I frequently order MRI brain scans. My patients, of course, come to me with various brain injuries or other brain diagnoses, such as autism, stroke, cerebral palsy, etc. for hyperbaric oxygen treatment, so it is no surprise that the scans usually come back with abnormalities. My purpose for ordering a scan is to determine the extent of the problem, or to make an accurate diagnosis when one is not available, or to distinguish one disease from another and so forth. What happens, however, if an MRI is ordered for screening purposes or vague symptoms and the scan shows an abnormality?
A recent report describes the results of more than 19,000 MRI brain scans performed in patients without neurological symptoms. In many of these patients, the MRI was ordered for no more reason than a health check up. After all, the MRI does not expose a patient to radiation so the procedure has essentially no risks. The only risk, it seems, is trying to figure out whether someone with an abnormality discovered under these circumstances requires exposing the patient to further diagnostic or therapeutic intervention.
On average, it took 37 normal scans to find one abnormality, though it took fewer studies in centers employing high resolution MRI scanners. The older the patient, the more abnormalities were found. The overall incidence of abnormalities was 2.7%, with 0.7% being cancers.
It is hard to know what to do with most of the abnormalities. The authors point out that the risk from an unruptured aneurysm or vascular malformation seems to be low, but the interventions required to repair them are risky. Even most of the cancers were probably meningiomas, which 90% of the time require no treatment at all. Besides the economic cost, the time and anxiety to the patient to work up one of these abnormalities carries its own price tag.
I came across this report from my favorite medical website, Medpagetoday.com. Not only does Medpagetoday.com offer up-to-the-minute medical reporting, my alma mater, the University of Pennsylvania School of Medicine, gives busy physicians like myself a convenient way to earn Continuing Medical Education credits, required by many, if not all, state medical boards to maintain an active medical license.
Although I have stayed away from politics on this blog for the most part, I am disturbed by the following comment that one of my colleagues made on Medpagetoday.com about this MRI report:
“It’s a dilemma for the patient and his doctor. The neuroradiologist is bound to find anything not within the norm, or suffer a possible suit for malpractice. Insurance companies must collaborate to back up and be responsible for a company that will cover people with these pre-existing conditions. “Over the counter” MRI’s should be made illegal without a prescription to have one, based on clinical findings, from the patients’ physician.”
I disagree with everything this doctor said except for the first sentence: an abnormal brain MRI is truly a dilemma. But is nebulous fear of a hypothetical malpractice lawsuit the best reason to read an MRI scan accurately? Has any radiologist really ever been sued for missing an arachnoid cyst or a silent infarct or even a slow growing meningioma? I doubt it. And, why should an insurance company be forced to cover someone it doesn’t want to? Even the rascals of the health-insurance industry still live in America, a semi-free country, sort of. Besides, free-market economists have pointed out that but for the asphyxiating regulatory scheme that insurers are subjected to, the free market would quickly create better and cheaper health insurance policies that would cover even those with preexisting conditions. Make MRIs illegal without a prescription? I thought they were already illegal without a prescription. The commentator apparently wants to outlaw companies that employ physicians to prescribe MRIs for anyone who wants to pay for one. So, if someone wants to pay out of his pocket for a brain MRI, why shouldn’t he be allowed to spend his own money?
We have all grown up in a society becoming less free with each passing year. When I went to a public high school, we had a shooting range in the school and a marksmanship team and no one thought anything of it. When I went back to a reunion recently I had to pass through a metal detector to get in the front door; the shooting range was long gone and would today be unthinkable. Our loss of freedom has been insidious so that we get used to the pain. In fact, it wasn’t all that free in the 1960’s and freedom was even becoming a memory in the 1930’s. At least then, the Supreme Court had the gumption to dismantle some of the more egregious power grabs of the New Deal–the National Recovery Act and the Agricultural Adjustment Act–legislation that had sailed through Congress. Remember that Republicans of that day gleefully voted to create Social Security, a scheme that few of us will ever collect from an amount even close to what we contributed. Would any sane person voluntarily buy such a retirement plan? So, beware the Republican alternative to the catastrophe being proposed by Democrats.
We are on the brink of losing what’s left of our free-market health care system. It seems like most people are satisfied with their coverage, even though I don’t think we get what we pay for and what isn’t directly controlled by Medicare, Medicaid, the Veterans Administration and other government institutions is subject to tight government regulation. Soon enough, we may have even less freedom in our medical care system and the solution to the new problems that will arise will eventually be a European-style health care system. So what, you say? Well, I doubt I will be allowed to treat anyone with hyperbaric oxygen for neurologic problems and I wonder if I’ll even be allowed to treat patients with chronic wounds, once the number crunchers take over. Italy outlawed its hyperbaric chambers some 15 or 20 years ago. Will there be “fugitive” hyperbaric chambers in America like the fugitive CT scanners of the 1980’s? We’ll know soon enough.