How Surgeon training has led to misdiagnosis and poorer patient outcomes

November 18, 2020

So, I think the interesting thing about today’s training of surgeons, both orthopedics and neurosurgery, as far as it relates to spine, has a lot to do how they’ve been trained. Years ago, when I started my residency in the mid seventies, which was a while ago, we didn’t have MRIs, we didn’t have cat scans. What we had was our eyes and our ears, and we listened and we examined. And based on those things, with a great deal of trepidation, we moved ahead to do a surgery or treat someone either operatively or non-operatively. This is how I was trained to see patients. And you listened to them. The payment was what it was. Because the economics have changed, and Medicare by default is the reimbursement standard, now down 70% in the last 30 years, we have changed the way people are trained.

I don’t blame the doctors today for operating as much as they do. I’ll go into that in a minute. What happens is, is it becomes an economic engine. If you don’t make enough money for the university to work or the hospital system to work, whether it be in New York or Colorado or Miami or Chicago or San Francisco, it doesn’t make any difference. The money has to be generated. Now, doctors only get seven and a half percent of the medical dollar. Think about that for a minute, seven and a half percent of the medical dollar. The rest goes to hospitals and insurance companies. So what is healthcare? Without doctors, healthcare is nothing. But doctors have not spoken up. And being employed, now, has generated a shyness by physicians to speak up.

So back to the original topic, doctors are now using Cat Scans and MRIs. The people who are teaching them have been taught by other people that taught them. We’ve got three generations of failure to teach these guys how to diagnose anything. You order a test, you order an MRI. And in the previous comments I’ve made, MRIs were basically an image based diagnosis. If you had a herniated disc, that’s probably the cause of the problem, without any clarification of objective clinical findings. I practiced for 10 years before MRIs ever existed. And we were elated when cat scans came in in the mid eighties, that was a revelation. But now, the MRI has taken precedent. Nobody examines anything. The priority placed on a correct diagnosis and a correct exam has been replaced with procedures, and procedures, the more screws you put in, the more this, the more that, the more money you make for the institution and the more you justify your check every two weeks and your bonus at the end of the year, utilizing the RVU score

MRIs became evident and useful in 1988 or 1989. And so, we have, in order to facilitate a replacement of the economics that’s missing with reduction in reimbursement and insurance companies reducing their payment by 80% of Medicare, or less than 80% of Medicare, they are now focused on procedure numbers. And what better procedure is there, but a minimally invasive surgery? You go in, you do the surgery, and they leave. And unfortunately, my old chiefs used to say, don’t send a boy to do a man’s job. And guess what? What great cottage industry has come into being in the last 10 or 15, 20 years? It’s pain management. So a failure, a failure of a minimally invasive surgery without a correct diagnosis, without knowing where the actual pain is coming from, just looking at an image, a failure is basically treated with narcotics.

I recently had a patient from the university who came in who has had two surgeries, one in March of this year, one in May of this year, and was sent to physical therapy and the pain was worse! Then Sent to pain management. And he’s only 35 years old. This is terrible. Two surgeries already. I got flexion extension films on him and his screws are loose. An L5/S1 fusion, and the L5 screws are a windshield wiping… basically have created a wallowing in the L5, which proves that it never was fused. It was all done minimally invasive. Again, you can’t send a boy to do a man’s job. The salesmanship of “we can just sneak in there and get something done” as evidenced by one of the most highly marketing guys in Miami, means that the patient is alleviated from worry and concern until after the surgery fails. I’m not saying they all fail, but it’s a mechanism by which you can get the patient to agree and go ahead with surgery, because nothing else is offered them.

I think the most important thing that I’ve learned in taking care of spinal injuries is muscle strength. You go from 0 to 5, 0 equals paralyzed, 5 equals normal. 2 over 5 means you can’t lift your arm against gravity. 3 is weak, 4 is weak, and 5 is normal. You apply this to the core strength of the muscles, with some degenerative discs. There’s many things that can be done. Yet, doctors don’t even understand this, they’ve never been taught that. So again, I go back and my heart goes out to the doctors that have not been trained by the second and third generation of doctors that have been training them, to even understand this. But guess what? There’s no money in that. So therefore, anti-inflammatory medications are not given, instead the narcotics are given one, two, three until they don’t work, and then they go to surgery. And that is the flaw in today’s medicine with the background as I’ve outlined. Examine the patient and if in doubt get another opinion.