Harmed by the Healer: The Dangers of Mindless Aggressive Care

Almost everyone has negative experiences with healthcare, but few people are aware of how the dysfunction is done, and how to fix it.

When I am asked about problems in our country’s healthcare, I always think back to the story of Debra*, a 72-year-old woman who came to my clinic after a disastrous spine fusion surgery.

Debra had experienced a foot drop for the past five years due to arthritis of the lower back with no significant back pain. Her niece suggested a neurosurgeon to work with. The best practice for chronic foot drop is managed by physical therapy to strengthen the healthy nerves and muscles, along with managing any systemic conditions like diabetes to help the nerves recover and an ankle foot orthosis AFO. That course of care takes about 4 months and costs around four thousand dollars (Doctor $1,000, PT $2,500, Labs $400, and AFO custom $1,000, or off-the-shelf AFO from Amazon $39). The prognosis is good with improved mobility and fall prevention and no or very little pain. I have treated over 100 patients like this with predictable outcomes.

Without any of the above considerations, the surgeon offered as the first and ONLY treatment option a massive spine surgery. She received a multilevel spine fusion surgery with 21 screws drilled down into her spine (see image). Since that surgery, she has had severe pain that required large doses of opioids which she never needed before surgery because her pain was not significant. When Debra came to me, she could barely walk and needed opioids around the clock to cope with the pain. We helped her through extensive physical therapy, but she was ultimately unable to regain most of her mobility and independence. The damage was already done, and sadly she would have to struggle with chronic pain for the rest of her life.

These extensive, overly aggressive surgeries are wildly lucrative for doctors, hospitals, hardware, and opioid manufacturers. At the same time, such surgeries will cost the payers around $400k in-direct costs. But what is worse is the long-term lifetime cost of medical care and disability that patients, families, and society have to deal with.

Physically this patient had debilitating pain and little-to-no range of motion, muscle weakness, numbness, tingling, and dependence on prescription drugs. A miserable existence exists with permanent disability and chronic pain.

As a practicing medicine and rehabilitation physician (aka a doctor of function), I feel a visceral punch to the gut every time I see a patient like Debra — whose pain and fear were exploited by physicians selling false hope for monetary gain, and offering the most aggressive and expensive treatment as a first-line and only treatment option. And like Debra’s case, these aggressive options often lead to a lifetime of catastrophic chronic pain, drug dependence, and disability for the patient.

In short, the choice that Debra made changed her stable spine arthritis claim into a catastrophic claim that shortened her lifespan and made it miserable.
On an even sadder note when Debra went back to complain to her surgeon about her worsening condition, he had a typical response of “I did my best, go find another doctor.”

Important to note that the current system of medical management, and pre-auth process will never prevent these catastrophic claims, because they simply follow step therapy (a check off list) that a financially motivated doctors will easily go through to get his surgery done.

Why Choosing The Right Doctor Is Essential

Seeing these ramifications of aggressive surgery and false promises breaks my heart. But unfortunately, these scenarios happen all too frequently. In the US, 40% of patients who undergo spine surgery experience chronic pain and pain-related disability long after the procedure, and 44% are more likely to become dependent and prolonged opioid users as a direct effect of the surgery.^1,2

Choosing the right doctor at the outset has a ripple effect on the patient’s outcomes and quality of life and impacts their families, employers, community, and society at large. Currently, there is no clinically oriented or systematic process in place to help guide patients when making the important decision of choosing a doctor. This is made all the more difficult in the face of the multibillion-dollar industry that profits from excessive opioid use and aggressive procedures that result in $2-8.5 billion of needless spending every year.³

Although physicians take an oath to “first do not harm,” acting in the patient’s best interest doesn’t always happen. And when providing procedures and surgeries, it is imperative to only do so when the benefits outweigh the risk of harm to patients. On the other hand, it is a misconception that the Hippocratic Oath and monetary gain are mutually exclusive.

“There is nothing wrong with profits if we provide value in return, but we should never promote harm to achieve profit.” – Ali Alhimiri, MD

References

1. Chan, C. W., & Peng, P. (2011). Failed Back Surgery Syndrome. Pain Medicine, 12(4), 577–606. https://doi.org/10.1111/j.1526-4637.2011.01089.x

2. Lawal, Oluwadolapo D., et al. “Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis.” JAMA network open 3.6 (2020): e207367-e207367. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767637

3. Schwartz, Aaron L., et al. “Measuring low-value care in Medicare.” JAMA internal medicine 174.7 (2014): 1067-1076. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1868536
   
4. Gold, M. Financial incentives. Journal of General Internal Medicine, 14(S1), S6–S12. (1999) https://doi.org/10.1046/j.1525-1497.1999.00260.x