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Unintended Consequences

Over-reporting and under-reporting of findings

Being able to clearly communicate with patients is one of the skills that patients and other healthcare professions admire most in chiropractors.  Chiropractors have raised the report of findings to an art form.  

Based upon my experience working with medical doctors and chiropractors, I find that chiropractors tend to over-report findings, and medical doctors tend to minimize or under-report abnormal results. (1)  I have a theory for this phenomenon. 

Chiropractors come from a background of treating ambulatory and generally healthy patients.  Abnormal findings and pathology are a relative novelty to the chiropractor, and we are prone to expound on it:  “Mr.  Nelson your MRI shows that you have a Tarlovs cyst, a tear of one of your discs, a benign renal cyst, and some joint (facet effusion) swelling.” (These findings would infrequently be mentioned by a medical doctor to patients.)

Medical doctors come from a [training] background of treating sick patients in hospital settings.  Medical doctors in training may be criticized by their superiors for over-interpretation of findings.  I have seen medical residents and interns scolded for paging their attending physicians after hours with concerns about abnormal findings that the attending did not feel were noteworthy.  The physician becomes comfortable working with abnormal findings, tests, and radiologic studies.  Some physicians allow this comfort level to arise to the point of being cavalier.

According to Casalino, et al. the failure rates of medical doctors to inform their patients of clinically significant test results was 7.1 %, with a range of 0%- 26.2%.(1)    Failure to inform patients of clinically significant findings and to document the results is common:  common and dangerous.  Fortunately this problem has been recognized, and there are systematic steps being taken that should reduce this failure rate.

While medical doctors may have problems with under-reporting of findings, chiropractors may over-report.  I do not have studies to cite the over-reporting by chiropractors, but I know that many of my acquaintances in chiropractic take x-rays on new patients and read a lot of detail into the x-ray report of findings.  Some chiropractors tend use x-rays for practice management as well as a screening for pathology. 

Does early use of radiographic studies adversely affect patient outcomes?

Whether radiographic studies are over-read or under-read is less interesting than the adverse effects of early use of radiology.  Findings from a study by Srinivas et al. tells us that the early use of MRI or other radiographic studies actually leads to worse clinical outcomes in those suffering from back pain. (2)  Another study of work-related injuries revealed that the early use of MRI is associated with an increased likelihood of disability and a prolonged recovery. (3)  Regardless of the interpretation of the radiographs, the simple fact that they were taken seem to affect patient outcomes.  Further study is warranted, but findings like these will be used by decision makers in the reimbursement realm.

How should we interpret this information?

  • Make sure that you share all relevant clinical, radiological, and lab findings with your patients and their physicians. 
  • Do not over-interpret or extrapolate objective findings.
  • Refer to radiographic guidelines. (4)
  • Be prepared for third party payers to be even more stringent in approving radiographic studies early in the care of back pain patients.

It is against my nature to withhold even clinically insignificant findings (like benign renal cysts or perineural cysts) from my patients, but I do not want to unnecessarily concern my patients either.  By taking some extra time in sharing information, I find that I can share the findings while putting them in context.  My patients can trust me to share everything with them, and they trust me to know when we need to be concerned.   Communication is one of the qualities that set chiropractic apart.  Take the time to adequately communicate with your patients; it will build a strong relational bond.

(1)Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009;169:1123-1129.

(2)Srinivas SV, Deyo RA, Berger ZD.  Application of "Less Is More" to Low Back Pain. Arch Intern Med. 2012 Jun 4:1-5. doi: 10.1001/archinternmed.2012.1838.


(3)Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM.  Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine.  2012 Aug 15;37(18):1617-27.

(4)Bussières AE, Taylor JA, Peterson C.  Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach, JMPT, 2007 Nov-Dec (30) 9, 617-717