Blog 1: “What do the common cold and persistent pain have in common?”

Here it goes – the first instalment of my blog series. It is titled as above.

I took this photo the other day at my local train station on the way to work:

(It is easier to see the details if you click on it)

2015-07-16 08.27.15

It may be apparent by now that my brain works in strange ways but I couldn’t help seeing a connection between this sign and my work.

The medical profession has known all along that antibiotics are only effective against bacteria and not viruses and that there was no direct benefit and potential problems in terms of resistance in over-prescribing antibiotics.

Yet, like a large number of people, I was always prescribed antibiotics every time I got a bug when I was growing up. Feeling awful, the local GP visited (house calls, ha – remember those?), a 3.5 minute consultation with usually a cold stethoscope and always a prescription. And I remember feeling better afterwards every time! There it is, that good old placebo effect again.

And as a consequence of this as a general habit what happened next was that the public became understandably conditioned to thinking that every time they caught a cold or flu-like illness they required antibiotics as part of their treatment. I still hear my bike riding buddies say this regularly when they get ‘chesty’.

So to cut a long story short, here we are in 2015 facing the real threat of ‘super bugs’ and antibiotic resistance threatening to take us back to the horrific results of infections in the pre-antibiotic era unless some clever scientist can figure out a solution.

Now what has that got to do with persistent pain you say?

A dinosaur like me goes back to the pre ‘scan’ era where we had no MRIs to help us with our injury management. The 3 medical idioms in those days (I was told by a recent graduate that they still are being taught) were:

  1. First, do no harm.
  2. Treat the patient, not the x-ray (scan now)
  3. Only order an investigation if it changes your management.

Apart from ultrasound all investigations carried a radiation exposure issue and so especially in young footballers, we relied heavily on our clinical judgement.

And then MRI scans came along.

High quality imaging. Ability to visualise so many more structures etc, etc. And no radiation.

Let’s go crazy … and we did.

Fast forward to 2015.

Every patient who walks through my door, either expects a scan or already has them and gives them to me right after they walk in to my office and then they tell me the diagnosis based on the report. And how scary are those reports (and getting worse)! A perfect very recent example (Oh, I have so many …) was a scan of a local athlete’s hamstring injury with the following description:

“… There is disruption of the intra-muscular tendon rachis with retraction of the tendon to create a wavy serpiginous appearance. Furthermore, there is myofibril disruption with oedema and blood fluid products tracking into the torn muscle fibres …” It actually goes on and on like this but that is enough. MYOFIBRILS! Ha. And all this in the background of my own experience finally backed up by recent research that  scan changes in good old common hamstrings strains makes NO difference to management and return to play outcomes compared to clinical management alone **.

Actually, in this particular athlete her hamstring effectively self released. After excellent rehab she was asymptomatic and fully functional; she presented worried about her other side threatening to do similar.

Back to my point. Good old HISTORY and examination and sensible judgement is now taking a back seat in a long bus to scans.

And here is the kicker. Even when you want to manage a patient sensibly and holistically without a scan, they mostly look at you with a ‘you are an idiot’ look and seek a referral elsewhere.

Just as the general public have been conditioned to think that a cold will not get better without an antibiotic they also have been emphatically conditioned to think that a scan is a vital part of the management of almost any injury or pain condition.

Furthermore, given the propensity of such scans to find things, the next conditioned thought is that what is found needs to be fixed!

Then even if one practitioner says that a procedure is unnecessary, there is always someone else who will offer that and more.

I recall several recent conversations with a few surgeons who, like me, said that they spent their time trying to reassure their clientele and advise that surgery was not appropriate. Like me they then bemoaned the fact that so many patients would go back to their GPs and get a referral to another less obstructive surgeon and they would then never see a referral from that GP again.

At this point I think it is clear where this has been going especially as there is much financial reward in scanning and intervening but exceedingly little in talking, education and reassuring (and then many don’t listen anyway).

But things do change direction when crisis points are reached. The numbers of VOMITs (Victims of Modern Imaging technology*) are increasing alarmingly and if you connect the dots with the pain neuroscience and placebo / nocebo stuff that I explain on this site (hopefully adequately) then you really can see the image of the perfect storm building to similar proportions as the problems with the ‘super bugs’..

I suspect we will be seeing similar billboards at some stage in the future regarding unnecessary scans.

*VOMIT (victims of modern imaging technology) – an acronym for our times. Richard Hayward, consultant neurosurgeon. BMJ 2003;326:1273:

“…The history of imaging since the discovery of x rays has been one of an exponential rise in the volume and accuracy of information, acquired against a background of firstly increasing and then reducing invasiveness—and rising costs … It is small wonder that the flood of information from these investigations and our knowledge of how to deal with it may be several years out of step … So where does this leave us doctors? We adapt to a world in which we must accept VOMIT as a reasonable price for our technological advances. But it’s also a world in which that well tried and tested concept, the doctor patient relationship, exists to help us translate the anxiety provoking generality into, we hope, the reassuringly individual.”

** MRI Poor Predictor for Return to Sports After Hamstring Injury. Medscape. Sep 03, 2015

 PS: First ever blog over and out. That feels good. Amazing what can be done lying in my hammock on a perfect Melbourne day with a laptop. What a great context I am fortunate to enjoy!

27/08/16 UPDATE (to reinforce the point of this blog):

I came across this publication which seemed quite relevant:

“Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data”

Check out the sad conclusion which applies oh, so well to scanning in pain:

Conclusion Patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.”

QED.

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kalfried

I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990's. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to 'de-sensitise' persistent pain, the biopsychosocial management model and exercise & conditioning prescription.

2 thoughts on “Blog 1: “What do the common cold and persistent pain have in common?””

  1. Why aren’t there billboards or posters up in public places, saying that many MRIs are unnecessary?

    I wholeheartedly agree with the gist of what you are saying, especially in workers’ compensation cases, but it is not black and white. I do at times recommend against MRI scans in someone who has never had one, giving the reason that it won’t change management and hope that the patient accepts my rationale. Do you think that it serves any purpose in certain patients to get an MRI scan so that the patient or even some health care providers (like anxious GPs) can be told that there is definitely no “pinched nerve” to reinforce a message that conservative management is the right treatment? Just to be the devil’s advocate, if a patient won’t embrace conservative treatment because he/she believes that there is something terrible waiting to be diagnosed, and therefore fails to recover and return to productive life, is the resultant cost to the individual and to society more than the cost of getting that MRI?

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