Note: This post first appeared at e-patients.net
Gina Kolata’s must-read article in last week’s Science Times points out vast differences in the quality of MRI’s as well as vast differences in the expertise of the radiologists who interpret them.
Patients need to understand this, because physicians sure as Hades aren’t going to tell you.
Kolata uses sports injuries as example. With suspected cancers, the stakes are life and death. A poor MRI was part of the reason my daughter nearly failed to get a proper diagnosis of a malignant sarcoma in her arm, and then nearly failed to get the proper treatment.
The initial MRI was the only baseline image which her oncology team
had to grade the tumor before it had been cut open. Besides tissue
analysis, grade of tumor is determined by size, depth and firmness of
the mass. A physician at a university medical center finally explained
that the films were junk. Useless due to poor quality.
As Kolata points out, there is a vast difference in the quality of
MRI’s as well as vast differences in expertise of the radiologists who
interpret them.
Second, there is no substitute for research and patient
pro-activity. None. Nor, given the fractured state of health care in
the United States and the flailing economy, is there any substitute for
e-medicine for cancer cases in terms of speed, research capability and
candor.
Third, organizations like the American Cancer Society and the Lance
Armstrong Fund need to take the lead in getting the word out about
clutzy MRI’s. This is unconscionable.
As a further insight, the wife of my daughter’s high school biology
tutor, head pharmacist at a local hospital, informed us that in decades
past that my daughter’s case would have automatically been referred to
a major university medical center like UCSF. Now, given local oncology
facilities, insurance companies force the patient to beat his or her
way through the local medical scene, making referrals to true centers
of expertise extremely difficult if no t near impossible for the
ordinary citizen.
The locals may be fine for diagnosis and treatment of the Big Four
cancers, but they ain’t fine for pediatric cancers and/or rare cancers
which present as suspicious lumps and bumps. For this, they can be
fatal.
It would be different if physicians were to openly admit the limits
of their expertise, but I have yet to encounter that particular
situation.
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The quality can vary even with the same machine and techs. My last MRI on my arm was a 1.5 hour marathon (that’s a LONG time for a 6’5″ 240 lb guy to be stuck in a small tube). Turned out that they didn’t like the first set of images, something about getting the right settings to differentiate things. After consulting with the radiologist they made changes and rescanned. I didn’t find all this out until over an hour in when they pulled me out to put in contrast.
Decent machinery, attentive techs communicating with the radiologist are all key. That just makes it even harder to ensure you’re getting the imaging you need.
Dr. Evans:
If one lives iin a rural area, is there a tactful way to inquire about either the quality of the equipment or the level of expertise of the radiologist?
Should one assume with a suspected cancer that a second expert opinion is always a good idea, even with common results like calcification on a mammogram? Can one assume that local-level radiologists read enough mammograms in a single day/year to be confident of their interpretation?
I always wonder as a mom how I should have handled the situation. I did not understand the “cascade effect” of that single MRI.
When you have a MRI, get a copy of the scan on the disc. If there’s any question about the result, it can be helpful to ask your doctor for a second opinion or interpretation by a radiologist who is a specialist in reading MRIs in that part of the body (the doctor will know but for example musculoskeletal, neuroradiology, etc).
MR equipment is much more complex and difficult to operate than CT, and there is surprisingly large variation in image quality on identical machines, depending on how they are adjusted. There are also a lot of people besides radiologists reading MR scans, and a lot of variation in how much training they receive. Finally, a lot of differences in the targeted tissues are really subtle, and some anomalies may represent what radiologists call “pseudo disease”, things that look threatening but aren’t.
The most logical solution is that being pursued by United Healthcare- rigorous certification of imaging centers. Eventually, Medicare will follow. There is still a surprising amount of “art” in the science of radiology, and Kolata’s article is a useful warning to consumers.