Imaging of Low Back Pain Fails to Change Outcomes

The real cost of MRI

Health care costs are obfuscated beyond belief. The list price of an MRI might run $1200 to $2000 depending on locale. The actual cost paid by insurance is in most cases far, far lower. In some cases what is actually paid for an MRI approaches the same cost as what some pay to see a physician. It can be far less than the cost of going to the ER, for example. One 10 million dollar lawsuit for malpractice could pay for 20,000 MRIs.

Cost in medicine is a real problem that cannot even begin to be fixed without greater transparency overall.

Finally, each person has to decide what knowledge is worth. I know too many people who have had delayed or missed diagnoses because their doctor didn't order an imaging study. These people are the reality and so long as they exist, there will not be a one-sided dictum to avoid imaging to cut costs.

Differential Diagnosis vs. Correct Diagnosis

This is a ridiculous arguement because it is not based in reality. Economies of scale have already been reached. Every dinky town in America has an MRI machine. Price will not come down enough to implement Mr. William's plan.

If the results of an MRI don't change the treatment plan, it is useless, however, it is a good generator of income for many facilities. When you can get a scan for less than $100 then we can talk. Any first year med student should be able to differentially diagnose acute low back pain and if they can't go see a PT or Chiropractor because they can.

The issue is the patient/client mentality that they need a scan to "know what's going on". Even when they get a scan, many rarely accept the fact that they need to be an active participant in their recovery.

So now you know what the pain generator is, it didn't change the treatment plan, and even then the patient is unwilling to accept the best practice of conservative care because they want the quick fix. Those who are willing to be active in their care typically have very good outcomes and having an MRI didn't make one bit of difference in achieving the outcome.

Clinicians have become too reliant on technology. It is good to have when needed but clearly overused in the US. Is it any wonder we have a healthcare crisis.

Differential diagnosis vs. correct diagnosis

MRI can show the condition of a patient's spine. It can demonstrate the more serious contributors to back pain. The technology is great. The flaw really lies with primary care doctors. They are trained to treat differential diagnoses, and focus away from specific ones. That means that what is actually wrong with a patient is less important than know how to manage it. If 9 causes of back pain are treated with conservative therapy and only 1 needs surgery, they would argue that it does not matter which of the nine causes the patient has as long as they don't need surgery.

Direct knowledge of what is wrong is valuable even if it doesn't change the treatment. It is objective, reproducible, and subject to review. A single physician's exam in his or her office doesn't inspire the same confidence. The real solution is to lower the cost of imaging and make it more available.

If we compared going to the doctor for back pain against staying home until it really bothered you, we might find that going to the doctor is fairly useless. If economies of scale lead to MRIs costing less than going to the doctor, then maybe the MRI should be done first. Perhaps then Dr. Chou will publish a very different paper.