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Imaging, Ethics, and Institutionalized Prejudice

It’s been a long time since another healthcare provider said anything disparaging about me. I know it happens, but I haven’t been the personal subject of someone else’s lack of understanding since I was brand new in practice over seven years ago.

Last night, that changed.

A medicare-aged female patient of mine (we’ll call her Jane) came into the office last night after a trip to her PCP. Prior to that visit, she and I had decided she needed an MRI due to a slow response to conservative care.

MRI of disc herniation lumbar spine

(The evidence-based guideline for ordering imaging is to attempt one course of conservative care before diagnostic imaging is ordered. We followed this to the T.) Because of the antiquated nature of current medicare coverage, I decided to explain Jane’s case to her PCP in writing and ask her to order it. I try to keep costs down for my patients whenever I can.

The letter went something like this:

“Jane has had several setbacks during her initial treatment plan, which have resulted in a slow response to conservative care. Therefore, I have referred her for an MRI. Although it is well within my scope to order this type of imaging, medicare will only pay for this procedure if the order comes from you… I’ve included the results of her initial neurological screening/orthopedic exam for your review. If you require any additional information, please contact me… thank you in advance…”

Pretty standard stuff. I’ve written letters like these dozens of times in my career and they are received without a hint of resistance.

So last night, when Jane came to my office in obvious distress, I was shocked to learn that my letter had not even been read, except in the most cursory of ways. She played the voicemail from her doctor’s office (left by the NP on staff) and I stood there in shock. The voicemail stated that the MRI would not be ordered unless my patient agreed to be seen by a physiatrist (a pain management specialist) and to undergo care. It also tacitly mentioned that ‘if chiropractic care hasn’t worked, it should be discontinued.’

The message here is wrong on so many fronts. Let’s list them in the order they occurred to me last night:

  1. Jane’s attempt at conservative care hadn’t failed; it was slow. It’s valuable to mention that she broke her foot two weeks into her care plan and had to hobble around in a boot, utterly changing her gate and putting extra stress on her pelvis and spine.
  2. An MRI is a diagnostic tool – used to confirm diagnostic impressions and lead to additional treatment methods. It is not a carrot to be dangled. Demanding that a patient see someone and agree to a different course of care in order to receive imaging is tantamount to extortion. It’s as illogical as it is unethical.
  3. This other doctor doesn’t trust me, just because of the initials after my name. If she had read my letter, she would have seen that I am incredibly thorough and thoughtful in my management of patients.
  4. If Jane didn’t trust me, she might not have come back and told me this story. She might have seen that physiatrist and become another statistic in the opioid epidemic. I’m so thankful that she trusts me.

It was a disappointing, saddening, alienating experience.

So this morning, when I woke up, I decided to do some literary exorcism and educate in the process.

Doctors of chiropractic are portal of entry healthcare providers across the United States. We are trained and responsible for identifying a wide array of known diseases and pathologies and treating or referring out appropriately. Our education is almost identical to that of an MD/DO in the first two years. It includes the full gambit of anatomy, physiology, differential diagnosis, diagnostic imaging and clinical laboratory testing, just to name a few. During the second two years, when our counterparts are learning about pharmacology and surgery, we’re studying nutrition, rehabilitation, and advanced manipulative techniques. (For a side by side comparison of credit hours, check out this link.)

And in this situation, I followed the rules better than Jane’s PCP (who is a DO, btw). The rules, in this case, are evidence-based guidelines for conservative management of musculoskeletal conditions. They make up the clinical framework in which patients are treated with the most conservative Smiling woman in black and whitemeasures first and only more aggressive treatments after those have failed. In this case, nothing failed; we needed more information.

Luckily, this patient trusted me enough to come back and tell me the story. Also lucky are places like Metrowest MRI. They have transparent, discounted, cash pricing for MRIs. Because of them, my patient is about to get this MRI for a fraction of the cost she would have had to pay out of pocket at another institution. And when we have those results, she might still need a referral, but future treatment isn’t going to be agreed upon until we have a chance to see what she’s dealing with. We’re using the diagnostic process in its most unadulterated, scientific form.

[Exorcism complete.]

Until next time,

Dr. Chris Cherubino

 

Dr. Chris Cherubino is a chiropractic physician and certified medical examiner. She is committed to open access to healthcare information and the promotion of evidence-based principles in the treatment of mechanical spine conditions.

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