A Question of Balance

I am reminded of an experience I had as a lowly medical student. I was on the cardiac surgery service. I was scrubbed on a case as the fourth person scrubbed. As the fourth person scrubbed, I was standing at the very perimeter of the surgical site, looking around others for a glimpse of the action. It was the intern's job to hold the heart while the surgeon and fellow performed the surgery. The staff surgeon (Dr X) was a bit of a tyrant, as heart surgeons were prone to be in those days. Dr X repeatedly stated “a little more,” “a little, not so much,” etc, as it pertained to the retraction of the heart by the intern. Finally, after incessant staff commentary about the “inadequate” retraction by the intern, the intern in frustration finally lashed out by stating, “Dr X, do you want me to retract too much or too little?” Needless to say, the intern was immediately dismissed, and as it goes in professional football and surgery, “next man up!” Next thing I knew, I was holding the heart, reaching around the fellow, trying to do my job just right. So I raise this question in neurosurgery: Are we doing too much or too little? Do we do too little surgery? Or could it be that we do too much surgery? One has only to assess the rising percentage of gross domestic product that is devoted to health care (nearly 20%) or the high annual cost of medical care per capita in the United States ($7000 per capita per year) to answer these questions. To put this in perspective, $7000 per person multiplied by 300 million people is more than $2 trillion spent on health care annually in the United States. Healthcare expenditures in the United States far exceed that in comparative first-world countries worldwide in all cost of care categories. However, there must be other culprits, not just us, in the United States. Indeed, there probably are. The politicians make laws that are not in the people's best interest. They are at fault as well. The insurance carriers withhold reimbursement for quality services and reimburse low-quality services. They must bear part of the burden of blame. The insurance carriers have been the processing agent that has funded health care for years. Their profit margins have not changed. Hence, as costs increase, they reap greater benefit. In fact, insurance carriers benefit when the cost of health care increases. They thus have no incentive to lower premium costs. This just does not seem fair. The spinal implant industry historically has had ridiculously high profit margins. This only recently has begun to change. This industry has not had an incentive to diminish costs. It has lived on what is called a supply curve (Figure 1A). When quantity and volume of services and products are increased, they actually increase the cost, thus amplifying and escalating the cost of care. This is instead of being exposed to the rigors of a demand relationship whereby a decrease in cost actually increases the quantity sold (Figure 1B). Only recently have we begun transcending from a supply- to a demand-type curve. Essentially, we have been living in a “what the market will bear” economic environment.FIGURE 1: The price-quantity relationship seen when the economic environment follows a supply relationship in which quantity increases as price increases (A). A demand relationship in which an increase in quantity decreases price (B). The latter (demand) relationship fosters the development and maintenance of a stable economic environment. A, B, and C refer to varying price points and their relationship to supply (A) and demand (B).Finally, the hospitals use physicians as pawns to generate profits, and the attorneys manipulate the medical environment to enhance their gain at the expense of hospitals, insurance carriers, physicians, and patients. The physicians cannot be at fault, can they? They, however, like all others, game the system. One only has to look at the surgery use map for spinal fusion across the country to see that there are regional valleys and peaks—regional peaks within which exist 10-fold greater surgery rates than in the valleys (Figure 2). How can this be? It is clearly not due to variance in pathology. Thus, it must be due to variance in indications for surgery.FIGURE 2: A map of the United States demonstrating variation in spine surgery rates. As much as a 10-fold variation in the rate of surgery exists between regions.In 2003, 2 writers for the New York Times (Reed Abelson and Melody Peterson) asked if I would do a telephone interview for an article they planned to write. The article was subsequently titled “An Operation to Ease Back Pain Bolsters the Bottom Line Too.” I thought that this may be an opportunity but also a potential journalistic trap. Hence, caution was in order. At that time, I was relatively new at the Cleveland Clinic. Hence, I talked to the Cleveland Clinic media team. They encouraged that I “go for it” but asked to coach me. I said, “Please do.” Their advice, which I heeded, revolved around this recommendation: No matter what they ask, I was to respond with 1 or a combination of 3 prepared answers. I thought to myself, “I am feeling like a politician here.” The media team went on to say that if I answer the questions in this way, I could not be misinterpreted. I dutifully proceeded. My 3 answers (sound bites) were: Less than 50% of the operations for spine pain are appropriate (my opinion). This specifically referred to fusion; Surgeons often cave into market pressures; and The system for physician reimbursement is perverted. I indeed was not misquoted. Only these 3 sound bites appeared in the article. For some time after the publication of the article, I felt like I needed to have somebody start my car for me when I went home at night. However, as time passed, it became evident that my opinion increasingly became the norm, with more and more physicians agreeing with, or at least appreciating, my sound bites. VALUE Value equals quality divided by cost. Although such a simple equation, it perhaps is the most fundamental equation of medical economics. It goes without saying that the use of goods and resources, including surgery, procedures, and medications, should approximate their value. Unfortunately, we have seen over the years that the use of these goods, resources, technologies, and surgeries has increased without a perceived commensurate increase in value. A divergence between use and value had, in fact, evolved. As I see it, our responsibilities moving forward are to objectively and accurately establish the diagnosis, to use established treatment strategies, to objectively assess the patient, and to adjust and act accordingly. In other words, we should logically and objectively manage the entire decision-making process. OBJECTIVELY ESTABLISH ACCURATE DIAGNOSIS Two patient/pathology categories, within which significant improvement in value can be realized, are chronic pain and end-of-life care. However, there are many additional arenas within which we could direct our focus from a resource use and value perspective. For example, do we neurosurgeons perform too many operations on glioblastomas, cranial metastases, or spinal metastases? Are endovascular procedures truly cost-effective? Although each of these, and many more, arenas merits further attention, I focus on chronic pain and end-of-life care as a “low hanging fruit” template. Chronic Pain Syndrome We spend $635 billion per year (20% to 30% of our healthcare dollars) on chronic pain. For the most part, this money is money “thrown down a rat hole.” We spend more money on chronic pain and chronic pain syndromes than we do on cancer, heart disease, diabetes mellitus, and arthritis combined. I consider money spent on chronic pain to be money thrown down a rat hole on the basis of poor outcomes and multiple ineffective operations, reoperations, procedures, and medications (predominantly narcotics and anxiolytics), all to no avail. This results in an associated chronic misery, not only for the patient and the patient's family but also for physicians and as a whole. The reason: a wrong diagnosis. In reality, the solution should be very simple. We, however, often do not see the proverbial elephant in the room. We often look at this elephant while wearing a blindfold. We may begin the examination by feeling the tail. The tail feels like a rope (Figure 3). Wrong diagnosis.FIGURE 3: The elephant in the room, as visualized by blindfolded examiners.While assessing a patient with pain in the outpatient setting, we may be looking at an imaging study and seeing an L4/5 degenerative spondylolisthesis with spinal canal stenosis. However, with our blindfold on, we may not be listening to the patient and seeing the true diagnosis. The patient may be telling us something completely different. The patient may, in fact, be telling us that he or she has a chronic pain syndrome, a clinical entity that is most often not optimally treated with surgery. Chronic pain syndromes are common. Neurosurgeons commonly see such patients presenting with back pain. Neurosurgeons, however, see but a fraction of the overall chronic pain patient population. Analogous syndromes in other specialties include temporomandibular joint pain for the otolaryngologist, headache for the neurologist, pelvic pain for the gynecologist, abdominal pain for gastrointestinal physicians, joint pain for orthopedic surgeons, and fibromyalgia for the rheumatologist. In addition, neurosurgeons encounter chronic pain patients in the domains of headache, Chiari malformation, pseudo-tumor, and back pain—all difficult problems to sort out and often presenting as a chronic pain syndrome. Chronic back pain is by far the most common culprit of those seen by neurosurgeons. Satchel Paige Satchel Paige was one of the first professional athletes to break the color barrier in the United States (Figure 4). Of note, he actually took a pay cut when he moved up to the major leagues, coming from the Kansas City Monarchs of the Negro League. He was, in addition to being a superb athlete, a philosopher and a comedian of sorts, often uttering insightful and humorous commentary.FIGURE 4: Satchel Paige.One of his quotes truly resonates here: “It's not what you don't know that hurts you, it's what you know that just ain't so” (http://en.wikiquote.org/wiki/Talk:Satchel_Paige). Satchel's insight into the way we think and feel is impressive indeed. So, we enter a room within which sits an elephant, an elephant we cannot see. What we might see is a patient with back pain of long duration and an L4-5 spondylolisthesis and stenosis. What may in fact be present, however, is a patient in the room with a chronic pain syndrome, presenting with atypical nondermatomal and nonmechanical pain, along with a host of other warning signs. The clinical diagnosis here may in fact be chronic pain syndrome, not lumbar stenosis. We may be sure that the imaging tells the story, but such may not be so. “It's not what you don't know that hurts you, it's what you know that just ain't so,” says Satchel. “You are never going to make the diagnosis of a disease you never thought of.” If we do not see the elephant in the room, we cannot make the diagnosis (of an elephant in the room). If we do not see that the patient has a chronic pain syndrome, we will likely make the diagnosis that correlates with what we do see, ie, L4-5 spondylolisthesis and stenosis. We, then, act accordingly but misguidedly. How can we consistently establish the correct diagnosis, ie, the diagnosis of chronic pain syndrome? Well, chronic pain syndrome patients do indeed have characteristics that should afford us the opportunity to establish the appropriate diagnosis. They are in general noncompliant, with a relative lack of motivation. They have an external locus of control, which essentially implies that they allow external forces to control their lives rather than taking control themselves. They classically experience nonrestorative sleep and exhibit low energy levels, with multiple unrelated somatic complaints. They suffer. They dramatize. They amplify their symptoms and catastrophize. They are often chronic narcotic or anxiolytic users/abusers. Finally, they do not pass the “sniff test”; ie, their neuropathic pain complaints, burning pain, nondermatomal pain, and chronic pain behavior just do not quite make sense. When an imaging diagnosis is not consistent with the clinical diagnosis, a pseudo-concordance of sorts exists. An imaging/clinical pseudo-concordance exists when imaging findings suggest a pathology such as L4-5 spondylolisthesis but the clinical diagnosis (ie, chronic pain syndrome) does not. The L4-5 spondylolisthesis may cause the surgeon to operate. In the patient with imaging/clinical concordance, this might be appropriate. In the case of imaging/clinical pseudo-concordance, in which the imaging findings are not consistent with the clinical findings, surgery would not be appropriate. They must jive, or decisions will be misguided. We can break back pain down into multiple subcategories (myofascial, inflammatory, mechanical, chronic, etc), only one of which, ie, mechanical back pain, should be considered surgical. Such pain is deep and agonizing in nature, associated with an improvement with unloading and worsening with loading of the spine. Inflammatory pain (eg, early ankylosing spondylitis) is best managed by rheumatologists. Early diagnosis is critical. Misdiagnosis in its early stages can lead to a series of unnecessary and harmful operations while avoiding a course of appropriate treatment and prevention of the ravages of untreated ankylosing spondylitis. Mechanical back pain (deep and agonizing pain that is worsened by loading and improved by unloading) is potentially managed best by surgery. In such a patient, the clinical triad is associated with an imaging finding that is consistent with spinal instability, ie, a degenerative L4-5 spondylolisthesis. There indeed exists, in this situation, a concordance between the imaging findings and the clinical diagnosis. Can we identify chronic pain syndrome patients? Some physicians can or chose to; others do not. The foundation of the disease/pathology identification and decision-making process hinges on the capitalization of acquired knowledge by accumulated experience. Knowledge can be considered to be equivalent to a collection of dots (ie, information; Figure 5A), whereas experience facilitates the connection of dots (Figure 5B). Then, with an appropriate consideration of patient centricity (ie, focusing on the patient and managing the patient as we would want to be managed ourselves by application of the “golden rule”), we can make good decisions for our patients or, rather, help our patients make the right decision.FIGURE 5: Experience can be thought of as an accumulation of dots (A) that experience allows one to connect (B).THE USE OF ESTABLISHED TREATMENT STRATEGIES It goes without saying that we should use established value-based diagnostic and treatment strategies. We must treat patients who are best managed by nonsurgical means with nonsurgical means and vice versa. We lack meaningful metrics in the chronic pain syndrome domain. At the Cleveland Clinic, we are developing a systematic approach to the diagnosis of chronic pain syndrome. We have devised a 5-question questionnaire that is designed to identify such patients. This true/false questionnaire assesses sleep, energy level, and the emotional response to pain. Perhaps, such work might eventually provide a much needed objectivity to this process. This may help minimize the confusion created by imaging/clinical pseudo-concordance and provide a clinical objectivity that can help us identify and appropriately manage the patient with chronic pain syndrome. Finally, we must provide treatment alternatives. If surgery is not indicated, we should offer alternatives and not simply “throw the patients back out to the wolves.” Chronic pain rehabilitation programs are very effective for compliant patients. The development of such teams, beginning with a relationship with a clinic psychologist who is well in the of chronic pain is The of (ie, 2 of is the or 2 of billion (nearly of healthcare expenditures in the United are spent on the of of this is money We and often for time and of rather than quality of There exists, however, a break which we should be for quality of rather than of We should begin focusing on quality as to quantity of in the course of What truly patients? They might want to They might want from pain and They might want of thought and the of They might being with family and the of those they they might not a burden to family and at has recently a titled In this he about and and we as physicians with and He a superb article in the New in titled In this article, he the about he on health care for patients at the of than other in the are are by patients they are and and care is The patient and family are encouraged and to the not when the time OBJECTIVELY It is difficult to truly assess Hence, we might the Are we our in the healthcare it is difficult to perhaps we can the value equation in more We have not been our and the cost of medical care has been Hence, the of the equation has been The cost of health care in the United States is and out of So, what about the of the value equation our quality high and commensurate with the look at some very fundamental in the United States is much than in other first-world countries (Figure is first-world countries (Figure is very to that at other first-world So, are we our rate in first-world in first-world States A orthopedic surgeon from has been a of that the and most in the should have a healthcare system while of the services to those who can afford it and thus the most likely to not it, the or by the cost of Do we want This will if we neurosurgeons do not The are going to to They will fusion from us if we do not up with to surgical This is but a We must adjust and act accordingly. If we the 2 pain and end-of-life there exists opportunity for cost and improved care. The annual cost of chronic pain and end-of-life care is This to of all healthcare If we could this by say down to billion per we would of our healthcare does that put us with our percentage of gross domestic product back to the way we were in the early (Figure is a Do we want We will indeed be looking at such the do as of have means to make appropriate We to The is truly The percentage of gross domestic product by medical seen if a in is to Dr he want me to retract too much or too little? I think what he was telling me was to retract We to that in too as we forward the In addition, we to make it so we can see the elephant in the room. We to think and act more like they do in when end-of-life We to focus on patient and most we to start by is the to and for the of clinical We all are and we should gain knowledge by the dots by of our (Figure We must the to make So, will we be to the from the to the value-based healthcare (Figure Such is truly a question of the of Satchel “It's not what you don't know that hurts you, it's what you know that just ain't The that must be between and value-based health care. value and the between volume and value-based The has no or in of the or in this article.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.