Medicine is a Procedurally Driven Profession
Medicine has become a “procedure driven” profession having taken a big step away from “managing” patient care, particularly with spine cases. This is even more true for the medical specialist seeing decreasing rates on office evaluations forcing them to focus their practice on either injection [Interventional Pain Management] or surgery [Orthopedic, Neurosurgery]. These specialists cannot afford to see patients that they are not going receive their “procedures”.
Primary care physicians are swamped with chronic disease management with a major focus on heart disease and diabetes. The spine pain patient is lost in the middle when the portal of entry for diagnosis and management is the primary care community or the medical specialist. When they do, this is what happens…
1: The patient is sent for treatment without an accurate diagnosis. Ex: Immediate referral for physical therapy for a “muscle” problem.
2: Referral to the medical specialist for diagnosis and management. Ex: Medical specialists cannot afford to see the patient, refer for imaging and manage that case up to the time of their procedures. Particularly because most spine patients don’t actually require the procedure.
3: The patient is prescribed pain medication and told “your pain will resolve naturally”. We know that the idea that spine pain [back pain in particular] has a natural history that ends in resolution of the problem is untrue and has been disproven in 2010 by Tamcan et al. What they found over a 52-week time period was that patients suffering from chronic lower back pain moved into and out of care based on their pain tolerance, not one of those patients  had reported their pain resolved. Opioid medication has been disproven as an effective method of treatment. A recent publication by the CDC stated “A recent study of patients aged 15–64 years receiving opioids for chronic non-cancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose.”
4: They are told there is “nothing wrong”. This is particularly the case in spine pain of biomechanical origin where we see imaging negative for pathology. The MD community is focused on anatomical causes of spine pain which we know rarely correlates well with spinal pain. There is no training in spinal biomechanics in medical school outside of spinal surgery residency and fellowship training.
WHAT YOU SHOULD DO ABOUT IT
1. Educate yourself, educate your patients and educate the medical community!
2. Make academic introductions to EVERY MD that is involved with the care of your patients, that means PCP and medical specialists.
3. Share your CV as an introduction, I no longer use business cards. If they have an iPhone I airdrop my contacts to them, if not then I share it through text. Everyone will lose a business card.
4. Ask to “see” their office and use that opportunity to educate staff on your credentials (CV) and teach them what you do “Specializing in the diagnosis and management of mechanical spine pain”
5. Discuss with staff, referral coordinators and providers that you “Also have a network of medical specialists should the patient require additional medical management”. That means injections, medication or surgical referral.
6. Maintain your focus and teaching on Spinal Biomechanics.