Crosstalk

A message popped up on Rahul’s Slack telling him that Samir, a patient wanted to speak with him.

Samir had recently undergone an MRI of the lumbar spine, which Rahul, a radiologist, had reported. Samir had a left posterolateral intervertebral disc hernia, a slipped disc that was pressing on his exiting nerve root at the L4/5 level and this had minimally progressed over a month, compared to an earlier MRI.

The phone rang and Samir was on the line. Rahul asked him, “Hi Samir, this is Rahul. How can I help you?”

Samir came straight to the point. “Dr. Rahul, thanks for speaking with me. My surgeon has said that surgery is a must. Is it required?”

Rahul asked him back, “What is your problem?”, to which Samir said, “I have no problem.”

“If you have no problem, Samir, then why do you need surgery?”

“Oh, but then why did the surgeon say I need surgery?” Rahul did not know how to answer that question. There are so many variables involved when it comes to this kind of decision making. Normally, Rahul would have told the patient that the decision to operate or not was best left to the orthopedic or spine surgeon and that as a radiologist, he was not the best person to answer such questions.

Unfortunately, Samir was the son of a friend of his mother’s and given that this wasn’t even a question of epistemic trespassing, since Rahul had been looking at spine MRIs and interacting with patients and spine surgeons for over 20 years, he couldn’t just wriggle his way out of this situation by using the stock radiologist answer that their referring doctor would be the best person to answer that question.

Rahul decided to help him. “Samir, why did you get the MRI done then, if you have no problem?”

“Because, the surgeon asked me to.”

“Why did you go to the surgeon in the first place?” Rahul was trying to understand Samir’s clinical issue. With disc hernias, especially in young people like Samir, who was 30-something old, surgery is usually indicated only when there is motor weakness, when the nerve is compressed to such an extent, that apart from pain, there is actual weakness of the muscles supplied by the nerve.

“Because my family doctor asked me to.”

Rahul sighed. This was clearly going to be difficult. “Why did you go to the family doctor?”

“Because I had pain”.

“When did the pain start?”

“About 8 weeks ago."

“Do you remember if there was any specific action you were performing at the time?”

“Yes, I had bent down to pick up something and I then felt a sharp pain starting in my back and going down my left leg.”

Finally!

“What did you do then?”

“I went to the surgeon."

“But didn’t you first go to your family doctor?”

“Yes, but then to the surgeon."

“Did you go the same day?”

“No, I waited for 8 days and when it did not get better, I went to the surgeon."

“And you did your first MRI of the spine after that?"

“No, I did the first MRI after the family doctor told me to and then with the report, I went to the surgeon."

This was frustrating. Samir was clearly not unintelligent, but Rahul was unable to understand why something as simple as trying to trace the origin, duration and progress of Samir’s pain was becoming so difficult.

If Samir was improving and did not have pain any more, then irrespective of the MRI picture of a herniated  or slipped disc, there was no reason to be operated upon. All these prolapsed discs eventually heal by themselves.

Rahul tried again.

“Samir, I am trying to understand. You had sudden pain, after which you went to the family doctor, who asked for an MRI and then 8 days or so later, you went to the spine surgeon. Right?”

“Yes, that’s right, Dr. Rahul.”

“What did the surgeon say?”

“He said that I should go to a physiotherapist.”

“Did it help?"

“Yes, I became almost 70% better."

“Then why did you get a second MRI done, just a month later?”

“Because when I went back to the surgeon, he examined me and said that the improvement was not as much as he expected.”

“And after the second MRI, did you go back to the surgeon?”

“Yes, he now says I need surgery.”

“But, didn’t you tell me, that you now don’t have any problem? Didn’t you to tell that to the surgeon?”

“I did, but he said that the the disc had worsened on the MRI, so I need surgery." Rahul was now struggling. Samir apparently had improved, but the surgeon said he hadn’t and needed surgery?

“But, do you have weakness?”

“I don’t know. I have a little limp, once in a while.”

“What about the pain? It’s gone right?"

“No, it has gone by 80%, but it’s still there."

“Are you still doing physiotherapy?"

“Yes."

“And does the physiotherapist think there is improvement?"

“Yes.”

“Then why do you need surgery?”

Rahul had asked a rhetorical question. He was trying to put himself in the surgeon’s shoes to try and understand the reason for surgery. Rahul had not seen Samir, had in fact never met him, did not know if his problem was just pain or was there muscle weakness, and given that the conversation had gone from “I have no problem”, to “I have 20% pain and I sometimes limp”, Rahul wasn’t even sure whether he could rely on Samir’s narrative to even give any form of advice. He did not want to second guess the surgeon.

But Samir anyway replied, “Because the surgeon asked me to.”

Rahul gave up. He told Samir to wait a few more days, continue physiotherapy and then decide for himself if he wanted surgery or not, but to use some common sense if he was improving. Or he could just follow the orthopedic surgeon blindly…whatever worked for him.

Rahul wondered. Was this difficulty in communication with Samir a result of how radiologists are perceived by people like Samir? Do people truly believe that a radiologist does not know any clinical medicine? Did Samir really expect Rahul to help him with his surgery decision solely on the basis of the MRI? Do people believe that technology is superior to a doctor’s clinical judgment skills?  Do they actually think that an MRI is the final word, irrespective of symptoms and signs?

Rahul shook his head and went back to reporting the next MRI on his workstation.