Do you think it’s normal for your dentist to check your prostate?” I ask the new hygienist. “Because Dr Plaque checks mine every time I come in.” At this point, somewhat alarmed, the hygienist glances at the last entry in my chart, under which, while unattended, I have written, “prostate normal.”
After I explain my little joke to the slightly creeped-out young woman, all my appointments go pretty much the following way. “You haven’t had X-rays for a while so we should do them.”
“Well, Dr Plaque likes to have them done periodically to check on things.”
“Well, then Dr Plaque can pay for them.” I don’t think the dentist likes me.
Imagine, doing a periodic X-ray to check on things. This has always been frowned upon in our profession. However, we are now on the crest of a brave new scanning wave. Patients can pay privately for almost any scan imaginable. Then with the scans and reports in hand they come to us for advice.
The problem is that nobody really knows what to do with the results. Randomized controlled trials that investigate the impact of routine diagnostic imaging on mortality and morbidity are scarce.
So what does one do with an otherwise healthy 50-year-old man who pays privately for a coronary CT that shows calcifications? Do you order a stress test, exercise MIBI, angiogram, or just monitor and encourage risk-factor modification (which is what was prescribed prior to the scan anyways)? How about tiny renal or lung lesions? What about small cerebral ischemic changes? The list goes on.
Private companies are happy to do the scans, but what is the next step? Patients are signing up for virtual colonoscopies, ultrasounds, CTs, PET scans, carotid dopplers, and more in ever-increasing numbers.
Let’s not forget magnetic resonance imaging (MRI). Oh, how I hate those three letters. It doesn’t seem to matter what the patient’s problem is, eventually they always come to the conclusion (based on the expert advice of their lawyer, spouse, parents, physio, massage therapist, barista, or gardener) that they need an MRI just in case something is being missed.
This happens despite my explanation that an MRI won’t aid in the diagnosis of their ingrown toenail or make their obesity-related back pain go away.
I am considering purchasing a big magnet to glide over people while I make a humming noise. I will then give them a stick drawing of the appropriate injured area and bill them for a discount MRI.
Technological advances are often a good thing, but some rational judgment must be applied. There is still an art to practising medicine, an art that can be intriguing, satisfying, and alluring. I’m calling for the use of good old common sense. A good question to ask is, “Is the management of this patient likely to change depending on the outcome of this test?” If not, don’t do it. If your patients remain dissatisfied, send them to my newly opened discount MRI clinic.
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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