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  • #46
    Before this convo gets even more dangerous, let me be clear. I believe Xrays are definitely indicated in many scenarios and i trust most doctors. What i have qualms with in ortho(or any other doctor) is getting xrays or any test before the doctor even see's me. Its just protocol in the one office ive been, to get an xray as soon as you walk in the door. Just like in my dentist they said i needed a deep clean likely because they heard I did not seen a dentist for a while(im curious if I did not mention that, would they have recommended the same thing). My only request is to please examine me first and then suggest an xray. I will be more inclined to trust the recommendations

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    • #47
      Originally posted by jz- View Post
      Beyond the $1800 laser and deep clean, the issue is trust. My non-MD friends are smart, definitely skeptical and question the profit angle.
      Are they smart because they have learned to question everything and be a professional skeptic, which lends oneself to sounding smart?

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      • #48
        Originally posted by Panscan View Post
        Thats a terrible argument. If you are doing an X-ray on literally every patient that comes in, by definition you are doing some amount of unnecessary x-rays. It doesn't take an ortho to realize that.

        You prove the problem when you say you send stuff out bc your images suck. That means that a) you bought a cheap, low strength magnet (which is what every office MRI is because it's cheaper, yet a crappy 0.5T magnet from 20 years ago pays just as much as a cutting edge 3T brand new MRI) b) you have no one involved who has any idea what they're doing to protocol the studies to make them look good. I'm sure somebody is ordering MRIs from your magnet and you aren't running it as a loss leader. These things don't exist for fun or for patient convenience, they exist to make money.

        I absolutely believe you can look at an MR and say if there is DISI or if the SL ligament is intact. I think you have no idea how to tweak protocols or acquire images which is also part of the battle. It's basically a printing press of money. You get to collect unlimited technical fees with doing essentially no work yourself besides the one minute you spend looking at the joint. Let's just recognize it for what it is and not lie to ourselves or patients.

        The right thing to do would be for the patient to receive diagnostic tests that are indicated, not because it makes your group money. I have no idea what you're talking about with salary. I don't think there's a scheme of PCPs refusing to treat CHF or diabetes so their patients keep coming back to their office. In fact the opposite is true and with tracking of metrics, people are probably more vigilant about treating stuff than ever.
        I say this and then I'll be done because I don't care enough to argue with you.

        Our MRI is older and we are getting a new one. I do ortho foot ankle and it's not good for those. But it's good for other things.

        I don't get xrays on literally everyone. I often talk people out of them. Again, you don't know what xrays are needed and what aren't. So stop saying unnecessary xrays.

        I am not talking about PCPs refusing to treat people. But if you're salaried, you have less incentive (that's all we are talking about here) to add a patient on to your clinic to see them. So they don't get seen for 6 weeks. Or a salaried orthopaedic surgeon maybe treating something nonop that should have surgery.

        I could give you reasons for why every xray I have ordered is indicated, but I don't have time to explain 5 years of my ortho residency and my fellowship to you.

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        • #49
          Well Panscan I am going to my orthopod next week. I expect to have plain films, an MRI, and possibly a CT. I have a new problem that has not been imaged. I think it is appropriate to image new problems. I like the plain X rays because they are immediate at My Ortho"s office. Other imaging will be a few days later usually.

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          • #50
            Originally posted by Bdoc View Post
            Before this convo gets even more dangerous, let me be clear. I believe Xrays are definitely indicated in many scenarios and i trust most doctors. What i have qualms with in ortho(or any other doctor) is getting xrays or any test before the doctor even see's me. Its just protocol in the one office ive been, to get an xray as soon as you walk in the door. Just like in my dentist they said i needed a deep clean likely because they heard I did not seen a dentist for a while(im curious if I did not mention that, would they have recommended the same thing). My only request is to please examine me first and then suggest an xray. I will be more inclined to trust the recommendations
            I think it depends on what your complaint is and your age/demographics. If you are here because you had an injury, you’re getting an X-ray. If you’re a 50+ year old woman complaining of base of thumb pain, you’re getting an X-ray. These can and should be done before the patient sees the doctor to save everyone time. I don’t have a standing X-ray everyone who comes through the door order, but my nurse and MA have learned over years which patients need xrays, and if they’re unsure then they’ll ask me or I’ll see the patient first. But honestly you can tell in 95%+ of cases who needs xrays before you even see them, even when those xrays turn out to be “negative.” A “negative” X-ray also gives a lot of information for certain diagnoses or complaints.

            If you come in and say your hands are numb, or your fingers are triggering, I’m not ordering X-rays.
            Last edited by MaxPower; 04-29-2021, 12:12 PM.

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            • #51
              Originally posted by Hatton View Post
              Well Panscan I am going to my orthopod next week. I expect to have plain films, an MRI, and possibly a CT. I have a new problem that has not been imaged. I think it is appropriate to image new problems. I like the plain X rays because they are immediate at My Ortho"s office. Other imaging will be a few days later usually.
              Obviously I'm not ortho but it would be pretty strange to do all 3. XR and MR are complementary and very commonly done together or in sequence. Obviously depends on what your issue is. Sometimes orthos also just say they feel more comfortable with CT than MR from an alignment and pre-op planning perspective which I guess is up to them.

              It would be hard for me to imagine a pathology that cannot be adequately characterized on an XR and MR where a CT would add real value. Its appropriate to image new problems but that doesn't mean you need to do overlapping modalities.

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              • #52
                talking msk joint stuff. for some head and neck stuff, ok sure it can help be helpful to do CT and MR but then you aren't doing an XR really



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                • #53
                  Another complicating issue is that many patients like imagine and expect it. They feel that you do not care or are blowing them off if you do not do it.

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                  • #54
                    Originally posted by Panscan View Post

                    Obviously I'm not ortho but it would be pretty strange to do all 3. XR and MR are complementary and very commonly done together or in sequence. Obviously depends on what your issue is. Sometimes orthos also just say they feel more comfortable with CT than MR from an alignment and pre-op planning perspective which I guess is up to them.

                    It would be hard for me to imagine a pathology that cannot be adequately characterized on an XR and MR where a CT would add real value. Its appropriate to image new problems but that doesn't mean you need to do overlapping modalities.
                    My rheumatologist wants the CT.

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                    • #55
                      I think some bad habits are learned in training. The FP resident sees a patient for knee pain and tries to refer to Ortho in the same academic setting. The Ortho resident knows this is probably not surgical and doesn’t really want to add a non-surgical case to their workload so says get an MRI first. The FP resident gets tired of getting their referrals bounced back with requests for more imaging so they learn to just order imaging for everything and then that practice continues after they finish residency.

                      One thing I wish everyone would do when they order msk imaging is say something like “we know your imaging is likely to have some abnormalities. Everyone experiences some degenerative change with aging. So just because your imaging has some “abnormal” findings that isn’t in itself a cause for concern, it’s expected. We are looking for specific abnormalities that correlate with your physical exam.” I say that that to patients and it makes the f/u much easier. I also see a lot of patients who arrive for a new visit freaking out stating “my PCP told me I have a deteriorating spine” and I have to spend sig time reversing the damage of that mental image before I can move on to the good news that they have a pretty normal exam with no neuro deficits and the main issue is lack of conditioning and what we (mostly they) can do to improve that.

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                      • #56
                        Salaried ortho trauma here. The vast majority of my patients get an X-ray for every visit to monitor fracture healing. Any patient with a new complaint of pain or injury should get a basic plain X-ray, at least two orthogonal views. Why aren’t more folks here upset that PCPs order MRIs acutely for low back pain? I wouldn’t inject anyone’s joint without an X-ray. I routinely get inpatient consults from the hospitalists for joint pain without an X-ray. That would be like consulting a cardiologist for chest pain without an EKG. I rarely use MRI unless concerned for osteomyelitis or ligamentous injury. Non-contrast CT with 3D recons for the win.

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                        • #57
                          PCP here. Managing patient expectations regarding imaging is a real problem. If you have a good relationship they are more likely to trust initial management with no films or plain films only. I almost never get an mri before ortho referral. I almost never do spine mri before PT, conservative care — but I do have some with true indications that get early studies and referrals. I also have frustrating patients who demand imaging and I kind of tweak my notes to reflect what I want the outcome of the prior auth to be. It’s pretty rare that a patient wants to pay for an out of pocket MRI.

                          re salaried and not - ortho at the VA simply refused to see anyone who had uncontrolled diabetes -“not a surgical candidate, reconsult when a1c improved and not smoking” or some such. It was absurd. And that patient panel had shockingly high opioid prescriptions, not surprisingly.

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                          • #58
                            Originally posted by gap55u View Post
                            re salaried and not - ortho at the VA simply refused to see anyone who had uncontrolled diabetes -“not a surgical candidate, reconsult when a1c improved and not smoking” or some such. It was absurd. And that patient panel had shockingly high opioid prescriptions, not surprisingly.
                            There’s a good reason for that. Have you seen the data on surgical outcomes and infections on patients with uncontrolled diabetes undergoing elective orthopedic surgery?

                            We routinely screened out patients when I was a resident at the VA who had uncontrolled diabetes, who hadn’t had plain films, or had no documented attempts at conservative management. Our weekly clinics were 120+ patients a day for 2 residents and 2-3 attendings, even with rigorous exclusion criteria and being on CPRS. Can you imagine seeing patients who weren’t surgical candidates beyond those kinds of numbers?

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                            • #59
                              Originally posted by Panscan View Post
                              Obviously I'm not ortho but it would be pretty strange to do all 3...
                              It would be hard for me to imagine a pathology that cannot be adequately characterized on an XR and MR where a CT would add real value. Its appropriate to image new problems but that doesn't mean you need to do overlapping modalities.
                              32F prior ACL reconstruction 15 years ago. New trauma. Xrays to eval for post traumatic arthritis, MRI to confirm recurrent ACL tear/ acute meniscal pathology, CT to evaluate bone tunnels and need for staged operation with bone graft vs one stage revision ACL.

                              18M contact athlete, prior bankart repair, now dislocated in the ER. Plain films to confirm dislocation, another set as post reduction films, MRI to evaluate failed bankart repair, which happens to show attritional bone loss, CT to quantify bone loss and decide between open bankart or laterjet. Axillary nerve palsy cause he was out for 8 hours so let’s get a EMG/NCV too.

                              67F metal on metal hip 13 years ago. Plain films to evaluate prosthesis, MRI to evaluate ALVAL, CT to quantify bone loss and plan for revision.

                              66M prior cuff repair 15 years ago now arthritic. Plain films show advanced arthritis with significant retroversion and medialization. No migration. AHI 9mm. CT for glenoid management- augments, high side ream, or bone graft for correction? MRI to evaluate cuff given prior cuff repair history- can I do an anatomic or do I need a reverse?

                              Want me to keep going? You do your job and we’ll do ours.



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                              • #60
                                Originally posted by Codfish View Post

                                32F prior ACL reconstruction 15 years ago. New trauma. Xrays to eval for post traumatic arthritis, MRI to confirm recurrent ACL tear/ acute meniscal pathology, CT to evaluate bone tunnels and need for staged operation with bone graft vs one stage revision ACL.

                                18M contact athlete, prior bankart repair, now dislocated in the ER. Plain films to confirm dislocation, another set as post reduction films, MRI to evaluate failed bankart repair, which happens to show attritional bone loss, CT to quantify bone loss and decide between open bankart or laterjet. Axillary nerve palsy cause he was out for 8 hours so let’s get a EMG/NCV too.

                                67F metal on metal hip 13 years ago. Plain films to evaluate prosthesis, MRI to evaluate ALVAL, CT to quantify bone loss and plan for revision.

                                66M prior cuff repair 15 years ago now arthritic. Plain films show advanced arthritis with significant retroversion and medialization. No migration. AHI 9mm. CT for glenoid management- augments, high side ream, or bone graft for correction? MRI to evaluate cuff given prior cuff repair history- can I do an anatomic or do I need a reverse?

                                Want me to keep going? You do your job and we’ll do ours.


                                Sure I’ll concede the last 3. An xr to eval for arthritis when you’re getting a ct and MR? That’s hilarious. If you said for a fracture or effusion sure.

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