“I Just Want an X-ray”

People often want to order their own test. Or, rather, they call and want us to order the test they think they need. I usually decline such requests. Not because I’m mean spirited or money hungry, but because I am a conscientious doctor.

I don’t make any more money by making the patient come in so I can examine them and be sure to order the right test for their symptoms. I’m on salary. But I know anatomy and physiology better than most patients, and I know which test is better for what.

The self-directed imaging request is not a one step process. Whether the test is positive or negative, there are usually followup questions that require medical advice, which takes time and creates liability.

A sparained ankle can be as disabling as a broken one. What (free) advice do I give a patient I didn’t examine?

I, personally, would hate to be asked by a malpractice lawyer why I settled for ordering a plain X-ray of Mr. Barnes severely bruised leg at his request, over the phone, when it was swollen and tender and he in fact turned out to have a deep vein thrombosis that caused his near-fatal pulmonary embolus.

The other day a nurse called and asked me to order a shoulder X-ray of her husband with shoulder pain. When I saw him in the office, he had an A-C separation, a condition better evaluated with X-rays of the acromioclavicular joint – sometimes both of them, carrying weights.

It is important to listen to our patients’ accounts of their symptoms and their fears and concerns about worst-case scenarios. Some people need more and earlier imaging than others: Their past medical history (of cancer, for example) or nuances in their symptoms can make all the difference in the world.

I believe in, and very much encourage, self care for common illnesses and injuries. But when medical tests are called for, a medical person needs to order them and interpret their significance.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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