Was Tolstoy Right on Why the MDT Innovation Isn’t Infiltrating Spine Care More Quickly?

October 26, 2015

I have been interacting with and attempting to teach physicians for the past 30 years about the methods, value, growing evidence, and clinical implications of the Mechanical Diagnosis & Therapy (MDT) form of care.  Guideline panels continue to ignore the substantial evidence validating the existence of LBP subgroups in favor of their near-total attention on randomized trials (RCTs) that target the non-specific symptom of low back pain (LBP).

Shared decision-making content “experts” are no different, choosing to ignore an option that every surgical candidate would likely jump at: taking 2-3 appointments for an MDT evaluation with a 50% chance of rapid and complete recovery without surgery.

The rate of progress in converting minds to even consider incorporating the MDT paradigm of care into one’s clinical pathways can be depressing at times.

Theories attempting to explain this reluctance to shift to MDT care include a resistance to change longstanding habits and patterns learned from mentors, even if there might be patient benefit in doing so.  There’s also the economic bias based on a concern that higher recovery rates and speedier recoveries might undermine revenue from “the hammer” wielder so focused on finding “a nail” rather than a patient-centric solution.

Tolstoy has a grasp on the human condition and this explanation when he states (I paraphrase from “What is art?” Leo Graf Tolstoy, 2014:124): “Most men who are capable of understanding difficult scientific, mathematical, or philosophic problems can very seldom discern even the simplest and most obvious truth if it obliges them to admit the falsity of conclusions they have formed, of which they are proud, which they have taught to others, and on which they have built their lives.”

I’ve always characterized his view as simple “pride and ego”.

In my experience, Tolstoy’s statement rings true for most spine care specialists, both surgical and non-surgical.  So many problems are made unnecessarily complex because of mis-diagnosis that is commonly and simply solved: making a mechanical diagnosis using MDT methods of care. But this is apparently just too simple for most spine specialists to grasp, acknowledge, and implement.

So who is ready to hear this MDT message? I believe it is only those in pain who would themselves benefit from high quality care at a lower price.  They essentially comprise two types: patients experiencing the actual symptom of pain and related impairment, and self-insured employers who suffer with the economic pain related to their employees being regularly mis-diagnosed in the community and consequently mis- and over-treated, leading to excessive direct and indirect costs.  Comparatively speaking, spine specialists are not in pain.  But they make a generous living by both providing services to those in physical pain and by accepting compensation from those in economic pain.

But there is one other clinical group that tends to truly have their patients’ best interests at heart without significant financial conflict of interest. They include family physicians, nurse practitioners, physicians’ assistants, internists, pediatricians, gynecologists, and urgicare and ER docs.  But even they have their established care pathways that enable them to efficiently manage their patients within the fast pace and short appointment times of their daily practice. Unfortunately, those pathways far too often include: 1-an early, often misleading MRI; 2-a specialist referral that is not always helpful, can even be detrimental while greatly increasing the cost of care; and 3-a narcotic prescription to provide some pain relief for their patient.

I am currently working on a book for primary care-givers that will introduce the idea of a primary “team-based” approach to musculoskeletal care, characterized by adding MDT expertise to their team.  As with my previous books(1, 2), this one will focus on the “Why” of MDT.  The “How” of individualized patient care is covered well in Robin McKenzie’s textbooks and his “Treat Your Own” series.

I’ll keep everyone posted on my progress with this project and its availability.

As always, please share your thoughts, this time about reaching doctors with the MDT message, as well as any questions that come to mind.

1. Donelson R. Rapidly reversible low back pain: an evidence-based pathway to widespread recoveries and savings. Hanover, NH: SelfCare First, LLC; 2007. FIND ON http://www.amazon.com

2. Donelson R. Solving the mystery: the key to rapid recoveries from back and neck pain. Hanover, NH: SelfCare First, LLC; 2010.  FIND ON http://www.amazon.com


2 Responses to “Was Tolstoy Right on Why the MDT Innovation Isn’t Infiltrating Spine Care More Quickly?”

  1. Ryan Tauzell Says:

    Thanks Ron! The PCPs of the world are the gate keepers, trusted by patients for advice on their health. An educational tool geared toward the PCP will be a very helpful in opening the eyes of the healthcare providers that have great patient influence.

    • Thanks for your comment on my recent blog posting Ryan. I agree with you re. the importance and influence of PCPs in spine and MSk care. Hopefully this book will help many patients receive more effective, safer, and less expensive care.

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