MRI: A Picture Of A Problem

May 1, 2005 by Natalie Salat

PHOTO: SIEMENS PRESS PICTURE

PHOTO: SIEMENS PRESS PICTURE

An MRI scan is used to examine internal organs.

They look like something out of Star Trek, massive doughnut-shaped contraptions that swallow you up, scan your body and churn out detailed images of what’s going on inside. They can show the brain at work, detect cancers invisible to other machines, and assist in zapping tumours, all through the use of sound, a magnet and a computer.

Magnetic resonance imaging or MRI machines are not new—they’ve been around since 1982—but demand for this life-saving diagnostic procedure already outweighs supply, and with 9.8 million Canadian baby boomers approaching seniorhood, that need is growing.

The current diagnosis isn’t rosy. According to Medical Imaging in Canada, 2004, a report issued by the Canadian Institute for Health Information, Canada’s 4.6 scanners per million population places Canada 13th out of 20 developed countries.

IMAGE: SIEMENS PRESS PICTURE

IMAGE: SIEMENS PRESS PICTURE

This figure does not reflect the range of waiting times across the country, which depend not only on how many machines there are, but how many hours they operate. The decision to approve and fund MRI machines, which cost over $2 million to buy and $400,000 a year to run eight hours a day, is a provincial/territorial responsibility. Some jurisdictions even have private clinics, for those who can pay $500 to $800 for a scan. While all provinces have at least one scanner, none of the territories do. The territories are at the mercy of the nearest province.

Emergency scans to diagnose strokes, heart attacks, etc. are done immediately, but radiologists have a tough task prioritizing the rest—with nearly 900,000 scans done annually. Alberta, with the most machines per capita, offers among the shorter waits, averaging 18 weeks. In Ontario the wait can be a year or more. “I would describe access as different shades of grey, where it should be black and white,” observes Ray Foley of the Ontario Association of Radiologists.

Yet, after years of health care cuts, the federal government has thrown billions into medical equipment since 2000. That year, the Liberal government created a $1 billion fund to assist provinces and territories with purchasing and installing equipment. Less than $10 million went to MRIs, according to CIHI. In fact, the Canadian Association of Radiologists identified in 2002, after a wide-ranging investigation, that $200 million dollars remained unaccounted for and a large portion of the money went to other things. The organization’s CEO, Dr. Normand Laberge, says one of the most flagrant examples was the New Brunswick government’s use of the fund to buy a $125,000 lawnmower.

The critical lack of access to diagnostic imaging got plenty of airplay thanks to the Romanow health care commission in 2002. In 2003, the federal government developed a $1.5 billion diagnostic imaging fund and has since added $500 million to reduce wait lists.

The good news is provincial governments have started taking action. The CIHI report asserts that in the last decade, the total number of MRI scanners in Canada has increased 75 per cent, to 151 in 2003. New Brunswick learned its lesson, and moved up the CIHI performance table with the establishment of three fixed and two mobile MRI units. Recent announcements in British Columbia, Ontario, Nova Scotia and Newfoundland, among others, mean there will be more.

The bad news is Canada still has a lot of catching up to do. “Seventy-five per cent of not much doesn’t add up to much,” says Laberge. “Canada was way behind…and we’re not there yet.” But he is tired of graphs and figures. “Those numbers don’t make sense unless the patient is at the centre of the preoccupation, which they’re not. Ryan (Oldford)’s story is putting a face on this CIHI report.” Oldford is the four-year-old Newfoundland boy who lost one kidney to cancer and was put on a MRI waiting list because his geneticist suspected the other kidney was at risk. Unfortunately, the wait was 2.5 years. Until February the province had one MRI machine in St. John’s. Nearly a hundred other children were deemed in more urgent need.

After the boy’s mother brought the story to the media’s attention, he got his scan in February. Brenda Oldford told the CBC she wasn’t sure whether hers was the squeaky wheel that got the grease, but encouraged others to lobby hospitals and politicians. The hospital management maintained that Ryan moved up the line only after one patient cancelled and several others refused the slot.

Since then, another MRI machine has begun operating in Corner Brook’s Western Memorial Regional Hospital. John Ottenheimer, Newfoundland’s minister of health and community services, says, “This addition will allow residents of the West Coast to receive MRI scans closer to home (and) will shorten waiting lists.” But Dr. Ed Mercer, chief of radiology at the hospital, was quoted in the local newspaper as saying the new machine “won’t be a cure-all,” especially given that the government is only funding eight hours of operation a day.

Laberge questions why it took more than five years for Newfoundland to get another MRI, as the province received funding both in 2000 and 2003. Ottenheimer says his government spent $43 million in the past four years on high-tech medical equipment such as computed tomography and MRI scanners. But according to CIHI, Newfoundland only acquired five computed tomography or CT scanners between 1997 and 2003, and one additional MRI machine. CTs are used to create three-dimensional images using X-rays and a computer.

Simply adding machines won’t solve the access problem, either, says Laberge —pointing to a shortage of radiology staff and the fact that some machines are only being used four hours a day. “If we don’t add them intelligently, we’re going to have as many waiting lists as machines.”

And without access to imaging, the rest of the health care system is out of reach, observes Foley. “Imaging is like a set of traffic lights. If the light never turns green, you’re never going to get through.”

Dr. Albert Schumacher agrees. “We have the paradox where some specialists won’t see a patient unless they’ve had the MRI done,” says the family physician and president of the Canadian Medical Association. At the same time, family doctors are not allowed to order MRIs in their own hospitals.”

Why does MRI command so much attention?

Partly because it is “sexy” technology, says Foley, but also because of its effectiveness. “Everywhere else in the world this is acknowledged as a standard and important part of the diagnostic imaging armamentarium.”

Dr. Rebecca Peterson, chief of radiology at the Ottawa Hospital, adds, “There are many things you can’t diagnose any other way—those are the things we do first—but there’s all sorts of applications that we have to put aside. People are just starting to realize how valuable it is.” MRI is especially effective for visualizing soft tissues, such as the brain, internal organs, muscles and ligaments. For many things it is superior to CT. “If you have a soft tissue tumour or bone tumour, the detail on CT isn’t good enough.”

Unlike X-rays and CT, MRI does not involve radiation. Instead, MRI machines employ a large, cylindrical magnet up to 30,000 times more powerful than the earth’s magnetic field, along with radio waves and a computer. The technology relies on the fact that the body’s atoms have a positive charge (protons) and a negative charge. “You put a person in a magnet (on a sliding scanning table) and that magnet makes those protons align,” explains David Hartman of Hitachi Medical Systems America. While the patient lies still, a pulse of radio waves is sent through the body to disturb that alignment. “Depending on whether the protons are in bone, muscle or blood, they send off a different signal (as they fall back into alignment).” The machine records these signals, which a computer then translates into an image.

During the procedure (between 20 minutes to 1.5 hours), numerous series of images are taken. Aside from the fact that MRI is painless and has no known risks or side effects, the scanner can take images from almost every angle, providing more scope than CT to identify problems such as stroke and multiple sclerosis. Due to the magnet’s strength, patients with metallic objects in their body—such as a pacemaker, surgical implant, shrapnel or metal fragment in the eye—cannot have an MRI done. Fillings are non-magnetic and do not pose a problem.

In the future, more powerful machines will make it easier for doctors to diagnose disease as well as get better images of the heart, which poses a challenge because it is constantly moving. Some newer procedures include biopsies of the breast, bone and abdomen, open brain surgery, and eradicating tumours using MRI as a guide for focused heat energy.

At the Ottawa Hospital, Peterson enthuses about MRI’s potential for breast imaging. “This girlfriend of mine had a small cancer in one breast. Of course she was terrified, but decided to have an MRI. They found a second one. Instead of having a lumpectomy with radiation, she had her whole breast taken off. She might have died a lot sooner if she hadn’t had the MRI when she had.”

Unfortunately, as Peterson will tell you, Ottawa is among the worst places to be for MRI access despite having one of the largest teaching hospitals. While a reasonable wait is eight weeks, some Ottawans are waiting up to two years. The Ottawa Hospital has two machines running 100 hours each week, at its Civic and General campuses. Only recently did this city of over a million people get scanners at two other hospitals.

André, a high-tech worker, is back at the Civic for his second MRI. The first, for which he waited eight months, revealed a small tumour in his lower back. It was benign, but his doctor wants to keep a close watch. Waiting for the initial MRI was nerve-wracking, says the family man. “It’s not bad now, because I know what the problem is, but the first time I was very anxious.”

Peterson understands patients’ frustration. “We’re behind the eight ball all the time. That resource is severely limited, and it’s controlled by the government. The hospital may have money, but can’t buy an MRI machine without (government) permission.”

For the last decade, Ottawa has been at the bottom of the totem pole, she adds. Several years ago, the Civic even resorted to buying and funding the operation of its own portable MRI without getting permission from the province. The province didn’t remove it—that would have been counterproductive, says Peterson—but the hospital got in trouble. “Politics affects everything. The budget all depends on how well you get along with who’s in power. The government of Ontario has not noticed us for a very long time, but I think we’re finally starting to get people looking.”

She is referring to the Ontario government’s February announcement of $120 million in funding to cut MRI and CT wait times and an independent commission to develop a wait-time strategy.

Ontario Health Minister George Smitherman acknowledged that Ottawa was “MRI-deprived,” but says his government has invested more here than anywhere else. “We’re working hard to play catch-up. Our strategy has been to increase access through nine new MRIs (provincewide), replacing some of the old equipment and buying more hours.” Ontario committed $5 million for extending hours and $21 million for new scanners.

While Peterson says the announcement is a step forward, “the reality is it’s only going to allow us to do just a few more patients. We need more machines.”

Foley says Ontario, which has some 50 scanners, would need 55 more MRIs to handle demand, and asks where its share of the 2003 diagnostic imaging fund—$500 million-plus—has gone. “We’re the ones that lobbied for that money. We convinced Romanow there was a crisis, the federal government announced the money was for diagnostic imaging equipment, only to find out the provinces are using it for one thing or another. The thing that alarms radiologists most is that there are people out there who are ticking time bombs. Radiologists are put in a position of having to act like God.”

Then there’s the human resources crunch. Radiologists, who require 10-plus years of training, are aging like the rest of the population; there are already too few to go around. “The government decided in the 1980s that they didn’t want to train any radiologists, so they cut back on residency programs,” explains Peterson. “They felt we cost a lot of money.” While the numbers have started to increase, she says, “Here in Ottawa there’s only one resident funded from the university every year to do radiology. That’s crazy.”

Smitherman says the government is working on it. “There’s no doubt we’ve still got serious work to do in a bunch of places. We’ve made good progress, but we’re not done yet.”

The highly political issue of MRI access could serve as a litmus test for the health care system. Should it be public, private, or something in between? More than 30 private MRI clinics are already operating throughout B.C., Alberta, Nova Scotia, and Quebec. “It’s not imaging that’s the issue. It’s the health care system,” asserts Laberge. “Do we want to provide state-of-the-art health care to the general population, yes or no? If we don’t, then we have to have a two-tier system. We have to make choices.”

Sharon Sholzberg-Gray, president of the Canadian Healthcare Association, considers the status quo unfair. “If someone can pay $500 to $800 to get faster access (to MRI), they can get access to $50,000 worth of services faster than someone else. That’s the worst kind of two-tier.”

Dr. Stanley Kitay, president of the Alberta Society of Radiologists, sees things differently. He says there are few cash-paying customers at private clinics in Alberta. Rather, “it is more third-party—workers’ compensation and insurance. That takes those patients out of the public setup and improves the access.

Federal Health Minister Ujjal Dosanjh weighed in that, while he would not judge patients who went to a private clinic, he “would be judgmental” about provinces that violate the Canada Health Act by having private health services when the government has given them “gobs of money” to provide public services. Little concrete has happened, apart from letter-writing and meetings; the federal ministry does not have the authority to inspect private clinics for health act violations, as health is a provincial/territorial matter.

While MRI access in Canada has improved in recent years, the technology’s life-saving potential has yet to be fully unleashed. The CMA’s Schumacher concludes, “The bad situation is getting better, but we’re still far below where we should be for a country that prides itself on cell phones and space arms.”

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