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• W2244703732 abstract "Commentary Medical providers should deliver a high quality of care to their patients without ordering unnecessary tests. This concept has been brought to the forefront at a time when health-care costs have markedly increased. Berwick and Hackbarth reminded us of the initial goals from the Institute of Medicine in providing care to patients and emphasized providing quality care that is safe, effective, timely, equitable, and patient-centered1. Today, an additional goal to improve quality is providing affordable care. We must understand these goals to improve the process of care in order to maintain high value and to minimize risk to our patients. The study by Wylie et al. uses knee pain as a model to evaluate this process of patient care. In 2011, the Bone and Joint Initiative demonstrated that up to 17% of adults presented to a physician with a chief symptom of knee pain2. Many different types of health-care providers are in a position to be the first to evaluate these patients with knee pain. All of these health-care providers should maintain a methodical approach to the patient encounter by starting with a defined chief symptom, followed by a complete history and a detailed examination. Typically, the initial workup consists of diagnostic imaging for the patient presenting with knee pain. Magnetic resonance imaging (MRI) is a valuable tool to help in the diagnosis of knee pain, but it is expensive. I agree with Wylie et al. that primary radiographic imaging of the knee should be made before MRI, a technique that is considered advanced imaging. A two-day summit sponsored by the American Board of Radiology Foundation and dedicated to addressing overutilization of medical imaging suggested that up to 50% of high-technology imaging procedures failed to provide information that improved patient care3. Wylie et al. should be congratulated for their excellent work. The objective of their work was to determine the completeness of the patient evaluation through history and physical examination documentation prior to ordering knee MRI, to correlate this within provider groups, and to provide an analysis comparing the rate of positive findings on MRI. In this study, when compared with primary care physicians, orthopaedic surgeons and nonsurgical sports medicine physicians were more likely to document a history of the present illness and a knee examination, to evaluate knee radiographs prior to ordering MRI, and to have more positive findings on knee MRI. The positive findings on MRI were defined as a priori as a diagnosis that could be treated by nonarthroplasty knee surgery or a major diagnostic significance. One limitation to this article was that this study did not correlate the MRI findings to the clinical diagnosis or the ordering physician’s impression. In fact, this study does not demonstrate what the treating physician’s clinical impression was, nor why MRI was ordered. Despite defining what I consider simple criteria of documentation via the electronic record of a history and physical examination, there was still worse support of this documentation by the primary care physician group. In this study, Wylie et al. demonstrated that 40% of patients treated by primary care providers underwent MRI before radiographs to evaluate their knee pain, four times as often as patients seen by either of the specialist types. Other data have also demonstrated this by documenting that only 12% of knee MRI ordered by a primary care physician would have been ordered by specialists and only 17% would have changed the treatment plan4. Intuitively, further education is needed in the understanding of the musculoskeletal system as it relates to a proper history, physical examination, and treatment plan. There is a perception that medical school education on the musculoskeletal system is inadequate. Education on musculoskeletal anatomy and physiology is covered, but the clinical skills to treat a patient with a musculoskeletal problem are lacking5-7. We also need to understand why the musculoskeletal specialists in the study by Wylie et al. had a positive MRI finding only 48% of the time. It is important to understand why primary care physicians are ordering MRI. Some may argue that the subspecialist requires this advanced imaging before he or she can make a referral. Furthermore, patients may demand MRI. As a surgeon, sometimes normal MRI with no internal derangement reinforces the need for nonoperative treatment. Despite these challenges in our understanding, it remains important that we have an opportunity to continue to educate all physicians on the importance of the process of care in evaluating musculoskeletal symptoms." @default.
• W2244703732 created "2016-06-24" @default.
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• W2244703732 date "2015-01-07" @default.
• W2244703732 modified "2023-09-27" @default.
• W2244703732 title "After the Bone and Joint Decade: It Is Still Time to Educate on the Musculoskeletal System" @default.
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• W2244703732 doi "https://doi.org/10.2106/jbjs.n.01130" @default.
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