Is a Picture Worth $20 Million?
- Aleksandra Nikolovski, PT, MScPT
- Dec 23, 2022
- 6 min read
Updated: Apr 12, 2024
About ten days ago, Sylvia Jones - Ontario's Minister of Health - released a statement that the government has committed $20 million to increase access to MRIs [1].
This funding is supposed to reduce wait times for diagnostic imaging and determine surgical need more promptly.
My question is this: do we need more diagnostic imaging? A 2019 study by Bouck et al., investigated the prevalence of unnecessary medical services (i.e. diagnostic imaging) across various regions in Canada, and found that over 30% of imaging for back pain was unnecessary and did not provide meaningful information [3]. While diagnostic imaging is critical for some individuals and can very much save lives and provide answers to medical mysteries, our system frequently pathologizes non-pathological pain.
Moreover, once a patient is told that they're "damaged", they run the risk of losing all hope that they can recover and feel relief from their symptoms.
I want to present a few cases to illustrate how physiotherapists (and other allied care providers) are more cost-effective and more efficient than running a diagnostic every time a patient experiences pain.
Case 1 - Knee Arthritis
A patient was referred to me, knowing that she has mild to moderate arthritis in both her knees (confirmed via x-ray ~1 year prior), and after the assessment, we established a plan of care which largely revolved around exercise therapy, because that is where the evidence lies. The 2020 GLA:D (Good Life with Osteoarthritis: Denmark) report found that 58% of participants with knee arthritis showed meaningful improvement in function at both 3 months and one year after finishing the 6 week program [4]. This patient attended two sessions with me, and since her pain wasn't gone yet, she called and cancelled all future appointments, telling me that she was going back to her doctor for updated x-rays and to "wait and see what the x-rays show". This patient felt that an x-ray that was going to again confirm OA would somehow give her a different outcome. Despite my best efforts at educating this patient, she was adamant that she needed an xray. What was most astonishing was that her physician requested the x-ray, knowing very well that the outcome wouldn't change.
Why?
Likely because the patient demanded it and the doctor was overworked.
Why was the physician overworked?
For many reasons beyond the complexity and scope of this blog, but in part because their day is filled with unnecessary appointments for unnecessary imaging requisitions.
When the x-rays came back, she was re-referred to physiotherapy. Those x-rays were a complete waste of her physician's time and energy, a waste of government spending, a waste of the patient's time, and overall completely unnecessary.
Case 2 - The Meniscus
A patient was referred to me for knee pain that occurred without any particular injury. I completed a thorough assessment, and began a program of care focused on exercise and manual therapy. There was no clear diagnosis, and his presentation was a bit of a mis-mash.
He told me that he was scheduled for an MRI, but that wasn't for another 6 weeks.
By the time the MRI appointment arrived, his pain was 2/10 at worst and he was almost back to his previous self. He went for the MRI anyway "just in case".
It revealed a meniscus tear, MCL sprain, and tendonitis.
He came back worried that his knee was in rough shape.
"Are you in pain?" I asked him. "No not anymore, not really".
"Can you live your life the way you want?" I followed up. "Yeah, I'm back almost 100%".
Then for all intents and purposes, his knee was fine. That MRI was a waste.
Case 3 - Plantar Fasciitis?
A patient was referred to me for back pain and foot pain that had been going on for a long time. She had been to her physician and the hospital on multiple occasions:
Visit 1 (doctor)- x-ray requisition (back and foot) - image was unremarkable.
If the foot x-ray came back negative, the pain must be from her back, right?
Visit 2 (hospital) - CT requisition (back) - image was unremarkable.
Visit 3 (hospital) - MRI requisition (back) - image was unremarkable.
Visit 4 (doctor) - Physio referral (not me)- treated for plantar fasciitis and did not get better
1 year later...
Visit 5 (hospital) - Ultrasound requisition - image was unremarkable
Visit 6 (doctor) - Physio referral (me)
This patient told me her story and said that nobody has been able to figure it out. Since all the imaging of her back and foot had been negative so far, she'd been written off to have "plantar fasciitis" for life, I guess.
Something wasn't right. I did every assessment I knew about from her back to her toes. Nothing made me think that her plantar fascia (or her back) was the problem.
When I took a closer look at her foot I noticed the following:
Her foot was cold to touch
Her toes were white
Her calf was a bit swollen
She had pain when I touched her calf
So I started asking questions (questions I ask almost every patient):
Do you smoke? No
Did you ever smoke? Yes (8 pack year history)
Do you have any heart disease or diabetes? No
Does cardiovascular disease run in your family? Yes
For the average person, this might not mean much, but for me it became blatantly obvious that this patient's pain was vascular.
Had anybody actually even looked at this patient's foot? Or do we just blindly send people for all the imaging when they're in pain?
I screened for a blood clot and it was questionable - not textbook positive, but not negative.
I wrote to her family doctor explaining my findings and requested an urgent vascular study.
She has a DVT and is now being appropriately medicated to break the clot. For those reading who may be unfamiliar, a DVT is a deep vein thrombosis, which is a blood clot that usually happens in the lower legs, but can move to the heart, where it becomes fatal. Her back is hurting less because she can put weight on her foot, because it hurts less, because her DVT is being treated.
It took over a year of imaging and and appointments with multiple care providers to figure out what a Resident Physiotherapist identified in about 30 minutes.
She could have died because "the MRI was clear".
I want to make some themes of this discussion clearer in case there are any misconceptions about my perspective:
I do not believe that doctors are failing us.
I do not believe that physios are better than doctors.
I do not believe that diagnostic imaging is bad.
Diagnostic imaging confirmed a potentially fatal issue for this patient.
What is clear though, is that diagnostic imaging should be wisely used and spared for:
People showing red flags
People who are in critical need
People who have sustained injuries (sports, falls, suspected fractures, severe MVA)
People who have been investigated (thoroughly and properly) and treated conservatively with no success
People who are high risk for certain conditions and require regular screening [5].
Imaging is a very important part of the healthcare process, and has many benefits. I do not entirely disagree with the Canadian Radiologists who've advocated for better access to diagnostic imaging - there are circumstances when critical illnesses are not identified soon enough [6].
What I am trying to point out here, is that wait times are long because people like the above three cases had imaging that was completely unnecessary and took up spots from people who were more at risk. People whose knee pain is getting better are going for MRIs, making the person with a potential tumor wait. I don't believe the issue is that there are not enough MRI machines or radiologists. What I believe is that we need to think more carefully about who we are referring for imaging, to allow the people who truly need it to access it.
Similar to the constant highway lane expansions, more doesn't equal lesser load. They've been adding lanes to Ontario highways for years, and the bumper to bumper traffic hasn't ceased. What happens is that when we increase the capacity, we increase the use.
More MRIs likely won't reduce wait times. It'll likely just increase MRI referrals.
So what do we do?
A small part of the answer is to utilize all primary care clinicians, not just nurses and physicians. Physiotherapists have the capacity to identify major red flags and clinically reason through an assessment to determine the appropriate course of action.
Another small part of the answer is treating physiotherapists and other allied professionals as the primary care providers that they are. Physios are labeled as primary care providers, but we aren't treated as such. We are clinicians that should be informing policy decisions based on our ability to save the health system money and improve efficiency.
Some opportunities to support this include:
Expanding the physiotherapy scope of practice to include the capacity to refer to diagnostics to reduce the load on family physicians and nurse practitioners
Allow physiotherapists to provide publicly funded care without a physician referral; allow us to be truly direct access
Employ physiotherapists in all family health teams, community health centres, and emergency departments to contribute to the health screening process and determination of need for imaging versus conservative care
Invest in better health literacy programs in elementary and secondary schools to improve general knowledge about the health system
So I leave you with this final thought:
Is $20 million actually going to reduce wait times and improve health outcomes?
Likely not, but I'd love to hear your perspective.
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