Mitigating Nocebo: Scan Without The Scar

By Mike Dare

Interrogating the clinical reasoning around scans, placebo, nocebo and clinical guidelines is a minefield in Musculoskeletal Medicine currently. I have, in my short career, seen a monumental shift in Musculoskeletal practice away from the biomedical model and towards a more holistic biopsychosocial model, largely for the better. However in many instances I find Musculoskeletal practitioners pooh-poohing scans and pushing a very strong agenda of not scanning due to the nocebo effect and often, dare I say, cost and guidelines which are enforced in certain healthcare systems. 

I do feel however that a lot of the time we do not appreciate the value investigations like MRI or ultrasound bring to our clinical practice, to our patients, and to the healthcare system as a whole. Personally I scan almost every patient I see on ultrasound, which takes me less than five minutes and has no additional cost or harm to the patient. This provides complete clarity on the diagnosis and allows me to offer truly patient-centered care and choice. 

Our clinical examination and reasoning I would argue is not as accurate or bullet proof as we like to think, and in many instances I would suggest that having a low threshold for using further investigations with appropriate reasoning is a good way to practice, especially in the age of rising medical litigation. Scanning and further investigations should be done to answer specific clinical questions, for example limited range of motion in the shoulder can be due to Osteoarthritis or adhesive capsulitis and ultrasound, X-ray or MRI are essential for differentiating, thus allowing for appropriate treatments to be offered. Scanning for the sake of scanning to give a diagnosis I would argue is bad practice and these imaging modalities should be used to answer specific clinical questions and guide treatment and provide appropriate treatment options to our patients.