There have been quite a few doctors already in the life of my new 66- year old patient, Anna. And I'm about to join the list. A weary husband and recently computerized daughter have "heard great things" about me. Here we go.
Anna has burning pains in her legs, pain around her hips and some low back pain. The crucial part of her story, for me, is that her pain is particularly bad when she lies in bed at night. On X-rays she has a little hip arthritis (a red herring) and quite a bit more spinal stenosis — a narrowing of the passages through which the nerves go from the spine to the legs.
Hers is actually a very common set of symptoms — you would think we had the cure. But we have little that really works well for spinal stenosis. Even the practical, surgical approach — "just get in there with some good steel tools and make those passages bigger" — doesn't always seem to make the pain go away.
So she has seen physiatrists and had physical therapy, epidural injections, nerve medications (gabapentin), pain medications (always a dangerous sign) and of course, anti-inflammatories. A couple of neurologists have seen her and given her oral steroids. A reliable neurosurgeon simply told her she was "not a good candidate" for the operations typically used for her problem. The other neurosurgeon recommended the big, dangerous operation but did say her chances of not getting better or even getting worse were at least as high as her chances of being cured by the surgery.
"No thank you" said Anna. A chiropractor and an acupuncturist have not helped. Her medical doctor put her on a diet and she did feel good about losing some weight — but the pains continued. She even went to a famous back doctor in the city who told her the problem was actually in her head; not surprisingly, this information also failed to relieve the pain. And so she finally made it to the "most famous orthopedic surgeon" — in my house at dinnertime anyway — trembling with the expectation of my bold new treatment plan and a rapid cure.
Jackie Mason used to do a bit on this topic — "my doctor is the best doctor." Books and magazines whose covers promise lists of the "very best" doctors sell well every year. A marketing business has grown up around the notion of the "best doctor"; for a hefty fee they bring famous athletes (interested in picking up a few easy bucks in the off season) to my office for me to examine while they take pictures. The ads then say, "When he gets hurt, Bubba only goes to the best — he sees Dr. Haig." I found this almost as funny as Jackie Mason. A bit less funny when I see Bubba's face in other orthopedists' ads and wonder if I'll have to take the marketing game more seriously.
But today I am the "best doctor" for Anna and her family, so we go through her long and detailed history, her unremarkable physical exam, all her films and reports. I don't really disagree with anything the other doctors have had to say about her and there's been no major screw-up in her treatment. I am amazed at how little Anna (and her family) actually understand about what's wrong with her though. We spend a long time discussing arthritis, stenosis and pain. The only addition I can make to her treatment is a basic explanation of the anatomy of the arthritic spine, and some really simple advice based on this; we tell patients with stenosis to try and keep the low back more rounded. Slouch a little and keep your hips flexed in bed. This keeps the nerve-passages a bit more open. It seemed to help Anna. And it seems to help me when my back aches.
Nobody much wants to be Anna's doctor. Her problem is not readily solved — at least in the way she would like it to be. She has the usual (bad) insurance which doesn't pay enough to cover expenses for the time it actually takes to educate and satisfy her. She has therefore been to at least six other doctors without learning what's wrong with her; she still thought the problem was in her legs. The "bend your back" advice must have been given to her by at least a few of the other docs, but she and the family looked wide-eyed and were firm that it was the first time they heard this.
I am unhappy about marketing forces shaping the world of medicine — a world which for most of us, at least in some part, is truly as sacrosanct as the life and health it aims to protect. Anna's case is an example of the new medical entity called "patient driven medicine." Patient driven essentially means it doesn't matter what we do or say to patients as long as they feel satisfied by their interaction with us. When the problem is complex and the best treatment mediocre, it's far more profitable to smile, cajole and refer on to the next doc. The next doc might actually do the heavy lifting of explaining and living with a difficult patient or, as was done times six in Anna's case, he too might keep it light and pleasant, do his thing and say goodbye.
All very inefficient, and — when you add it all up — a lot more expensive than giving one good doc a good fee for taking good care of a person who continues to be his or her patient.