Why are Vestibular Specialists so Hard to Find? Part III

Last week we discussed that many patients and physicians are unaware of the capabilities of vestibular diagnostic testing and management. This week, we look at some economic issues that diminish access to vestibular specialists.

Economics: Why do people with dizziness get full neurologic workups (usually including CT or MRI scans of the brain), and why are there so few specialists trained and equipped to deal with complaints of dizziness or vertigo effectively? Well, there is not a good reason, but there is a reason. Actually, a few reasons.

First, if a physician does not have the equipment and training to accurately diagnose the cause of dizziness, he/she has little choice but to make sure the symptoms are not the result of a stroke, brain tumor, MS or some other life threatening condition. While these conditions account for about 1 to 3% of dizziness complaints, the litigious mood of our country does not allow the option of forgoing MRI or CT scanning. A recent study shows that MRI found the cause of dizziness in 3% of patients, while ENG (the most basic vestibular test) found the cause in over 50% {{1}}[[1]]  Korres, S., Riga, M., Papacharalampous, G., Chimona, T., Danielidis, V., Korres, G., et al. (2009). Relative diagnostic importance of electronystagmography and magnetic resonance imaging in vestibular disorders. Jour Laryng Otol, 1, 1-6.[[1]] . In clinics with more advanced equipment, the cause is found in around 75 to 80%. Bottom line, until we do something about tort reform, practitioners are forced to go to extreme measures to avoid the possibility of being sued (and my opinion is that ordering a cranial MRI for the complaint of positional vertigo is extreme and contrary to published clinical guidelines). But, to be fair to the primary care physician, what choice do they have if there is not a vestibular specialist available? Hopefully, at some point in the near future, the specialties associated with “dizziness”, such as Audiology, Otolaryngology and Neurology will develop a clinical practice guideline with evidence based diagnostic and treatment pathways.