How Doctors Think (30 page)

Each of the various muscles, tendons, bones, joints, and ligaments in the lower back contains sensory nerves that can transmit messages of pain through the spinal cord to the brain. There are also organs in the abdomen and pelvis that, when they become inflamed or diseased, can signal pain in the back. Given all of these structures, the source of the chronic low back pain is often a mystery. Doctors can be hard-pressed to identify why a patient is uncomfortable.

How doctors think about a problem like chronic low back pain is heavily influenced by the specialty that they trained in. A research study published in 1994 entitled "Who You See Is What You Get" showed that each group of specialists favored the diagnostic tools of their discipline in evaluating patients. Neurologists called for electromyograms (EMGs) that assess the integrity of the conduction system of nerves. An EMG involves inserting needles into muscles and nerves and then applying a small jolt of electricity. Rheumatologists, who are experts in arthritis and other joint disorders, ordered blood tests called serologies that can identify relatively rare autoimmune disorders that affect the spine. Surgeons requested MRI scans, which reveal the anatomy of the vertebral bones and discs and may suggest a surgical solution.

One doctor who sees many patients with chronic low back pain and is an expert in anesthesiology and pain management told me that each approach to diagnosis and treatment is essentially a "franchise," and that too many franchises are battling for control. I recognized that he was using a business term as more than a mere metaphor. He pointed out that in medicine, when you do a procedure on a patient, even if it is just sticking a needle into him, the insurance company reimburses you at a much better rate than if you perform a physical examination. So, he said, there is a powerful drive to perform invasive procedures.

On the other hand, Dr. Richard Deyo, a primary care physician at the University of Washington who has studied the results of treating thousands of patients with low back pain, emphasized that in most cases these diagnostic tests are neither informative nor useful in guiding treatment. Research showed that 85 percent of patients who suffer from low back pain cannot be given a precise diagnosis; the pain is usually vaguely ascribed to "strain" or "sprain" in the lumbar region. It turns out that the diagnosis is not critical, because the outcomes tend to be similar anyway. With acute low back pain, 90 percent improve within two to seven weeks without specific therapy. Even with an acute ruptured disc the prognosis is good, although recovery is usually slower; 80 percent feel significantly better within six weeks without surgery. Over time, the disc retracts, so it no longer presses on the nerves and the inflammation subsides. As noted before, a simple discectomy will make you feel better faster if you have acute sciatica, so some people opt for this procedure. But the rationale for surgery for chronic, as opposed to acute, low back pain is much less clear; how physicians guide patients with chronic pain, alas, may be significantly influenced by economics.

The spine surgeons I spoke with were reluctant to be identified by name out of concern that candid answers would damage their standing in the medical community and reduce patient referrals. So let me call one of these surgeons Dr. Wheeler. He performs two or three spinal fusions a week. For many years, Wheeler recommended that his patients with back trouble avoid fusion surgery unless it was absolutely necessary—when the vertebral bones have been dislocated or damaged by diseases that endanger the spinal cord or the nerves. But such conditions are unusual, accounting for less than 2 percent of all cases of chronic low back pain. "'Spinal instability' is routinely given as a diagnosis to these patients with chronic lower back pain," Wheeler said. "It is a term used to justify an operation. And it is a great diagnosis, because it cannot be directly disproved."

Like Dr. Foyer, who is a believer in testosterone replacement therapy for older men, several spine surgeons I spoke with were believers in both spinal instability and the need for fusion surgery. They routinely ordered x-rays of the spine and interpreted minor movements in the vertebral bones when flexed or extended as evidence for this diagnosis. But experts in spine surgery, like Wheeler, and in rehabilitation medicine, like Dr. James Rainville at the New England Spine Center, expressed profound skepticism that these minor changes on x-rays could account for chronic pain.

Although Wheeler advised patients with long-standing back pain to avoid fusion surgery, he found that considerable forces weighed against his conservative recommendations, particularly when patients had a job-related accident or injury and thus could benefit financially from persistent disability. He told me that one group of four neurologists in his community works directly with lawyers. The lawyers refer the patients to these neurologists after an accident or work-related injury associated with back trouble. The neurologists charge up to $1,500 for an EMG and then get another $500 from the attorney for their report. (Wheeler averred that in more than twenty years of practice, he had never seen these neurologists read an EMG as negative in accident cases.) The neurologists then tell the patients that they have severe disc disease, which can enhance their perception of pain. Moreover, if they do have the surgery, they are told that they don't necessarily have to go back to work afterward.

Wheeler said that he is put in a difficult position whenever one of these referring neurologists tells a patient that the EMG or MRI indicates something seriously wrong with the spine. In the past, when Wheeler challenged one of these neurologists, the doctor would counter, "I'm a pro-patient advocate."

Of course, most doctors do not behave so egregiously, and most of them believe they advise their patients correctly with the information available from tests and scans. Nonetheless, the current culture of medicine fosters lucrative networks of referrals and procedures but discourages critical examination of their value. Insurance benefits also favor surgery: patients usually get greater disability payments if they undergo back surgery. Eventually Wheeler discovered that nearly all of the patients he turned away were operated on by other surgeons in his area. He decided that if his patients were to have surgery, he might as well be the one to do it. At least he would know that the operation had been competently done.

Insurance nearly always reimburses a surgeon at a much higher rate for a fusion operation than for a discectomy. For example, where Wheeler practices, the surgeon's full fee for a simple discectomy is around $5,000, as opposed to some $20,000 for a fusion procedure. The financial incentive tips heavily toward fusion.

For the majority of patients with chronic lumbar pain, fusion surgery has no dramatic impact on either their pain or their mobility. Yet many surgeons pay scant attention to the poor results. A prospective trial in Scandinavia compared patients who underwent fusion surgery for chronic low back pain with those who did not. After two years, an independent observer rated only one out of every six patients in the surgical group as having an "excellent" result—only marginally better than patients who had intensive physical therapy. Despite such a disappointing outcome, some spine surgeons cite the study to support the legitimacy of the operation.

In 1993, the federal Agency for Health Care Policy and Research convened a panel of twenty-three experts in back pain from a wide spectrum of disciplines—neurology, orthopedics, internal medicine, radiology, chiropractic, rheumatology, psychology, and nursing. The University of Washington's Richard Deyo was on the panel. He had recently published a statistical analysis of existing research which suggested that spinal fusion lacked a scientific rationale and that it had a significantly higher rate of complications than simple discectomy. The federal panel was to formulate guidelines for the clinical management of acute low back pain by assessing the scientific evidence concerning its diagnosis and treatment. Although the panel did not discuss insurance coverage, it seemed likely that Medicare and private insurers would consider these guidelines when determining reimbursements.

The federal group came under attack almost as soon as it met. The North American Spine Society criticized the panel for not having open deliberations and claimed that the panelists were biased against surgery. The society lobbied Congress to cut off funding for panels of the Agency for Health Care Policy and Research. Deyo told me that the line taken by the opponents was "These guys are antisurgery, antifusion." But, he insisted, "we really had no ax to grind. Our aim was to critically examine the evidence and outcomes of these common medical practices."

After the November 1994 congressional elections, which featured a dramatic shift from a Democratic to a Republican majority, the newly configured House of Representatives was receptive to the accusations against the panel. Although the American Medical Association, the American College of physicians, and the American Hospital Association all tried to save the healthcare policy agency, the House zeroed out its budget. Then the battle moved to the Senate. Although the agency ultimately survived, Congress cut its funds drastically. A company that manufactures devices used in fusion surgery sought a court injunction to block publication of the panel's findings. The guidelines that were eventually published emphasized conservative measures like physical therapy, but the controversy surrounding the panel tainted its credibility, and its recommendations have had little impact on surgical practice.

While one spine surgeon I spoke with still defends his actions against the panel, even he admitted that fusion operations have proliferated in the United States. He pointed out that when he began his training more than two decades ago, only a handful of fellowships in spine surgery existed; now there are more than eighty. Each year, more and more specialists are being trained, and those specialists naturally look for opportunities to use their training. The technology has also developed rapidly. New sorts of screws, rods, and cages, as well as other devices, can be inserted into the spine. These instruments are aggressively marketed and generate high profit margins for both the manufacturers and the hospitals that use them.

I spoke with a surgeon after his return from a meeting on spine surgery held at a luxurious resort. As with my surgeon friend mentioned earlier, the entire trip was paid for by a company that manufactures the hardware he uses in performing fusions. He claimed that the perk would not alter his practice, but also affirmed that he was a "believer" in fusion surgery. "My outcomes are better than anything in the published literature," he said. But when pressed, he admitted that long-term follow-ups are rare and that he has not participated in any randomized prospective controlled trials comparing fusion surgery with conservative measures such as physical therapy.

When the government won't stop unnecessary procedures, when corporate interests push for them, and when doctors come to believe in them, the only institutions that might stem the tide of needless surgery are the medical schools and their affiliated hospitals. And, indeed, many hospitals do try to disentangle medicine from corporate influence. The
Journal of the American Medical Association
published a paper in January 2006 that got considerable attention. In it, academic physicians from Columbia and Harvard recommended that doctors begin to police themselves against untoward influence by the pharmaceutical industry. No medical advance can be made without a partnership with the private sector, whether it be the development of a drug or a new implantable device. A free-enterprise economy presupposes that a business will try to gain as large a share of the market as possible and maximize profits. On the other hand, the decisions a doctor makes about his patients should be free from any thought of personal financial gain. The authors of the
JAMA
article went so far as to assert that even apparently trivial gifts could subtly influence a physician. They argued that in the psychology of gift-giving, consciously or subconsciously one feels obligated to give back.

Sometimes, though hardly always, the giving back may be at the patient's expense. Many hospitals and universities, as well as medical journals, now require that physicians disclose their financial relationships with businesses. Some of these relationships involve consulting; others, funding for research or educational activities. The purpose of disclosure is to make public the relationship and alert the patient or the reader of the journal to potential prejudice or bias.

But the authors of the
JAMA
article argued that such disclosure is not enough. They pointed to Wall Street, where stock analysts have inappropriately promoted the shares of certain companies despite financial links between the analysts' employers and the companies concerned. Indeed, such disclosure may work against its purpose: patients or readers may believe that disclosure frees the physician or scientist from potential bias associated with personal gain when in fact disclosure does no such thing. Dr. Thomas Stossell, an eminent hematologist at the Brigham and Women's Hospital in Boston, wrote a rebuttal in
Forbes
arguing that relationships with industry are essential to medical progress, and to sever or severely strain these relationships would, in the end, hurt patients in need of new drugs.

In appraising potential conflicts of interest, the hospital where I work distinguishes between clinical care and laboratory research. Laboratory researchers are encouraged to have relationships with industry, since these relationships are essential to developing cures for currently incurable diseases. On the other hand, the risk that personal financial gain could color clinical thinking is considered too great to allow doctors to test drugs in experimental protocols if they are consultants to a pharmaceutical company or device manufacturer. The restrictions do not extend as far as the
JAMA
article proposed, so personal perks like dinners at expensive restaurants or honoraria for speaking at conferences (given to doctors in the form of "educational grants" by the conference's sponsor) are still permitted. Most hospitals and medical schools today find themselves in this gray zone.