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 still 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 much better than any article could.
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 other images that can get across a message simpler, quicker, easier than a 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.
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 can be just wrong, and actually end up being more harmful than helpful. For example images of doughnuts shooting jam out often used as an metaphor supposedly reminding us not to ‘slip a disc’ when we bend, which is simply nocebic, harmful, myth perpetuating crap!
However, as crappy as some of these images are there are other more worrying examples of when an image is 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 still a widespread and 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, and the planning of interventions and treatments using medical images alone needs to be questioned and challenged a lot more.
However, I first 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 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.
However, where modern medical imaging is failing patients and clinicians is when it is being used inappropriately and incorrectly to explain why things hurt, and then goes on to recommend treatments including surgery for many musculoskeletal issues such as back, hip, knee, and shoulder pain. Unfortunately many patients and clinicians still think that pain and disability is as simple as structural irregularity or damage seen on scans, that is when something is misshapen, wonky torn, degenerative then it must be a source of problems.
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, or bulging 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 ology’s 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.
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! So its 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 just 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.
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 and 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