Khoury, Martin L. "The
Importance of Accurate Imaging," Advance
for Imaging and Radiation Therapy Professionals,
August 26, 2002.
The Importance
of Accurate Imaging
August 2002
The following case
study gives an idea of how important technologically
accurate imaging studies can be. Notice how the
quality and technical accuracy of all the imaging
studies played a part in the outcome. Because the
studies were done correctly, they all supported
each other. Even when there were slight deviations
in diagnosis, each physician who reviewed the studies
came to approximately the same conclusion. One can
imagine that if one of the studies was poorly done
it could have caused unnecessary surgery, expense
and injury to the patient. Each technologist played
a small but meaningful role in the care and treatment
of the patient.
When a waitress
hurt her back on the job, as part of her worker’s
compensation claim, she saw Doctor One who suspected
a coccyx fracture. She was referred to Doctor Two,
an orthopedic surgeon who ruled out a coccyx fracture.
A CT Scan showed a right-sided mild to moderate
herniation of her disc at L5-S1, although her symptoms
were left sided leg pain. Over the course of the
next month, her symptoms seemed to shift to her
right side until she was complaining of right-sided
leg pain. She was then referred to Doctor Three,
another orthopedic surgeon who ordered an MRI in
preparation for surgery.
The MRI showed
no herniation, but rather showed a normally hydrated
disc at L5-S1. Doctor Three could not recommend
surgery because the MRI findings negated the prior
CT findings. In deposition, Doctor Three testified
that there was simply nothing to fix, and suggested
a trial of epidural steroids. He also referred the
patient to Doctor Four, a neurosurgeon, hoping to
find the source of her right leg pain.
Doctor Four found
the patient’s CT and MRI to be unimpressive,
but he ordered a second CT and a myelogram as part
of his workup. Both studies showed only insignificant
findings of a small midline herniation at L5-L6.
He saw nothing that would explain the patient’s
right leg pain. He suggested a trial of physical
therapy and a three-week follow up.
A few months later,
Doctor Five saw the patient for an independent medical
examination, a common occurrence in worker’s
compensation claims. Doctor Five’s findings
were that the patient had reached maximum medical
improvement, and was not a surgical candidate because
she had a zero percent impairment with no restrictions.
The patient continued
to see Doctor Four, who agreed she was not a surgical
candidate but because her herniation was so slight,
he was at a loss to explain her right-sided pain.
Doctor Four ordered a thoracic MRI to rule out possible
pathology further up the spine, but otherwise said
he had little else to offer her. A month later,
the patient was seen by Doctor Six, an orthopedic
surgeon, who reviewed her myelogram, CT and MRI
films, and determined she had no evidence of nerve
entrapment, disc herniation or central canal stenosis.
Thinking her pain might be originating elsewhere,
Doctor Six ordered a bone scan. When that came back
normal, he placed the patient on anti-inflammatory
medications.
The patient then
requested, and the worker’s comp carrier authorized,
an examination by Doctor Seven a board-certified
orthopedic surgeon. Doctor Seven reviewed the prior
tests and did some testing of his own finding no
evidence of herniation or pressure on the nerve
root. Doctor Seven ordered an EMG and a thermogram,
both of which revealed nothing of significance to
explain the patient’s pain. He also agreed
that the patient was not a surgical candidate, noting
that while sitting the patient would sometimes shift
her weight to her right buttock and sometimes to
her left.
A few months later,
the patient petitioned her employer and insurance
carrier to allow her to see an osteopath for treatment.
The carrier authorized both the osteopath and several
of the patient’s prior physicians to provide
whatever treatment was needed.
Instead, by her
own choice, the patient began to see Doctor Eight
another orthopedic surgeon ostensibly under her
husband’s health insurance. Doctor Eight similarly
found no clinical evidence to explain the patient’s
pain, but referred her to Doctor Nine, a radiologist
to have a discogram. Normally in a worker’s
comp case a patient should receive prior authorization
before seeing an additional physician, but the patient
went for an evaluation by Doctor Eight first and
later made a claim requesting authorization. Before
receiving the necessary authorization to see Doctor
Eight, the patient saw Doctor Nine who performed
the discogram.
One month later,
Doctor Eight was informed that he was not authorized
to treat the patient. By that time no less than
22 physicians had been authorized to treat the patient.
Two months later, again without authorization, Doctor
Eight performed an extensive anterior and posterior
reconstruction of the patient’s lower back
with instrumentation.
The suit arose several months later when the patient
again sought authorization for the surgery performed
by Doctor Eight and requested total disability benefits.
The law held that if an employer failed to provide
treatment or care requested by a patient, the patient
could make a specific request, showing why the additional
care is medically necessary. The carrier is then
given a reasonable time period to provide the care.
If the carrier fails to provide the care, the patient
can obtain it at the carrier’s expense.
In this case, the
carrier did not fail to provide needed care. In
fact, there were 22 authorized doctors to whom the
patient could have turned, and although those physicians
could find nothing wrong with the patient, she never
sought a hearing on the medical reasonableness and
necessity of being seen by Doctor Eight. The court
stated the rule that it was up to the patient in
a worker’s compensation case to seek prior
approval from a compensation claims hearing officer
when seeking unconventional treatment. None of the
patient’s 22 doctors ever declined to see her
or told her further treatment was unavailable. The
patient simply turned her back on all 22 physicians
without articulating a meaningful objection to any
of them. The court denied payment for the surgery
performed by Doctor Eight, and for any disabilities
the patient suffered as a result.
One common thread
in this case is the hard work done by each imaging
specialist who saw the patient. The value of the
work done by a technologist is often overlooked
or taken for granted by the persons who benefit
most from the technological skill that goes into
creation of the final product. As a technologist,
I remember being frustrated by complaining patients
and radiologists who gave sometimes cursory or begrudging
approval of a film that took a Herculean effort
to obtain. Many times I would go home despondent,
feeling that my hard work was not appreciated. I
consoled myself by remembering that I had done my
best and had assisted the other members of the healthcare
team to reach accurate diagnoses. I knew I played
a part in helping my patients regain the most valuable
thing a human being can have, good health. I also
knew that if I didn’t do my job well, with
the precision and skill my training provided, that
I could do exactly the opposite: I could cause a
patient to be misdiagnosed, and their good health
or very life might be lost. Mine was a small contribution
in the overall scheme of things but each day was
a series of small victories, and I rightly took
pride in them.
Each of you plays
a vital role in a vital line of work, helping achieve
small victories over disease, pain and fear. All
of you who work behind the scenes fighting the good
fight and doing your best deserve a big pat on the
back. Appreciation is always in short supply in
the medical imaging and therapy fields so if you
haven’t heard it lately, a big heartfelt thanks
to each and every one of you.
Martin L. Khoury,
former ARRT CT Technologist, is available to speak
to your group on a variety of medical/legal topics.
Contact him in Miami at 305-670-1101. E-Mail at
mkhoury@QPWBLaw.com.
This column is for informational purposes only
and should not be relied upon as legal advice.
