Was Your Last EMG Performed By A Qualified Physician?

confused-doctorEMGs and nerve conduction studies are excellent tests if done correctly.  While they represent the “gold standard,” many physicians who rely on these studies have come to believe that they may actually represent “fool’s gold.”  The reason that there is some doubt about their usefulness is that these tests are routinely done poorly. Many unnecessary surgeries are performed because of tests which were done improperly.  Why are these tests done poorly?


1.     Many of the tests are done by providers who do not have adequate training.  The quality is often poor in these situations.  Would you want your surgeon to rely on a test that was performed by someone who wasn’t an expert?  Patients are inaccurately labelled with carpal tunnel syndrome, ulnar neuropathy and radiculopathy because the test is done by a person without the necessary skills. 
2.    The technicians who perform these tests are often poorly trained.   It is common for untrained technicians to have little understanding of anatomy, nerve disease, and may have little or no supervision.
3.    The physician and technicians who perform these tests often fail to understand the general principles and sources of error that can occur.  For instance, the temperature of a hand will critically affect the results of a carpal tunnel syndrome study, but most labs don’t even have a skin thermometer!
4.    The values used to differentiate normal from abnormal are incorrect.  There are some labs that report an abnormality on everyone.  Very small errors in measurement or technique can make a normal nerve appear abnormal.
5.    Substandard equipment.  Like other areas of medicine, the sophistication of EMG equipment has improved rapidly and computers are now an important part of the testing.  Many EMG machines are inexpensive “make do” units.  Many handheld units are limited by the type of conditions they can evaluate.  Often the results are interpreted by someone in another state who has never seen the patient. 

 


How can you be assured that the test is done correctly?  EMG Audit makes the following recommendations:

1.    Make sure that these tests are performed by either a physiatrist or a neurologist.  Both of these physicians have received training during their residency in electromyography.  It is preferable for this person to be board certified by the American Board of Electrodiagnostic Medicine. This assures that they have received formal training.  Very often, physicians of other specialties are trying to do this test in their own offices.  Although their expertise in this area is typically less than a physiatrist or neurologist, the bill may be the same.  Many payers will only reimburse procedures done by a physiatrist or a neurologist.
2.    Be cautious regarding handheld units.  Standard electromyography equipment should be used.  Standard equipment is capable of generating “real time” wave forms from the nerve and muscle.
3.    Try to determine if the EMG trained physician is actually on the premises when this test is being performed.  Each patient should have his/her test evaluated by the physician before the patient leaves the treatment room.  The physician should be the one performing the invasive part of the study which is called an EMG.  This is the part of the test that involves placing a small needle into several muscles to look for nerve or muscle injury.  The physician must watch the electrical activity on an oscilloscope as the needle is moved about.  This requires a great deal of expertise.  This procedure cannot be done with the handheld devices.
4.    Look at the recommended policy online for electrodiagnostic medicine.  This policy was developed by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM.org).

Scope of EMG Problems
 

EMGs and nerve conduction studies are excellent tests if done correctly.  While they represent the “gold standard”, many physicians who rely on these studies have come to believe that they may actually represent “Fool’s gold”.  The reason that there is some doubt about their usefulness is that these tests are routinely done poorly.  Unnecessary surgery may be performed daily because of tests which were done improperly.  Why are these tests done poorly?
1.     Many of the tests are done by providers who do not have adequate training.  The quality is often poor in these situations.  Would you want your surgeon to rely on a test that was performed by someone who wasn’t an expert?  Patients inaccurately receive the diagnosis of carpal tunnel syndrome, ulnar neuropathy and radiculopathy because the test is done by a person without the necessary skills.  
2.    The technicians who perform these tests are often poorly trained.   It is common for them to have little understanding of anatomy, nerve disease, and little (if any) supervision.
3.    The physician and technicians who perform these tests often fail to understand the general principles and sources of error that can occur.  For instance, the temperature of a hand will critically affect the results of a carpal tunnel syndrome study, but most labs don’t even have a skin thermometer!
4.    The values that they are using to differentiate normal from abnormal are incorrect.  There are some labs that report an abnormality on everyone.  Very small errors in measurement or technique can make a normal nerve appear abnormal.
5.    Substandard equipment.  Like other areas of medicine, the sophistication of EMG equipment has improved rapidly with computers now an important part of the testing.  Many EMG machines are inexpensive “make do” units.  Many hand held units are limited by the type of conditions they can evaluate.  Often the results are interpreted by someone in another state who has never seen the patient.  
How can you be assured that the test is done correctly?  I would make the following recommendations:
1.    Make sure that these tests are performed by either a physiatrist or a neurologist.  Both of these physicians have received training during their residency in electromyography.  It is preferable for this person to be board certified by the American Board of Electrodiagnostic Medicine. This assures that they have received formal training.  Very often, I find that physicians of other specialties are trying to do this test in their own offices.  Although their expertise in this area is typically less than a physiatrist or neurologist, the bill may be the same.  Many payers will only reimburse procedures done by a physiatrist or a neurologist.
2.    Be cautious regarding hand held units.  Standard electromyography equipment should be used.  Standard equipment is capable of generating “real time” wave forms from the nerve and muscle.
3.    Try to determine if the EMG trained physician is actually on the premises when this test is being performed.  Each patient should have his/her test evaluated by the physician before the patient leaves the treatment room.  The physician should be the one performing the invasive part of the study which is called an EMG.  This is the part of the test that involves placing a small needle into several muscles to look for nerve or muscle injury.  The physician must watch the electrical activity on an oscilloscope as the needle is moved about.  This requires a great deal of expertise.  This procedure cannot be done with the hand held devices.
4.    Look at the recommended policy online for electrodiagnostic medicine.  This policy was   developed by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM.org).

Contact Information

EMG Audit
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