In 2003, a neurosurgeon performed a laminectomy of his neck. That’s an operation where the lamina or the bone over the back of the spinal cord is removed to relieve pressure. He seemed to improve for a little while. In 2005, his symptoms worsened, and in 2009, he underwent a fusion through the front of his neck between his 5^th and 6^th vertebrae. Again there was a slight improvement but two years later he was in my office with crippling pain throughout his whole body.

Normal studies

As I talked to him, I could see how desperate he was for relief. He also wasn’t sleeping and his anxiety and frustration were a 10/10 on my spine intake questionnaire. I couldn’t find any neurological problems on my physical exam. When I looked at his neck MRI, I could see where the two prior surgeries had been performed, but there were no pinched nerves. The alignment and stability of the vertebrae were also fine. He also had undergone several workups of his brain and the rest of his nervous system. Everything was normal.

When I explained to him that I did not see a structural problem that was amenable to surgery he became understandably upset.  He was stuck on the idea that the prior surgeries had helped and that I was missing something. It didn’t matter what I said or how I explained the situation to him. He wasn’t buying it.

What I didn’t tell him was that I had also looked at his scans he had prior to undergoing each surgery. Telling a patient that they did not really need a prior surgery is a very unproductive, unpleasant interaction; I didn’t see why this patient’s prior surgeries were performed. On the first MRI of his neck, there were no bone spurs and the spinal cord was completely free. There wasn’t a structural problem that could have been corrected by surgery. On the scan before the second operation, there also wasn’t a hint of anything that could be causing any symptoms of any type.

The power of placebo

What’s difficult for patients (and physicians) to realize is that the placebo rate for any medical or surgical treatment is between 25-30% or even higher. The response and improvement is not only real but is powerful. It is the result of your body’s own healing capacity. It is a desired response, and you feel less pain.

The pain-killing effects of a placebo are reversed with Narcan, which is the drug used to reverse the effect of narcotics. There is a part of the frontal lobe of your brain that shuts off pain pathways for short periods of time. Another example is the placebo effect of cardiac medications causes the heart rhythms to actually change. Just because a prior surgery or procedure on normal age-appropriate anatomy might have been temporarily effective is irrelevant. It should have nothing to do with current decision-making. I tell my patients “If I can see it, I can fix it” and  “If I can’t see it, I can’t surgically correct it.” It’s critical to have a specific structural problem with matching symptoms before surgery becomes an option. Surgery: The Ultimate Placebo

I suggested that he take a look at the DOC website and I would be happy to explain the whole program to him in as much detail as needed. He was so angry that I didn’t think I’d hear from him again.

Early engagement

Over the next couple of months, I received a couple of emails and had a telephone conversation that seemed to go pretty well.  He was willing to engage in the DOC protocol and began some of the writing exercises. I had a second phone conversation with him a couple of weeks later that seemed to go even better. He was able to recognize that his thought of me “missing something that needed to be fixed” was an obsessive thinking pattern. I was encouraged and thought that maybe I had been able to break through his “story.”

Time went by and our third and final conversation was dismal. He couldn’t let go of the thought that “something was being missed” and that his seventh cervical vertebra was “out of alignment.” I assured him it was OK. As a surgeon, I am also quite obsessive about not missing problems that I can fix. At this point, it didn’t matter. He’d found a surgeon who was going to fuse his neck.

Injury conviction

Physicians use the term “injury conviction” to describe this phenomenon. It is the relentless pursuit of a cause for your symptoms that is well beyond reason. My concept has changed in that I feel this pattern of thinking becomes its own irrational set of neurological circuits. It is similar to phantom limb pain and my term is “phantom brain pain.” Regardless of whether the original source of pain is there, the symptoms are the same. Rational arguments have absolutely no effect.

Hell

I wrote a post Anxiety and Anger: The Highway to Hell. Unfortunately, if you’re in this pattern, you’re in Hell, and the only way out is through you. The deep tragedy is that if you don’t realize you’re in Hell, you’ll remain there. I never give up, but I have learned to let go when I can’t penetrate that firewall of obsessive thinking. For those of you that have let yourself out this hole, I am open to suggestions as to what gave you the insight to move forward. Awareness is the basis of the entire DOC process and is always the first step.

I don’t know how many more tests and surgeries he’ll undergo over the next 30 years. The personal cost to him and society will be enormous.

What’s puzzling is that if any of the surgeons who’d chosen to operate on this man’s essentially normal anatomy were examined by a board examiner about their indications for his surgeries, they’d be failed immediately for giving a “dangerous answer.” It’s our medical responsibility to you to not offer risky procedures that have been documented to be ineffective.

Video: “Get it Right the First Time”

The post How Many More Neck Surgeries? first appeared on Back in Control.

The post How Many More Neck Surgeries? appeared first on Back in Control.

I am on a much-needed vacation this week in Italy.  From 1980 until 1990, my wife lived in Florence.  We have many friends in Italy we like to visit as much as we can.  It is a unique opportunity for me in that she is fluent in Italian and we are able to spend time in our friends’ homes in the heart of Tuscany.  There is nothing quite like sitting down to a home-cooked Italian meal overlooking a beautiful valley.

Last night was one of those evenings.  Our friends not only put us up in their apartment, they had us over to dinner with several other friends.  The conversation drifted towards medical care.  One of the guests had experienced some medical problems of a moderate nature that required several physician visits and a couple of procedures.  He said that the aspect of his care that most struck him was that at no point during his care did anyone from the receptionist to the doctor ask him how he was doing.  Additionally, when he was asked some detailed questions about his condition, he was asked if he was a doctor.  When he replied that he was not, he was told that he had been informed enough and that he should not ask so many questions.  You might imagine his frustration.

I have witnessed a lot of success with the DOCC protocol, but it has become increasingly clear that the protocol is just a framework. It helps organize both the physician’s and patient’s thinking about chronic pain and therefore makes it much easier to create a treatment plan.  It is the patient who organizes and implements the plan. The physician is more in the role of a “coach” as well as being continually aware that there might be a potential structural problem.

About a year ago, I was talking to the pain psychologist I work with about what we were doing that seemed to be more helpful to our patients than either of us had historically observed.  She kept insisting that I was the factor that made the difference.  I was sure it was the DOCC protocol and the work she does.  After more and more positive results, I finally agreed that I played a major role in their recovery.  To clarify, I don’t believe that I have a special gift or am the world’s best doctor.  I simply stay committed to my work with the patient.  With increased attention over the last couple of years, I have seen more patients who had been in pain for decades become pain free.

Through my numerous difficult experiences, I have had many layers of my own personal labels stripped off.  Physicians, especially surgeons, are perfectionists.  It gives us an early competitive edge in high school and college.  It is somehow held up as a virtue by our medical culture and demanded by society.  Unfortunately, it is a complete disaster with regards to our ability to connect with our patients.  By definition a perfectionist is continually judging himself or herself by an unattainable standard.  As I have labeled myself, I have labeled others around me.  As it has been my reality for over 50 years I had no clue that this process was taking place.  I recently wrote an article, “The Cry of Chronic Pain—No One is Listening.”  The essence of the article is that once you have a label of a “chronic pain patient” placed on you, the world, including you, feels that it is just “something you have to live with” and your care becomes essentially palliative care.

I recognize that labeling is universal but it is not constructive.  I am aware that I label people constantly. As I work to become aware of the label I am placing, I am able to eventually see who you truly are.  You are a whole person.  Neither you nor I are the labels we place on each other.

The energy for your healing journey comes from you, not me.  What I contribute is that I am able to see you as a whole person and you are somehow able to remember that part of you that is really you.  When that part of you “wakes up,” there is no stopping you.  You are your own oasis in the middle of the desert.  I cannot ever tell who will engage or when.  The DOCC project is just a rough framework and every journey is completely different.  I am continually energized and inspired by the incredible obstacles you overcome to return to a rich, pain free life.

I recognize that essentially all physicians are compassionate.  Many physicians have figured out this journey and most have not had to experience burnout to learn it.  I am continually humbled by numerous examples of deep compassion by my colleagues.

I always thought I was compassionate. I was very well intentioned and always gave every patient my best shot.  However, the physician burnout rate is around 50% and we truly have a life full of more stress than you can imagine.  If you are just trying to survive, there is only so much you can give.  Additionally we have no resources or tools to help us out.  The safety net is a concrete floor.  It has been shown in several studies that it is during the third year of medical school that compassion takes a dive.

I am not writing this post for you to begin looking for a physician who is compassionate.  It is not a bad idea, but it is not necessary for you to heal.  Remember this process is about you taking full responsibility for every aspect of your care and your life.  You don’t need me.  You don’t need the DOCC project.  You just need to connect with that part of yourself that is whole and wants to thrive. The person who you need to experience compassion from is you. Use whatever means you have at your disposal to figure this out.  It will probably take some outside help but there are multiple resources. Quit trying to “figure all of this out” and just go.

NH, BF

The post Compassion and an Italian Dinner first appeared on Back in Control.

The post Compassion and an Italian Dinner appeared first on Back in Control.

I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

• Respect the injured worker and treat them accordingly.
  • It should be a major part of their orientation and ongoing in-service training.
• They should not be involved in medical decision making.
  • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
  • This process should be expedited as quickly as possible.
  • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
• Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
• They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF

The post Examiners from the Worker’s Perspective first appeared on Back in Control.

The post Examiners from the Worker’s Perspective appeared first on Back in Control.

The problem is that even an ideal system will never be able to respond to the needs of a given patient quickly enough to really make a large-scale difference.  Not only are there problems navigating through all of the various parts of the worker’s comp system, these patients’ personal lives are often a disaster.  I don’t know if many of them are still even on their feet.

The more effective strategy is to give patients the tools to deal with stress.  They can often navigate their way relatively quickly through the process.  The tools also make a difference in their personal life and their families will become their support system instead of targets for their frustrations.  Conversely, without any personal support, their anger will cause them to disengage from reason and the opposite effect occurs.

It’s true that, where I practice, 80% of injured workers do well with minimal intervention.  But we don’t know which injured workers will become one of the 5% that consumes 84% of the medical resources in the state of Washington. Even the simplest injury creates additional stress on a given worker.  It is the luck of the draw whether they end up with a physician and employer that can create a smooth process.  It is unpredictable what provider or circumstance will set off the cascade of extreme disability. The idea of being pro-active in a claim is 20 years ahead of its time. It has been incredibly frustrating watching employers, in the face of overwhelming data, still not want to engage in any type of innovative process.

The category of mental health strategies described are the one’s we have been routinely using.  My concept is to “calm down” the nervous system, which has consistently decreased my patient’s perception of pain.  However, I always start with sleep.  None of the tools are effective without sleep.

I think the roundtable could develop a laundry list of strategies that could be ferreted out and implemented.  This is a group that has the power to change some things and I would challenge us to get focused.

I did become incredibly discouraged last night thinking about national politics.  Regardless of your political leanings, jobs are disappearing.  No matter how skilled you are with these stress management tools, none of them are going to negate not being able to put food on the table for yourself or your family.

BF

The post Arm the Worker first appeared on Back in Control.

The post Arm the Worker appeared first on Back in Control.

His tests and treatment were as follows:

• His lumbar MRI showed disc degeneration at every level but no instability.
• He had crippling anxiety including fairly frequent panic attacks.
• He was open to psychological care.
• I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
• I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

• The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
• I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
• It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
• The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

• We know that chronic pain increases anxiety and frustration, which exacerbates pain.
• Psychosocial stress is a better predictor of outcome than the surgical pathology.
• The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
• The patient has documented severe untreated anxiety.
• In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
• The state still will not pay for any mental health resources
• They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
• If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?

BF

The post It Really is Upside Down first appeared on Back in Control.

The post It Really is Upside Down appeared first on Back in Control.