Preston Phillips, the spine surgeon shot this week in Tulsa, was a former colleague of mine in Seattle. I did not know him well but interacted with him in conferences and some patient care. He was as well-intentioned a surgeon and nice person as I have worked with. It is easy to blame him for doing a surgery that failed, but it is not his fault.
The patient had chronic pain, and almost none of us in medicine are trained to treat it effectively, and the data has been right in front of us for decades. Somehow, we are treating almost all symptoms and disease from a structural perspective, when most of them arise from the body’s physiological state of being in a state of flight or fight.
Health care professionals want to provide healing. When we don’t have the tools to help you, all parties become incredibly frustrated.
Additionally, the most basic healing modality is feeling safe with your provider, because it creates a shift in your physiology to a state of safety, sometimes also called “rest and digest.” This is the physiologic state in which healing occurs.
We in medicine are limited in making patients feel safe because the business of medicine is structured so that it won’t let us spend time with our patients. How can we know you? What is your life like? Are you feeling stressed? How can we methodically understand your care up to this point and make thoughtful decisions about what to do next? What has been done to optimize your chances of a good outcome of surgery?
Modern medicine is evolving in a dangerous direction with regards to your care. The major factor in deciding to offer a procedure or treatment is often whether it’s covered by insurance and how well it is reimbursed. The effectiveness of the intervention is a lesser consideration. In fact, we are sometimes encouraged to perform surgeries that have been documented to be ineffective. 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. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective.1 The downside risks include unnecessary costs, significant risks, and patients often worse off than before the intervention.2 It has also been documented that only about 10 percent of spine surgeons are addressing the known risk factors for poor surgical outcomes.3
Dr. Ian Harris, an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, in which he extensively documents the data behind many procedures for pain that have been proven to be of no benefit. But that hasn’t stopped their use.4
We physicians and surgeons want to provide relief—it is what we are trained to do—but we are not aware of alternative measures. It is like trying to hit a major league baseball pitch with a golf club. I would have no insights either—unless I hadn’t suffered with chronic pain for over 15 years.
There are many ways to cause your body to shift from threat physiology to a physiologic state of safety. A term for this is “dynamic healing.” In this state, input (your stresses) are processed in a manner that has minimal impact on your nervous system; The nervous system can be calmed down, and there are ways to directly stimulate the powerful anti-inflammatory effects of the vagus nerve.
Effective treatments are often not covered by insurance or don’t generate enough revenue for the business of medicine. For example, expressive writing has been shown to be helpful in multiple medical conditions in over 1,000 research papers.5 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, and rheumatoid arthritis, improve student’s athletic and academic performance, speed up wound healing, and diminish many other symptoms.
I had dinner with one of the pioneers of the technique, James Pennebaker, who is a psychologist from Austin, Texas. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate about why it works—but none 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 area shut down because they could not afford to keep them open.
Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a noted Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more penetrating observations: “The secret of care is caring for the patient.” He wrote those words in 1927, when the intrusion of technology into the patient doctor relationship was far less than it is today.6
What about the patient?
A person suffering from chronic pain is trapped beyond words. I call it “The Abyss.” These are just a few of the ways to get there:
· You have been told that there is nothing wrong and you have to live with your pain the best you can. The reality is that there is a physiological explanation for all of it.
· There does not seem to be way out. Most people lose hope. The solutions are there but not being offered. The patients who break out of it feel the healing process is “disturbingly simple.”
· You are labeled by almost everyone, including the medical profession. They include, drug seeker, malingerer, lazy, not motivated, making things up, not tough enough, and more.
When you are trapped by pain, your frustration and anger are deep and powerful. This scenario creates an intense flight or fight response, the blood supply to your brain shifts from the thinking center to the survival midbrain, and your behaviors are not rational.
Another problem that is not often acknowledged is that of inducing depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow.
Inducing depression–“the pit of despair”
Psychologist Harry Harlow pioneered research in human maternal-infant bonding using primates. During the first half of the 20th century, it was felt that mothers should touch their children as little as possible. Leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media. Interesting, or tragically enough, their recommendations were based on rodent research. Harlow was the leading force in changing the tide of opinion, studying various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum.7
In the 1960s, Harlow turned his attention, also based on primate research, to some of the smaller details of human interaction. He wanted to understand how to induce depression. He used various isolation methods and ways of simulating parental neglect or even abuse. He was able to create seriously disturbed monkeys, but not depressed ones.
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 mesh-covered top. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide 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 wouldn’t revert back 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 were upset and called the apparatus “the it of despair”. It was felt that this “learned helplessness” resulted from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.
The surgeon was doing what he was trained to do with the best of intentions. I would feel badly during the first eight years of my career if I could not find a way to relieve my patients’ pain with surgery. The patient was trapped at a level that is indescribable, and surgery is often viewed as the definitive answer. Surgery itself requires enduring more pain and a lot of anxiety about the whole process. So, the level of disappointment is especially high when it fails.
The literature also shows that pain is often worsened when surgery is performed in the presence of untreated chronic pain.2 I personally was not aware of that data until after I had quit my surgical practice. For the shooter to act out the way he did is unacceptable—but understandable. Suicide is problematic in patients suffering from relentless pain..
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? It is not difficult to understand actions taken in such a state of mind.
All the parties were victims of the business of medicine, and I am placing the blame squarely on its shoulders.
The business of medicine has trapped the providers as well as the patients, and the mandates of computerized medical records exacerbate the problem. There are real solutions, but both the medical profession and patients are going to have to demand them.