Answer:

This is the kind of problem many people experience. You have pain. It's not getting better. You begin to worry. You worry about what is really the matter. Is this going to be permanent? How am I going to get back into my normal activities? Is the pain persistent because the problem is really serious, or is my doctor overlooking something? Pain that is severe or persistent gives rise to many doubts and questions.

Nearly all the Tripod members who responded felt that Steve should talk to his doctor about his pain and frustrations. A few suggested he should simply get a second opinion -- preferably from someone not affiliated with his doctor's HMO. Both are reasonable options, although I suspect the process would be better if the doctor had a chance to respond to Steve's concern. That response might be a promise to do whatever is needed for Steve, while continuing to try alternative ways for treating his pain. Or it might be to locate not just any specialist, but the best one in the area.

There was also almost unanimous opinion that doctors should not receive financial bonuses for lowering the costs associated with their patients' care. The conflicts of interest are pretty obvious. If Steve's doctor does not order the MRI, he'll take home more money at the end of the year. Medical ethical literature abounds with articles written about such conflicts of interest. Virtually no support can be found from these ethicists for the use of financial incentives. And yet, financial incentive contracts are being used routinely now in order to encourage doctors to keep the overall cost of healthcare down. The pressure to control costs is coming from employers (through whom most insurance is provided in the US), the government (Medicare and Medicaid programs), and ultimately all of us -- everyone would like to pay less for their health insurance. What is this going to do to the relationship between doctors and patients? No one really knows. But if doctors stop being advocates for doing the right things for their patients we are all in trouble.

On a practical level, Steve and his doctor are going to have to work closely together. His pain is apt to last longer than he wants. Back pain does that. Months may go by before he feels better. Steve needs to know that his doctor cares about his pain, will order whatever test, and refer to whatever specialist is required in order to help him to get better. With this assurance, a reasonable decision about the MRI scan is possible.

The only valid reason for getting an MRI scan after an acute back injury (assuming there are no complications such as nerve damage from spinal cord compression) is to find something (such as a herniated disc) that Steve would be prepared to go to surgery for. Even herniated discs are preferably treated without an operation. Many people simply get better with conservative care. You do surgery only if the conservative stuff doesn't help (and it may take a number of weeks and trials of different therapy to know). If Steve's not ready to consider surgery, then he's not ready for the MRI. Of course we would all like to know what is going on in his spine -- just to know. But unless that knowing leads to a different course of action, it is pretty hard to justify.

It should be mentioned that this approach is not carved in stone, and does not necessarily apply to every patient. But it should be considered a reasonable starting point for any discussion about further testing.