After the Bone and Joint Decade: It Is Still Time to Educate on the Musculoskeletal System

Medical providers should deliver a high quality of care to their patients without ordering unnecessary tests. This concept has been brought to the forefront at a time when health-care costs have markedly increased. Berwick and Hackbarth reminded us of the initial goals from the Institute of Medicine in providing care to patients and emphasized providing quality care that is safe, effective, timely, equitable, and patient-centered. Today, an additional goal to improve quality is providing affordable care. We must understand these goals to improve the process of care in order to maintain high value and to minimize risk to our patients.

The study by Wylie et al. uses knee pain as a model to evaluate this process of patient care. In 2011, the Bone and Joint Initiative demonstrated that up to 17% of adults presented to a physician with a chief symptom of knee pain. Many different types of health-care providers are in a position to be the first to evaluate these patients with knee pain. All of these health-care providers should maintain a methodical approach to the patient encounter by starting with a defined chief symptom, followed by a complete history and a detailed examination. Typically, the initial workup consists of diagnostic imaging for the patient presenting with knee pain. Magnetic resonance imaging (MRI) is a valuable tool to help in the diagnosis of knee pain, but it is expensive. I agree with Wylie et al. that primary radiographic imaging of the knee should be made before MRI, a technique that is considered advanced imaging. A two-day summit sponsored by the American Board of Radiology Foundation and dedicated to addressing overutilization of medical imaging suggested that up to 50% of high-technology imaging procedures failed to provide information that improved patient care.

Wylie et al. should be congratulated for their excellent work. The objective of their work was to determine the completeness of the patient evaluation through history and physical examination documentation prior to ordering knee MRI, to correlate this within provider groups, and to provide an analysis comparing the rate of positive findings on MRI. In this study, when compared with primary care physicians, orthopaedic surgeons and nonsurgical sports medicine physicians were more likely to document a history of the present illness and a knee examination, to evaluate knee radiographs prior to ordering MRI, and to have more positive findings on knee MRI.