TO MAKE YOU THINK:
I have been practicing medicine for over 35 years. The problem of chronic pain has been my major interest for much of that time. My friends and colleagues have been urging me to write about some of my experiences especially incorrect diagnoses and their impact on injured people and disability.
Like 6 million others, my South Florida office and family are recovering from hurricane Irma. Trees and buildings that stood for over 30 years have toppled, the landscape around neighborhood changed dramatically. In some areas, entire neighborhoods will have to be rebuilt. They had all been vulnerable, it was just a question of when and how much force it would take. On the other hand, if the trees and buildings had been reinforced and made stronger, the damage would have been far less.
Our healthcare system is in big trouble and quite fragile or even broken. Just look at the news. Nowhere is this more apparent than in the problem of chronic pain. Despite using increasingly more aggressive care [spinal surgeries, joint replacement surgeries, injections, and opioids], disability is at an all-time high; one-third of all Americans suffer chronic pain; and we are formally in the middle of an opioid abuse crisis.
Why? The answer to that three-letter question is found in three simple words: Greed, Sloth, and Lying. Let me tell you a story about an injured worker we’ll call AJ. The goal is To Make You Think.
AJ is a 68 year old male with a history of back and neck surgeries, lung disease, high blood pressure, cholesterol, and depression. He is on medications for all these things. Despite this, he works part-time doing limited physical labor. Several weeks ago, he fell and hit his head suffering some lacerations. His arms and legs went numb and became mildly weak. He was taken to a hospital where he was found to have a mild spinal cord bruise. He was hospitalized for a few days and was feeling partially better. He also had neck arthritis [like every near-seventy-year old especially with prior neck surgery]. He walked out of the hospital with minimal weakness in one hand and his legs, as well as, some neck pain, and some sensory numbness and tingling.
The major problem was that the patient had suffered a clear neurological problem – a spinal cord bruise. Everybody should know that when you have a problem with your electrical system, you call an electrician. The patient should have been referred to a neurologist with training in rehabilitation or a rehabilitation specialist with training in spinal cord injury. Instead he was referred to an orthopedist. Because this is a work-injury, all care has to be authorized or “okayed.” This job falls to a company that oversees the injured worker’s medical care. This company has many resources and people. The adjustor, a case manager, their supervisors or advisors all had the chance to catch the mistake. They could have asked questions or gotten advice from a consultant. Nobody however did so. They had an unusual case and simply did the easy thing; they just signed off on it.
The orthopedist did not correct the error either. He is trained to know that this was a case of spinal cord bruising, but he changed the diagnosis and decided to treat this acute neurological injury. The new diagnoses became neck arthritis with cord compression. He gave AJ some medications, he sent AJ to the physical therapy practice he owns. Together they have been getting paid to treat AJ for many weeks. AJ has gotten somewhat better but is still not back to work. Now the discussion is whether to operate on AJ’s neck by doing aggressive major neck surgery. AJ is being sent to a major local university orthopedic department for a second opinion.
I was asked to do a paper consultation. I don’t know AJ. At age 68, he is working because he likes to or he needs to do so. He has lived a reasonably normal life and had been functioning at a very good physical level for his age. The injury is dramatic but not serious. He already had full return of almost all his strength [except one hand according to the records] and had some mild residual sensory tingling and numbness. Neurologists know that bruises to nerve tissue heal slowly and sometimes incompletely. The sensory symptoms can take months to get to their maximum improvement and there is no known treatment that definitely improves recovery time or completeness. The only proven treatment is time and rehabilitation. Surgery will not change that fact.
Does AJ need surgery or orthopedic care? The science is well known and the answer is no. A group of people with spinal arthritis and mild cord compression were followed who did not undergo initial surgery for over ten years. Eighty percent of those people never progressed and maintained good function. Only 20 percent needed surgery when they started to get functionally worse. Studies show that waiting until progression slowly occurs does not harm the patient. AJ does not need neck surgery at the present time and probably will never need it. The problem is no one is giving him that information.
I wrote my five page report explaining all the above with references. I sent it to the adjustor, her supervisor, their attorney, and the company that employs AJ. I then had a telephone conference. Nobody was willing to ask the orthopedist any questions or talk to AJ. No one was willing to let me discuss things with the orthopedist or AJ.
Apparently AJ received a copy of my report. The problem is that unless he understands highly technical medical writing, he probably won’t understand it [nor will most people]. It’s like reading an article written by a nuclear physicist – you better have someone who can explain the stuff to you. I doubt that AJ would understand my report. I was willing to explain it to AJ or anyone he wanted [that should be the job of any doctor]. Despite the fact that AJ is probably being led to believe he needs immediate major neck surgery [which he probably does not], I was told that no one would contact him, contact his orthopedist, or contact the university orthopedic department. They instead would simply authorize all the care. AJ will literally put his neck on the line, risk major disability, chronic pain, and other terrible outcomes. If things go well, the university orthopedist may tell him all the things that I think AJ should know, but chances are probably not.
Why and how did this happen? Let’s start from the beginning.
- If AJ was referred to a neurologist or rehabilitation specialist for his acute, improving neurological injury; then the hospital knows that it is far less likely that he will in the future need hospital based surgeries [as the studies prove].
- If the orthopedist corrects the mistake, he loses the business. He loses the office visits, the physical therapy, and the potential surgery. That adds up to big bucks.
- If the University orthopedist tells AJ everything I wrote, then he is going to make the referring orthopedist look silly. That orthopedist will never refer anyone to the University again. That’s not good for business.
- The Third Party Administrator company and their lawyer get paid for managing and arguing the cases. It’s easier for the adjustor just to approve than to question. After all, they make money as a percent of all medical care. The company claimed they didn’t want the threat of attorney involvement if they denied care. This was an excuse. They have the right and obligations to ask questions and get answers before they give approval. That’s their job and the meaning of the word “authorize.” The real truth is that if too many cases get settled more quickly, that’s not good for business.
AJ does not know any of this. He’s just doing what he’s supposed to do. He’s listening to his doctor and having faith in the system. I knew all this going in when I accepted the assignment. What I did not expect was the reaction of his employer. My father was an executive for General Electric. I own my business. My father taught me that my employees were my most important asset and to take care of them. I always thought that was a self-evident truth. Here I was trying to protect AJ, while trying to save his employer the very high costs of an unnecessary surgery, the prolonged rehabilitation, and the probable resulting disability claim [that will exceed probably $100,000]. With the company’s support, we could have changed things. In a terse email, I was told to stop — “the program has created a significant degree of administrative challenges.” My father is turning over in his grave. He told me that all significant improvements created challenges; that should never stop me from trying. My father was right. I realize that this particular Risk Manager did not care about the employee or change. The “challenge” is too great. As for the costs, the Risk Manager will simply pass them on to the consumer — a cost of doing business.
“Wow !!” you’re all saying. “Man, you must be paranoid or something.” Unfortunately, I’m not. This month, there was a survey of 2100 doctors; the doctors admitted that about 20% of all healthcare is medically unnecessary. They also stated that the percentage goes up if there are is a financial bias. Don’t believe me, look at a summary —
If doctors admit that they are over doing it for 1 of every five decisions, then at least every one of five major surgeries [or more] are possibly done for unclear reasons. Major surgery is no cake walk. It is unpleasant, painful, dangerous, and requires recovery. Many people like AJ are at risk. They should be told. The costs are unbelievable. Chronic pain costs American $650 billion per year; saving only 20% of that total adds up to $130 billion per year. The actual savings would be much higher. Surgeons, hospitals, insurance companies, and management companies will lose a lot of money.
Why should I care? I’m nearing retirement. I don’t know AJ and never will. I got paid well for my consultation. There will be more. However, a close friend and my parents’ teachings remind me that we are supposed to try to do the right thing. We are supposed to care. AJ deserves better. We all do.
Then I worry about the future. I’ll be fine, but someone will pay the price down the line. When the hurricane hits the healthcare system, major parts of it will collapse. Irma proved that. Our children and grandchildren will be paying for the cleanup with their money and lives. They deserve better. It should Make You Think,
David B. Ross, M.D.