Rammya Mathew: GPs have to be able to request MRI scans for patients in primary care

At a recent clinical meeting, I heard that GPs local to me are about to lose the ability to request magnetic resonance imaging (MRI) scans for patients presenting with musculoskeletal symptoms. We’re instead advised to refer our patients to a musculoskeletal clinical assessment and triage service (CATS)—staffed largely by musculoskeletal advanced practitioners, who will assess our patients and determine whether imaging is warranted.

The hope is that fewer patients will have unnecessary imaging and that this will reduce the potential harms of overdiagnosis. Radiologists rarely report musculoskeletal MRI scans as entirely normal, and it can be hard to know what to do with abnormal findings on an MRI. More often than not, patients with abnormal scans are referred to orthopaedic teams, even though there may not necessarily be a surgical target.

At a population level, this is problematic on two fronts. Firstly, MRI scans are expensive and need to be used judiciously. Secondly, elective orthopaedic services are under tremendous pressure, with some of the longest waiting times in the NHS. So, any effort to reduce waste and streamline referrals makes a lot of sense.

On the flip side, however, it can be extremely challenging to help patients with chronic pain symptoms effectively in primary care if they haven’t had imaging. Many patients strongly believe that, without imaging, a serious diagnosis and/or the need for surgery can’t be ruled out. I’ve had patients consult with CATS and then come back to me saying that “nothing” was done for them—but what they really mean is that they had no advanced imaging. Without an MRI the patient feels as though there was no intervention by the clinician; they feel unheard and fail to engage in physiotherapy or self-management, and their symptoms continue to deteriorate.

My experience is that many of these patients continue to re-present in primary care, and some even attend the emergency department repeatedly out of sheer desperation. Patients can be bouncing around the system, and this too has a cost—not only a direct cost to the healthcare system but often also a wider economic cost related to worklessness.

The work we do in general practice is seldom black and white: it’s about using the evidence, but it’s also about applying it to our individual patients and working alongside them and their health beliefs, which are rarely modifiable. GPs may not be specialists in musculoskeletal medicine, but we’re the only clinicians who take accountability for the longitudinal care of patients with chronic pain symptoms, and ultimately we’re experts in the whole person. So, although I fully agree with the rationalisation of imaging through musculoskeletal CATS, I also believe that it has to be within the gift of GPs to decide what’s best for their patients in the wider context of their symptoms.