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 unfortunately more often some heartbreaking situation far better than an article can.
A heartbreaking picture expressing a 1000+ words
There are also many examples when pictures can convey information effectively and easily within healthcare, such as the use of an infographic to help disseminate scientific literature just like the excellent Yann Le Meur @YLMSportScience and Chris Beardsley @SandCResearch do so very well. There are also many images that can express an idea or message simpler, quicker, easier than a blog or an article can such as my ‘physio treatment pyramid‘ or ‘road to recovery‘ pictures.
Some of my info-graphics
However, there are also many times when a picture is NOT worth a thousand words and does NOT covey complex information very well. Instead, some pictures can oversimplify, or add more confusion and end up being more harmful than helpful. For example images of crumbling bones, glass inside knees, and doughnuts shooting jam out used as so-called education tools to help warn people not to ‘slip a disc’ when they bend over are all nocebic, harmful, myth perpetuating crapola.
But there are also many other examples of when medical images are not put to good use such as X-rays, MRIs, and ultrasounds. There is a commonly held belief by both patients and many clinicians that an image of a herniated disc, a degenerative joint, a torn tendon can explain why someone hurts or not functioning properly, and yes at times this can, but unfortunately in a lot of cases it isn’t as simple as this, and the use and dependence on medical imaging needs to be questioned a lot more.
However, I do 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 techniques such as CT, MRI, ultrasound etc, they have all helped to identify serious life-threatening diseases, illnesses, and injury’s quicker, faster and saved millions of lives. Simply put modern medical imaging has and will continue to be an invaluable tool… when used appropriately.
But where medical imaging is failing is when it is being used inappropriately and incorrectly to explain why some things hurt. Many patients and clinicians still think that pain and disability are as simple as a structural irregularity seen on a scan, that when something is misshapen, wonky torn, degenerative on a scan then it must be a source of pain or problems.
Now at times it can be this simple, break your ankle and it will hurt due to the broken bones, 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 it all gets a little bit more confusing and uncertain.
There is growing evidence that demonstrates many so-called worn out, wonky, misshapen, degenerative, and even torn things seen on scans are found commonly in people with NO pain and NO disability. We are 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 a 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.
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. Then Teunis et al shows an increasing prevalence non painful cuff tears with age and with up to 65% being non-symptomatic, or Schwartzberg et al demonstrating 72% of middle-aged subjects had non-symptomatic SLAP lesions, or Le Goff et al showing that over 50% of calcific deposits seen in cuff tendons are non-symptomatic, or Lesinak et al highlighting that nearly 50% of young elite level professional baseball pitchers have cuff tears and SLAP lesions with no effect on their performance.
And all that 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! So we can see it is not just as simple as seeing that worn out, wonky, misshapen, or torn thing seen on a scan is causing someones pain or needs to be treated or fixed.
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 ageing on the outside like wrinkles in the skin and grey hair on our heads. Another way to explain this imaging a picture of a telephone, just because you see this picture of a telephone, you can’t tell if its ringing or not? This is the same for a picture of a torn or worn out structure, we can’t tell if its ringing (i.e painful) or quiet (i.e non painful), that’s why we need to use the scan COMBINED with a full history and of course a physical examination.
Happiest day of my life!
Another way to explain this that I also like comes from David Poulter @Retlouping. He explains that a scan can be like a wedding photograph, just like mine above. Just by looking at the group photo with everyone looking all happy you can’t actually tell who is happy, who is sad, who is angry, or even pissed etc… just like we can not tell by looking at an MRI with all the things reported as problematic which actually are, and which are not.
While we are on the subject I want to discuss a few more issues I come across that I find are becoming more frustrating and more annoying. The first is that many think scans help reassure patients and so I see and hear more and more clinicians referring patients for scans to reassure the patient when there is absoultly no clinical indication. Not only is this wasteful, and lazy practice, it is actually not evidence-based. Despite common belief there is little evidence that scans help reassure patients (ref), in fact there is more evidence that they can do the opposite and cause more fear, angst, and harm (ref).
To put this as bluntly as I can it is the job of the CLINICIAN to reassure a patient, not a fucking scan!
I also want to discuss some issues with the reporting that occurs on many 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 profession in general. However, unfortunatley many radiologists do not take full patient history’s or conduct a thorough exam of the patient. Yet despite this, I am seeing 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 is unfounded and incorrect, however, once the seed is planted into a patients head it is really, really hard if not impossible to unpick it, and when I tend to give alternative advice it often leads to confusion and mistrust for the patient as they are not sure who best to beleive. So please radiologists if you are reading this, please stop giving diagnostic and treatment advice based soley on what you see on a scan.
Whilst still on the subject of reporting it should be recognised and understood that although this is a skilled job 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 had a total of 49 different pathologies reported. However no pathology, that’s none, zero, zilch, nil, nada were 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 aware of the prevalence of changes seen in the non-symptomatic populations more this would change the way they interpret and report images, which can have a huge impact on patients. 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. I think it is all healthcare professionals 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 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 human!
As always thanks for reading