When Less is More for Treating Back Pain and Heart Disease (One of a series: Becoming a Smarter Consumer of Health Care in 2010)
Here’s another in our occasional series of newsletters on getting better medical care for yourself and your family.
Today, we’re talking how less can be more in surgery. We’re focusing on two huge health issues: back pain and heart disease. The simpler approaches can work just as well as or better than more complex kinds of surgery.
Now your first reaction might be: Why do I need to read this? Isn’t my doctor going to recommend what’s best for me?
Reality is a little more complicated than that.
Studies have found over and over that the heavy hand of economics works on doctors too: they will tilt toward recommending something that’s more lucrative for them, not because they’re bad people, but because they’re human like the rest of us. Self-interest is always at work.
And think about this: The one person who really knows you is you. That’s the person who needs to have the final say in deciding what’s best for you.
So if you or anyone you know is thinking about back surgery or heart surgery, please read this newsletter first.
Back Pain: The Simplest, Tried & True Surgery Can Be the Best
First, some basic terms and anatomy:
Most back pain that isn’t relieved effectively with medicines or other non-surgical therapies is caused by disk herniation or spinal stenosis. Spinal stenosis is growth of bone near a nerve coming out of the spinal cord which presses on the nerve root and causes pain to radiate down a leg.
The vast majority of patients who need back surgery because of spinal stenosis in the lower back can be benefited from a fairly simple lumbar decompression. This involves removing bone, ligament and facet joint material which is compressing the nerve root. This operation has a high degree of success as it’s been developed over the last 20 years.
The problem is that more and more patients are being sold on much more elaborate, expensive and tricky types of back surgery that they probably don’t need.
Nearly every week, I hear about a patient who had surgery to relieve terrible chronic back pain and ended up far worse off than before. One of the biggest problems is that money motivates surgeons to talk patients into much bigger and more complex operations than they really need — and then those surgeries result in predictable complications.
The greed allegation sounds a bit harsh, but it comes straight from the top: The Journal of the American Medical Association, in an editorial by a leading Stanford orthopedic surgeon, Eugene Carragee, and in a study carried out by a group of doctors at Oregon Health and Science University led by Dr. Richard Deyo.
The Oregon study found that the rate of complex surgeries for back pain in Medicare patients jumped by 15-fold over a recent five-year period, but there was nothing in the patient population — like increasingly complicated back deformities — to justify the increase.
Joanne Silberner of NPR reported:
Deyo says there’s no reason to think people suddenly started developing the spinal deformities that justify the complex surgeries. He offers several possibilities for the upswing. “Many surgeons genuinely believe that the more invasive procedures offer some benefits,” he says. “But certainly there are important financial incentives at play as well.” Surgical fees for simple decompressions are about $600 to $1,000. The complex surgeries earn surgeons as much as 10 times more. He says another possible factor is the tendency for both doctors and patients to go for a new, more expensive approach just because it sounds better.
The problem is that the more complex surgeries carry at least double the risk of a bad outcome, according to the Deyo study.
According to Dr. Carragee’s editorial, if the patient also has some deformity of the spine — front to back or side to side — the simple lumbar decompression can result in spine instability with increased deformity, so those patients might need a fusion where adjacent vertebrae are fixed together with bone grafts. But even here, simpler techniques get just as good results than more complex procedures that add metal or other instrumentation into the back.
A very small minority of patients, says Dr. Carragee, have spines that are so collapsed and twisted that the spine is unbalanced and tilted forward and the patient has severe pain and poor quality of life. These are the patients who might qualify for the complex surgeries now being done so commonly. Techniques have improved in the last ten years, but the surgeries in these patients still carry a very high complication rate — 30 to 40 percent. And a lot more patients are getting the complex, multi-level surgeries than is warranted by the medical evidence, according to Dr. Carragee and other researchers.
Consumer Reports has rated spinal surgery as No. 1 on a list of overused tests and treatments.
As quoted by NPR, Dr. Deyo said he would like his study to alter the practice of medicine. “The effect I would hope it would have is to have surgeons and patients choose the least invasive procedure that would accomplish the surgical aim,” he says. But he’s pessimistic about it, unless there’s a change in the financial incentives.
This is yet another area of medicine where it pays for patients to be skeptical and to get multiple opinions. It fits our natural instincts to think that bigger and more elaborate surgeries have a higher likelihood of success, but the human body proves over and over that it prefers minimal interventions.
Heart Disease: Many Unneeded Stents
I’ve written before in this newsletter about overkill in heart surgery. But it’s sobering to read about the real-life scandal in the Baltimore area, involving Dr. Mark Midei, a cardiologist at St. Joseph’s Hospital in Towson, Maryland. Dr. Midei is accused of having done upwards of one thousand unnecessary stent procedures. (You can read a news account here.)
Why did the patients not realize that Midei was rushing them into unwise and risky surgery?
We Americans have a bias toward dramatic action. If one doctor tells us we need a stent to prop open the coronary arteries in the heart, and another doctor says all we need to do is take a pill every day, most of us will tilt toward the big intervention. Which can be a big mistake, because we then get a piece of metal permanently implanted in a blood vessel, and we have to take medicines anyway for the rest of our life to avoid getting blood clots from the metal that could cause a devastating stroke or more heart damage.
In the case of Dr. Midei, it appears that outright fraud might have been involved. You have to have a significant narrowing of the artery, 70 percent or more, to even start to qualify for stent treatment, and Midei aggressively over-read his own X-ray studies of the heart’s blood vessels to make it seem that patients had much worse narrowing than they really did, according to news accounts.
Patients need to know that this is not just an issue of a few rogue bad apples. Medicine’s fee-for-service payment system pushes doctors toward advocating for more aggressive and profitable interventions. The only way to find out what your body really needs is to shop for second and third opinions, every time. I have more on this subject in chapter 9 of my book, The Life You Save.
The chapter title says it all: “The Second Opinion: Always Your First Choice.”
Now, you might think that second opinions would be mandatory on any patient with blood vessel narrowing. But they’re not, as of yet, so smart patients need to take things into their own hands.
You can read more about the scientific evidence on what works and doesn’t work for blocked heart arteries in an excellent article by the Harvard Medical School. (Click here.) Many studies have found that unless a patient is having repeated symptoms, the stent treatment does nothing to extend his or her life, even if an artery looks dramatically narrowed. As I wrote in an earlier newsletter, the bottom line is that balloon treatment — angioplasty — can save your life during a heart attack if it can be done fast enough to open the artery before permanent damage is caused to the heart muscle. But for symptom-free patients — even with proven blockages — angioplasty is worthless and exposes patients to the risk of dying from a complication of having wires and tubes poked into your heart. And for patients with non-debilitating chest pain, angioplasty doesn’t work any better than taking drugs and making lifestyle changes.
Not Bad People, Just Self-Interested, Like All of Us
A postscript: When I focus on conflicts of interest in medicine, I don’t want readers to get the wrong idea. I don’t give advice about being your own patient advocate because I think doctors are bad people. My mission is to help readers recognize that doctors are human too and are subject to the same self-interest as the rest of us — and this can subtly tilt them to make recommendations for treatments that may not really help us.
I was struck when reading a letter to “The Ethicist” column in the New York Times Magazine. The writer was a husband whose wife had been told she needed a CT scan, and the doctor sent her to a radiology lab that he owned. The husband said: “I’m OK with this lab — I say you either trust the specialist or you don’t — but my wife is not so sure.”
Columnist Randy Cohen responded by quoting bioethics professor Katie Watson of Northwestern University:
“I trust my physicians not to be criminals who intentionally order unnecessary tests to feed their yacht habits. I also trust them to be human beings, which means they’re vulnerable to subconscious influences and incentives just like the rest of us.”
That’s exactly right.
This is not to excuse those doctors who create conflicts of interest for themselves that they could easily avoid. There’s no reason to buy a CT scanner for your office when there are plenty of others available.
Nor is it to excuse the doctor for failing to disclose up front to the patient that he has an ownership interest in the imaging machine. Patients shouldn’t have to cross-examine their doctors to get this basic information.
But it is to say that patients need to learn how to be sophisticated consumers of the medical industry. This is not a question of “do I trust or don’t I?” And it’s not a matter of trading naive trust for paranoid suspicion. It’s just to recognize that we’re all human, and that the medical industry unfortunately has many built-in conflicts of interest for doctors that require patients to look out for themselves when it comes to getting sound medical advice.
Of course, even when the doctor has absolutely no conflicts of interest, I strongly believe that we’re all better off as active participants in our care, and not just passive recipients of care.
So ask lots of questions, do your own research, and get second and third opinions. You’ll be healthier for it.
To your continued health!
Patrick Malone & Associates