by Augusto Sarmiento, MD
Through the many media available today we are constantly bombarded with comments on an ongoing “epidemic” of drugs prescription. I venture to share my personal views after having concluded that in our orthopaedic profession the abuse of prescriptions is an “epidemic” where drugs play a relatively minor role. Nonetheless, the abuse of “prescriptions” touches a myriad of areas, which may be creating a scenario that eventually might lead to a situation that could seriously affect the overall discipline.
Our infatuation with major technical advances made in the diagnosis and treatment of many musculoskeletal conditions, has led to extremes oftentimes difficult to justify. Perhaps the extreme trends, no matter how much we find unacceptable according to a long-standing tradition, may be an inevitable expression of evolution where the forces of change cannot be stopped. However, to surrender to the trend without careful scrutiny of its genesis, its development thus far, and its likely further evolution, may not be the right approach.
There is a feature, which though only peripheral to the issue at hand, may have been a major factor in the genesis of the current condition. It has to do with residents’ education. Even after a superficial glance, one cannot help but surmise that in the eyes of many, the education of orthopedic residents is at this time almost entirely aimed at “training” them to become first class technicians. The old ethos that governed the premise that residents are young, relatively immature people seeking to be “educated” to be surgeons/scientists is no longer current. This trend plays a major role in the abuses which I now attempt to illustrate.
A quick glance at areas where the abuse of “prescriptions” in orthopaedics seems to be the most egregious is the use of MRIs. Today it is widely accepted that in many quarters any patient presenting for the first time complaining of pain in the knee, even in the absence of a history of injury, immediately and prior to a physical examination, has an MRI. To justify this protocol it is claimed that the MRI provides more information than a plain x-ray. Along with MRI, however, a radiographic examination is also obtained. Though it is true that the MRI is likely to provide new information, the need to find that additional information should be determined on whether or not the results from a physical examination and plain radiographs seem insufficient. Furthermore, the cost of the MRI is high, an issue of major importance at this time when the cost of medical care is much too high and begging for a solution.
No doubt the day might come when MRIs, CT scans and other not yet developed new techniques become inexpensive, so their use for virtually any condition may be more acceptable. However, that day has not as yet arrived.
I am stricken with nostalgia at the sight of residents seeing a new patient complaining of pain in one knee without a clear history of trauma. The resident asks where the pain is and proceeds to bend the painful knee to find out if any limitation of motion is present. Then, he flexes the joint, sits on the patient’s foot and looks for cruciate ligaments’ instability. The medial-lateral joint stability is now tested through the usual technique. A few minutes were required to complete the examination. An MRI is then requested and a return appointment is given, after a prescription for an analgesic is written.
I have often recorded the average time that residents spend examining these patients and that typing on the computer. Usually the latter occupies twice as much time.
One week later the patient returns to clinic. The MRI is likely to show –particularly if the patient is over 55 — some “pathology” in the posterior horn of the medial meniscus. Almost without exceptions, arthroscopic surgery is recommended. The resident explains to the patient the procedure and mentions the possible complications, which are described as being “extremely rare.”
Following the arthroscopic procedure the patient is sent for Physical Therapy for modalities consisting of “muscle strengthening exercises.” This step is the same one that follows other conditions, such as a diagnosed partial tear of the rotator cuff, whether treated surgically or nonsurgically. Often the therapy is mandated after an injection of cortisone has been performed.
I routinely ask residents the likely rationale behind the routine use of such exercises following the diagnosis of a non-full thickness tear of the rotator cuff since the analgesic effect of the injected drugs may result in the completion of the tear. It is known that such injections used for inflammatory conditions at the attachment of the tendo Achilles not infrequently result in complete tears?
I also ask to know the muscles in the shoulder that are weak and in need of strengthening. My argument that very often there is no muscle weakness but pain that makes it impossible for muscles to withstand resisted motions is readily dismissed. It is challenged with the retort that there is evidence to support the fact that patients feel better. Is this true scientific evidence-based data considering that it is entirely supported with subjective data?
Just the other day I carefully read the form residents must fill as they refer patients to Physical Therapy. I was appalled to find out that the form consisted of seven pages of questions, the overwhelming majorly of them rich with ridiculous, inconsequential minutia.
It would take a too long chapter to enumerate the many other examples where the epidemic of diagnostic tests and surgery saturates our profession. Fracture care, low-back pain and hip and knee osteoarthritis are probably the most common of all. Simple fractures of the ulna, distal radius, humerus, clavicle, malleoli, metacarpal and phalanges, and many others are managed surgically without any consideration given to conservative treatment.
It was at the University of Miami where I first conceived and developed the philosophy and technique of functional casting and bracing for a number of fractures, beginning with the tibia, followed by the ulna, the humerus, forearm, metaphyseal femur and certain nonunions. The results for the most part were very gratifying. As time went on, however, improvements in surgical techniques reduced the indications for the system in some areas while increasing them in other areas. To deny the proven fact that there are many indications for the conservative treatment of certain fractures requires an explanation, which up to now has not been articulated. I have asked myself a thousand times, why is it that at the institution where the functional treatment was born, residents graduate without having treated a single tibia fracture by nonsurgical means. The only answer I can give is that greed, an obsessive and pathological passion for more money, is the answer. Not satisfied with my own conclusion, I have asked graduating residents to give me their opinion. Their answer has been the same: greed.
When I pursue the argument, I ask them to tell me why they are so obediently accept the practice. They respond,”We are not allowed to treat those fractures any other way.” Greed, pure, unadulterated greed is the reason for such a rigid and unreasonable system.
I mentioned that another area where the abuse is rampant throughout the land is in the care of low-back pain where at the drop of a hat pedicle screw fixation is the ready approach to the condition. Testing a conviction I had already formed, I recall sending a lady in her late fifties to see a back surgeon when she was in the last stages of recovery from low-back pain that had begun a couple of months earlier after lifting a heavy object. The surgeon had recently stated that low-back pain, in most instances, can be successfully treated nonsurgically through a series of exercises. After being subjected to radiographic studies and MRIs the patient was informed that her condition was one that could not be treated nonsurgically and therefore surgery was the treatment of choice. She went back home and six weeks later she was totally asymptomatic. Sanctimonious hypocrisy is the only possible explanation that can be given to such behavior. Greed underlines the entire affair.
This episode reminded me of a conversation I had with a back surgeon who had said in a number of occasions that in his practice there was room for laminectomies alone as well as fusion procedures in the care of lumbar disc disease. Several years later I asked him if his views on the matter had changed. He readily responded, “Yes. The reimbursement for laminectomy has been reduced. Now, I fuse them all.”
The other area worth touching is the “epidemic” of total joint replacement. Despite the great benefits that replacement of hips and knees has brought forth, there should be no doubt that the procedures are being performed in many instances prematurely and oftentimes irresponsibly. The successful misinformation given through direct-patient marketing that the procedures are proven to last the life time even in the case of the very young and athletic has given impetus to the surgical procedures, which benefits enormously the hospitals, surgeons and specially the implant manufacturing industry. The latter is currently in virtual control of orthopaedic education.
These examples force me, and it should force others, to conclude that Othopaedics is in the eyes of many no longer a profession but a business, where profit is its raison d’être. The adoption of the ethos and practices of the business world is moving medicine in a direction that sooner or later will be deeply regretted.
Complacency in the face of such a serious challenge will do nothing but give others outside of orthopaedics, such as allied health professionals, the stimulus to embark in the care of many conditions, thus far the exclusive purview of the orthopaedist. To pretend that through lobbying and photos with legislators will prevent such a scenario is naive at best.
The currently ongoing investigation conducted by the United States Justice Department of what it calls, “serious ethical transgressions” and “corruption” in the relationship between orthopaedists and Industry should tell us to ponder upon the magnitude of the problem. Who would have dreamt fifty or even thirty years ago that our noble and altruistic profession would be charged with such crimes? It behooves us to step to the plate and make a commitment to stamp out the festering ulcer that will likely, if left undressed, have serious consequences.
Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons. He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.