We live in a society that is enamored by technology. That love affair has led us to view technology as always good and beneficial. It may help explain why the patient in this story was so focused on the need to have her MRI. The reality is that the technology is amazing, but that doesn’t automatically translate into always being helpful. The question isn’t whether the picture provides an almost magical view of the body’s structures. The question is whether that picture helps the doctor figure out how to get you better. The outcome can be quicker recovery, higher rates of absolute benefit, or both. This story delves into this simple but confusing issue. Just because these tests are readily available, do they help?
When one gets past the technology fad and into how this is simply another piece of information that can help (or harm) the patient as he/she works with a doctor to arrive at a treatment plan, that’s when things get complex. The story does a great job of making this complexity easier for the reader to understand. Fundamentally, these amazing imaging tests pick up lots of imperfections that none of us are aware of, and that may have nothing to do with the pain in the first place. The key problem is that many of these abnormalities seen in imaging tests that can be a real source of pain can also be seen in individuals who have no symptoms at all. So the question is how can that be and how can one differentiate between imaging findings that cause pain and ones that don’t.
The answer to the first question is that many of these abnormalities are natural processes of aging and that the body has developed ways to cope and perform its basic functions. The answer to the second question, how to figure out what imaging findings matter and which don’t is harder and gets back to the physical examination. The imaging findings must be seen in the larger context of the patient’s symptoms and physical findings. Unfortunately, sometimes one can’t be 100% sure, but in that case the issue is whether the use of this information, however imperfect, leads to better patient outcomes or not. And here, the data is getting pretty clear, sometimes less is the same or even more. Patient outcomes in studies that provided imaging results were no better than outcomes where the patient and physician did not have such information.
But there are down sides to our love of the picture – higher costs are clear. The other one that is often overlooked is psychological. We want the test to show that we’re fine. However, back MRIs in older patients are almost always going to find something like degenerative arthritis. That knowledge doesn’t make us feel better, it makes us feel worse. Its not just a minor ache, it’s "a meniscal tear", it’s "degenerative arthritis." Yes, the picture is great, but no you don’t need it right now. That is a lesson that would lower the cost of care and make us feel better. We need a lot more stories that present complex messages in simple understandable ways. Congratulations!
The story adequately describes what insurers pay for the scans.
The story does not say how many meniscal tears were found on MRI in the current study. The story could have also said that there have been no randomized trials of MRIs for knee pain that quantify the benefits and harms of such a management strategy.
The story mentions unnecessary surgery as the most serious harm of scanning, as well as needless worry and potentially, feeling worse about the diagnosis. The story could have mentioned more common problems with MRI (claustrophobia) and CT scans (radiation exposure), but the real concern is that the imaging test makes the patient and physician more likely to chose an invasive treatment such as surgery.
The story adequately describes the current study. The study brings in relevant scientific evidence to support the contention that imaging studies sometimes do not provide information that changes patient outcomes. As noted in the story, the evidence is more compelling for low back pain than for knee pain. However, it inaccurately claims that this is the first study to look at imaging of the knee. There have been several studies, albeit with smaller sample sizes, that have shown a high prevalence of knee abnormalities in asymptomatic individuals.
The story does not engage in disease mongering. A strength of this story is that it puts common complaints (knee or back pain) and common abnormal findings (meniscal tear for the knee and disk degeneration for the back) into a larger more complete picture. However, the story inaccurately describes the meniscus as "a ligament that stabilizes the knee". In reality, the meniscus is a cartillage-like pad that cushions the knee joint . [Note: the NYT later corrected this error]
The story quotes multiple experts. The story quotes Dr Jarvik but does not describe his speciality or institutional affiliation. [Note: the NYT later added this]
The story did a good job of providing an alternative to routine early imaging tests – specifically, the old fashioned careful history and physical examination. The story could have focused more on the fact that these are increasingly becoming lost medical arts as imaging tests become more ubiquitous.
Clearly MRIs, CT scans and other scans are widely available.
Clearly scanning is not a new idea, but it is being increasingly used earlier in the diagnostic process.
Because the story quotes multiple experts, the reader can assume the story did not rely on a press release as the sole source of information.