Dr. Hanscom's Blog The Scrap Heap

Modern medicine has forgotten its foundational mission – to take care of you – all of you. The capacity to deliver high-level services for a given challenging situation is commendable and beyond reproach. Physicians’ commitment to excellence approaches unbelievable, requiring years of training, long hours, ongoing learning and just plain hard work. The ability to deliver most of the specialized interventions comes from prolonged repetition, similar to any high-level performer. I spent 15 years in training after I completed high school. The minimum for any physician is 11 years. Doctors give up their 20’s in order to learn the skills required to deliver quality care. Why do we do it?

Originally, it begins with a deep wish 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. It becomes more intense in practice where you are now on the front lines, with little backup and the business of medicine is demanding that you are productive. There are many consequences of this for you, the patient, with the basic one that your doctors are not allowed to talk to their patients without significant financial consequences and sometimes punitive actions. 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 our patients – if we 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 we don’t know the full story behind your symptoms – and you don’t feel heard. Anything that remotely appears complicated is met with a referral or dismissal. No situation in any arena in life can be effectively assessed and addressed without knowing the details. This is particularly true in medicine where 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. One common example is patients coming in who are on over ten different medications and sometimes many more. Just the potential drug interactions will create its own universe of problems. It takes time to keep sorting through what the best combination might be instead of prescribing a drug for the next symptom.

So, 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.

Spine surgery

This scenario is especially problematic in spine surgery. Spine surgery is often the most profitable service line of a hospital system and every effort is made to increase productivity in the form of more surgeries – whether they are effective or not. The most glaring example is performing fusions for low 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 one of those who had a successful outcome, consider yourself fortunate. That is not the case with most people.

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

FBSS

You might be referred to a pain specialist and there are not nearly enough of them. 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 primary care and they are completely overwhelmed by the system – and also not given the time to talk to you. There is nowhere 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 run across 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 with pain from her low back 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 5 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 now 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 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!

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 takes much less structure than you might think to get people on track. Patients are smart and resilient if given even a glimpse of a solution. It is how the DOC project evolved and most of it is self-directed. Patients organize their own set of resources to pull themselves out of the hole.

It is also the reason why I quit my spine surgery practice. I am both trying to prevent and solve this problem of “hit and run” surgery. You, the patient, just got hit and it is more profitable for the medical system to have you hauled off to the junk yard than to salvage you. My upcoming 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.







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. Compassion and an Italian Dinner
2. Your Doctor Might Not be Listening
3. Compassion in Medicine