Date: Thu, 30 Jul 1998 04:12:32 -0500 To: chiro-list@silcom.com From: Neil and Deanne Tarvin Subject: Re: To buyor not buy X-ray in start-up practice This is not the only time someone has commented about using an x-ray to find an aneurysm - this one the size of a grapefruit. (!!!!) Are you all just NOT doing plain old physical exams???? We were taught several different ways to locate anuerysms during physicals. I should think that any one of those ways would locate an anuerysm the size of a grapefruit.... I can see locating a borderline-sized anuerysm via x-ray, but this????? But, then - maybe I'm missing something here - The total of replies on the x-ray issue (public and private) was *exactly* split - half said yes, half said no. Lots of good comments, both pro and con... We've decided that we are NOT going to get an x-ray for at least 6 months for several reasons.... (1) Having an x-ray to start with means we'll almost be *forced* to use it - probably more than we would normally - simply to justify the cost. (We don't have the cash to just let a $600-700 per month piece of equipment sit idle. Everything we've gotten for the office has to "justify it's existence"...) (2) Malpractice issues - we do NOT want to be held responsible at this point for what might be missed on an x-ray taken in our office... (3) Maintenance and upkeep - as a startup, we don't anticipate seeing very many patients to start with, but the chemicals, etc. would have to be kept up on a daily basis whether we use the equipment or not. Another example of something not justifying it's existence. (4) We are within approx. 1 mile of a diagnostic imaging center - We would rather have a full report from them than do our own interpretations right now. X-ray has been a tough issue for us - Deanne saw a lot of older clinic patients who had serious conditions, and shot a lot of x-rays - I, on the other hand, had a younger group of patients who were basically healthy and whose conditions did not warrant x-rays, and I really had to scramble to make my x-ray requirements. (It's tough to justify an x-ray on a 21 year old dance student with a sacrotuberous ligament sprain, or a 32 year old male with an active deltoid trigger point, etc, etc.) We've heard over and over again from graduates that they're surprised that their practices reflected the same type of patients they treated in clinic. Since I will be the one practicing to start with, and I'm very conservative about x-rays, we decided to wait on the machine until after the first of the year. We thank all of you for your opinions and suggestions - you've been most helpful... Neil & Deanne BTW - we now have our office just about ready to go... ----------- At 02:44 PM 07/29/98 EDT, you wrote: >Dr.Ferguson is absolutely correct. As I stated in a previous post an X-ray >is an absolute necessity. >I have probably been in practice longer than anyone on this list. The >things I have see-----For example, this patient had been to his MD. He >presented to me with low back pain. X-rays revealed an abdominal aortic >aneurism about the size of a grapefruit. >Suppose I had given this patient a lumbar roll adjustment. Probably goodbye patient, goodbye me. > >The patient appreciated my finding the aneurism as well as his MD. > >H>MOOREDC ----------------------------------- Date: Sat, 01 Aug 1998 00:42:38 -0600 From: Lawrence Low Subject: Re: To buyor not buy X-ray in start-up practice Mark, At 08:36 AM 7/31/98 -0700, you wrote: >I totally agree with Sig on this one. Finally something we agree on! I have to also agree with Sig. I moved my office about 5 years ago and decided not to install an x-ray machine in my new office. I have never regretted it. If I feel I need films to confirm a diagnosis or if I suspect a fx I refer to the local hospital. I get the benefit of two opinions that way, my own interpretation and that of the hospital radiologist. I have an added benefit in that if there is a question about a particular region on the film, the hospital can fax the film to University hospital in Denver for yet another expert opinion. >On Fri, 31 Jul 1998, valuenet wrote: > >> I would never consider buying an x-ray machine. If I'm concerned...simply refer patient for films....regarding your post below...it is goodbye you if you missed the signs and symptoms. If not, you are not negligent. Do you >> x-ray everyone to rule out a remote dx if there are no signs or sx....? >> >> Sig Larry ------------------------------------ Date: Sat, 01 Aug 1998 07:46:50 -0700 From: valuenet Subject: Re: To buyor not buy X-ray in start-up practice I hope you guys don't mind if I stick with something that someone agrees with me on... I am involved with interviewing many DC's for Camber regarding the process to acquire clinics. Many x-ray machines are either in disrepair, inadequate or simply are not being used for any number of reasons. Since many patients are cash paying or tied to managed care, it is no longer profitable to take an x-ray and the DC is realizing they can do without it. The DC for the most part is prescribing fewer films, or when necessary refers the patient out. For the most part they realize it has not affected their outcome which is something I've supported for years. A positive outcome is about balancing quality care with cost savings. I measure a positive outcome by how the patient perceives their quality of life has improved...in other words in how they now can perform certain activities of daily living that they couldn't perform as a result of pain. Yes it is about tx symptoms so if they are reduced the patient then can play golf on Sunday... ..you get the drill. You can disagree with that one all you want, but when questioning the patient during initial consult one of the more important questions are "what would you like to do that you cannot do now as a result of your pain? Address that issue and succeed at providing the patient what they want and need...and the referrals will take care of themselves. Sig --------------------------------- From: "Alan M. Tebby, D.C." Subject: Re: To buyor not buy X-ray in start-up practice Sig: I have got to disagree with you on this one. I have an x-ray unit and use it. If I have a question on a film I send the film to the radiologist (MD) for a second reading. For those who don't take films, I think that they are not giving appropriate care to the patient. Let me explain. How many patients have you seen that have have osteophytic spurs, degeneration, fusions, etc. These are not available through palpation and if anyone has a better way of detecting these problems, great! I would like to know. Now Sig, you have to agree that if the patient wants to get back to doing something they have not been able to do it is neccessary to get a complete picture of the patient. And certainly in your review of patient files, do pre-exisiting problems not figure into your assessment of whether the patient should be treated or not treated? Sig, if you don't take a film how do you know? One final point. I was asked to review a file for an attorney who was contemplating a malpractice case against a doctor. A male patient in his 30's walked into the doctors office with the complaint of neck pain which had gradually gotten worse over the last couple of weeks. Past medical history was unremarkable. The onset of the pain was insidious although he thought that he may have "slept wrong". Examination was unremarkable with the exception of restriction in the range of motion 30% in all planes. Palpation revealed spasm bilaterlly in the c-spine. Soto-Hall positive and Compression test positive. No x-rays. Patient was adjusted and said at the time "the adjustment hurt". The doctor then sat the patient up and attempted to check the ROM, the patient was uncooperative and would not allow the doctor to perform the test citing that it was too painful. The patient was placed in a collar and told to come back the following day and to use ice at night. Sig, do you want to X-ray the patient? If not why? If so why? Patient presented to the ER later in the day with neck pain and stiffness. X-rays were performed....lytic tumor at C4. For thse who do not take X-rays, there wasn't anything in the history or examination that indicated there was a potential problem. Yet the doctor was sued for policy limits and a young man's life is forever changed. For those who do not take films on all new patients, please tell me what your defense would be in this case. Alan ----------------------------------- Date: Sat, 01 Aug 1998 14:17:08 -0700 From: "Mark Street, D.C." Subject: Re: To buyor not buy X-ray in start-up practice To buy or not to buy is really not the issue. All imaging decisions should be based on cost effectiveness, potential benefits weighed against potential risks. Routine use of radiography on each and every patient is not considered appropriate or acceptable. A $20,000 x-ray system would take 200 - $100.00 dollar x-ray studies to pay for itself....... Plus all the other expenses that go along with it... X-ray constitutes only a small part of the diagnosis......for those that attempt to make a diagnosis.... The imaging examination should answer specific questions that come up in the history and physical examination. Imaging will not provide all the answers. The different types of imaging examinations have their own inherent sources of error, needs and limitations. One major reason for not ordering radiographs are those ordered based on insufficient clinical indications. It has been demonstrated that clinicians that own their own x-ray equipment use radiography far more frequently than those who do not own their own. The increased use of x-ray by those with a financial interest raises the question of the clinical need for many of these studies. Phillips, RB: Plain film radiology in chiropractic, JMPT 15:47-50, 1992. Hillman BJ et al: Frequency and costs of diagnostic imaging in office practice - a comparison of self referring and radiologist referring physicians, NEJM 323:1604-1608, 1990. Imaging, when used appropriately and coupled with clinical findings is an important component in the diagnosis and management of chiropractic patients. The clinician must determine which patients require x-ray and also the more advanced imaging procedures and which of those many methods are most appropriate for their patient at the time. Mark Street, D.C. - jet@sonic.net --------------------------------------- Date: Sun, 02 Aug 1998 06:45:13 -0400 From: "Timothy A. Langley" Subject: Re: To buyor not buy X-ray in start-up practice Is PAIN your only criteria for caring for a patient? Rarely do we ask "... as a result of your pain?" We DO always ask "How does this condition affect your life?" We have patients that have been coming for years and bring their kids. Rarely do they do so for pain. We also maintain 300-350 patient visits per week and have for over 5 years. Tim Oh BTW we do x-ray our patients. Film is inexpensive. We don't consider x-rays a profit center nor an expense. Just a necessary tool. --------------------------------------- Date: Sun, 02 Aug 1998 07:16:54 -0700 From: "Mark Street, D.C." Subject: Re: To buyor not buy X-ray in start-up practice OK, lets get away from the emotions of buying and making a profit off of x-ray machines. Yeah they are profitable, but for a doc just starting out the added expense could be devastating. Lets look at some of the History and Physical findings that would indicate the need for spinal radiographs. Clinical History ---------------------- Patients more than 50 years old Significant trauma Neuromotor deficits Unexplained weight loss Suspicion of ankylosing spondylitits Drug or alchohol abuse History of cancer Corticosteroid use Fever above 100 F Diabetes and or hypertension Recent visit for same problem and not improved Patients seeking compensation for back pain. Physical Findings ------------------------ Dermopathy - psoriasis, melanoma Cachexia Deformity and immobility Scars - surgical or accidental Lymphadenopathy Motor or sensory deficit Elevated erythrocyte sedimentation rate Elevated acid or alkaline phosphatase Positive Rheumatoid factor Positive HLA B27 antigen Serum gammopathy Anybody have anymore reasons?????? Mark Street, D.C. - jet@sonic.net ------------------------------------ Date: Sun, 02 Aug 1998 21:33:32 -0700 From: Moses Jacob Subject: Re: To buyor not buy X-ray in start-up practice I suggest we also take a look at this from the consumers point of view as well. I would encourage all to get a copy of the book, "The X-ray Information Book, a Consumers Guide to Avoiding Unnecesary Medical and Dental X-rays, by Priscilla Laws PhD. Although dated, originally published in '83, it gives us the other side of this debate ie., from the consumer's perspective who after all is subject to the dosage. I for one am comfortable in practicing with less than more x-ray. So are my patients. Moses ------------------------------------------ Subject: Re: To buyor not buy X-ray in start-up practice From: racedoc@juno.com (Michael D. Massey) Date: Tue, 04 Aug 1998 08:11:20 EDT On Mon, 3 Aug 1998 20:25:46 -0700 Rob & Wendy Ward writes: >Why is it that I've yet to meet a single DACBR who agrees with your viewpoint (and I know many of them)? ...maybe you haven't met the right one? I know several too... Two of them are currently teaching in chiropractic colleges, one is a full-time DACBR, one is on the "lecture circuit"... We've discussed this issue many times. Their concensus opinion is "be safe"... >Couldn't agree more. Let's act like doctors. That means performing diagnostic procedures mandated by clinical >findings, not "screening" every person who walks in for pathologies. What you choose to "screen" for or not "screen" for is certainly your business... I only hope that one of those you don't choose to "screen" doesn't have something you wished you'd have screened for... Be safe. Michael Massey, DC, CCSP Athens/Cleveland, TN ----------------------------------- Subject: Re: To buyor not buy X-ray in start-up practice From: racedoc@juno.com (Michael D. Massey) Date: Wed, 05 Aug 1998 00:23:42 EDT On Tue, 04 Aug 1998 06:39:44 -0700 valuenet writes: >Mike, >I understand your point...taking x-ray, mri, ct, lab any dx test should not be completed unless there is inidication >and can positively impact the outcome to treatment or not to treat for that matter. It is a hard pill to swallow so to >speak....but the cost of care enters into this issue and one you or I can't ignore. >Sig, You're preaching to the choir here when it comes to justifying necessity and cost-effectiveness of procedures. However, the cost I have to figure in is that of emotional trauma to a patient or his/her family members when something is missed, and the financial/psychological costs of dealing with a malpractice suit (justified or not...) >Whether the additional cost is $100 or 10,000...the test or treatment should not be prescribed unless in will >favorably impact outcome. I do think X-ray studies favorably impact my outcome... They help me to diagnose, rule-in, and rule-out...and confidently move forward with my treatment of choice or make the appropriate referral... >Doing a test that rules out less a condition that occurs in a small % of patients when there are no signs or >symptoms is not clinically responsible. Maybe out west you don't see many pathologies or contraindications to manipulation (or even to "osseous" manipulation) but in my relatively short time in practice I've come across a lot...and I remain glad I took the films and didn't treat the patient blindly by "assuming" or "guessing" about their condition. For those who don't ultimately demonstrate pathology, I have had very few which didn't prove to be of some value in confirming/denying a conclusion I'd drawn from H&PE, or simply as an observational or educational tool for the patient... They aren't taken lightly, they are taken minimally and with the patient's safety in mind, and they aren't just thrown to the side after my initial viewing... Rarely do patients present to my office without symptoms. Likewise, they rarely present without at least one of the indications for imaging that Dr. Street listed in his post... Maybe we'll just have to agree to disagree on this one, but you're still going to have a hard time convincing me that I should concern myself more with the cost of a procedure than with its ultimate benefit... I'd hate to think I went to a doctor who weighed economic impact of a procedure ahead of the informational value. I'm all for being prudent and being frugal. However, I believe part of those includes doing what's necessary, safe, and proper, not just what's economically efficient. My $2 worth.... Mike -------------------------------