This is the pinnacle post of the series on medical testing, which starts here.
It's the pinnacle because I've finally climbed the mountain of scheduling, and I'm going to the radiation center for my test. Hooray! I'm at the top of the mountain! It will be easy after this, just getting the results and the bill.
I've been to the imaging center before. I'm well aware of their attempts to hide behind misleading signage:
Its nearly-secret location is several floors deep in the basement -- only those who really want to get there, and have the persistence to get there, make it.
I arrive more than the half hour early they requested, to allow plenty of time for the front-office staff to do their work. What's there to do? I've been there before; how can there possibly be anything about me they don't already know?
First of all, it's an iron-clad tradition to give entering patients a clip board full of paper that needs to be filled out, with lots of boxes to check. Have I been through this before? Yes. Every single time I visit. There's a simple explanation for this. Think back to cop shows you've seen where there's a witness or suspect the cops think might be lying or leaving something out. Or where there are two people who they think have concocted a story, and they interview them separately, trying to trip them up. The cop usually starts by saying, "I know you've been through this with my doughnut-eating colleague X, but I need you to take me through it again slowly, step by step." If it works for the cops, it should work even better for the medical staff, right? They carefully check every answer I give and cross-check it with all the previous answers I've given and analyze the differences. This way they can tell when a patient is lying, or when their memory is crashing because of whatever is wrong with them. Or simply to gauge the patient's intelligence and memory, to rank all the patients and do something wonderful with the results that only members of the doctors' cabal know about. AlI I know is that I have to waste time on each visit, only to have the staff glance at the first page, and file it.
I end up waiting for about an hour. Finally someone calls my name, and I follow her out of the waiting room through the trackless maze of hallways. After a bit of walking, I'm introduced to a person who, she tells me, will take my blood for testing.
The pre-MRI blood test
I've been through this before, and nothing bad happened. It just caused, as usual, another delay in starting the MRI, because they wait for the results of the blood test. Which results (of course) no one gives to me, the person blood was tested.
But there are a couple things to note about this practice.
- The main purpose of the test is to see if I'm likely to have an adverse reaction to the extremely safe contrast material that will be injected for some of the images.
- The main concern is with the few subjects who have abnormal kidney function.
- I had an MRI with contrast just 3 months prior. How likely is it that my renal function went south during the interval?
- Doing the test for everyone is just not needed. See this, for example.
- Doing the test for me was a waste of time and money.
- In any case, it's clear that there are no standards that are followed here!
- The main concern is with the few subjects who have abnormal kidney function.
- Given that you're going to do a test, of course my blood needs to be drawn.
- My blood was drawn by ... an RN.
- Registered Nurses are amazing people with years of training, often including an undergraduate degree and more.
- My blood could just as well have been drawn by a phlebotomist.
- You can train to become a phlebotomist by having a high school diploma, taking a month-long full time course, and taking a certification test. Boom, you're done.
- I don't think I need to comment about the different in cost.
- My blood was drawn by ... an RN.
After more waiting in a special waiting room, I'm finally called into the MRI room.
The MRI itself
The MRI nurse/technician was courteous and professional, like everyone else I encountered during the testing process. But the process was inexcusably bad, wasting time and money and reducing quality.
First, the nurse asked me where the tumor was that was to be imaged. This could have been good. It's classic checklist, the sort of thing you should do to avoid error. See this for details. Why wasn't it good here? She wasn't double-checking to make sure the computer-based instructions were correct -- she was asking to find out!
Imaging studies have been done on me of this area. Multiple times. Including at Mount SInai. Mount Sinai has incredibly detailed information about exactly where the tumor is, more accurate by far than anything I know. Nonetheless, I was the nurse's primary source of information about exactly where the pictures should be taken! She placed pieces of tape on my body indicating the limits, and those pieces of tape were her only source about where to take pictures.
Next, I laid down on the MRI bed. The nurse had me slide my shoulder into a little compartment, something which had never happened on any prior MRI. Clearly the dial on my paranoia control was set way too low, because I just vaguely thought, hmm, this is different, well she must know what she's doing. After adjusting me a couple times, I got to enjoy the usual loud noises in a confined space during which I was to remain rock-solid motionless; this pleasure went on for 20 minutes or so. Then I got rolled out.
The nurse tells me that the compartment my shoulder is in is a "camera." Unfortunately, the camera wasn't capturing all the area of the tumor, so she would have to use a different camera and do everything again. She gets out a thick, flexible plastic sheet and places it on my shoulder. I recognize it immediately, because it's exactly the same device that has been used on each MRI I've had, regardless of the imaging center that has done the work.
Amazing. Frightening. When I go a hair-cutting place, they record my visit and the choices and selections I made for getting a cut. When I go again, even if it's a different person, they'll ask something like "same as last time?" And then they'll normally do the checklist thing of confirming their understanding of what last time was. The point is: they know what I got last time. They recorded it. A hair-cut place. The only thing I can imagine is that the advanced technologies that hair salons use for keeping information about their customers haven't yet made it to the world of medicine. The plain fact was that Mount Sinai had either not recorded (probable) or not used (possible) key information about the image that was taken and how to take it. I would use the word "inexcusable" for this, but without a few choice 4-letter words, such a word would be far too mild to describe what went on here.
About 3 hours after I arrived, the MRI had been taken and I was free to go.
The MRI technology and equipment
This isn't part of my test specifically, but it's on my mind every time I encounter medical equipment. I'm a computer guy since forever (see this for details of my background), and I know too much about the technologies and the companies that are used in this equipment, and the hardware and software processes that create it.
The highly regulated companies using highly regulated processes to build this hardware and software are unique in technology. The regulation is supposed to protect the public and assure high quality. In fact what it does is assure that only a couple companies can supply the equipment in a government-protected monopoly, at absurdly high cost.
The net result of this is that specialized equipment and software are built to meet the regulations, even when COTS (commercial off-the-shelf) equipment is widely available to do the job with high quality and great performance at a fraction of the price. A prime example of this is the PACS (Picture Archiving and Control System) that all medical imaging systems include. This is basically a standard file storage system with a database that logs everything put in and enables access to images.
At the heart of the MRI is a body of software that could be built, maintained and enhanced at a tiny fraction of today's cost -- a 10X improvement is the minimum one could expect under a rational set of rules. Here is a detailed post with examples of the insanity and, just as important, a specific proposal for how to fix it.
Conclusion
I got the MRI. Nothing awful happened to me. I'm grateful that medical science/engineering has gotten to the point that something as truly amazing as an MRI is even possible. I can certainly imagine things being much worse than they were.
That being said, the opportunities for improvement on multiple fronts are HUGE. The patient's time and inconvenience could be greatly improved. The operational cost of performing the MRI could be considerably reduced, and the quality and consistency improved. Finally, the capital cost and rate of innovation of imaging machines in general could be HUGELY enhanced by drastic changes to the regulations controlling the design and manufacturing of the devices.
Even more good news: my saga was not yet over. I don't have the results yet! Wait until you read about what I went through to get them...