X-Rays – They Don’t Show Everything! #AtoZChallenge
Whether we suffer an illness or injury, often one of the first methods to look at the structures inside the body is often an X-ray. This is regardless of whether the suspected injury will show up on an X-ray or not. There are many forms of radiological studies which physicians can use to evaluate the nature of your particular complaint, illness, or injury. Let’s use a simple example to expand upon this concept.
You manage to trip over a toy when walking through your living room. Your ankle and foot hurt, but that’s understandable because you felt it roll as you tripped. You do everything you should have done, and applied ice and elevated it to reduce swelling. You stayed off it as much as possible for the next day or so, but to no avail. So after a few days, you wind up going to get the injury evaluated.
An X-ray is ordered. You think that this shall provide an answer. While you may be lucky and it will, the physician already explained that his exam has him fairly convinced it is a soft tissue injury as opposed to a fracture. But to be thorough he ordered the X-ray. Of course, the x-ray did not show a fracture. Given that soft tissue injuries are extremely difficult to discern on a standard radiograph, this isn’t entirely reassuring. The physician orders an MRI of the injured area, prescribes some anti-inflammatory medication, and crutches. He explains not to put weight on it until after the MRI and tells you to follow-up in a few weeks if it isn’t better. He states you can call for results of the MRI if his office doesn’t call you within a few days of the test.
You go home and attempt to schedule the MRI as your doctor ordered. However, the earliest appointment you could get is nearly two weeks away. So you attempt to resume as normal a life as possible while you await the date of the MRI appointment. It isn’t feeling much better at all. In fact, it feels worse, and you still can’t bear weight on it beyond just resting your foot on the floor. Thankfully you at least have a job that you can sit at your desk, as opposed to a physically demanding one where you need to be on your feet, else you wouldn’t even be able to work.
The afternoon before the day of your test, you receive a telephone call from the MRI facility. Apparently, they attempted to get approval for your MRI from your health insurance, and it was denied. The insurance company insists that you get a CT scan instead. After leaving messages three days in a row the nurse at your doctor’s office returns your call inquiring if the doctor would write a prescription for the CT scan. She explains that the doctor said that the CT scan will not show what he needs to visualize, and insists on the MRI. You explain (again) that the insurance denied the MRI. The nurse says she will talk to the doctor again and get back to you.
The following week you finally hear back from the doctor’s office. They inform you that the insurance company denied the MRI. “No, really, ” you think to yourself as you bite your tongue. “Now what?” you ask the nurse. She proceeds to explain that you must get the CT scan. She said she argued with the insurance that the CT scan will not show the suspected injury the physician wants to see. They essentially said that’s fine. But you cannot get an MRI without first getting a CT scan.
So you schedule the CT scan and wait only a week longer for this test to be done. After waiting a few days for the report to be electronically sent to your doctor’s office, you decide to call for the results since you haven’t heard from them. Of course, it takes a day or two until you hear back. When you do, you learn what the physician already expected. The CT scan did not show anything out of the ordinary. He told the nurse to reorder the original MRI scan and see if it will be approved this time.
When you call the MRI facility they inform you that it should be approved since you did the requisite CT scan the insurance demanded prior to an MRI. However, they will not actually attempt approval for it until the day before the test, as is their normal policy. The first available appointment is nearly three weeks away this time. You are beginning to get understandably frustrated that it has been many weeks and you till have no answers. You still cannot tolerate putting any weight on your foot and ankle, and the pain and swelling have increased.
Three more weeks go by, and you finally get the MRI that the doctor ordered mere days after the original injury. A few days after the MRI, you get a phone call from the nurse at your doctor’s office, and she informs you that you need to go see an orthopedist to determine if you will need surgery to repair the damage done to the soft tissues in your ankle. That’s all she tells you other than the first available appointment with the surgeon is another four weeks away since it is not an emergency.
What is the point of this story you may ask? Well, it’s actually quite simple. The decision-making ability regarding appropriate medical care, including diagnostic imaging, has been stripped from them by a system supposedly designed to save money for the insurance companies. Your doctor knew what he suspected the final diagnosis of the injury to be, and knew precisely what imaging was needed to achieve visualization of those structures. Yet the insurance company denied the test.
To add to the frustration and senseless process, they demanded you receive a test that would not adequately visualize the suspected injury within. When those results came back they finally agreed to the MRI, which was significantly delayed due to their supposed cost-saving policies. Instead of saving themselves money, they mandated a test known not to show what needed to be examined by the ordered radiological study.
This costs not only the insurance company money, but you incur the cost for anything beyond what is covered by your insurance. And in a realistic sense, they cost the facility providing the CT scan money in unnecessary wear and tear on their CT scanning equipment, wages for the radiology technicians to provide the test, and the fees for the radiologist to read the test. All this in the name of saving money?
In the abstract sense, it is also causing you, as the patient, more money yet. Delayed diagnosis can often lengthen recovery time as injury specific treatment often can’t be prescribed until the diagnosis is ‘official’ which couldn’t be achieved until the MRI was completed. These unnecessary delays can significantly lengthen not only adequate and injury appropriate treatment but can aggravate the original injury, resulting in lengthy recovery time. Physical therapy may take significantly longer to yield positive results as the injury was immobilized for two ((??)) months while playing the insurance game.
If you had a job that required you to be on your feet and did not have the flexibility to permit you to sit down to do your job, you likely could have lost all the income during the time you fought with the insurance company.
I realize that, in theory, these practices have been put in place to assure cost-effective treatments and avoid the overuse of expensive imaging studies like the MRI. However a claims adjuster is not examining you, nor are they often qualified to determine that a test is not appropriate. They simply consult the company flowchart of approved tests for a suspected injury or even more generally just approved procedures and in what order they can be done. Instead of saving themselves money, they are in fact increasing their expenses.
It is high time at least a little bit of the diagnostic and other clinical decision-making ability be returned to the physicians that actually see, examine, and treat us.