The MRI Surge: How Primary Care Physicians Fuel the Surgical Machine | Podcast Ep. 249

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid and today we are looking at a study that has implications for your practice and your communication. We're talking about the patterns of care after MRIs of the spine in primary care. There's a lot of context to this. The stats might surprise you. This is an episode going to want to pay attention to for sure. Before we get started, I will ask if you have not left us a rating or review on itunes, please do so. If you're listening on your iPhone you can scroll on down and tap the how many stars you think we deserve button right there within the app. Or if you're listening within Spotify or something else, I'm sure you can get to it. But that helps more and more people find out about this podcast. Last week there were over 13,000 RSS subscribers to this podcast, which is eight. Absolutely incredible. Thank you for tuning in. Thank you for caring, thank you for listening, thank you for shooting the feedback, thank you for everything. But if you have not left a rating or review, I'll ask you to do that so more and more people can find out about this podcast. So as I said at the top today we are looking at a study that came out in Spine in 2012. So that top tier of research, it's titled Patterns of care after magnetic resonance imaging of the spine in primary care. And this is a topic that I am super passionate about. Working as an associate, having my own practice, working within an orthopedic group and then working within a surgical group gave me a really unique viewpoint on this. And obviously with the evidence based chiropractor we focus on referral relationships. So we have hundreds of docs spread out all around the world that interact with primary care doctor offices all the time. And I have a bone to pick with this because of this reason, time and time again I saw patients would go in with musculoskeletal issues to their primary care doctor, things that would you and I would instantly recognize as probability of a disc injury. Right? They have some sort of radiculopathy, they have some numbness entangling, they're having radicular symptoms which tells that there's a nerve compression ultimately or symptoms of spinal stenosis. And inevitably what I saw time and time again would be that the primary care doctor would recommend medications which are not only guideline discordant, they're not really going to do much. The patient might feel better for a week or so marginally because steroids just make things Feel better. However, anti inflammatories, for that matter, make things feel a little bit better, typically. But these individuals had structural issues that within one sentence of an accurate case history, you or I would pick up on. So patient would then go back because the medication, quote unquote, didn't work well, never stood a chance to begin with. And then the primary care doctor would order advanced imaging, they'd order an MRI and say, lo and behold, I spotted your issue, you have a disc problem. And the patient would be off to the pain management doctor or to the surgeon for an eval just like that. Because they did the whopping one week course of conservative care of an nsaid, which was never going to work to begin with. So this is something that passionate about and it's why I believe so much in building referral relationships. Because this is happening to the tune of hundreds of thousands of surgeries per year, which means it's happening to the tune. As we'll learn here, the percentage of people with findings that get sent to an MRI that have surgery is low. So if 500,000 to a million are having surgical intervention, and as we'll see here, that's probably 5% of the individuals getting MRIs from their primary care physician. This is tens of millions of people who are going into primary care physicians and basically getting bad advice or getting upgraded, so to speak, to a neurosurgeon or a pain management doctor well before they've gone through anything with conservative care. So with all that being said, you probably know where I'm going to stand on this study. But let's take a look at the study and see what they came to from a conclusion standpoint and discover what they found. So they basically had a, they looked at the data and they found MRI people who had lumbar MRIs had an age around 50 years old and 50.5% were women. So just about an even split. Now, MRIs of the lumbosacral spine were requested for one or more of the following indications. 52% were for back pain, 51% were for leg pain, sciatica, radiculopathy, suspected disc herniation was in 11%, suspected stenosis was about 10% and, you know, weakness, altered tone, lower extremity issues, about 6%. So obviously that adds up to more than 100% because you could have a combination of those things now in the cervical spine. So they looked at lumbar and cervical spine. In the cervical spine, the average age was right around the same, 49.4 years and 54% were women. So it did skew in the cervical spine a little bit more towards women. Now, the reasons and rationale for requesting the image. Arm pain or radiculopathy was about 54%, neck pain was about 40% and upper extremity issues, weakness, tone issues about 10%, suspected disc herniations about 8% and or trauma about 6%. So important to begin right there. Right. We see a lot of people getting sent for MRIs because of back pain that does not even have radiculopathy, which is a little nuts, but, you know, some stats to take home there. So nearly half of the patients, 44.5%, were seen in consultation by an orthopedic surgeon or neurosurgeon during the subsequent three years. And nearly a third of the patients, 30%, were seen by a non surgical specialist, which they were had as a neurologist, rheumatologist or a physiatrist. Subsequent interventions included spinal injections in about 14%. Wonder why we're having 250,000, or, excuse me, 25 million injections given per year? Well, when you see stats like this, that's what it adds up to in spine surgery in about 7% of the individuals. So that was for the lumbar spine. In the cervical spine, 44% of the individuals who received the MRIs were seen by an orthopedic surgeon or neurosurgeon. In the three years that followed, 37% were seen by a non surgical specialist. 10% got injections. So, I mean, these stats are pretty crazy. And this is where it tells the realistic story of what I experienced in practice. When we see, you know, 44% of individuals that get an MRI from their primary care doctor being referred to an orthopedic surgeon or a neurosurgeon within a few years. And most of that happened almost immediately. That is a big problem that can result in a lot of trauma. It can result in a lot of surgery. And not because the surgeons are doing anything outside of their scope. If the primary care doctor has informed them that conservative care has, quote, unquote, been exhausted and the surgeon sees something he or she thinks they can work on, they're probably going to make that recommendation. They are surgeons for a reason. But it also stands to reason that the guidelines need to be upheld. Individuals need to truly exhaust conservative care before they entertain the idea of surgery. And many patients out there have no concept that findings on an MRI are normal. If you're above 35 to 40 years old, there will be findings on your MRI, if you're above 45 to 50 years old, there's probably going to be multiple levels with multiple challenges or findings. But as I always told patients in practice, my job as the doctor is to separate the not perfects from the problems. When you're over 40 to 45 years old, you're gonna find an array of not perfects on any imaging. The question is, what is the problem in determining what that problem is? Is easier said than done. And as we see here, with a lot of individuals being referred for advanced imaging with just minimal pain or not even ridiculous symptoms, there's a lot of lack of case history and examination specifically going on in many primary care offices. So these researchers found, quote, we determined that among patients who received an MRI scan of the lumbosacral or cervical spine in the primary care SETT setting, MRI scans almost always contain abnormal imaging findings, and referral for surgical assessment is frequent. So that's a problem. They also found, quote, centralized, standardized, multidisciplinary assessment and referral processes have been effective in streamlining care for hip and knee arthroplasty. And more research is needed to determine whether a similar approach could be successful in optimizing the management of patients with spinal complaints. Well, as I said at the top, this study was in spine in 2012 and dreams came to reality. There has been more research, and that research shows time and time again that a multidisciplinary approach, that going a non pharmacological route, that going a non surgical route is by far the best way to do things. And this ties into the study that we highlighted just either last week or the week before, where, hey, if people that go through conservative chiropractic care don't get relief and they're really having challenges, right? Really hard neurological symptoms, diminishing thing, those are actually great candidates. And the research shows they get fantastic results with surgery. But you can't flip it the other way because once the surgery is performed, the anatomy has been changed, the biomechanics have been changed forever, and there's really no going back. Now. There's scar tissue in the area. This is even in a non fusion based procedure, you end up with a lot of scar tissue, you end up with the potential for fluid collection, you end up with biomechanical changes, you end up with how gravity loads the joint and how the patient moves changes forever. Even in a minimally invasive, even in a microdiscectomy type situation, once things have been touched, there is no going back. And that's an important thing when we see that MRIs are being ordered by primary care physicians at a frequency that is outrageous. And we see nearly 50% of those individuals who have an MRI are being immediately referred to an orthopedic or a neurosurgeon. So there is two things that I look at that. One is that that's a big opportunity for you and I as chiropractors to educate, to build relationships and to ultimately change that. If all of those individuals were being referred to conservative care providers, as it stood today, it'd be a lot harder to be able to gain traction and to be able to get those referrals. But considering how guideline discordant the primary care doctors are often it's not every doc, right? There are exceptions to the rule, but overwhelmingly the primary care doctors are so guidelined discordant that there's really a big opportunity once you get in there. The question is, do they know who you are? Like literally do they even know who you are? Do they have any concept of what you do within your practice? And do they know how to select the patients to send to you? Those are the really big items. They're never going to send somebody. It's very rare that they're going to send somebody if they have no idea who you are. Obviously they need to know at least what your practice is, if not who you are, to be able to make the referral number two, they have to be able to identify who's a good patient, what should they be on the lookout for? And if it's everybody, it's nobody, everybody makes no sense. So you have to be able to delineate to them what they should be on the lookout for. Now, over time that might expand. But before you get 100 referrals, you have to get the first one. The clearer you can make that to them, the easier it will be for you to get that relationship started. And then the other piece of it is they need to have a general understanding of what you do. Because. Because if their patient asks questions and they don't have any answers, they're just not going to bring it up anytime you're putting them at a disadvantaged position with their patients. Friction, that sort of friction and confusion is going to kill conversion and referrals. So you want to proactively address all that. Obviously that's what we do at the evidence based chiropractor, helping docs build referral relationships. For between half decade and a decade now, it's resulted in tens of thousands of referrals into chiropractic practices around the world. But this is something that you can start conversations. If you wanted to go it alone, you could start these conversations with the docs in your community. You have to make yourself known. They have to understand who you are, what you do, and what type of patients to be on the lookout for. And patients that have findings a disc bulge, a disc herniation, a disc prolapse, a disc protrusion on mri. They also need to understand that that does not automatically mean that that is the HOV lane directly to the surgical suite. It's not that way at all. An overwhelming majority of those patients are going to heal conservatively with time, with strength training, with exercise, with rehab, and obviously with getting the segmental biomechanics straight with an adjustment. But a primary care doctor is never going to know that unless you bring it up to them, let them know, and build that relationship. So get out there, have fun with it, start those relationships. If you want to check out this study, you can click on down to the show Notes. And again, if you have not left a rating or a review on itunes, that helps more and more docs find out about this podcast. Have a fantastic week in practice and I'll talk to you soon.

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