Adventures in Imaging

I was turning a ripe old age and wanted to improve my physical conditioning. My program included hoisting two 15-pound dumbbells and two sets of twenty sit-ups. This exercise, intended to preserve my last trace of youth, resulted in a self-inflicted injury of my left elbow. After a very uncomfortable month, I relented and sought out an orthopedic surgeon. (Why not a rheumatologist and/or a primary care physician? Read on.)

After taking a brief history of my non-existent medical conditions (except previous detached retinas), my physician told me I needed to have an x-ray taken of my elbow. I asked why I needed an x-ray and stated that I didn’t want one prior to seeing the orthopedist. After conferring with the surgeon, the reply from the physician was simple and direct: NO X-RAY, NO VISIT.

So my doctor—without telling me why or initiating a conversation with me to go over the risks and benefits of such an x-ray—demanded that I have the x-ray. I guess I am not the hero type; I relented. I felt, as I’m sure most patients have felt at one time or another, that I was put in a precarious and untenable position. I had a vacation to go on and wanted to see a doctor before I left. It was perfectly clear that there was no way I would be seen quickly if I protested further, so without ever having a physical exam by a physician, I consented to an x-ray. Maybe there should be a new policy: no visit, no x-ray.

I wish my visit had gone as follows:

1. the physician examined my elbow;
2. after a physical exam, he determines I have tendonitis;
3. we have a conversation about whether to do an x-ray to find any bone fragments or calcification and discuss the benefits and risks of the test;
4. I was asked how I wanted to proceed, given my circumstances (and I wasn’t subjected to, “If it was my mother…” to sway my decision.)

It was a fairly easy diagnosis and treatment, although the prescribed course of resting my arm is not easy for an active person. I wish my treatment plan had included a conversation that centered on ways to rest the left arm rather than being handed a prescription for a wrist brace.

Great variation of practice was demonstrated in this somewhat painful elbow. A rheumatologist friend told me he would have prescribed an elbow brace in lieu of a wrist brace, and anti-inflammatory drugs. So I sometimes wear a wrist brace and sometimes an elbow brace but most of all, I try to figure out how to barely use my left arm – a hard feat.

As a patient I should, whenever feasible, have the power to control what happens to my own body and to have choices about the radiation inflicted on my body. “Nothing about my body without me,” to adapt a phrase often used by Don Berwick, MD. There is growing evidence of the danger of radiation exposure. (They were careful to place protection over my “family jewels” as they x-rayed my wrist.) It is not about just the one x-ray, it’s the accumulation of x-rays over 20 to 30 years and beyond that worries me. I think an x-ray was unnecessarily done “to” me in this instance and would have felt more comfortable refusing the x-ray for the sake of my long-term health. Others may chose otherwise but the evidence is clear that informed patients generally opt for less care rather than more and when given an opportunity, they “choose wisely.”

This experience highlighted the lack of patient-centered care and shared decision-making – two keys to Choosing Wisely®– in the current system. The kind of care I received must change and it can by putting more of the focus on patients and appealing to the professional values of physicians and organizations. All patients should be offered only what they need and they should be involved in the decisions that affect their bodies.

Daniel B. Wolfson
EVP and COO, ABIM Foundation