A 53-year-old man comes to the emergency department of an academic medical center with back pain after lifting a heavy box a day earlier. The patient appears anxious and in pain. He says, "I'm worried I've twisted a nerve in my back, and I really hope you are going to do an MRI." A second-year resident obtains the patient's history and conducts an initial physical examination. Palpation of the lower back reveals paravertebral tenderness on the left side at the L4 level; there is no tenderness to palpation over the spine. Strength and sensation in both extremities are intact, and deep tendon reflexes are symmetric. The resident presents his findings to the attending physician, mentioning the patient's concerns and request for MRI. As the attending physician examines the patient, which of the following statements is most recommended to reduce patient requests for unnecessary imaging?

Question

A 53-year-old man comes to the emergency department of an academic medical center with back pain after lifting a heavy box a day earlier.  The patient appears anxious and in pain.  He says, "I'm worried I've twisted a nerve in my back, and I really hope you are going to do an MRI."  A second-year resident obtains the patient's history and conducts an initial physical examination.  Palpation of the lower back reveals paravertebral tenderness on the left side at the L4 level; there is no tenderness to palpation over the spine.  Strength and sensation in both extremities are intact, and deep tendon reflexes are symmetric.  The resident presents his findings to the attending physician, mentioning the patient's concerns and request for MRI.  As the attending physician examines the patient, which of the following statements is most recommended to reduce patient requests for unnecessary imaging?

Quizplus · Accepted Answer

Explanation: Resource overuse (eg, unnecessary imaging for uncomplicated low back pain) is associated with increased health care costs and suboptimal patient outcomes. Current guidelines specify that imaging is not indicated for uncomplicated, acute back pain (<4-6 weeks) lacking "red flags" (eg, constitutional symptoms, prior malignancy). However, patient concerns about serious but unlikely causes of pain (eg, significant nerve injury) may precipitate expectations for imaging that conflict with optimal care and physician judgment. Patients with low back pain are less likely to request imaging studies when they believe the physician has performed a thorough physical examination that checks for serious pathology and they receive a specific explanation of their condition. Recommended practices include the following: Apply patient-centered (rather than paternalistic) approaches to build a patient-physician partnership and directly address patient concerns. Perform a detailed physical examination, giving special attention to areas that are concerning to the patient and providing ongoing commentary on what structures are being assessed and the significance of findings. This patient's request for imaging is likely linked to his concern for nerve damage; providing specific commentary during the examination confirming that his nerve function is normal is likely to reassure the patient and support subsequent discussions explaining why imaging is unnecessary. (Choice B) This statement simply reiterates the physician's perspective regarding imaging but does not address the concerns that precipitated the patient's imaging request. (Choice C) This statement is vague (eg, physical examination is "normal"), does not address the patient's specific concerns, and is less likely to reassure the patient. (Choice D) This statement is physician- rather than patient-centered, does not address the patient's specific concern, and is likely to be perceived as dismissive. (Choice E) This statement describes a potential cause of the pain; however, it does not reassure the patient that the physician has assessed for nerve damage and is likely to be less effective than specifically addressing nerve function. Educational objective: Patients with low back pain are less likely to request unnecessary imaging studies when they believe the physician has thoroughly checked for serious pathology and has addressed their specific concerns (eg, nerve damage). The physician should perform a detailed physical examination with specific, ongoing commentary on the structures being assessed and the significance of findings. References: Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/21282698)

A 53-Year-Old Man Comes to the Emergency Department of an Academic