Clinical judgment and when neurologists should order an MRI

With healthcare reform dominating the news recently, MRI and other imaging tests have become the (misguided) targets of many critics.

Although MRI makes up only one-half of one percent of total healthcare expenditures, it is easy to demonize since the average healthcare consumer can understand imaging much easier than the diagnosis related groups (DRGs), hospital facility fees or insurance contracts that have a much greater impact on the cost of health care.

It is unfortunately true that some physicians order unnecessary imaging tests to avoid lawsuits, but I felt it would be important to share the proper decision making criteria our clinicians utilize when making decisions about ordering these tests.

Many guidelines are publicly available as “appropriateness criteria,” from organizations such as the American College of Radiology and Medicare. The most important thing for patients to understand is that MRI is an incredibly powerful tool for the clinician to detect and evaluate symptoms and their causes.

Imaging decisions should come after, and as a result of, the clinical examination

Nothing can substitute for the clinical judgment of an experienced physician who understands the significance of treating the patient at the highest level of competency and is evaluating with eyes, ears and hands the patient in front of them.

While the guidelines are meant to be used on a case-by-case basis by qualified, healthcare professionals as a tool in making medical necessity decisions, they must always be used in the context of clinical judgment. Patients wondering whether an imaging test is necessary should ask their physician about their experience with MRI, and whether they are qualified to read the results themselves or must rely on a report by a non-specialist, general radiologist.

All MRI studies are not created equal

Because an MRI machine is only a tool, the quality of a patient’s results are extremely dependent on how the tool is used. Once a decision to image the patient has been made based on the outcome of a history and physical examination of the patient, our clinicians rely on four important elements to order and perform the most useful neuroimaging possible.

1. The careful selection of the particular MRI or MRA protocol and sequences needed to evaluate the patient’s symptoms.

2. The use of highly trained and experienced certified technicians. Even the best equipment does not insure that the image quality will be achieved without the experience of qualified technicians.

3. The use of an accredited (ACR or ICAMRL) neuroimaging center. This assures that the equipment and procedures used meet a high level of competency and that procedures are in place to constantly evaluate and improve quality.

4. Fellowship trained or board certified neuroradiologist interpreting the images. A general radiologist who is minimally trained in MRI and in particular central nervous system MRI will not give us the quality we expect or patients deserve.

In the end, the treating physician must be able to trust the results from each test and must correlate all test results with the patient being examined, in order to design an optimal treatment plan for each patient. Delayed evaluation for any reason squanders the most valuable assets in patients’ lives, namely, their time and their health. The subsequent effects on their lives and the lives of the organizations they serve, is incalculable.

Vernon Rowe is a neurologist and the founder of MidAmerica Neuroscience Institute who blogs at NeuroNews.

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