Who's to Blame for the Overuse of MRI Scans: Doctors or Patients?

Are doctors and empire-building hospital executives abusing some of their authority or are patients exploiting their economic power?

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Gina Kolata reports on the overuse of magnetic resonance imaging (MRI) scans in sports medicine in the New York Times. She reports that one leading Florida orthopedic surgeon, Dr. James Andrews,

scanned the shoulders of 31 perfectly healthy professional baseball pitchers. The pitchers were not injured and had no pain. But the MRI's found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI," Dr. Andrews says.

Some consumer and medical reform advocates might point their fingers at greedy doctors and empire-building hospital executives. But it's not that simple. Some physicians sincerely believe that the scans improve care, and like the rest of us, they may place their subjective experience above rigorously controlled studies. And malpractice claims and defensive medicine may be factors, although I haven't yet located evidence one way or the other about whether doctors who order fewer tests really are sued or are found liable more often. (A recent Time article suggested that exposure of mistakes in confidential peer "morbidity and mortality" [M&M] conferences rather than uncommon lawsuits condition doctors to order more tests, of course thereby exposing patients to other kinds of risks.)

Critics of medicine often fault the supposed godlike authority of physicians. But maybe the problem is the opposite, that lay attitudes and demand -- consumer sovereignty -- often outweigh doctors' own analyses. Scans in sports medicine may be similar to antibiotic prescriptions for viral infections, expectations (especially in pediatrics) that may be easier to meet than to resist and risk losing patients. Only a small number of elite practitioners can lay down the law, like the University of Washington Medical School professor Dr. Sigvard T. Hansen, Jr.:

Dr. Hansen teaches his fellows -- doctors in training -- to be careful with scans and explains the risks of making the wrong diagnosis if they order them unnecessarily. He also knows it is not easy to refrain from ordering an MRI.

It's different for him, Dr. Hansen says. He is so eminent that patients tend not to question him.

"When I say 'You don't need a scan,' then it's over," Dr. Hansen said. His fellows get a different response. Patients, he says, "look at them like, 'You don't know what you're doing.'"

Far from having too much authority, then, the average doctor might not have enough. Yet there is also a bright side to the power of American venturesome medical consumers, a higher standard for comfort and outcomes (including advanced technology) that still brings even people like some Saudi royals to hospitals like the Cleveland Clinic in preference to Europe's finest. And there is a corresponding downside in some otherwise admirable health care systems that affect provider behavior in other ways. England's National Health Service has been a model of efficiency and cost reduction, and avoids American excesses. But even the Labor-friendly Guardian has been exposing the downside of that efficiency, the long waits and poor attitudes that can be consequences of a lack of competition.

(I recently discussed technology and patient safety with Dr. Robert Wachter, director of a leading online M&M program, here.)

Image: AP Images.

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Edward Tenner is a historian of technology and culture, and an affiliate of the Center for Arts and Cultural Policy at Princeton's Woodrow Wilson School. He was a founding advisor of Smithsonian's Lemelson Center.

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