Dr. Allan M. Block
In dementia workups, or even with more benign forms of cognitive impairment, a cranial imaging study is always needed. Like most neurologists I prefer MRIs, although I am willing to settle for a head CT when I have to.
These studies aren’t cheap, but as part of the workup, to exclude other causes, they are invaluable.
Generally one is all that is needed, although there are exceptions. But some patients and families seem to think MRIs need to be repeated often, anywhere from annually to every few months, “to make sure nothing has changed.”
You usually can’t talk them out of it either. There must be “some reason” why the patient keeps getting worse. Explaining that it’s a degenerative process that doesn’t show up on MRI gets me nowhere. They read something on the Internet about it, or heard a story about the uncle of a friend of a friend, or they focus on an incidental finding that must be the cause (like an 8-mm meningioma).
Generally I stand my ground. Obviously, there are times another imaging study is warranted, such as for a dramatic, acute neurological change, but in most cases all we’re really seeing is the sad progression of disease.
I’m not unsympathetic to these people. I feel bad that this has happened to them and that they’ve been given incorrect information. I take as much time as needed to explain the disease and why another study is not needed. It’s easy to write an order for the study to appease them, but it only leads to repeating it again in a few months. Every MRI I order costs time and money, and could take the same test away from a person who truly needs it.
Sometimes the patient and family will understand after we discuss it and the request is forgotten. Other times they leave my office upset, post a bad Yelp review about me refusing to treat their ailing parent, and change neurologists. Occasionally they’re able to get their internist to give in and order a repeat MRI, and when the repeat study hasn’t changed they call me wanting to know when the next one should be done.
Throwing more money at a problem, especially when you already know what the answer will be, is never a good idea. Not now, not ever ... in medicine or anything else.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.