It's a day shift in the middle of the week. Your patient has one month of increasing back pain, and now it's radiating down his right leg. He has no urinary incontinence or other finding consistent with an emergent condition. You suspect he has intervertebral disc disease, and you know the best imaging test is an MRI. You could just give pain meds and refer him to his PCP, but you call radiology. They can do this study right now. What are you going to do?
From experience, I can tell you the acute phase of intervertebral disc disease is pure agony. Patients suffering from this problem in the 1980s might require an imaging study called a CT myelogram. The patient would be admitted, and contrast would be injected into the spinal column before CT imaging. As you might expect, this required the emergency physician to convince someone (usually a neurosurgeon) to admit the patient. Most of the time emergency physicians just handed out narcotics and referral slips.
But MRIs provide an easier solution. No spinal needles involved. If an open slot is available in the MRI schedule, it's just a matter of a computer click and maybe some Ativan for the claustrophobic. Then you see other patients while you wait for the results of the study. Once it's done, you can walk into the patient's room with confidence to give him the definitive results. It makes you look good and feel good.
The hospital likes this, too. MRI machines cost from $500,000 to $1 million, and this does not include the facility, the technicians, maintenance, and the radiologists reading the studies. Hospital administrators want their MRIs humming all day long, and if each study takes 30 minutes, you will only get about 20 studies per day per machine. Administrators obviously do not want open time in the schedule.
How about the patients? You can see where they might like it a lot also. People come to the emergency department for three things: fast care, pain relief, and an answer. You get to provide all three. This is why they blew off their PCP. Like everyone, patients crave technology and convenience.
Of course, you should order the study. It's the best test on a day when you can get the patient in the MRI in a reasonable amount of time. This is a win-win-win situation. Go for it.
But, as with nearly everything, there are unintended consequences. You go back to see the patient. He tells you he sells shoes at a local retail store, and he lives with his wife and two young children. You notice on his chart that he is listed as self-pay. Can he afford it?
Before you think this is a thinly veiled discussion about doing a wallet biopsy for expensive tests, consider this: The medical bill you are about to generate has the potential to create big problems for the patient. The average emergency department visit costs more than the average American's rent ($1,250 versus $890). The average bill for an MRI is more than $2,600. (The Washington Post, March 2, 2013; http://wapo.st/1YHq7Z0.)
An unpaid medical bill can be disastrous. These debts can drop a credit score by more than 100 points, and this makes getting reasonably priced credit like a car loan difficult and expensive. Physicians take this for granted because they can get great credit anytime they need it, but the majority of their patients are at significant risk for hardship if they cannot afford to pay their ED bill.
Think about this as you go forward in your career. Consider how much it costs before you order a test like this. Most residents just want to be right. They want to work up the patient correctly and order the best test. But does the best test really help the patient in the way he wants to be helped? You might be surprised how many of them simply opt out of the expensive ED test and look for cheaper options, particularly if you explain that you do not think their condition requires the test immediately. Few if any patients have any idea how much ED care costs when they sign in, and for that matter, not many doctors do, either. Just take that little bit of extra time to discuss this issue, and you might prevent an even more difficult decision for your patient in the future.
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