Doctor's View: Can Health Coverage Cause Pain?

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Close readers may have wondered how octuplets mom Nadya Suleman was able to manage multiple pregnancies and the resulting child-rearing while suffering from a back injury so serious that she has been unable to return to work and has collected $167,000 in workers' compensation in recent years.

But to doctors in clinical practice, the realities behind her story are all too familiar. Cases like hers, in clinical research, make for difficult findings; emotional and ethical issues have always marked the infertility field.

Clinical research in my field, shoulders, can be almost as inflammatory. It usually goes like this: Take 100 people with a certain injury, like a rotator-cuff tear. Treat them the same way, with the same operation, then bring them back a year later to see how they turned out. This is pretty much how we officially get the information we need to answer patients' questions like "How well does the surgery for torn rotator cuffs work?" It's sometimes how we decide to start doing new operations in place of old ones, or even not do any operation at all. (Remember, Beatles fans, how all your friends had their tonsils out when you were a kid? Hardly any kids have them out today. Clinical research determined that all those tonsillectomies just weren't necessary.) (Read "Study: A Simple Surgery Checklist Saves Lives.")

All sorts of embarrassing facts turn up in clinical research. The rotator-cuff study (conducted in 1995 and involving 103 patients) found that surgery patients on workers' compensation felt better and returned to work only 42% of the time, compared with 94% for those not on workers' comp. How do we explain that the same surgery "works" less than half the time if you're on paid leave from work but nearly all the time if you're not? When patients ask, "What are my chances of getting better with this surgery?", do we really tell them, "Well, that depends on what kind of insurance you have"?

Sometimes I do. The truth can be very powerful: some patients are completely frank about not wanting to go back to work, ever, if they are having an operation triggered by a workplace injury, and will claim to be in pain long after they should have recovered. We can't tell a patient, "I know you're faking," but we always know; our little pokes and prods are telling. When I read that paper back in '95, I remember thinking that I'd be able to get a different result: I would communicate better pre-op, be more truthful. I would sew them up better, stick with them more closely during therapy, be a better doctor, and my comp cases would be back at work just like everyone else.

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Then I met "Chester." He is an undercover cop who fell during a chase and hurt his shoulder. He came in through Emergency with no broken bones but in severe pain. He could barely lift his arm out of his lap. Very respectful, clean-cut and strong, he was also clearly a good friend of the other detectives who came in with him. They lifted together at the gym. I was happy to have him as a patient. One of the problems we face with shoulders is that the tissue we have to repair can be weak or brittle from disuse — even when sewn up, it can easily rip again. Chester's cuff tissue was thick and strong, freshly ripped off the bone; if put back properly, he could certainly return to police work. I had treated many athletes with injuries like his. They do well — pain-free and back to sports — the vast majority of the time.

After the operation, Chester continued to be a great patient. He did his exercises, drove himself to the office for his follow-ups, got back full motion and was making way above average progress. He was off pain meds and — an important milestone with shoulders — was able to sleep through the night. At four weeks I got a call from his police surgeon, who officially clears police officers for return to work. He was reasonable enough, asking if Chester could come back just to work the phones. There were, apparently, quite a few cops out, and they needed help in the precinct house. "Nothing more than desk work — but I need it in writing, from you," he said. He faxed over the form, and I checked off "light duty" on his activity sheet; this meant he could sit at a desk, answer the phone and do paperwork. That was on a Tuesday.

Wednesday morning I came out of my first case to find three messages marked "urgent" taped to the door of the surgeons' locker room. Chester, his mother and his police surgeon all needed calls.

"They came in here going crazy," was the first thing my secretary said. "His mother says you're trying to kill him. They're calling the Board of Health on you. I didn't know what to do."

So Wednesday afternoon he was back in the office. This time his mother drove. I closed the door of the exam room.

"What's wrong?"

Mother was angry. Chester tried to look betrayed.

"It's not fair," he said. "My sergeant had the same operation, and he got six months off. Do you know what that desk work is like? I can't pick up those phones, can't write in those notebooks. Oh, and I'm in constant pain ..."

"But Chester, it's your left arm and they know you're right-handed. And the physical-therapy notes say you're doing 30 reps with 5 lb."

"But the pain ..."

There was no reason to believe that Chester's shoulder was any different than it had been the day before. But I knew the mess I was in. You can't argue with the complaint of pain. I could imagine the grimaces I would see when I examined his shoulder, and I realized how utterly impossible it would be to get him back to work before he completed the time off that he thought he "had coming." What an embarrassing phone call it was going to be to the police surgeon. (See five truths about health care in America.)

"... and given the multifactorial nature of his pain ... environmental stressors in the workplace ... and the mounting dysphoria associated with the perceived functional deficit ..." The police surgeon mercifully cut me off. He'd heard it all before.

"Just give it to me in writing."

He was back to work at four months. Chester was again the model patient and very happy. He stayed on light duty for another two months; I think it was actually the gang back at the gym who lured him back. Six months, exactly the official prediction. It's hard to argue with those embarrassing facts of clinical research.

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