“My accountant says you need surgery.”

May 10, 2012

The cartoon showed a doctor in his office talking with his patient, saying: “I’ve just consulted with my accountant and he says you need surgery.” Like most jokes, the humor here is tied to an element of truth. Surgeons are often recognized for their financial conflict-of-interest (shall we say “economic bias”?) as they decide whether or not to recommend surgery.

Spine surgeons are paid well for performing surgical procedures and so it is imperative that their decision to recommend surgery be as objective and as standardized as possible. The need for standardization is perhaps most apparent in the Dartmouth Health Atlas data that reports a 20-fold variation in the rate of spinal fusions and an 8-fold difference in the rate of discectomies across U.S. hospital regions.

In a Journal of the American Medical Association (JAMA) editorial, Dr. Eugene Carragee of Stanford University School of Medicine and Editor-in-Chief of The Spine Journal wrote “Consumer Reports rated spine surgery as number 1 on its list of overused tests and treatments.” He added that: “…..financial incentives and market forces….result in a formidable economic and social problem.” Should we add “ethical problem” as well?

With the need to identify ways to implement objective decision-making, I’ve reviewed in other SCF blog postings multiple published studies that report that, not only are 50% of disc surgeries performed unnecessarily, but it is possible to reliably identify those who need it and those who don’t.  Importantly, in these same studies, those who don’t need surgery are not just those who can get better slowly over the next few months or year, as depicted in shared decision-making presentations, but patients who can rapidly and completely recover without surgery in a matter of days or weeks.

Distinguishing between those who need and don’t need surgery, plus providing rapid recoveries for those who don’t, is the focus of an inexpensive but innovative mechanical spine exam that is part of a spine care paradigm known as Mechanical Diagnosis & Therapy (MDT). That exam identifies how great numbers of individuals can quite quickly eliminate their own pain and then prevent its return.  Further, other studies report that those same patients could have recovered much, much earlier in their course of care, while their pain was acute or subacute, if they just had been referred for this MDT assessment at that time.

But if the means to rapidly reverse their condition is never examined and never detected, the painful episode so often persists, and too often, surgery is undertaken……..unnecessarily.

The economic impact alone of reducing the 650,000 (and increasing each year) U.S. spine surgeries per year by 50% would obviously be huge. But is this realistic? It is if this assessment was a routine part of each patient’s pre-surgical care.  Even the most aggressive spine surgeon cannot justify surgery for a patient who rapidly and substantially improves or fully recovers.  Routinely providing this evaluation pre-operatively is completely compatible with surgeons’ ethics-based mantra of exhausting all non-operative means of treatment before deciding to operate.

A group of us will be presenting these data and an overview of these MDT methods in a symposium (“Directional Preference and Pain Centralization: Medical, Surgical and Research Implications“) on Friday at the annual meeting of the North American Spine Society (NASS) this October.  Although over 80% of its 6,000 members are spine surgeons, I’m expecting only a small number to attend.  After all, why would spine surgeons be interested in how to better select their surgical candidates, especially if this might disrupt their routine decision-making process and also diminish the volume of surgery they do?  However, two surgeons will speak on how utilizing this MDT examination has enabled far better patient selection for surgery resulting in improved surgical outcomes. This form of examination has become a valuable part of their clinical routine.

As always, I value comments and questions which you can insert in the space below, or email me at: blog@selfcarefirst.com

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