Dr. Hanscom's Blog Stay Out of the Surgical Scrap Heap

Objectives:

• Although there is no question about the dedication of physicians to providing excellent care, the rigors of training, the demands of practice, and the business of medicine have made it increasingly difficult to treat you – a person.
• A major factor is doctors are not allowed the time it takes to talk to you and understand the full nature of your problems. Major decisions are made based on inadequate data.
• Spine surgery is one of the bigger problems because the downside of a failed spine operation can destroy your life.
• An even larger issue is that once you have failed a surgical procedure, who is going to take care of you and the fallout of the procedure? Almost no one.
• You are essentially thrown onto a scrap heap. Much of my surgical practice involved pulling patients out of this pile. But the successes I witnessed were from the patients climbing out of The Abyss on their own with guidance – not from more surgery.
• Please do not allow yourself to become part of this mess and if you are already in it, become keenly aware of how to pull yourself out.

Physicians’ commitment to excellence borders on heroic. They undergo many years of training, endure long hours, continue to learn, and just plain work hard. Modern medicine with its technology allows doctors to deliver high-level services for a wide-range of challenging situations. The ability to deliver most of these specialized interventions comes from prolonged repetition, similar to any high-level performer. I spent 15 years in training after I completed high school, and the minimum for any physician is 11 years. Doctors give up their twenties in order to learn the skills required to deliver quality care. Why do we do it?

Originally, it begins with a deep desire to help others. A paper out of Philadelphia measured the level of compassion of college students applying for medical school, and it was significantly higher than the national average. However, it plummeted during the third year of medical school. (1) The reasons are clear. Many training programs require long hours, compliments are few and far between, and the mindset is often, “If you can’t take the heat, get out of the kitchen.”









Where did the patient/ physician relationship go?

This study didn’t even look at the rigors of residency and fellowship, which makes medical school seem like a tropical vacation. The stress becomes even more intense in practice. Doctors are now on the front lines with little backup, and the business of medicine is demanding that they are productive.

There are many consequences of this for you, the patient. The largest one is that doctors are not allowed to talk to their patients without significant financial consequences, and sometimes punitive actions are taken. Physicians are increasingly on an “assembly line,” and burnout is skyrocketing, rising well above 50% depending on the study. (2) Ironically, in the midst of all of this chaos, the one factor that prevents and helps burnout is their patients – if they can sneak in the time to talk to you. The patient-physician relationship is the essence of healing – for all parties.

The most dangerous aspect of this situation is that doctors don’t know the full story behind your symptoms – and you don’t feel heard. No situation in any arena of life can be effectively assessed and addressed without knowing the details. This is particularly true in medicine. Stress creates changes in your body’s chemistry, and it translates into many different physical symptoms. The end result is that simplistic solutions are quickly prescribed for complex problems. Anything that remotely appears complicated is usually met with a referral or dismissal.

One common example is patients will come in with prescriptions for ten different medications, sometimes many more. The potential drug interactions alone creates its own universe of problems. It takes time to sort through what the best combination might be, and it is much faster to prescribe another drug.

The end result of this current environment is that few physicians have the training or capacity to take care of you – the whole person. The rise of integrative medicine is promising but isn’t going to effectively solve your problem today.

The business of modern medicine has forgotten its foundational mission – to take care of you – all of you.

Spine surgery

This scenario is especially problematic in spine surgery. Spine surgery is often the most profitable service in the hospital system and every effort is made to increase productivity. “Productivity” is demonstrated in the form of more surgeries – whether they are effective or not. The most glaring example of this is surgeons performing fusions for lower back pain. The success rate at two-year follow up is less than 30%, and there is a significant chance of making you worse. (3,4) If you are a patient who had a successful outcome, consider yourself fortunate. That is not the case with most people.

The reason I took the time to explain the above scenario is because that isn’t the end, or even the worst part of this story. Once the post-op care is done, patients are usually discharged from the surgeon’s ongoing care, whether they are doing well or not. Surgeons feel like they did the best that they could, but their part is now done. Physicians are not only supposed to be productive (i.e., profitable), but have no incentive or encouragement to care for patients if the operation fails. Then what?







FBSS

One option is that you might be referred to a pain specialist, and there are not nearly enough of them. In our current medical culture, another surgeon isn’t going to care for another surgeon’s failure. Maybe you were sent to a psychologist, but chronic pain is not primarily a psychological issue. The rehab physicians can work on mechanics. The group that is best equipped to care for you is your primary care doctor and they are often overwhelmed – and also not given the time to talk to you. There is nowhere for you to go. You have literally been dumped onto the scrapheap of failed backs. There is even a name for your condition – “Failed Back Surgery Syndrome” (FBSS). This is a rapidly growing group, as we are continuing to efficiently perform ineffective operations.

Your life devolves into fighting for pain meds, embarking on an endless quest for answers, convincing the world that you really are in pain, and so on. Now you really are trapped, your body chemistry is way off, and your family is also suffering the consequences. These letters are representative of scenarios I see every week.

Pennsylvania failure

My mom had back surgery 15 years ago by a prominent spine surgeon in Pennsylvania. He ended up damaging a nerve, and sadly she has suffered greatly all of these years. She has pain from her lower back down to her one foot. Nothing could be done. She walks with a limp and needs Lyrica just to have some pain relief. She says over and over, “I wish I NEVER had this damn surgery.”

This should not be happening to people who just want pain relief and trust their doctor’s judgment fully. This physician is still practicing in Pennsylvania, which is so upsetting. He never claimed any responsibility for this terrible outcome.

A parent’s plea

My 28 year-old daughter was in a car accident five years ago. Three years ago, she had a fusion in hopes she could stop suffering from horrible back pain. Now, she’s worse. Her back surgeon is dismissive/offers no help.

Now my daughter is seeing a neurosurgeon who may suggest another operation (after studying her myelograms & doing a pain block in the area that appears to be impinging on her nerves). Meanwhile, my daughter, one of the most personable & dynamic people you could ever meet, has become antisocial, angry, anxious, etc. and the collateral damage to our family is extreme.

How can we help her become whole & happy again? She is more than willing to go somewhere for a period of time to get the tools to live a happy & fulfilling life. Can you suggest anything? Are there such resources? I hope you can help!

Please don’t join this club

Over half of my practice was working on providing an overall plan of care for patients who had prior spine surgery that had failed. It is not that difficult to create the structure needed to get people back on track. Patients are smart and resilient, if given even a glimpse of a solution. This is how The DOC Journey evolved. Patients organize their own set of resources to move back into a normal life and often thrive.

This is the reason why I quit my spine surgery practice and it is still getting dramatically worse. Even larger documented ineffective procedures are being performed that have a high incidence of complications. I am committed to doing what I can to prevent and solve this problem of “hit and run” surgery.

You, the patient, may have gotten got hit and it is more profitable for the medical system to have you hauled off to the junkyard than to salvage you. My book, Do You Really Need Spine Surgery? Take Control with a Surgeon’s Advice, is one of my efforts to prevent you and your family from joining the FBSS club.

Recap

A basic factor in any successful endeavor is understanding the relevant issues that are affecting the situation. The combination of chronic pain being a complex problem and you being unique makes it particularly critical. It is not possible to make a good decision about your care without being listened to and heard. That is not happening often enough in the context of modern medicine becoming industrialized. None of this is going to change anytime soon.

You have to take on responsibility for your care. It is not a simple task but more doable than you might think. The DOC Journey provides a foundational set of knowledge and skills and allows other intervention to be more effective.

Do You Really Need Spine Surgery? Take Control with a Surgeon’s advice, breaks the decision to have spine surgery into two variables – your anatomy and the state of your nervous system. There are four categories of choices, and your decision will become clearer. One of my intentions of this book was to make surgeons more accountable to their patients and primary providers.

Hopefully, you can prevent yourself from having a failed spine surgery and then not being able to find the help you need. The system is not set up to care for the complexity of a “Failed Back Surgery Syndrome.” If you are already a member, you can still find your way out and a reason for you to consider embarking on The DOC Journey or a similar program. I was one of those who found my way out and the next lesson is my story.

References:

1. Mohammadreza H, et al. The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Acad Med (2009); 84:1182–1191.
2. Bundy, C. Physician Burnout and Distress: Is the Health Care System Impaired? Washington Medical Commission Newsletter (Winter 2018); pp. 1-2.
3. Carragee E, et al. “A gold standard evaluation of the ‘discogenic pain’ diagnosis as determined by provocative discography.” Spine (2006); 31:2115-2123.
4. Franklin GM, et al. “Outcome of lumbar fusion in Washington State Workers’ Compensation.” Spine (1994); 19:1897–903.

Related posts:

1. The Surgical Scrap Heap
2. Anger Altering a Surgical Decision
3. My Early Surgical Philosophy