The other day I got the opportunity to work in a social security, disability and workman’s compensation clinic. If you are like me, prior to this experience, it sounds revolting. Basically the physician I was with was tasked with evaluating whether or not patients had injuries or disabilities and if the employer was liable. To me that is like being stuck behind a rock and a hard place, someone is going to come out upset.
And yet he did this with the utmost pride, and he did a damn good job.
I met this physician while attending a state medical society event. He and I began talking about patient advocacy; he had much to say on the topic. "Everyday,“ he explained, "I work with patients who think the world doesn’t care about them. I then have to motivate them to get better, be their advocate when they need it and come down on them when they are malingering.” Though he was trained in physical medicine and rehabilitation he felt that most of his job was psychiatry. "Getting people over an injury physically is easy. Getting them over an injury mentally is much harder.“ Needless to say I was intrigued and took him up on an offer to spend a few days in his clinic.
He really did practice what he preached, speaking to me about the psychology of the patient before and after each visit. But one exercise he had me do really stood out, both in the lesson and his views.
We saw a patient who had been injured on the job as a firefighter. By the time he came to our clinic he was well, having had steroid injections for the injury and ample time to recover. He had been on full duty at work and our job seemed to be mostly clerical; we did a short exam, checked his physical ability and signed a form saying he was clear to work.
As we walked out of the room and back into the physician’s office he seemed miffed. "What a waste,” he said. "You know how much they are paying me for that? In disability we get 100% of billed. That company will pay me a couple hundred dollars for something his family doc, who treated him, could have done. In fact his care is rife with waste because he was mismanaged. How much do you think his care cost?“
He then made his resident and I step up to a whiteboard with a marker. From there we made a timeline. The patient injured his back. Within 5 days he received an MRI. This procedure was wrong for a couple reasons. First and foremost back pain should be treated conservatively. When jumping to imaging it is extremely common to find benign disc herniations that aren’t actually causing any symptoms. Even if they are, outcomes between waiting and surgery are about the same. Second, his pain did not descend in a dermatome pattern; it stopped at his knees. This means it could not have been a radiculopathy. He had us place "unnecessary MRI” in the waste column.
“Let’s see what they found on MRI,” he said, picking up the report. Indeed they had found two small herniations, neither of which could have corresponded to his symptoms (wrong side, wrong spinal level). Yet, they diagnosed him with a disc herniation and sent him for steroid injections. "Steroid injections" went into the waste column.
The patient received an epidural and thought he felt better. Then, within a few days he started having spinal headaches, which landed him in the ER. At this point they gave him a blood patch and sent him on his way. His headaches resolved and he has gradually felt better ever since. "ER visit" and “blood patch” were placed in the waste column.
His family doctor, who had coordinated the patient’s care, released him to full duty after his recovery. Unfortunately the primary care physician didn’t do the necessary workman’s compensation paperwork and so the employer’s insurance company sent the patient to us. "Visit to disability doctor" went in the waste column.
As we looked at the timeline we realized there was a lot of waste. "Now,“ said the doctor, "what should they have done?”
He eyed his resident who responded, “nothing.”
If they had put this patient on a rehab program, which probably could have been done at home, chances are he would have followed the same clinical course. His pain was not indicative of disc herniations. The herniations on MRI did not explain his symptoms. Our interventions led to complications and overall we did more harm that good cost-wise and quality-of-life-wise.
So what happened?
This is the problem with the system. We, as providers who desperately want to make patients feel better, value action over restraint. More and more we find that conservative measures for treatment are no worse, and in many cases better, as compared to costly and invasive interventions. Back pain is but one example.
Imagine if we treated back pain the way evidence says it should be treated. How many less surgeries would there be? How many less complications? How many less wasted dollars?
No one was at fault here, they were just misguided. In medicine it is sometimes best to temper our innate desire to act. Healthcare is extraordinarily expensive. We hear everyday about its impact on the U.S. debt. Regardless of what the news might say, swift action isn't necessarily what we need. In fact, perhaps we need just the opposite.