Modern medicine is evolving in a dangerous direction when it comes to your care. People want to trust their doctors, so they do. Most physicians are well-intentioned, but modern medicine has forced us to see more patients a day, and we are measured by production, not outcomes. I have several colleagues who have been forced out of their jobs because they took the time to talk to their patients.
The main factor in deciding whether to offer a procedure or treatment is often whether insurance covers it and how well it is reimbursed. The intervention’s effectiveness matters less. Additionally, there is little accountability for the outcomes unless there is severe negligence.
Profits over quality
The business of medicine, like any other business, is focused on making a profit. Computer programs monitor physicians’ contribution to the profit margin. Most revenue comes from procedures, many of which have been documented as ineffective. (1) The downside risks include unnecessary costs, significant risks, and patients being worse off than before the intervention. (2) It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes. (3) Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures that have been proven to be of no benefit, and it hasn’t stopped physicians from using them – at all. (4)
What works
Effective treatments are often not covered or don’t generate revenue. For example, expressive writing has been shown to help with multiple medical conditions in over 2,000 research papers. (4) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk, and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, rheumatoid arthritis, improve students’ athletic and academic performance, and diminish many other symptoms. I had dinner with the technique’s original author, James Pennebaker, a psychologist from Austin, TX. The methods may differ, but it has been repeatedly shown to be an effective tool. There is a lot of debate about why it works, but not about whether it works.
Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open. Listening is a proven healing modality and a basic requirement for understanding a patient’s full situation. Dr. Francis Peabody, a famous Boston physician, was concerned about technology intruding on the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927. (5)
The business of medicine
Today, much of mainstream medicine puts up a front to deliver compassionate medical care. At the same time, people still trust their physicians. My observation is that individual physicians aren’t the issue. The corporatization of medicine is backing us into a tight corner. Not only are we not given time to talk to our patients, but many are also heavily penalized for not being “productive enough.”
One problem that is not often acknowledged is that of inducing depression from repeatedly dashing people’s hopes. Harry Harlow powerfully demonstrated this. (6)
Harry Harlow
Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates. During the first half of the 20th century, many believed mothers should touch their children as little as possible. The leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media. Interestingly, or tragically enough, their recommendations were based on rodent research. Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well presented in the entertaining book Love at Goon Park by Deborah Blum. (6)
In the 1960s, he turned his attention, still based on primate research, to smaller details of human interaction. One model he worked on for a while was that of inducing depression. He used various isolation methods and ways of simulating parental neglect or even abuse. He was able to consistently produce monkeys that were seriously disturbed, but he wasn’t able to cause depression. At the time, he was experiencing his own severe depression associated with his wife’s diagnosis of terminal cancer.
He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside. The top was covered with mesh. For the first couple of days, the monkeys repeatedly climbed up to look out and quickly slid back down. Within a couple of days, they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they would not revert to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse, and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers called the apparatus “The Pit of Despair”. The research team felt this “learned helplessness” came from a combination of losing a good life, being reinforced by occasional glimpses of the outside world, and feeling trapped. Within half a week, every monkey spiraled down.
Anger is a significant factor in prolonging chronic pain, and the more legitimate your anger, the harder it is to let it go. The problem is magnified in spine surgery because it is a major intervention, and patients legitimately have high hopes. When it fails, patients are often worse off. Now, in addition to being angry about being trapped in pain and their circumstances, they are now angry at their surgeon. I have found that getting past this hurdle is much harder for people who’ve had multiple failed procedures.
Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope?
- Jonas, JB, et al. Are invasive procedures effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
- Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
- Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
- Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
- Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
- Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.