A picture is not always worth a thousand words…

The saying “a picture is worth a thousand words” is often used to explain how a complex situation, idea, or thought can be conveyed with a single picture. There are many examples of when this is true, such as in the media when a poignant photograph expresses some joyful, or more often unfortunately some heartbreaking situation much better than any article could. 

902639-enfant-aleppo3hjpg

A perfect example of a heartbreaking picture expressing a 1000+ words

And there are many examples when pictures can convey an idea or information effectively and easily within healthcare, such as the use of an info-graphic to help disseminate scientific literature and research just like Yann Le Meur  @YLMSportScience and Chris Beardsley @SandCResearch do so very well. Then there are images that can get across a message simpler, quicker, easier than any blog or an article ever could such as my recent ‘physio treatment pyramid‘ or my ‘road to recovery‘ graph to highlighting the normal twists and turns that occur when getting back after in injury or painful issue.

images

Some of my info-graphics 

However there are many times when a picture is NOT worth a thousand words and they do NOT covey complex information very well. Instead some pictures over simplify, add more confusion, or are just wrong, and end up being more harmful than helpful. For example images of crumbling bones, glass inside knees, and doughnuts shooting jam out used as a reminder not to ‘slip a disc’ when we bend, are all nocebic, harmful, myth perpetuating crap!

However, as crappy as some of these images are there are also many other examples of when real medical images are not put to good use in healthcare. I’m now talking about the misuse and over use of medical images such as MRIs and ultrasounds (US). There is a commonly held belief by both patients and many clinicians that an MRI or US image of a herniated disc, or degenerative joint, or a torn tendon can explain why things hurt or are not functioning properly. Well unfortunately in a lot of cases it isn’t as simple as this, and the dependence on medical imaging needs to be questioned and challenged a lot more.

However, I want to make it clear that there is no doubt that advances in medical imaging and technology have improved and enhanced modern healthcare hugely. From the first accidental discovery of the X-Ray by Wilhelm Roentgen back in 1895 being quickly put to good use by battlefield surgeons to locate bullets and shrapnel in wounded soldiers, to the development of other techniques such as CT, MRI, ultrasound etc, they have all helped to identify serious life threatening diseases, illnesses, and injury’s quicker, faster, more efficiently. Simply put modern medical imaging has and will continue to save countless lives, and is an invaluable tool… when used appropriately.

But where medical imaging is failing patients is when it is being used inappropriately and incorrectly to explain why things hurt. Unfortunately many patients and clinicians still think that pain and disability is as simple as structural irregularity or damage seen on scan, that is when something is misshapen, wonky torn, degenerative then it must be a source of problems.

xray

Now at times it can be this simple, break your ankle or your wrist, and it will hurt due to the broken bones and other damage. But what if you haven’t had an accident, what if the broken bone heals and the pain persists, what then? Well this is where is all gets a little bit grey and murky, this is where its not just as simple as seeing wonky, misshapen, worn out things and blaming them for the pain.

There is now a growing evidence base that demonstrates many worn out, wonky, misshapen, degenerative, torn things seen on MRIs and other scans are also found very commonly in people with NO pain and NO disability. We are now beginning to recognise and understand that what we thought to be pathology may just be morphology, or ageology, or normology! I’ve just made those last two words up by the way!

For example Guermazi et al demonstrated that many if not ALL the common pathologies seen in knee scans such as meniscal lesions, synovitis, and articular cartilage damage are found just as much, if not sometimes more in subjects WITHOUT pain as those with pain. Next Brinjiki et al showed high prevalence of so called pathology in lower back MRIs in well over 3000 people without any pain or issues in ages from 20 to 80 years old, and Nakashima et al showed similar results in over 1200 neck MRIs in subjects again with NO pain or issues.

images-1

Then in the shoulder we have Grisih et al who found a staggering 96% of subjects with no pain or issues had at least one so called pathology on their US scans… 96%…. Then Teunis et al shows an increasing prevalence with age of non painful, non limiting cuff tears with up to 65% being non-symptomatic, or Schwartzberg et al demonstrating 72% of all shoulder SLAP lesions in middle aged subjects are non-symptomatic, or Le Goff et al demonstrating that over 50% of calcific deposits seen in cuff tendons are non-symptomatic, or Lesinak et al showing nearly 50% of young elite level professional baseball pitchers have cuff tears and SLAP lesions with no effect on their performance or injury rates.

And this is just in the shoulder, I could go on and on showing study after study conducted on symptom free subjects that shows so called pathology in many areas that do NOT cause ANY pain, or ANY dysfunction! It is not just as simple as seeing that worn out, wonky, misshapen, or torn thing on a scan and saying it needs to be treated or fixed. We first have to understand what is normal before we can say what is abnormal, and where we thought defects in structure where abnormal it seems that in some cases these are normal signs of aging or activity.

A saying that is often used to explain this, is that many things seen on scans are just signs of ‘aging on the inside’, just like we see signs of aging on the outside like wrinkles and grey hair. Another way to explain the issues in interpreting  what we see on scans and images in healthcare comes from my mate Mike Stewart @knowpainmike. He uses a picture of a telephone to help explain to patients that just because you see this picture of a telephone, you can’t tell if its ringing or quiet? This is the same for a torn or worn out structure seen on a scan, we can NOT tell if its ringing (i.e painful) or quiet (i.e non painful), that’s why we need to use the scan COMBINED with the examination to check.

wedding-2

Happiest day of my life!

Another way to explain this that I also like comes from the enigmatic David Poulter @Retlouping. He explains that a scan image can be like a wedding photograph, just like my one above. Just by looking at the group photo with everyone looking all happy you can not actually tell who is happy, who is sad, angry, pissed etc… just like we can not tell by only looking at an MRI with all the things being reported as problematic which actually are, and which are not.

Now while we are on the subject of medical images I want to discuss a few issues I often come across that I find are becoming more frustrating and more annoying. The first is that scans help reassure patients. I often hear and see clinicans referring patients for scans because the patient wants it when there is no clinical indication. Not only is this wasteful, unethical, and lazy practice, it is actually not evidence based. Despite common belief there is NO evidence that scans reassure patients (ref), in fact there is more evidence that they can cause more fear, angst, and harm (ref).

Simply put it is the job of the clinican to reassure patients, not a scan!

Next I want to discuss some issues with the reporting that occurs on scans. Now I have many radiologist colleagues and friends and they are without doubt experts in reading and interpreting medical imaging, and their role in doing this is invaluable to me and the healthcare professionin general. However, what radiologists are not is diagnostic clinicians, that is they do not take full patient history’s or examine the patient functionally, so they only ever gain a small part of the clinical picture.

However, I am having more and more of my patients being informed by radiologists that they need a certain treatment or surgery based on what they see on a scan. This drives me bonkers, as more often than not the recommendation by the radiologist is incorrect, however, once the seed is planted into patients heads it is really, really hard to unpick, and it only leads to confusion and mistrust for the patient. So please radiologists if you are reading this, for the sake of my blood pressure, just stop it.

Also still on the subject of reporting on images it should be recognised and understood that although this is a skilled profession it is still remarkably unreliable. This recent study by Herzog et al  highlights the lack of consensus in the interpretation of just one patients lumbar spine MRI. This one patient visited 10 different medical centres and had 10 MRIs within a 3 week period. Each scan was reported by 10 different radiologists and a total of 49 different pathologies where reported on. However no pathology, that’s none, zero, zilch, nil, nada was reported consistently by all 10 radiologists, not one! As the saying goes, interpretation really is all in the ‘eye of the beholder’.

Finally I think if more radiologists were educated or understood the prevalence of defects and degeneration in the non-symptomatic populations more, this would change the way they interpret and report images far better, which would have a huge impact on patients care. For example this study here shows that when an image report is put into context with epidemiological data patients are less likely to be prescribed unnecessary medications by their clinician. And this study here demonstrated that by simply rewording reports again with epidemiological data and in a positive light, such as changing the word tear for high signal or defect, it was shown to improve patient understanding and satisfaction.

So in summary we can see that pictures and images used in healthcare have both positive but also negative effects, as do most things. I think it is all our responsibility to try and maximize the positive and reduce the negative when it comes to medical imaging. Clearly it has a role, but we need to use it wisely and sensibly. I will leave you with the brilliant acronyms used by Richard Heyward in his seminal editorial on the issues of imaging in the BMJ back in 2003 here. When it comes to medical imaging and scans do not B.A.R.F or create V.O.M.I.T, that is do not use Brainless Application of Radiological Findings and create Victims Of Modern Imaging Technology

Never treat the scan, always treat the man!

As always thanks for reading

Adam

 

 

17 thoughts on “A picture is not always worth a thousand words…

  1. Well done article. It makes me think that an entrepreneurial enterprise would be to create software that includes epidemiological data of imaging findings to amend the reported findings and reduce the nocebo effect, which, as we all know, is very difficult to undue.

    One suggestion, please amend your last line to, “don’t treat the scan, treat the man, or woman. ” thank you 🙂

    • Thank you for your comments.

      The saying don’t treat the scan treat the man, is merely a metaphor than a literal statement. It’s not meant to be sexist but rather a just a saying. If it’s changed it won’t have the same ring or appeal to it!

  2. I recently had to go see a doctor for lateral epicondylitis and he insisted on Xray for my neck and told me I would “never get better” with my elbow because my neck showed “severe degenerative arthritis” the “worst he’d ever seen”. My neck doesn’t hurt, my elbow is better with strengthening and that doctor is the worst kind of idiot. Enough said.

  3. Great post. We’re dealing with this on a daily basis with the chronic pain population. Over the last decade, prescriptions for opioids, MRI scans, spinal injections and surgery levels for back pain have risen by 20-30%, disability levels for lower back pain have increased by 15-20%, with a chronicity prevalence of 80% and life time prevalence reaching 60-70%! Even more alarmingly, back pain prevalence among adolescents and children have also risen, being 3-4 times higher in Western Europe compared to the rest of the world. 133 million work days are lost annually in the UK with lower back pain listed as the most prevalent cause. That is a not only a huge loss of productivity and cost, but a damning presentation of what could be called a failing model of health care.

    Just like a nocebo effect, patients being told their scans shows “damage” or “crumbling”, or their back is “worn out”, “looks like that of a 70 year old” or is “stiff”, “immobile”, “out of alignment”, often end up with further fear of movement, increasing tension and stiffness, persisting pain, sleeplessness, health anxiety, low mood which again affects their ability to work or stay in employment – affecting financial health and further increasing anxiety in a never ending evil circle. And here we are, we’ve succeeded in transforming our patient into a nice, big VOMIT.

    Only after people have been through packets of medication with ever increasing strength – from painkillers to antidepressants and gastro protectors, then eventually ending in repeated injections of corticosteroids – only then does the patient end up in a pain clinic, where they more often than not are told their pain cannot be taken away and they need to learn how to live with it. Can you imagine the impact that this can have on someone’s self efficacy and rehab potential? Only then they might be introduced to mindfulness, pacing, the actual importance of diet and exercise, sleep hygiene, talking therapy, movement retraining, education and advice about what is actually happening in their nerves, muscles and brain. And whilst it is never too late to improve someone’s symptoms, it is certainly much more difficult once all aspects of the patient’s life have been affected, and significant health care beliefs have been formed.

    Never treat the scan, always treat the man indeed!

  4. I am brand new to your blog and can already tell you are my kind of therapist. I deal with this every day, despite the fact that I work with a great team of doctors and radiologists. My explanations usually get through, but it can be difficult. The latest thing I am seeing a lot is patients coming to therapy because their MRI will not be approved until they have a trial of therapy. While I still believe that insurance companies are evil, I have to say that I am not completely opposed to this. It gives me another tool in my arsenal to explain to the patient that even if the MRI showed the worst, that a trial of therapy would still be the best course of action. And very often, after I get them moving for a couple of weeks, they end up not needing the MRI.

    Great article. Keep it up!

  5. Hi Adam. If you are who I think you are I am saddened, disappointed and extremely angry at your comments. As a radiologist and clinician I find your comments rather u professional. Have you spent 5 years at medical school? Have you practiced medicine and surgery after that and gained a further degree in medicine or surgery? Have trained in CLINICAL DIAGNOSTIC RADIOLOGY? I think not. I am diagnostic radiology clinician. We so take histories and examine. Ita what we are trained to do. It is very dangerous to pick up a prime and say I’m going to learn this by going on a short course ans then claim to be an expert. So you work un the NHS most of the time? I believe not. So you thought ill make money this way. There are good docs and there are not so good docs. A radiologist can provide an examination amd report that is meaningful amd clinical based on their years of medical training and knowledge. Who do you go to when u have a difficult case?

    • Dear Dr Chahil

      Thank you for your comments, however I am a little confused at your angst and slightly upset and disappointed at your allegations. First as my profile clearly states I am both an ESP for the West Hertfordhsire Hospital Trust as well as a clinical lead for a private healthcare company in Hertfordshire. And I do work over 50% of my time within the NHS as a front line autonomous clinician in three busy general hospitals, and if you think I make any money from my blogs you are very much mistaken, and I resent the accusation that this or any other of my blogs are doing this

      Next I am at a loss as why or how you think this blog is unprofessional. I make it very clear if you read again that I have many radiologist colleagues and friends who do an invaluable job and who help me both professionally and personally a great deal. This is not in question. Nor have I stated otherwise.

      However, what is in question is that many clinicians, that is both radiologists, physios, doctors, etc etc still confuse pathology with morphology and think pain is simply explained with what is seen on scans. It is not this simple and the many papers I quote highlight this, and I will not apologize for raising this issue and making more aware of it, as I routinely have to correct patients who have been misinformed by others that their scan shows X and this explains Y and need Z, when this is not the case.

      Also I am trained in radiology, and physiology, and anatomy, and pain science, and history taking, and clinical examination etc etc. but I do not have a degree in medicine or surgery, I don’t need one to know who needs, or doesn’t need onward referral for medicine or surgery.

      Finally your appeal to authority and experience is tiresome and mistaken. Just because you have years of practice, this shouldn’t be confused with equal years of knowledge. I have only a years knowledge, but this has been refreshed every year for the last 15 years.

      I would however be interested in your views on the recent Herzog et al MRI reliability study in the case of the patient with low back pain and the lack of consensus between radiologists.

      Kind regards

      Adam

  6. Hi Adam, thanks a lot for the blog – a crucial issue and I’m sure a day-to-day sticking point for physiotherapists the world over. I strongly agree with your message however I fear that this can be taken too literally by some clinicians i.e. that a scan is always irrelevant to understanding why someone has pain (beyond the assessment for red flag pathology). For example, you quote the Guermazi et al (2012) study showing a high prevalence of ‘abnormalities’ in asymptomatic knees on MRI. However, it should be noted that patients with any evidence of radiographic OA were excluded in this study. From pooled data which included that same cohort, Neogi et al (2009) actually showed a strong correlation between signs of radiographic OA and knee pain. Serbian (2016) also produced similar findings examining patients with bilateral knee OA, that cartilage loss emerged as an independent predictor of both pain intensity and WOMAC score.

    I feel caution is needed our interpretation of the research here. Neogi et al provide a good discussion of the research and discrepancies between studies in their paper. Pain and function can be closely related to scans in some joints/circumstances and I wonder if we will see replication of the above knee example in other joints such as the foot/ankle. However, as clinicians, we are told not to use terms such as “wear and tear” or “degeneration,” nor to give them negative prognoses, even when the clinical picture suggests such. How then, to communicate these findings honestly in a way that avoids, or at least minimises, distress in the patient in addition to avoiding medical jargon? This is a clinical challenge and I’d be grateful for your thoughts.

    • Hi Mike thanks for your comments and I was not aware of the Neogi paper so thanks for pointing me towards that.

      You make excellent points, and I do try to stress that medical imaging is useful and needed when appropriate and in conjunction with a good history and physical exam!

      As for words to use when we explain these findings and the pain patients experience this is not a simple answer, and think it needs to be done on a case by case basis. Personally I don’t see much wrong in calling arthritis arthritis, as for other terms e.g. Wear and tear, degenerative joint disease etc well these can induce fear and threat in SOME patients so caution with these terms is important!

      Cheers

      Adam

  7. ” what radiologists are not is diagnostic clinicians”

    You lack the knowledge that the actual job title is a ‘clinical radiologist’, following formal trainingin both medical and/ or surgical specialties prior to radiology training. I would encourage you to go through 5+ years of medical school followed by a minimum of 7 but usually 10+ years of postgraduate training and countless exams to become a consultant. You would then be qualified to offer an opinion on imaging and patient management at the same level. You seem to hold yourself to the same regard as a consultant sports physician/ orthopaedic surgeon etc in terms of your understanding of the ‘clinical picture’. I wish you and your patients all the best.

    • I do not hold myself in any regard Sumeetra. I know there are clinical radiologists however I also wonder how many clinical radiologists do actually take a full history and do a full physical examination including functional testing etc, as well as then have the time to conduct the imaging tests requested?

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s