere too much with self-advocacy. MRI machines will become smaller and more portable. Perhaps a biotech company will even market such machines directly to patients and bypass medical providers. The point is, cost will not be a barrier to advanced imaging forever no matter how much health insurance companies and hospitals seek to maintain the status quo.

Another criticism of MRIs is that the information contained therein is per se harmful. For example, an MRI of somebody with non-specific low back pain reveals that she has moderate bilateral foraminal stenosis, disc protrusion at multiple levels, osseous changes, and no nerve root compression anywhere. Symptomatically, the pain is localized to one side and there is no reported paresthesia or demonstrable motor weakness. In other words, the findings on the MRI don’t seem to explain the clinical presentation, something that happens all the time. As a clinician, however, I’d generally prefer to have access to MRI reports if they weren’t such a burden to obtain. It’s only information. The clinician determines the degree to which the information is meaningful. MRIs are a medical miracle that save lives and prevent unnecessary suffering on the whole. The goal should be to create ways to make them more accessible and less costly so that they can be employed more frequently, not less.

With increased access to information comes responsibility though so for patients in pain, clinicians need to explain the relationship, or lack thereof, that exists between the picture on the MRI and the patient’s symptoms. The increasingly popular narrative that the mere mention of a herniated disc is psychologically traumatizing is such a discredit to patients. The spine is supposed to be robust in spite of things like arthritis and disc herniations, but the mind somehow can’t withstand the utterance of anatomical impurity. MRIs aren’t harmful because some clinicians lack emotional intelligence, social skills, or clinical reasoning. Patients don’t need to be protected from medical terminology. They do deserve to receive competent care and to have somebody confidently articulate the range of treatment options without unnecessary fear-mongering or mindless risk aversion (e.g. “you can’t ever do ‘x’ again”). The problem is not the MRI but the medical providers who tell a 20-year-old patient that he has an “exploded disc” and the spine of an 80-year-old. I wonder if primary care providers are suggesting that patients don’t get blood work because some of their colleagues are too quick to medicate people for high cholesterol.

Clinicians should be advocating for technological and systemic reforms that make it easier to undergo an MRI, not harder. The counterargument here is that most people in pain don’t “need” an MRI because the findings typically don’t change the plan of care. As an ethical matter, however, the net gain of routine advanced imaging outweighs the cost (potential to miss something important). Assuming price is eventually controlled, why not err on a more thorough evaluation? Though an MRI is not a treatment in itself, there is a concern that greater access to imaging will lead to interventionism. The solution here is better training for medical providers, not denying clinicians and patients an incredible diagnostic tool. Teach critical thinking, heuristics, and risk mitigation instead of making people memorize the Krebs Cycle or something they can look up on a smartphone in ten seconds. Seriously, we’re going to deprive the public of something that has the potential for so much good because medical training is antiquated and memorization-based? Imaging isn’t the problem. The problem is us.