WhiteCoat

Get Your Own X-ray

GruntDoc had a post that illustrates a point I have been trying to make for quite some time.

The post is simple enough.

It starts out with a Twitter post by a physician named Brett (@EMDocBrett) noting “Ottawa Ankle Rules? People follow them? I try to explain to pts but really, they [just] want an [x-ray].”

For those of you not familiar with the Ottawa Ankle Rules, they are a way to predict with high accuracy whether a patient does not have an ankle fracture. In other words, if you don’t meet the criteria in the Rules, it is almost certain that you don’t have an ankle fracture.

GruntDoc relayed a story about how, through use of the Ottawa Ankle Rules, he was able to substantially cut down on the number of ankle x-rays at a clinic where he worked. He was proud of the impact he made … until he learned that all the corpsmen drove to the local emergency department to get their x-rays anyway.

Then he cited the scholarly Nick Genes (also at @nickgenes) who once said “Canadians get exams, Americans get x-rays.”

What’s the simple solution to the problem of everyone wanting ankle x-rays when no injury is present?

Deregulation.

If people want to have an x-ray, they should be able to walk into any radiology facility and have an x-ray without a doctor’s prescription. Why are we requiring doctors to be the “middlemen” between patients and testing? Common knowledge that if a patient goes to a doctor demanding an x-ray, the patient will get an x-ray. Press Ganey has made it likely that you will get what you want in the emergency department even if it is medically inappropriate. And if one doctor doesn’t write a prescription for an x-ray, then, just as they did with GruntDoc, the patients will just go somewhere else to get their x-ray done.

Allowing patients to get their own x-rays would cut down on the number of doctor visits and emergency department visits significantly. How many patients go to the doctor solely because they want a prescription to have an x-ray done?

Allowing patients to get their own x-rays would also cut down on medical liability. If patients get an x-ray without their doctor knowing about it, then the doctor doesn’t have to worry about following up on the study or the results. If the patient wants to discuss the results with the doctor, they make an appointment. Otherwise — just like if you choose to fix the brakes on your car — if something goes wrong, you’re on your own.

Deregulation would also mean that patients have to pay out of pocket for the x-ray.

Patients would then be faced with a dilemma: Do I pay $100 for an ankle x-ray, do I just follow those Ottawa Ankle Rules and save the $100, or do I go get a professional opinion from the doctor?

Let’s say that the patient decides to go purchase an x-ray. It’s normal. After a few normal ankle x-rays, then patients may be a little more hesitant to get radiated next time they twist their ankle. Now what? See a doctor for an exam? Go pay for an MRI?

Let’s pay $1000 for an MRI and interpretation. Or perhaps we save money on the radiologist’s interpretation and we look up MRI ankle interpretation on the internet. Now what?

Want to discuss what to do with the results? Your family doc can probably get you in to the office in a day or two. Or … our emergency department doors are open 24/7. We don’t interpret MRIs, but we can place your ankle in a splint and refer you to an orthopedist.

Want to reconstruct your lateral collateral ligaments on your own? You’re empowered to make that choice.

Just do an internet search.

You can even x-ray your ankle when you’re done to see how you did.

6 Responses to “Get Your Own X-ray”

  1. Roo says:

    How would the insurance determine if the x ray is indicated? Is ankle pain a good enough diagnosis for that? I was an athletic trainer we used pretty much the same protocol as the Ottawa rules to determine the necessity for an x ray. If one of our pt’s wanted an x-ray, too bad. I’m not going to talk to the doc and ask for one, don’t need it. Don’t like it? Too bad, my training supersedes your want for an image study.

  2. Wayne Conrad says:

    Essays like this one are why I’ve told Google reader to file your blog under both “rescuers” and “liberty.” Nicely said, Dr. WC.

  3. Jane Farries says:

    “Ottawa Ankle Rules” — what a great name for a hockey team. I’ll suggest it to the NHL.

  4. Kipper says:

    When my ankle was broken, neither an X-ray nor Ottawa ankle rules were needed to know there was a problem: my foot was facing the wrong direction. However, the orthopedic surgeon still needed X-rays before making the repair, so the ER doc saved me time and stress when he ordered them.

  5. Nurse K says:

    We x-ray plantar fasciitis and atraumatic foot pain all the time. My favorite x-ray was the chick who was wearing high heels all day who said her feet hurt from walking in high heels all day.

    We Americans don’t even need an injury for an x-ray! Ottawa Ankle Rules are like Step 10 in the X-Ray 10-Step Program…Step 1 is just trying to convince doctors that people with plantar fasciitis don’t need x-rays.

    But our doctors are “special”.

  6. Vladimir von Winkelstien says:

    My experience:
    Me: “Hi Doc. I rolled my ankle yesterday, now it’s swollen and it hurts like crazy.”
    Doc: “Do you want an x-ray?”
    Me: “Um. Actually, I wanted to know what I need to do to make my ankle better.”
    Doc: “Okay, let’s get you an x-ray.”

    I don’t think the problem is entirely that patients are demanding x-rays…

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