Treatment Plan: Do Nothing?

It’s cold and flu season again and we all do the best we can to stay well and avoid catching an all-too-contagious virus. We each have our own go-to plans of how to fight it: vitamin C, zinc or elderberry supplements, gargling with salt water, staying warm, rest and binge-watching Netflix shows. My grandmother swore by anise candy that she made from scratch, while my father prefers a hot toddy to remedy a cold. Washing hands is still the number one way to avoid illness — along with avoiding contact with your face, and keeping your immune system strong. Far too many of us have also taken antibiotics despite the fact that they do nothing for a virus and their overuse has now created resistant strains of bacteria for all humans (Ventola, 2015). You may be tempted to go to the doctor for antibiotics “just in case,” and then the antibiotics are falsely credited for your recovery since you always do eventually recover. Primary care physician and medical director at Chapa-De Indian Health, Dr. Mike Mulligan, says in reference to antibiotics, “If I do nothing I will be doing right by patients most of the time compared to if I prescribe something. If I prescribed antibiotics for everyone who wanted them, I would most often be doing wrong.”

Typically when we go to the doctor we expect someone to do something, yet overtreatment is far more common than under-treatment and the impact causes real harm. Dr. H. Gilbert Welch has investigated how and why this happens for many health problems including heart conditions, headaches, back pain, knee and hip joints, gastrointestinal disorders, and even cancer. In his book Less Medicine, More Health (2015), he examines how early detection hasn’t led to saved or improved lives, which defies logic at first glance. The over-prescription of medications alone is nothing short of epidemic, most glaringly seen with the overuse of opioid pain medications.

Chronic pain is that much more frustrating because of its long duration and frequently leaves people feeling Something More Should Be Done. It seems like Something Else Must Be Wrong if only the doctor could find it. Each specialty department shakes their heads and gives the “good news” of normal or inconclusive scans. Navigating health care systems is not easy to begin with chronic pain rehab programand there are still far too few comprehensive pain management programs that focus on functional rehabilitation. Once in a while the ragged pursuit of Something Else can lead to a more thorough workup or referral to a good treatment program. It depends where the Doing More is directed. Too often, the quest for the Something Else leads to tests and treatments that carry their own risks without relief; often frustrating and distracting to the patient and doctor, resulting in more pain, medical appointment exhaustion, and patients feeling demoralized and hopeless.

Chronic pain has few circumstances where invasive procedures are the best choice. Usually if surgery is warranted it becomes quite clear early on and a 2nd or 3rd opinion will render the same conclusion. The risk of more pain is high with surgery when done because “it might help,” even if the structure has been “fixed.” To a surgeon, fixed means correcting the abnormality. To you as a patient, fixed likely means less pain and improved function. The past 30 years has revealed that abnormal scans of the lumbar spine are common among pain-free individuals and normal scans are common among those who experience pain (Jensen, et al., 1994; Borenstein, et al, 2001). So if the abnormal is normal and abnormal findings do not predict pain, what do we do now?

Last week my daughter’s knee swelled up larger than a softball until she could no longer bend it. We had an x-ray and waited. And waited. The swollen mass grew bigger and her doctor reassured us that ice, elevation and anti-inflammatories were the best treatment. This was hard for me to believe and my mind raced: What caused it? There must be a reason! Why is it so large? Can’t we test the fluid? Can’t we do something to make it go away quickly? I felt like I was Doing Nothing and this felt terrible, but her doctor had ruled-out life and limb-threatening infection and it was the right call. Had I gone to the emergency room, the fluid may have been tapped, risking infection, leading to antibiotics, potential complications and unwanted effects, including more time in bed. An MRI may have revealed an abnormality that was unrelated, which could have led to Doing Too Much. My worst fears were not realized, but it was tempting to buy into the fear that Doing Nothing would lead to a bad result that could have been avoided if I had Done More. What felt like Doing Nothing really was doing something – something at home (elevation, ice, anti-inflammatories, and coping with fear and pain) and Nothing More at the hospital.

The Temptation

It is tempting to assume:
• If there is pain, something is wrong.
• If something is wrong, it can and should be found if we look hard enough.
• Once it is found, it can be fixed.
• If it is fixed, I will feel better.

These assumptions are myths that have been dispelled over time. Sometimes we hurt without any abnormal findings. Sometimes looking harder leads to more problems rather than fixes. Even if the source of pain is found, it may be best to avoid invasive treatments. And the fixing of found abnormalities helps — if you are a car (but even then be cautious of overtreatment!).

But isn’t the pursuit worth the risks? Welch’s data suggests not. One common example is a CT scan – the radiation may increase cancer risk and should be avoided whenever possible. But there also are lesser known risks he calls “incidentalomas” – those incidental findings that appear abnormal on a scan, but do not actually explain or contribute to the symptoms you are experiencing. These red herrings lead to many unnecessary procedures including what I call health-ectomies, or removal of healthy organs in the hopes that it will solve the problem. This is very common in abdominal pain, one of the leading causes of emergency room visits (CDC, 2011). In our highly medicalized society that relies on technology to save us, we can be misled to think that everything can and should be found on a scan or test. However, the search may only distract you from good self-care in the pursuit of an outside fix. Living in the information age leads us to think that more information is better, but more is not always better. “Better information is better,” Welch says (2015). We need useful information to move forward with clarity in medical decisions and health. “At least I would know” does not work if it distracts you from the truth. The truth may be that your disks are degenerating, but it is not typically the cause of your discomfort.

The Frustration

It’s frustrating to be told no, you don’t need that test, that the cause of your do nothingsuffering is unknown, or that there is no cure. “That’s all I can do,” are not words we like to hear. They rank up there with “Could it be depression?” Your doctor may or may not have explained to you why more tests are not recommended. Some people suspect it’s to save money, but most clinics have financial incentives to perform more tests, not fewer. You as the patient may feel more taken care of, more thoroughly examined, but it may not lead at all to better care. Sometimes it is best to Do Nothing, at least nothing at the doctor’s office.

The Fear of Missing Something

The Fear of Missing Something is real and powerful. Any doctor can tell you how terrible it feels when something has been missed. It haunts them for a lifetime. This is a fear of patient and doctor alike, although it is overtreatment that is the common daily occurrence. Most of us feel better Doing Something. Mistakes are made when we are guided by fear rather than facts. We depend on doctors to rule-out anything life-threatening. Afterwards, it can feel devastating when it’s suggested that you “learn to live with it.” But this is not because doctors don’t care enough to do more. Most health care providers really do care, and they care enough to do less. This is where their job ends and yours continues.

Chronic pain is often part of a feedback loop with the central nervous system that becomes sensitized even when the pain signal from body to brain carries no new or useful information about the condition of the body. Inflammation and degeneration are common pain-related issues best treated by lifestyle improvements. A spinal fusion may “fix” the current instability, but create more instability in surrounding areas. It may “fix” the problem, but also severely decrease range of motion. Medication almost always has unwanted effects. Injections have risk and the benefits must outweigh the risks for it to be a good choice for you. Physical therapy may hurt and you swore you would never go back, but finding a physical therapist who specializes in chronic pain is a key part of rehabilitation. Dr. Nobert Boos and colleagues (2000) found that the physical and psychological aspects of a person’s job predicted pain over a 5-year period better than MRI results. If the chronic stress of a tyrant boss or conflict-filled relationships are fueling inflammation in your body, you might consider treatment that targets these root causes of inflammation rather than pursuing a traditional medical fix targeting the wear and tear that’s found on MRI.

Often the body does best when it’s left to its own devices rather than modern medicine interfering at all. You may feel like More Should Be Done, but for chronic and stable conditions or the common cold and flu, wellness is best found at home, not at the doctor. Self-care is a full time job and the goal is to get so good at it, less effort is required over time.

References

Boos, N, Semmer, N, Elfering, A, et al. (2000). Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity. Spine, 25, 1484-1492.

Borenstein G., O’Mara, J. W., Boden S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel S. W. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. Journal of Bone & Joint Surgery, 83, 320-34.

Centers for Disease Control (CDC). (2011). http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. D., Malkasian, N., & Ross, J. S. (1994). MRI imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 369-373.

Schwartz, A. L., Landon, B. E., Elshaug, A. G., Chernew, M. E., & McWilliams, M. (2014). Measuring low-value care in Medicare. JAMA Internal Medicine, 174(7), 1067–1076.

Ventola, C. L. (2015). The antibiotic resistance crisis. Part 1: Causes and threats. Pharmacy and Therapeutics, 40(4), 277–283.

Welch, H. G. (2015). Less medicine more health. Boston, Massachusetts. Beacon Press.

Date of last modification: 12-22-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

Reducing Overtreatment & the Profit-Motive in Healthcare

It might be easy to conclude that anyone who wants to reduce the role of the profit-motive in healthcare must be either an extremist or a fool. Upon reflection, however, it becomes clear that we are experiencing an era of overtreatment in healthcare (see, for example, Dr. H. Gilbert Welch’s piece here) and one area where it is particularly apparent is in the management of chronic pain. While there are likely many causes of overtreatment, one of them surely is the profit-motive that occurs within a fee-for-service model of reimbursement.

In the last few posts (dated 12-22-13 & 12-29-13), we have been exploring the role that the profit-motive plays in the generation of recommendations for treatment. We have seen that in a fee-for-service model of reimbursement the treatment of chronic pain can constitute a ‘perfect storm’ for overtreatment (i.e., providing an overabundance of care that has a low likelihood of effectiveness). Let’s review how it might play out.

How overtreatment occurs in chronic pain management

Patients with chronic pain are commonly distressed. This distress can lead to a willingness to try any number of medications and procedures, sometimes even repeating previously failed treatments over the years. Their healthcare providers lack any incentive to discourage such an overabundance of care, even if therapies have little chance for success. Rather, because of the fee-for-service system of reimbursement, they are in fact incentivized to make the recommendations. Indeed, the more care they recommend, the more they are likely to provide, and the more care they provide the more money they make.

It’s not that such providers are making recommendations solely on the basis of what’s in their financial best interests. As healthcare providers, they are charged to work in the best interests of the patient as well. They make recommendations and provide care in the ways they do because it is possible that such care might be helpful. If asked, they’d say that they see patients helped everyday by the medications or interventions or surgeries they provide. And it would be true.

Most any therapy can be helpful. Any clinician can point to patients for whom any numbers of the common available therapies have been helpful. For most patients and providers, this justification is good enough. If a particular therapy has been helpful in the past for Mr. Smith, why not try it for Ms. Jones? Besides, Ms. Jones has chronic pain, likely for years, and is in distress and seeking care, wanting to try something. Ms. Jones’ provider can thus recommend the therapy with a clean conscience. It’s what the patient wants and it’s possible that it will be effective.

 

Notice that the bar to justify a treatment recommendation gets set pretty low. A recommendation for a particular therapy seems reasonable if there’s a possibility of success. Both the patient and the provider seem satisfied to move forward with it, as long as it’s possible that it will be helpful. No one in this interaction seems to require a higher degree of justification, such as some degree of probability that a therapy will be effective. The possibility of effectiveness, rather than then probability of effectiveness, is good enough.

This all-too-common justification for treatment recommendations leads to overtreatment because it masks the profit-motive that underlies it. As we saw in our initial post, the justification only seems reasonable when it occurs within the context of a fee-for-service reimbursement system. In other words, providers would require a higher level of justification, if they themselves were the payer of the fee for the therapy, rather than the receiver of the fee. In a capitated system, for example, where providers stand to lose money rather than gain money when providing care, they might inquire more fully into how likely a given treatment will be effective before proceeding, rather than simply asking whether it might be effective. In contrast, in a fee-for-service system of reimbursement, there is no incentive to have a higher criterion for the care we deliver.

This state of affairs leads to scenarios like those of patients I see everyday. Working in chronic pain rehabilitation, we tend to evaluate patients after they have exhausted countless pharmacological, interventional, and surgical options – no matter how remotely likely they were to have been effective. The typical patient we see is in their forties or fifties and has had chronic pain for more than five years. They have been managed on opioids for most of these years. As a consequence, by the time they get referred to us, our patients have trialed a number of opioids and have become tolerant to even very high doses. They typically have been to two or more interventional pain clinics, where over the years they have had ten to twenty spinal injections and have had three or four repeated radiofrequency neuroablations. They commonly have had three or more spine surgeries.

I am not exaggerating.

They often tell me that I am the first person who has ever told them that they have chronic pain. I sometimes find it difficult to believe. I think what they must mean is that I was the first person to tell them in a way that they really understood – that “chronic” really means chronic, i.e., incurable. What they tell me, though, is that all other providers have tended to leave them with the impression that, while their pain has been long-lasting, it’s only a matter of finding the right procedure and they can be cured. When I ask, they tell me that no provider has ever sat them down and had a serious discussion of exactly how unlikely such a cure really is. Instead, what appears to happen is that they have undergone countless procedures and therapies over the years with very little chance of serious success. What it appears is that they have been overtreated.

Overtreatment in chronic pain management is exceptionally common. It is not just my impression. It’s been shown in systematic ways that the rates of use of opioids, interventional procedures, and spine surgeries have grown exponentially over the last few decades (Deyo, et al., 2009; Manchikanti, Pampati, et al., 2010).

What can healthcare providers do?

The first thing any provider can do is to decide whether this state of affairs is a problem or not.

I suspect that some providers in chronic pain management won’t think it is problematic at all. Spine surgeons and interventional pain providers profit greatly from the current fee-for-service practice patterns (Medical Group Management Association, 2011). Recurrent studies over the years show that their routine care for pain disorders persistently fail to follow established guidelines for common conditions, such as back pain. Instead of obtaining care that professional organizations agree is the most effective, patients continue to obtain MRI or CT scans, interventional procedures, and spine surgeries at increasingly high rates (Deyo & Mirza, 2006; Deyo, et al., 2009; Hrudey, 1991; Ivanova, et al., 2011; Mafi, et al., 2013; Pham, et al., 2009). Such less than optimal tests and procedures constitute some of the most over-utilized assessments and treatments in our healthcare system.

Thought leaders in the field of interventional pain management advocate against policy changes that encourage the use of empirically supported treatments (Manchikanti, Falco, et al., 2010). Organizations of both spine surgeons and interventional pain providers have also advocated against the Affordable Care Act and its provisions to encourage the use of empirically effective treatments (see, for example, Branch & Rao, 2009; Manchikanti, et al., 2011).

Many of us, however, in chronic pain management consider overtreatment unacceptable and are committed to delivering healthcare based on what’s most effective. Indeed, it is a moral obligation. Whether done out of a business practice or ignorance or both, it is simply wrong to withhold the most effective therapy from patients or to recommend tests and procedures that lie outside of treatment guidelines, assuming that guideline based treatments have not already been tried.

If your patient had cancer, you wouldn’t want him or her to pursue less effective treatments before pursuing more effective treatments. But, this is exactly the scenario of care that most chronic pain patients get recommended today in our field.

These points bring us to the next thing that providers can do to reduce profit-motive and overtreatment in chronic pain management.

Learn about established treatment guidelines

The American Pain Society has developed and published a number of treatment guidelines. A brief list of them can be found here.

As a profession, we are called to first provide the most effective care to our patients. To do so, we first need to know what these therapies are. We are therefore obligated to know these therapies and to provide them or refer accordingly.

Take the time to teach patients about what therapies are most effective

It takes time to teach patients why orthopedic treatments for chronic pain, such as spine surgeries and interventional procedures, are commonly ineffective. The prevailing zeitgeist remains that chronic pain is an orthopedic condition. Initially, it often doesn’t make sense to patients why rehabilitation therapies are more effective.

A common complaint among providers is that it takes too much time to explain it to patients and so often ‘the path of least resistance’ is to refer them to orthopedic care that lies outside the treatment guidelines (see, for example, this problem as discussed by DeNoon in the Harvard Health Blog).

Another version of the profit-motive, however, underlies this complaint. It only takes too much time to explain to patients important aspects of their care if you are attempting to see as many patients as possible as a means to increase productivity reimbursement.

If, however, we take our calling as a profession as the primary value, and place business as a secondary value, then the practice of taking time to explain to patients the nature of their condition and the reasons why they should pursue guideline based care becomes our moral obligation. It’s not inefficient. It is not a nuisance or an inconvenience. It’s our job.

We have the opportunity everyday – often multiple times daily – to do our job and explain to patients the following: chronic pain syndromes are a nervous system problem and not an orthopedic problem; and chronic pain syndromes are most effectively treated with chronic pain rehabilitation programs, not narcotics, spine surgeries, and interventional procedures.

To help in these discussions, refer patients and their families to the Institute for Chronic Pain and other resources. Indeed, keep a list of reputable websites and blogs to provide to patients so they can continue to educate themselves.

Support policies and organizations that encourage effective care over profitable care

Support organizations such as the following:

If you find important information, pass it on to all of those in your network. (Indeed, please pass this blog post on to all in your network.)

Also, if you are an American healthcare provider, support policies and laws, such as the Affordable Care Act (ACA), that encourage experimentation with getting away from the fee-for-service reimbursement system. For example, in some minimal ways, the ACA contains policies that experiment with moving away from paying provider organizations based solely on the quantity of patients they see and quantity of tests and procedures they perform; instead, it begins to experiment with paying provider organizations based on the quality of their performance in keeping people well. The jury remains out, of course, whether such projects will prove fruitful, but their intention is an admirable attempt to reduce the profit-motive in healthcare and subsequently reduce overtreatment.

Suggested reading: Unnecessary care: Are doctors in denial and is the profit motive to blame?

References

Branch, C. & Rao, R. (July 28, 2009). Letter to Honorable Speaker Pelosi. Retrieved from http://www.spine.org/Documents/NASSHealthCareReformLetterPelosi.pdf

DeNoon, D. (July 31, 2013). Back pain often overdiagnosed and overtreated. Harvard Health Blog. Retrieved from http://www.health.harvard.edu/blog/back-pain-often-overdiagnosed-and-overtreated-201307316546

Deyo, R. A. & Mirza, S. K. (2006). Trends and variations in the use of spine surgery. Clinical Orthopedics 433, 139-146.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Hrudey, W. P. (1991). Overdiagnosis and overtreatment in low back pain. Journal of Occupational Rehabilitation, 1(4), 303-312.

Ivanova, J. I., Birnbaum, H. G., Schiller, M., Kantor, E., Johnstone, B. M., & Swindle, R. (2011). Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine Journal, 11(7), 622-632.

Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581. doi: 10/1001/jamainternmed.2013.8992

Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the healthcare reform for the new decade. Pain Physician, 14, E35-E67. Want to do away with the measures that change fee-for-service to reimbursement systems that pay for effectiveness

Manchikanti, L., Falco, F., Parr, A. T., Boswell, B., & Hirsch, J. A. (2010). Facts, fallacies, and politics of comparative effectiveness research: Part I: Basic considerations. Pain Physician, 10, E23-E54.

Manchikanti, L., Pampati, V., Singh, V., Boswell, B., Smith, H. S., & Hirsch, J. A. (2010). Explosive growth of facet joint injections in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. BMC Health Services Research, 10, 84. doi: 10.1186/1472-6963-10-84

Medical Group Management Association. (2011). Physician Compensation and Production Survey 2011 Report Based on 2010 Data. Washington DC: Medical Group Management Association.

Pham, H. H., Landon, B. E., Reschovsky, J. D., Wu, B., Schrag, D. (2009). Rapidity and modality of imaging in acute low back pain in elderly patients. Archives of Internal Medicine, 169(10), 972-981. doi: 10.1001/jamainternmed.2009.78

Author: Murray J. McAllister, PsyD

Date of last modification: 1-5-2014

How to Reduce the Influence of Money on your Healthcare

In the last post, we looked at the influence of money on your healthcare providers’ recommendations. We saw that in a fee-for-service model of healthcare, which is the predominant model in the U.S., individual providers, clinics and hospitals get paid based on the number of patients they see and the number of procedures and tests they perform. In other words, the more patients a provider, clinic, or hospital sees or the more procedures or tests they perform, the more they get paid. As such, a fee-for-service model of healthcare incentivizes productivity – providing more care leads to making more money.

In turn, the financial incentives of the fee-for-service model can lead to overtreatment. Overtreatment is care that is provided despite a high likelihood that it will be ineffective or unnecessary.

Chronic pain patients are especially prone to overtreatment. Chronic pain can be a highly distressing experience. It can be difficult to accept. As such, patients and their providers can go against all odds to get rid of it. It’s not uncommon to see patients who have had numerous interventions and surgeries, often with the same procedures repeated even when they weren’t initially helpful.

The fee-for-service model of reimbursement reinforces the pattern of pursuing care that has little chance of success. Providers financially benefit from providing care whether or not there is much chance that it will significantly reduce pain or improve function.

This combination of factors – difficulties in accepting the chronicity of pain and the fee-for-service model of reimbursement – is a ‘perfect storm’ for overtreatment in chronic pain. It leads to providers making recommendations based on the possibility of effectiveness rather than the probability of effectiveness. It’s a certain willingness on the part of patients and their providers to try something to reduce pain, even if it is not very likely to be helpful.

Over the past twenty years, the field of chronic pain management has witnessed exponential growth of the use of spine surgeries, interventional procedures (i.e., epidural steroid injections, nerve blocks, neuroablations, and the like), and opioid medications. The growth rates of this care have occurred despite evidence that they are not particularly effective. During this period of time, there have been record numbers of disability applications for chronic pain (Deyo, Mirza, Turner, & Martin, 2009) and numerous publications of clinical trials, reviews, and meta-analyses that show that these treatments are unlikely to be helpful for most patients (see, for example, Gibson & Waddell, 2007; Martell, et al., 2007; van Tulder, et al., 2006; van Wijk, et al., 2005).

Why, then, do healthcare providers continue to recommend them at such high rates? Patients, of course, might be excused for not knowing that these common therapies are ineffective for most people, but healthcare providers should know about their low level of effectiveness. While they might know of the research, it may be that it doesn’t enter into their decision-making process when making recommendations on a day-to-day basis. Here’s how it might play out.

All these therapies can help some minority of people. That is to say, it’s possible that they are helpful for any given patient. However, it’s not likely that they will be helpful. This distinction can get overlooked in a fee-for-service reimbursement system. Money comes to influence healthcare recommendations because providers, clinics, and hospitals get paid based on quantity of patients seen and procedures provided, not on how healthy patients become or how effective procedures are.

In a fee-for-service reimbursement system, the criteria for whether to pursue a treatment gets lowered to whether it is possible that the procedure could be helpful, and not whether it is likely that it will be helpful. The consequence is overtreatment.

So, what can you, the patient, do about it?

Importance of the therapeutic relationship

As a patient, you can do a number of things to reduce the role that money might play in your care. They all relate to being able to establish and maintain a healthy therapeutic relationship with your chronic pain management provider(s) that allows you to make effective and informed decisions about your care.

What does such a healthy therapeutic relationship look like? It’s a safe, non-judgmental relationship in which you can have mature, adult-to-adult discussions about your concerns and your care. It’s a relationship in which you can take an active role in the decision-making processes of your care. I sometimes tell patients to think of it like a high school or college level seminar in which the things that you are discussing are open to interpretation and respectful debate. There is no absolute, right-or-wrong way of going about managing chronic pain. There is no clearly defined conventional agreement about what treatments to pursue and what not to pursue, even for common conditions, such as chronic low back pain. As such, recommendations for treatment are open to some respectful debate. If you have a safe, non-judgmental relationship with your healthcare provider, you can have an adult-to-adult, respectful debate about what to do.

Appreciate the conflict of interest that your healthcare provider has

In this relationship, you can keep in the back of your mind an appreciation for the inherent tension that occurs in your healthcare provider when practicing in a for-profit healthcare system. On the one hand, as a professional and based on a high level of expertise, your healthcare provider is charged to act in your best interest, making recommendations that are going to work best for you. On the other hand, understand that your healthcare provider is also operating a practice that is essentially a business, one in which your healthcare provider’s recommendations also serve his or her own self-interest. When you appreciate this inherent tension in the relationship that you have with your healthcare provider, you are in a better position to make more informed decisions.

The point, here, is not to accuse providers within a for-profit healthcare system of wrong-doing. They are simply engaging in the practice of healthcare delivery in the manner that is encouraged by their system. Rather, the point, here, is simply to know the lay of the land, as it were. The ground on which you stand when obtaining care from a chronic pain management provider involves an inherent tension between conflicting motivations. The provider, clinic, or hospital that you seek care from is attempting to work in your best interest and their own self-interest at the same time. It’s important that you understand this tension that is inherent in the recommendations that you receive from your chronic pain management providers and take it into account as you decide on which recommendations to pursue and which not to pursue.

Stay grounded when making decisions about your care

It also helps if you can stay grounded when making decisions about your healthcare. While it is understandable that you may become overwhelmed or desperate or angry at times, you likely may not make your best decisions when feeling these ways. It fosters the likelihood that you’ll be willing to ‘take a long shot’ – a treatment that might work, but is unlikely to work. In turn, being willing to try anything, fosters unnecessary care, which may be recommended to you in part because of profit motive. Instead, you will be more successful in managing pain when you make decisions about treatment based on probability of effectiveness, not the possibility of effectiveness. While all things are possibly helpful, only a few things are likely to be helpful. So, when you are ungrounded and apt to want to ‘throw a Hail Mary pass,’ maybe the first thing to do is to get grounded and then have a respectful, adult-to-adult discussion with your healthcare provider about what treatment is most likely to be helpful.

Know which treatments are effective and which are not effective

Related to this point, and in order to have such a grounded discussion that minimizes the role of money in your healthcare, you need to know what is effective and what is not effective in the management of chronic pain. The Institute for Chronic Pain and other organizations (such as Body in Mind) attempt to translate published, clinical research into language that is approachable to patients, their families, primary care providers, and third-party payers. To minimize the role that money plays in your care, it pays to educate yourself about the empirical evidence for the effectiveness of common treatments for chronic pain. By having a command of such knowledge, you will be able to have a more sophisticated discussion with your healthcare providers about the recommendations that you receive.

Seek out second opinions

Another important strategy is to seek out second opinions from providers whose training and practice are different from the provider who made the initial recommendation. By doing so, you allow yourself a greater amount of options from which you can make a more informed decision about your care. As such, it minimizes the risk of acting on recommendations that may in part have been provided based on profit motive.

For example, if you receive a recommendation from a spine surgeon for your chronic low back pain, don’t just seek out a second opinion from another surgeon, who may very likely come up with the same recommendation; rather, seek out a second opinion, say, from a chronic pain rehabilitation provider who will likely conceptualize and treat your chronic low back pain differently.

Understand that there is no conventional agreement as to how to manage common chronic pain disorders. Surgeons, interventional pain providers, and chronic pain rehabilitation providers all treat the same condition differently. Among all the different types of chronic pain management providers, there is considerable debate as to how to conceptualize and treat chronic pain. Some commonly performed procedures have very little empirical support for their effectiveness and still others have been shown to be ineffective. In the on-going debate, it is common to highlight the potential role of the profit motive when discussing why these procedures continue to be performed (see, for instance, Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

When you obtain a second opinion that is outside the field of the initial recommendation, you are more apt to obtain an opinion that reflects another side of the debate that goes on among chronic pain management providers. In doing so, you learn about options that you might not otherwise obtain. Subsequently, you can learn about the relative effectiveness of each option you receive, discuss them with your healthcare providers, and foster an informed decision. Consequently, you minimize the degree to which profit motive influences the recommendations you receive and pursue.

Seek out care from salaried providers or non-profit organizations

Lastly, if you have the option, seek out healthcare providers who work in organizations that pay them on a salary, rather than through a fee-for-service model. When the livelihood of your healthcare providers are not dependent on whether you give consent to the recommendations they provide, you minimize the role that money plays in generating those recommendations. It’s interesting to note that some of the most prestigious healthcare institutions in the U. S. pay their healthcare providers on a salary. Some examples are the Mayo Clinic, the Cleveland Clinic, the VA, Kaiser Permanente, and GroupHealth.

Of course, many patients do not have the option to seek care in one of these organizations. In such circumstances, you might try to obtain care in a non-profit healthcare organization. Non-profit organizations might still pay their providers through a fee-for-service system, but they may also have a mission that tempers the profit motive of their individual providers.

References

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved December 27, 2013, from The Cochrane Library, Wiley Interscience.

Martell, B. A., O’Conner, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

Perret, D. & Rosen, C. (2011). A physician-driven solution – The Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-29-2014