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Whole-Body MRI Screening — Is More Testing Always Better? · Wellness In Every Season

0:00
SPEAKER_00: We are talking about MRI imaging.
0:03
SPEAKER_00: And this is something that I had done a month ago.
0:07
SPEAKER_00: So it's really had me thinking about it.
0:08
SPEAKER_00: And this is the reason why I asked Dr.
0:10
SPEAKER_00: Davenport to be on with me today.
0:15
SPEAKER_00: Welcome to Wellness in Every Season.
0:17
SPEAKER_00: We talk all things wellness regarding the environment that you spend a lot of your time in, your physical health, your intellectual health, your financial health, your spiritual health, your professional health, your social health, who you have relationships with, your emotional health.
0:37
SPEAKER_00: This is a really big umbrella, so expect all kinds of topics within all of these amazing dimensions of your wellness.
0:48
SPEAKER_00: Let's dive in.
0:55
SPEAKER_00: So welcome, Dr.
0:57
SPEAKER_00: Davenport.
0:57
SPEAKER_00: I'm very happy that you're here and that you said yes to being on with me.
1:01
SPEAKER_01: Of course.
1:02
SPEAKER_01: My pleasure.
1:02
SPEAKER_01: I'm happy to be with you, Autumn.
1:04
SPEAKER_00: Yeah.
1:05
SPEAKER_00: Let me tell you a little bit about him, and then we will get started because we're gonna go pretty deep pretty fast, which I'm excited for.
1:14
SPEAKER_00: He is the William Martell Professor of Radiology and Professor Professor of Urology, Associate Chief of Staff for Michigan Medicine, Service Chief of Staff, and Executive Vice Chair in the Department of Radiology.
1:31
SPEAKER_00: So he does a lot, co-director of the Weiser Center for Prostate Cancer, and special advisor to the Vice Dean of Clinical Affairs.
1:42
SPEAKER_00: He is a practicing physician, researcher, educator, and national leader.
1:47
SPEAKER_00: He is a co-author on national policy statements, has published over 275 peer-reviewed manuscripts, and is frequently interviewed regarding important issues in radiology.
2:01
SPEAKER_00: And he actually, when I asked him to be on, he said the timing was really great because he had a paper come out and we're going to be talking a little bit about that as well.
2:10
SPEAKER_00: So I'm really excited for this.
2:13
SPEAKER_00: This is something that I have thought about in terms of walking my clients through as they're on their wellness journey for myself.
2:22
SPEAKER_00: What type of imaging do we need?
2:24
SPEAKER_00: Is it helpful?
2:25
SPEAKER_00: Is it not helpful?
2:27
SPEAKER_00: So let me start with my first question before I start going off on tangents.
2:32
SPEAKER_01: Sure.
2:33
SPEAKER_00: What can whole body MRI actually detect and what can it miss?
2:38
SPEAKER_01: That's a great question.
2:39
SPEAKER_01: MRI can detect lots of things.
2:42
SPEAKER_01: It can detect benign things in your body like cysts and small benign tumors and things which are technically abnormal that don't ever hurt you.
2:52
SPEAKER_01: It can also detect cancers.
2:54
SPEAKER_01: It can detect small cancers and advanced cancers.
2:59
SPEAKER_01: It can detect things in your body that are not related to tumors, like for example, aneurysms or changes in your brain matter.
3:09
SPEAKER_01: It can also detect things related to your cardiovascular health.
3:13
SPEAKER_01: So for example, how much fat you have underneath your skin surface, called subcutaneous fat, or how much fat you have around your organs or so-called visceral fat.
3:24
SPEAKER_01: It can give you an idea of how big your muscles are and how fatty your muscles are.
3:28
SPEAKER_01: It can look for other things like hernias and there's a whole variety of things, basically, that it can detect.
3:35
SPEAKER_01: Some of the things it has a hard time detecting are things that are next to gas.
3:39
SPEAKER_01: So it would do a bad job, generally speaking, of looking for things inside your colon.
3:44
SPEAKER_01: So it would not be, for example, a good replacement for colon cancer screening or things that are inside the lungs unless special things are done to optimize that because the lungs are full of air.
3:55
SPEAKER_01: It also cannot detect things that are too small to see.
4:00
SPEAKER_01: And it also does not do a good job of detecting things that are rapidly growing.
4:05
SPEAKER_01: And the reason why is because if you are randomly sampling the population, randomly getting imaging at a random point in time, the odds that you see something that's rapidly growing are really small.
4:18
SPEAKER_01: So if you imagine this is going to be a hyperbolic example, but imagine that something started off as some small cells that you can't see and then grew really quickly, and then within three or four months it already spread, MRI would do a bad job of detecting that because the window to see it would be really brief.
4:37
SPEAKER_01: So the odds that you would see it would be quite small.
4:40
SPEAKER_01: So all sorts of stuff it can detect, and some things that it cannot detect.
4:44
SPEAKER_00: I was surprised that it detected that I have arthritis for my car accident.
4:49
SPEAKER_00: That's the reason why I was in the tube.
4:51
SPEAKER_01: Yeah, for sure.
4:52
SPEAKER_01: So the things that are most people who are familiar with MRI because of musculoskeletal reasons.
4:58
SPEAKER_01: So let's say you're watching football on the weekend and you see one of the football players go down with a knee injury, they usually wind up with an MRI by Monday.
5:06
SPEAKER_01: And so when we're looking at things and tendons and muscles, that's a common ligate cartilage, that's a common reason that people would do MRI.
5:15
SPEAKER_01: MRI is also used for looking at organs.
5:18
SPEAKER_01: So as part of routine clinical care, let's say that somebody had severe liver disease because of either hepatitis or alcohol use, and that it's progressed to cirrhosis.
5:29
SPEAKER_01: Some patients would end up with MRIs to monitor for the development of cancer in the setting of cirrhosis or to monitor someone who's already had a cancer development and looking at the treatment of that cancer and seeing whether it's working or not working.
5:41
SPEAKER_01: So MRI is used for all sorts of things.
5:44
SPEAKER_01: And it's MRI in general, as a general topic, is viewed as one of the most successful innovations in health ever.
5:53
SPEAKER_01: Probably most in fact, this has been looked at if you ask physicians, this has been done.
5:58
SPEAKER_01: If you ask physicians what are the most noteworthy or notable advancements in healthcare over the last hundred years, MRI oftentimes is on the list of the top 10, in some cases, the top five of the most important innovations, because it allows you to see things that otherwise would be hard to see.
6:16
SPEAKER_00: Makes sense.
6:17
SPEAKER_00: And then for most people, most people ask this question for you've been asked it a lot.
6:22
SPEAKER_00: Why go to MRI versus ultrasound?
6:27
SPEAKER_01: Yeah, so the different imaging tests, they they have different properties.
6:31
SPEAKER_01: So MRI does a great job of looking at soft tissue detail.
6:36
SPEAKER_01: It also creates unique forms of image contrast.
6:40
SPEAKER_01: It can image things and tell you, for example, give you an indicator of how much fluid content or water content is in it.
6:47
SPEAKER_01: It can actually measure things like the movement of water molecules.
6:53
SPEAKER_01: It can give you a sense of whether those water molecules are freely moving around or whether those water molecules are having a hard time moving around because they're stuck inside densely packed cells, for example.
7:05
SPEAKER_01: So it can give you information about soft tissue detail and also some information about physiology.
7:09
SPEAKER_01: Ultrasound is a completely different imaging modality.
7:13
SPEAKER_01: It's totally different.
7:14
SPEAKER_01: So ultrasound works really well when it's something's close to the skin surface because ultrasound has a hard time penetrating deeply into the body.
7:24
SPEAKER_01: And it gives you different forms of image contrast that are based on the movement of sound waves.
7:30
SPEAKER_01: So there the image is being created in different ways.
7:33
SPEAKER_01: The types of image contrast is different.
7:35
SPEAKER_01: They have unique benefits and weaknesses depending on what you're looking for.
7:39
SPEAKER_01: For example, if you're looking to see past some bone, like for example, to image the knee, MRI would probably be a better choice because ultrasound, for example, does not penetrate bone.
7:50
SPEAKER_01: MRI has a hard time looking through gas, so does ultrasound.
7:55
SPEAKER_01: So they have they sort of have different properties.
7:57
SPEAKER_01: MRI is much more expensive, it's much more kind of energy dependent.
8:03
SPEAKER_01: Ultrasound is portable and quick and right at the point of the bedside.
8:08
SPEAKER_01: So they have different strengths and weaknesses, and it really depends on what the goals are.
8:12
SPEAKER_01: I'll give you an example.
8:13
SPEAKER_01: So your rotator cuff, which are the muscles that surround your shoulder and hold it into place, allow you to move your shoulder around.
8:20
SPEAKER_01: MRI conventionally had been used to evaluate that.
8:23
SPEAKER_01: But now we know that ultrasound does a great job at looking at those muscles and tendons because they're very close to the skin surface.
8:29
SPEAKER_01: So it's just it just depends on what the clinical question is.
8:32
SPEAKER_00: That makes sense.
8:33
SPEAKER_00: And I think that's helpful for the patient who's been told they should get an MRI and they're scared and they're like, can I do something else as to take out all my jewelry?
8:42
SPEAKER_00: I have to be in this tube that makes tons of noise.
8:44
SPEAKER_00: Depending on what I'm having done, I have to hold my breath.
8:48
SPEAKER_01: It is scared.
8:49
SPEAKER_01: Yeah, it is.
8:50
SPEAKER_01: And in fact, I would say that of people who undergo MRI, one of the more common, this is not a major complication or anything, but one of the more common things that the patients talk about is that feeling of claustrophobia of being inside of a tube and feeling it kind of very close to you.
9:05
SPEAKER_01: And there it's a little bit disconcerting.
9:07
SPEAKER_01: We have, I'd say a good fraction of patients who opt to do either some kind of oral sedation or anxiolytic or in some cases the intravenous sedation, that's uncommon.
9:17
SPEAKER_01: But people who just feel a little bit uncomfortable being in the tube for a prolonged period of time, that could be upwards of 20 minutes, 30 minutes, or even upwards to an hour, depending on how long the scan, what what body part we're taking a picture of and how detailed we want those pictures to be.
9:31
SPEAKER_01: There's always alternatives to things.
9:33
SPEAKER_01: So MRI is used for some things.
9:35
SPEAKER_01: You could use ultrasound, you can use CT scans, you could do no imaging depending on the situation.
9:40
SPEAKER_01: It really depends on the clinical question.
9:43
SPEAKER_00: Yeah, that's really helpful.
9:44
SPEAKER_00: I know when I was in the tube, she asked me if I was okay.
9:49
SPEAKER_00: And in order to respond, I opened my eyes and I realized bad idea.
9:53
SPEAKER_00: And she even heard me say that.
9:56
SPEAKER_00: Just go.
9:58
SPEAKER_00: And I wanted to scratch my nose or do different things.
10:01
SPEAKER_00: And I told myself, no, it's faster if I just stay still.
10:03
SPEAKER_00: Just suffer their convenient doll.
10:06
SPEAKER_01: That's right.
10:07
SPEAKER_01: And also to that point, Autumn, when you're in the scanner, because the imaging takes time to acquire, if you move when you're inside the scanner, it actually distorts the image and makes it harder to make a diagnosis.
10:20
SPEAKER_01: So the best quality images are when you're really perfectly still.
10:23
SPEAKER_01: And when people are anxious or uncomfortable a little bit, they might move a little bit more.
10:26
SPEAKER_01: I'll tell you a small anecdote about this.
10:28
SPEAKER_01: So I'm a radiologist.
10:29
SPEAKER_01: So my practice is I do medical imaging, I interpret medical images as my job.
10:34
SPEAKER_01: And we train people, we train residents and fellows and medical students about how to be radiologists.
10:40
SPEAKER_01: And one of our fellows one year, this is maybe 10 years ago or so.
10:44
SPEAKER_01: This person's been reading MRIs for the last five years of their life.
10:47
SPEAKER_01: They're very experienced with it, and they needed a research volunteer to sort of test out a sequence.
10:52
SPEAKER_01: And he volunteered, he's like, Yeah, what's the big deal?
10:54
SPEAKER_01: I'm happy to just pop in and show how, see how it goes.
10:56
SPEAKER_01: And he was in there for about 60 seconds.
10:58
SPEAKER_01: He's like, Nope, I'm done with this.
11:01
SPEAKER_01: And he and he came right out of the scanner.
11:03
SPEAKER_01: He's like, I don't know.
11:03
SPEAKER_01: I just I thought it was not a big deal.
11:05
SPEAKER_01: And then when I got in there, it was just scary.
11:08
SPEAKER_01: Now, the average person handles this perfectly well.
11:10
SPEAKER_01: We do this all day long.
11:12
SPEAKER_01: This is not a risky thing to get the picture taken in the first place for the most part, but it can be a little unnerving for some people, no question.
11:19
SPEAKER_00: Yeah, I think everybody should experience it at least once, low stakes.
11:26
SPEAKER_00: You don't even have the imaging done, just see what it looks like, experience it from a movie perspective, anything to kind of prepare themselves ahead of time.
11:36
SPEAKER_00: And there's also the knowledge that there are different types of MRIs because you can have it where you have injections, and I forget what that fluid is, but it makes you feel like you're peeing when you're not.
11:48
SPEAKER_00: That one's not my favorite.
11:50
SPEAKER_00: And then there's ones where you don't have anything attached to you except hopefully if you're in the right place, headphones, put some music in, then you can ignore the noises that are going on.
12:00
SPEAKER_00: I was actually teasing the tech that they need to make techno that matches the sound of the machine, so it just feels like it all blurs together.
12:07
SPEAKER_00: There's no way that would work.
12:09
SPEAKER_00: Know that if you had a bad experience with an MRM machine, your next experience more than likely will be different because you've already experienced it once.
12:19
SPEAKER_00: And it's probably going to be a different area of your body, or maybe you were hooked up to an IV and this time you're not.
12:27
SPEAKER_00: There's going to be different things.
12:29
SPEAKER_00: And I think as humans, we tend to psych ourselves up in not the positive way, in the stress way.
12:37
SPEAKER_00: And maybe spend some time meditating right before.
12:42
SPEAKER_00: What are different things that you have found helpful from talking to other people, especially because you do this with so many patients a day?
12:50
SPEAKER_01: Yeah, I think for each person it's going to be unique to them, how they cope with a stressful event.
12:56
SPEAKER_01: And obviously the stress may differ depending on the reason we're getting the scan done in the first place.
13:00
SPEAKER_01: If someone is getting it because they know they have a cancer and it's being monitored, there can be a lot of, they call it scan'sity, where you're nervous about what that's going to show, what's the result going to show.
13:11
SPEAKER_01: And some for some people, I mean, this is life or death.
13:14
SPEAKER_01: They need to know it's a huge deal.
13:16
SPEAKER_01: They know they have a problem.
13:18
SPEAKER_01: The image is going to determine whether they're going to be eligible for this therapy or that therapy.
13:22
SPEAKER_01: And one could be for curative intent, one might not be.
13:25
SPEAKER_01: And the MRI is going to tell them which of those two options is on the table for them.
13:29
SPEAKER_01: So it it can be a very high-stakes endeavor.
13:31
SPEAKER_01: And I think for folks who are in that category, it's very stressful.
13:35
SPEAKER_01: And then for people who have less severe reasons to do it or less aggressive reasons to do it, there might be less anxiety associated with it.
13:42
SPEAKER_01: And to your point earlier, it depends on what body parts being imaged.
13:46
SPEAKER_01: Some of them require your head to be fully inside the machine and others don't, for example.
13:51
SPEAKER_01: Some of them have a, you know, the hole that you go through.
13:55
SPEAKER_01: We call it a bore.
13:56
SPEAKER_01: The hole is the bore.
13:58
SPEAKER_01: And some of them are wide and some of them are narrow.
14:01
SPEAKER_01: And then more narrow that bore is, the more claustrophobic somebody can feel.
14:05
SPEAKER_01: So I think sometimes just like the calming language that people use, the technologists that we work at University of Michigan are really, really thoughtful people and they do a great job of kind of coaching people about how to process it and how to think of it.
14:19
SPEAKER_01: And they're always in their ear, sort of talking to them, okay, we're going to take a big breath now, we're going to hold it.
14:23
SPEAKER_01: They're kind of coaching them basically through the process to relieve some of that anxiety.
14:28
SPEAKER_01: Some people, that's not enough, and they need some help, and they can get help through.
14:32
SPEAKER_01: Their doctor can prescribe something for them, or they can get something over the counter to help them cope cope through that.
14:37
SPEAKER_01: To your point earlier, meditation might be a good idea.
14:39
SPEAKER_01: We, uh, for our pediatric patients, we actually have a process where the child and their family can come and it's not a it's not a working MRI, but it's a replica, and they can kind of see what it's like.
14:51
SPEAKER_01: They can lay in it, they can talk them through it.
14:54
SPEAKER_01: It kind of gets them used to the idea of what it would be like to be in a real scanner so that when they do it for real, they're more comfortable.
15:00
SPEAKER_01: And this has been really huge for us because it decreases the need for uh pharmaceutical sedation for children.
15:06
SPEAKER_01: It decreases the need for anesthesia, which is really a big deal for us.
15:11
SPEAKER_01: Uh for a while, we actually tried developing a 3D Oculus headset you can put on.
15:18
SPEAKER_01: We tried to do this in a way that simulated an MR environment.
15:21
SPEAKER_01: And so we sort of, it was on the technical development stuff, and it never kind of went into clinical production, but we explored it as a way to kind of get people used to the idea of coping with it.
15:29
SPEAKER_01: There's different strategies, I guess, at the end of the day.
15:32
SPEAKER_00: It's really helpful.
15:33
SPEAKER_00: And I know when I was explaining to my children why I was a little bit stressed out and what I was going to have done, and I wanted to share with them just that it's okay to be nervous for things.
15:45
SPEAKER_00: And one thing that I really stress with them is if you're nervous about something, research it.
15:51
SPEAKER_00: So I was showing them pictures, especially after the fact that this is what I went through.
15:55
SPEAKER_00: It made these different beeping noises because it was capturing things.
15:59
SPEAKER_00: And maybe actually I'm gonna ruin it.
16:01
SPEAKER_00: So what do the different noises mean?
16:04
SPEAKER_00: Because I know some people are like me, and the more they learn about it, the more it kind of relaxes them and okay, I know what's going on.
16:11
SPEAKER_01: Right.
16:11
SPEAKER_01: Uh that question could get really physics-oriented really fast, and I'm gonna spare your audience some of those details, but they they call them gradients, and they're it's basically they're setting up let's say this they're setting up a different level of magnetism across your body, which allows the information that comes back to be spatially mapped back to you.
16:31
SPEAKER_01: And it allowed it basically enables the image that's created to map anatomically in a correct way to your body, it's just a fair way to say it.
16:39
SPEAKER_01: And essentially that is the machine doing its work of trying to create the image that your doctors can interpret is basically what those noises are.
16:48
SPEAKER_01: And depending on what kind of image is being acquired, you might hear those noises more or less frequently.
16:56
SPEAKER_01: So within an MRI, you'll have different kinds of images that are acquired within the same MRI.
17:02
SPEAKER_01: They'll have names, like, well, I'll skip the names, but they have sequence names, and those that each of those different images that are acquired have different information in them.
17:11
SPEAKER_01: So it's not a single picture, it's actually a whole series of pictures.
17:15
SPEAKER_01: And each of those pictures has unique information in it that the doctors use to understand what's going on.
17:20
SPEAKER_01: And when an MRI is interpreted, it takes all those different images, takes all those images and synthesizes them together to get kind of a full picture of what's happening.
17:29
SPEAKER_00: So you're telling me there's no way to turn down the noise, there's no way to have the noise in a different room, and there's no way to have techno music that incorporates the noise because depending on the patient and what's being done, it's always going to be different.
17:44
SPEAKER_01: There's a lot of technical development to make it quieter and a more relaxed experience.
17:47
SPEAKER_01: So I think on the horizon are those kinds of things where we keep decreasing the noise.
17:51
SPEAKER_01: Secondly, we do use ear protection.
17:53
SPEAKER_01: So we do have things that you put on your to kind of cancel out some of that noise.
17:57
SPEAKER_01: And you can actually have some noise overlay that's coming on top of it, so long as the patient who's in the scanner is still able to hear what the technologist is telling them, the instructions they're giving, when to hold their breath, and also so that the patient can communicate with the technologist if something's going on that's not expected, if they're having a reaction to something or if they're feeling a certain way, they can communicate back.
18:19
SPEAKER_01: Absolutely, yes.
18:20
SPEAKER_01: In fact, for our children, we actually have shows that they watch during the thing.
18:25
SPEAKER_01: They're literally watching a show to capture their attention.
18:28
SPEAKER_01: So absolutely, you can have, in fact, for the some of the headphones, you can have music that's piped into the headphones in addition to the noise canceling.
18:35
SPEAKER_01: So, yeah, all that stuff's on the table and it cannot be eliminated completely.
18:39
SPEAKER_01: And unfortunately, you can't put the noise in a different room, to my knowledge.
18:43
SPEAKER_00: Because it's part of the machine.
18:44
SPEAKER_01: Part of the machine.
18:45
SPEAKER_00: Yes, I've spent a lot of time thinking about this for myself.
18:48
SPEAKER_00: And I remember I think I was 18, 19.
18:51
SPEAKER_00: I don't know how old I was, but I remember saying, I need a minute, and they were able to pull the bed back out.
18:56
SPEAKER_00: I was able to breathe.
18:58
SPEAKER_00: Actually, I think I was 12.
18:59
SPEAKER_00: I was able to breathe and then, okay, let's go back in.
19:03
SPEAKER_00: So you can ask for what you need, I think is really what I'm trying to get to here.
19:09
SPEAKER_00: And maybe it's research the place where you're going to have it done.
19:13
SPEAKER_00: Maybe you're willing to drive a little bit further if they offer a heated table like I had, or if they offer music on top of the earplugs, or even better, a TV show.
19:24
unknown: Right.
19:24
SPEAKER_00: Okay, let me get to my next question.
19:26
SPEAKER_00: Cause I did go a little bit off topic, but I wanted to make sure that it worked for people who were questioning this.
19:31
SPEAKER_00: They need to have this done.
19:33
SPEAKER_00: So here's a question, and this is something I started to go down this rabbit hole within myself because lesions were found.
19:41
SPEAKER_00: So it was this I had an x-ray that led to an MRI that led to it, and it ended up being fine.
19:47
SPEAKER_00: So here's the question that is related to that.
19:49
SPEAKER_00: What are the financial and emotional consequences of investigating findings that may never have caused harm?
19:56
SPEAKER_00: And I know this can be a little gray.
19:59
SPEAKER_01: No, this isn't this this is the the crux of it, of the whole conversation around diagnostic testing, actually.
20:06
SPEAKER_01: So it's really the right at the heart of it.
20:07
SPEAKER_01: And Autumn, I don't know your personal story, but you alluded to the fact that you had had some imaging that was done that found some findings that went to sort of other tests that were done.
20:17
SPEAKER_01: I think I heard you say that it everything was okay.
20:19
SPEAKER_00: Yep, totally fine.
20:20
SPEAKER_01: Yeah, that story that you told resonates with me as a radiologist because I see that every single day.
20:25
SPEAKER_01: In fact, yesterday I was interpreting MRI scans as part of clinical service, and I was chatting with one of our fellows who had some who was bringing cases to me to interpret and look at, and we talked about it together.
20:38
SPEAKER_01: And of the cases that we had read together, him and I, more than half of them were in the category of what you just described, which are findings that were of low clinical importance that were found incidentally on an imaging test that provoked additional testing, investigation, workup, and it was of no consequence.
20:59
SPEAKER_01: And the patient's life was not affected in any way other than what you just said, which is the financial and emotional consequences of that investigation.
21:07
SPEAKER_01: No, there was no health improvement to the patient.
21:10
SPEAKER_01: It was simply a consumption of resources and some anxiety and stress around the monitoring.
21:16
SPEAKER_01: The economic impact really varies depending on your personal financial situation, what kind of coverage you have, what country you live in, and how healthcare is handled in that country.
21:26
SPEAKER_01: For the sake of argument, let's just assume you're in the US.
21:29
SPEAKER_01: You're either uninsured, in which case everything's out of pocket, or you are insured and you have either a high deductible plan or a low deductible plan as it comes to consumption of imaging or the downstream clinic visits.
21:43
SPEAKER_01: Or you have government paid care in which some things are covered and some things are not covered, and on pretends you have a copay.
21:50
SPEAKER_01: It can the costs come out pretty fast, actually.
21:54
SPEAKER_01: So an MRI could be upwards of thousands of dollars if you have a commercial insurance.
22:00
SPEAKER_01: Plan, or if you have a government paid insurance plan, oftentimes that it's much less than that, and you just pay your copay.
22:05
SPEAKER_01: But if you have a high deductible plan, let's say your deductible goes up to let's say$10,000, and then above that, certain things are covered with a copay.
22:13
SPEAKER_01: And then someone charges you$3,000 for a test.
22:16
SPEAKER_01: Well, that's$3,000 that you probably don't have your fingertips to pay.
22:21
SPEAKER_01: It's very expensive.
22:22
SPEAKER_01: Oftentimes it's not just a single test, it's a test that begets another test that begets another test.
22:29
SPEAKER_01: And there's a word for that, and it's called cascade of care.
22:33
SPEAKER_01: And it's a very familiar thing to physicians, practicing physicians, because it happens so commonly.
22:38
SPEAKER_01: And you might think to yourself, well, if it's not important to follow these things up, then why are we doing it in the first place?
22:45
SPEAKER_01: If they're low risk, then why are we continuing to investigate them?
22:49
SPEAKER_01: And that is it'd be definitely a question.
22:52
SPEAKER_01: Because if you think about it, some people would say, look, Doc, if there's a one in a million chance this could be important, I could be that one in a million, so we should do this.
23:03
SPEAKER_01: Also, let's say that there's an absence of evidence about whether following something up is a good or a bad idea, and you're relying on an expert's opinion without evidence behind it, or even a non-expert's opinion with no evidence behind it.
23:16
SPEAKER_01: You just err on the side of doing more because that the logic is, well, an imaging test is not that harmful, or clinic visits not that harmful, or maybe that endoscopy is not that harmful, or maybe that biopsy is mostly riskless, and you just end up in this, for lack of a better word, this vortex of testing.
23:37
SPEAKER_01: And you kind of take a step back, maybe a year at a year into this, and you look back and say, wow, what have I done to my what how much cost have I built up?
23:45
SPEAKER_01: How many tests have I done?
23:46
SPEAKER_01: How much engagement have I done?
23:47
SPEAKER_01: And do I feel better?
23:48
SPEAKER_01: Am I happier?
23:49
SPEAKER_01: Am I healthier?
23:50
SPEAKER_01: Am I living longer?
23:52
SPEAKER_01: And in so many cases, it ends up being kind of a question mark for some of these incidental low-risk findings that get detected.
23:58
SPEAKER_01: The emotional piece is a real one.
24:00
SPEAKER_01: I know that your group is interested in wellness and the psychological state that we're in on a daily basis.
24:07
SPEAKER_01: One thing to point out is that when you decide to opt in to this, let's say that you're a healthy person, you're feeling fine, you don't have any symptoms or signs of disease, you identify as a healthy person.
24:20
SPEAKER_01: Your primary goal today is making sure you get your kids to the bus stop and making sure that you do your podcast and you make it sure that you you're financially successful.
24:29
SPEAKER_01: This is how you conceive of yourself.
24:30
SPEAKER_01: This is your day, your day-to-day.
24:32
SPEAKER_01: And you decide, well, maybe I'll just go get some testing just in case.
24:36
SPEAKER_01: And it's not evidence-based, it's off guidelines, it's just kind of, I'll just give that a go.
24:41
SPEAKER_01: And you do that, and the test results come back with a litany of things that now you should be thinking about or concerned about with recommendations for follow-up testing and more things.
24:52
SPEAKER_01: And in on an instant, you're now no longer just the person who's taking your kids to school and doing your podcast and wanting to be financially successful and being happy and healthy in your house.
25:01
SPEAKER_01: Now you've got 10 things to think about that were on your imaging test.
25:04
SPEAKER_01: And which of these things are important or not important?
25:07
SPEAKER_01: And many times you don't get an answer right away.
25:10
SPEAKER_01: That answer could take years to resolve.
25:13
SPEAKER_01: Someone might say, Well, I don't know if this is important.
25:16
SPEAKER_01: It's probably not, but maybe it is.
25:17
SPEAKER_01: Let's do follow-up for the next 10 years and see what happens.
25:22
SPEAKER_01: Right, exactly.
25:24
SPEAKER_01: And before you know it, you've ended up with 15 clinic visits and 20 imaging tests, and you're like, what have I gotten myself into exactly?
25:31
SPEAKER_01: Now, I don't want to paint too broad of a brush here.
25:34
SPEAKER_01: There are huge benefits to healthcare.
25:38
SPEAKER_01: And there are also cases in which healthcare ends up being potentially harmful.
25:44
SPEAKER_01: And the difference between the two is you kind of think in your mind, what are the benefits of this test?
25:50
SPEAKER_01: Are those benefits proven benefits or are they a guess?
25:54
SPEAKER_01: And then what are the harms of this intervention?
25:57
SPEAKER_01: And are those proven harms or are they guesses?
26:00
SPEAKER_01: And then you stack those things up and you make an educated guess about is it in my best interest to do this thing?
26:07
SPEAKER_01: So whenever we talk about medical testing in general, a core piece of this about whether that medical test is a good idea or not a good idea depends on your likelihood of having important treatable disease before you do the test.
26:22
SPEAKER_01: It's a fundamental piece of this.
26:25
SPEAKER_01: If your odds of having important treatable disease before the test are really low, then when you get that test, the odds that it hurts you are become greater than the odds that it helps you.
26:38
SPEAKER_01: And it's not a function of the accuracy of the test.
26:41
SPEAKER_01: It's not a function of whether the test detects findings.
26:44
SPEAKER_01: It's not a function of whether the test is one of the best medical revolutions to ever happen in the last hundred years, which MRI is.
26:49
SPEAKER_01: It has to do with how likely are you specifically to have important treatable disease that's going to be detected by that test.
26:56
SPEAKER_01: Because if the odds are too low, what you will end up finding on that test is a bunch of stuff that's probably not important to you, but that will create uncertainty and anxiety and doubt and more testing and more intervention that follows from that.
27:11
SPEAKER_01: So we talked about imaging in general or diagnostic testing, whether it's blend-based or whatever, that pretest onset disease really becomes fundamental.
27:20
SPEAKER_00: Was it two years ago when I did that?
27:22
SPEAKER_00: This last MRI was to figure out exactly what's going on, why I wasn't healing from a car accident.
27:27
SPEAKER_00: But that other one, I went in because I always had this question in the back of my mind from the surgery that I had when I was 12 when I first experienced the MRI machine and wanted to make sure that I'd fully healed from that surgery, that surgery was right, and being a mom, I have low lung capacity, so that's what I had done was an x-ray.
27:49
SPEAKER_00: And then this was found.
27:50
SPEAKER_00: So then MRI and then specialists, and the specialists like, why are you here?
27:54
SPEAKER_00: You're fine.
27:55
SPEAKER_00: Exactly what you said.
27:56
SPEAKER_00: And I went through that stress and then the scheduling and having my husband take off work so that he could be there for the kids because this was the only appointment that I could find, and just all of that.
28:07
SPEAKER_00: Absolutely.
28:18
SPEAKER_00: Okay, I can breathe.
28:19
SPEAKER_00: Okay, the chances are lower.
28:22
SPEAKER_00: Okay, I am still in the driver's seat of my life, and I can have this conversation with the doctor before any referrals are sent out of okay, what is the likelihood?
28:34
SPEAKER_00: Is this really something that we should do, or is it not?
28:39
SPEAKER_00: Because most doctors are going to err on the side of caution, probably because of how Sue happy we are.
28:46
SPEAKER_00: Right.
28:47
SPEAKER_00: So let's remember that we are in charge of our health at the end of the day.
28:51
SPEAKER_00: It's not up to everybody else.
28:53
SPEAKER_00: And that's what really impacted me of what you were saying of I'm an adult, I'm going to take charge and I'm going to have that conversation with my doctor instead of just assuming.
29:05
SPEAKER_00: And especially because with the doctor, they only know what we tell them or what they see in reports or what they see looking at us, where when we open our mouth and we have that conversation, they get so much more information.
29:19
SPEAKER_01: Yeah, that's exactly right.
29:21
SPEAKER_01: And it has to be a dialogue between you and the person taking care of you.
29:26
SPEAKER_01: And the olden days, two years ago, I think it's fair to call it paternalism, because at that time almost all the doctors were men.
29:33
SPEAKER_01: But this paternalistic idea that the doctor decides for you what's in your best interest.
29:38
SPEAKER_01: And that is extremely antiquated.
29:41
SPEAKER_01: And if you feel that dynamic blossoming between you and your healthcare provider, that should be a warning flag for you.
29:47
SPEAKER_01: It needs to be a conversation.
29:48
SPEAKER_01: Your goals and interests need to be kind of front and center in that conversation.
29:52
SPEAKER_01: The doctor's responsibility is to give you the best possible evidence-based information that they can and then make a joint decision in partnership with you.
30:01
SPEAKER_01: You'd mentioned earlier, I do have a role in the Weiser Center for Prostate Cancer, and its entire focus is around patient-centeredness and patient autonomy and patient decision making.
30:11
SPEAKER_01: The decision to screen for prostate cancer is explicitly described as a conversation with the patient.
30:19
SPEAKER_01: In other words, it's not a default you should, or a default you shouldn't.
30:23
SPEAKER_01: It's you should have a discussion about it because it's so nuanced and so contextual and it depends on so many circumstances.
30:29
SPEAKER_01: It's not a blanket yes or no.
30:31
SPEAKER_01: It's a we should have a discussion about it.
30:33
SPEAKER_01: And that's the recommendation.
30:34
SPEAKER_01: I think that's it's fair to say that should be true for a lot of what we do, that conversation, because the person's values and what's important to them will vary.
30:43
SPEAKER_01: You could have one person who really values maximal knowingness.
30:47
SPEAKER_01: You could have one person who prioritizes avoidance of complications, you could have one person who's prioritizing their financial situation.
30:54
SPEAKER_01: And those things will really affect the choices that they make about their health.
30:58
SPEAKER_01: It's no different than, I guess, most of life.
31:00
SPEAKER_01: But yeah, of course, you you need to have that partnership, that conversation is really, really important.
31:05
SPEAKER_01: Now, let's say that you're involved in a doctor-patient relationship where you feel like there's not good resonance.
31:11
SPEAKER_01: Doctors are not infallible people, and doctors have a range of personalities and perspectives and thoughts and feelings as well.
31:19
SPEAKER_01: And if you don't have a good resonance with your healthcare provider, it is okay to say, on reflection, maybe this isn't a good relationship for me.
31:27
SPEAKER_01: Maybe I should find a different healthcare provider that's more kind of understands where I'm coming from or what my goals are.
31:33
SPEAKER_01: Again, you what you want from your healthcare provider, I think, is to give you the best information that they can and to be honest with you and to tell you what they think is most likely to make you live longer, happier, healthier life, and to be supportive of you and your family's decisions.
31:47
SPEAKER_01: I think that's really important.
31:48
SPEAKER_01: That does not mean that the doctor should be entirely enabling of whatever decision that you make.
31:54
SPEAKER_01: So let's say you went to your doctor and said, I would really like to start the fentanyl habit.
31:58
SPEAKER_01: Their responsibility is to say, no, I don't think that's in your best interest and try to do what they can to stop you from thinking that way.
32:04
SPEAKER_01: So there is, it's, it's, it's not a blanket, whatever the patient wants that that's that decides it, but it should be a conversation where you feel respected and listened to.
32:13
SPEAKER_00: You made me think about how our body changed over time, right?
32:17
SPEAKER_00: And maybe we have a new diagnosis or a new area of our life that we want to focus on.
32:22
SPEAKER_00: And maybe that particular doctor, especially if it's your primary care physician in this context, does not match where you want to go.
32:31
SPEAKER_00: Because all doctors, even this doctor that we're meeting with right now, they have continuum education.
32:38
SPEAKER_00: And maybe his continuing education, so pretend you're my PCP, even though you're you're not.
32:45
SPEAKER_00: So maybe his continuing education, his interest that he selected is different from where I am headed.
32:52
SPEAKER_00: That is also maybe a relationship that I need to look at and say, maybe I need to change to another doctor who has an interest in continuing education in this area that I want to focus on within my life to better my health.
33:06
SPEAKER_01: Yeah, and each person's gonna have specialized expertise at the time of the completion of their training.
33:11
SPEAKER_01: And then from there, your point is well taken that someone might choose to continue learning or developing or training in a specific area, or they might choose not to.
33:20
SPEAKER_01: You might have maybe your provider is somebody who is gonna do whatever the bare minimum is to keep the credentialing up, and that's it.
33:27
SPEAKER_01: Or you might have somebody that spends an enormous amount of time researching, learning, studying, whatever the topic is.
33:33
SPEAKER_01: So you're gonna have a range of expertise on a whole bunch of different things, and that's why it's important to have that good fit.
33:39
SPEAKER_01: The other thing, too, is each patient is really a unique person.
33:43
SPEAKER_01: I mean, your life story is your own, and it's you're the only person with your story.
33:48
SPEAKER_01: You're the only person with your medical history exactly the way it is, your genetic history exactly the way it is, your priorities and values, and you're the only person who has that.
33:55
SPEAKER_01: So there will be some doctors who are good fits for that, and some doctors who are not good fits for that, depending on how they mesh up with you, their puzzle piece, I guess.
34:05
SPEAKER_00: Yeah, absolutely.
34:07
SPEAKER_00: I am going to ask another question that you it's my hook to get people to go over to my newsletter because you're gonna answer it in the newsletter.
34:15
SPEAKER_00: And it's yes.
34:17
SPEAKER_00: This is kind of similar to what we already asked.
34:19
SPEAKER_00: So this will be in the newsletter, but the one that I'm going to ask is what evidence should physicians need before whole body MRA screening could reasonably be recommended for an average risk adult?
34:31
SPEAKER_00: And he's going to answer that in the newsletter.
34:33
SPEAKER_00: So jump over there.
34:34
SPEAKER_00: And the reason why I started doing it this way is because how many times do we listen to this and we already have another podcast queued up?
34:41
SPEAKER_00: And we don't spend time really reflecting on this and how to really apply this to our lives.
34:47
SPEAKER_00: I know I am the same way.
34:49
SPEAKER_00: I am usually working out while I'm listening to podcasts, and the next one comes up and I already lost all the thoughts that I had.
34:55
SPEAKER_00: So in the meantime, if we have any questions MRI related, where is the best place to look?
35:04
SPEAKER_01: Hmm.
35:05
SPEAKER_01: It's such a broad question.
35:07
SPEAKER_00: Besides in your articles, just Google your name.
35:10
SPEAKER_01: It's such a broad question because I think it the the best answer that depends on why this why it's baked up.
35:16
SPEAKER_01: So for example, the answer would be different if you were saying I have a I am somebody who has a specific disease, and I want to know whether MRI is helpful or not helpful for this specific disease.
35:27
SPEAKER_01: I would give you a different recommendation depending on that.
35:30
SPEAKER_01: So let's say your primary concern, let's say you had a disease that affects the brain, and you want to know whether MRI was a good or a bad idea, I might direct you to a neuroradiology society and some of their position statements on MRI.
35:44
SPEAKER_01: Or maybe your question was curious about that substance that they inject sometimes, that contrast substance, the gadolinium-based contrast material, a good a good reference to that might be the American College of Radiology's manual on contrast media, for example.
35:57
SPEAKER_01: So it really depends on what the specific question is.
36:01
SPEAKER_01: If you're asking, what if I'm specifically interested in this sort of commercial cash pay, whole body MRI for the general public thing?
36:12
SPEAKER_01: I've written some articles about that.
36:14
SPEAKER_01: There are other people who have written some articles about that too.
36:17
SPEAKER_01: There is no randomized trial that I could point you to that that shows that it's beneficial because it doesn't exist.
36:25
SPEAKER_01: So there isn't, there is not a set of evidence I could point you to to encourage you to do that test.
36:31
SPEAKER_01: But I think people have written about and talked about some of the potential challenges of that.
36:35
SPEAKER_01: And I guess we're going to talk about that in the newsletter.
36:37
SPEAKER_01: So I'll stop there.
36:38
SPEAKER_01: Okay.
36:39
SPEAKER_00: So related to that question, what I normally ask people who, if I interview another coach or something like that, is where do we follow your work?
36:46
SPEAKER_00: And it sounds like there are still places where we can follow your work.
36:50
SPEAKER_00: Is that correct?
36:52
SPEAKER_01: I I do not self-promote.
36:54
SPEAKER_01: So with with that, with that is the caveat.
36:56
SPEAKER_01: I if you're interested in whole body MRI topics, there are two articles that I wrote recently that you may be interested in.
37:03
SPEAKER_01: One is anyone can access.
37:05
SPEAKER_01: It's a it's it's in Time magazine.
37:08
SPEAKER_01: It's an ideas piece in Time magazine, and it's something effect of why does more diagnostic testing not always improve our health?
37:14
SPEAKER_01: Something to that effect.
37:16
SPEAKER_01: And then there's one that I wrote with one of my co-authors, Scott Reeder, who's the chair of radiology at Wisconsin, about the topic of whole body MRI, is published in JAMA, which is one of our important medical journals, and it's some of the effect of whole body MRI buyer beware.
37:31
SPEAKER_01: And it talks about some of the ethical considerations around that and a potential informed consent statement for someone considering doing it.
37:38
SPEAKER_01: Unfortunately, the JAMA one is behind a paywall, which is annoying for the average person, but the timepiece is not.
37:44
SPEAKER_00: I think you can pay per article, if I remember right.
37:47
SPEAKER_00: I took a research class in my undergrad, and JAMA is the one that you want to go to, and sometimes it can be hard to get into unless you are a student or you work for a college.
37:58
SPEAKER_01: That's right.
37:59
SPEAKER_00: Well, thank you so much for your time.
38:01
SPEAKER_00: This was very helpful.
38:03
SPEAKER_00: And I know that this will be something that people will go back to years from now because this is timeless information.
38:10
SPEAKER_00: So I really appreciate that.
38:12
SPEAKER_00: And it's the last two questions that I sent you are the ones that, if you don't mind responding to them, and then I will make sure they end up in the newsletter.
38:21
SPEAKER_01: Okay, terrific.
38:22
SPEAKER_00: And I will stop recording.
38:24
SPEAKER_00: Thank you so much for joining our discussion.
38:27
SPEAKER_00: If you enjoyed this, please like, subscribe.
38:32
SPEAKER_00: Most of all, share the love with others.
38:34
SPEAKER_00: Please share this episode so that we can help other people really recalibrate every aspect of their lives so they can be the best version of themselves.
38:46
SPEAKER_00: And I will see you in the next episode.
38:49
SPEAKER_00: I want to have my quick disclaimer here that this is not a one-size-fits-all.
38:56
SPEAKER_00: If you want one-on-one coaching, let's talk and we will make sure what wellness means to you is really put into your life, put into practice.
39:08
SPEAKER_00: I am using my undergrad and applied health and my life coaching experience to bring this podcast to you.