In general, complexity is the enemy of efficiency. When there are multiple different ways of doing things, it becomes harder to streamline processes (from an engineering or design point of view). From a medical workup perspective, there’s a reason why specialists exist: having the fullest extent of medical information at your immediate grasp and memory retention for a particular subject requires devotion, dedication, and study, not to mention keeping up with the latest advances, and even learning to differentiate which alleged “advances” are mere fluff and which ones have true substance. This insight usually comes from years of training and a focus on a narrow field of clinical entities. Now, add in surgical techniques which in addition to diagnostic evaluations are a skill set that needs to be honed with practice and improved with innovation.
It’s easy to understand why an average practitioner, even an average neurosurgeon, might shy away from complex conditions or sets of complaints. Even more so in today’s era of medical and surgical practice consolidation, negative pressure on physician incomes, and inflationary times. As more and more physicians (and surgeons in particular) work for “someone else”, that “someone else” wants to get the most out of their clinical time and most are incentivized based primarily upon the number of procedures (it’s the number and value of the procedure-related codes, but that’s a little bit more complicated to explain; see, complexity?).
For the most part, surgeons split their “clinical time” between their office hours and their surgical days. Finding ways to increase the volume through a surgical practice usually focuses on encouraging surgeons to identify surgical candidates in the least amount of time in the office environment, i.e., see more patients in an hour, and then operate on as many patients as possible during their surgical days.
“Outcome” is the term in medicine for how the patient does after a treatment or surgery. For example, insurance companies (including Medicare) don’t have any significant difference between the pay for a surgeon’s procedure regardless of whether the patient has a “great” outcome, a “good” outcome, a “mediocre” outcome, or even a “malpractice-level bad” outcome. They get the same reimbursement. And while a larger program can negotiate a better in-network rate, generally a single “better” surgeon can’t do so on their own.
So, it may not seem financially beneficial to take more time to refine the workup for a patient (for example, with back pain) to make sure all reasonable possibilities have been evaluated and really make sure the exact source of the pain has been identified, then craft a custom solution to their problem that takes into account their specific needs. In other words, average surgeons tend to judge more quickly the next steps and move on to either “surgery” or “no surgery” as quickly as possible, deciding to treat the “most obvious” issue instead of looking deeper, taking the time to test and eliminate other potential causes of that pain that might not initially seem obvious.
While this Henry Ford-style “factory” approach to medicine may seem cold-hearted, it certainly makes fiscal sense. If spending less time with each patient and operating on more patients doesn’t result in an excessive number of malpractice lawsuits, the reimbursement to the employer/hospital/PE firm is mostly independent of the outcomes, and ultimately, making sure the patient gets “the best” outcomes is less important than getting “good enough” outcomes.
Over time, the reputation of the program that focuses on volume over quality can suffer, but if the majority of patients are being driven (due to in-network restrictions, and a perception that the average level of care is still adequate for most spinal surgery) to a single center or group practice, that may not matter.
Therefore, unless a continuing appraisal and improvement process is set in place and utilized by the clinician and/or the institution to ensure that indications are strictly applied and outcomes are important to clinicians and administrators, ”great” outcomes may be less important — at least to the administrators running the programs — than achieving a high volume of any outcome. In fact, most large practices don’t significantly track the average outcomes of patients long term. They track the “morbidities and mortalities”, but if the outcome is less than stellar but not a clear “morbidity” (bad “outcome”), that usually isn’t tracked.
As surgeons, we like fixing things. It’s what we do. And when faced with patients with very complicated pain pictures, including those who have multiple organ systems simultaneously contributing to a disability, we’re faced with outliers who may need a disproportionate share of our office time (which being the primary source of surgical volume and therefore revenue/salary needs to be “protected”).
Therefore, if one’s salary is based more on the number of one’s surgical cases than one’s reputation within the community for being the “best”, when faced with the choice between spending an hour with a patient whom it might take 45 minutes to an hour just to tease out all of the different aspects of their condition versus an hour seeing six more straightforward patients, it’s easy to understand why somebody might develop a habit of seeing the first type of patient, spending only a few minutes with them, saying, “I’m sorry, but there’s nothing else I can do for you. Go see pain management to try to control your pain”. And then that doctor moves on quickly to someone else, someone they think they can help more easily.
Sadly, this results in patient number one feeling diminished, put off, disappointed in the medical interaction, and in some cases exacerbates or creates anxiety, depression, and a sense of reduced self-esteem. After all, they’ve essentially been told there’s nothing wrong with them. “It’s all in your head”. “Nothing can be done”. Who wouldn’t get depressed when presented with essentially no good treatment options? Patients feel like they’ve been “ghosted”. This “Medical Gaslighting” has gotten more attention lately, with more than a dozen articles, news stories, or interviews on the subject in the lay press as well as the medical and scientific community.
One such example of these complex medical and neurologic conditions is the hypermobile variant of Ehlers-Danlos Syndrome, EDS-H as this syndrome is known, reflects one of many hypermobility related conditions and or symptoms. And even Ehlers-Danlos Syndrome itself is made up of more than a dozen subtypes, some of which have clearly identified genetic patterns for identification, and some which do not yet. However, a lack of a clear genetic test for these conditions does not mean that they are not recognizable and identifiable. And I suspect in the coming years we will identify the combinations of genetic anomalies that link together and may even be able to be used to predict severity and subtypes of propagation of symptoms.
One of the other aspects of managing complex neurologic conditions involves a willingness by the clinician and or surgeon to continue to educate themselves, collaborate with other clinicians in different specialties who treat the overlapping conditions from their point of view, and to find ways to innovate new solutions to old problems. That also takes time, time from clinical duties that could be spent seeing a few more patients or operating on a few more people as well. It also requires a willingness to put aside “making a few more bucks” for the advancement of the science and art of treatment of these patients, not to mention that it costs money to keep track of all these patients, support a research team, and go to meetings or publish articles — money that administrators may not see as being money well spent.
This research focus may not fit into the more “corporate” approach that comes with working as an employed surgeon found in today’s more “corporate” practices, such as large groups owned by private equity, or the many satellite facilities owned by large, even “academic” centers, which in reality have a large number of junior faculty who are often sent to small hospitals to build up a clinical volume practice but not supported in their research time. After all, even “not-for-profit” hospitals practice the “for-profit” mentality of “every cost center has to at least break even.”
It’s easy to understand as physician and surgeon groups get bigger and bigger, and institutions put more pressure on its surgeons to “do the heavy lifting” of generating revenue for their institution, that these more complicated patients might be deprioritized or even redirected to seek non-surgical solutions. In addition, today’s metrics-oriented physician evaluations might lose sight of the value of treating these marginalized patients, focusing on the easier work of treating simple problems. Some of these complicated conditions like EDS-H have higher complication rates due to their underlying ligamentous and soft tissue deficiencies, and higher complication rates might seem to hurt a physician’s outcome statistics. And in a statistics-driven salary/reimbursement system, surgeons generally don’t want to get paid less to do the same amount of work.
However, when somebody has a reputation for being able to help the helpless and improve the most challenging conditions, they can (and should) be able to charge more than what an “average” surgeon charges. And that system does exist. It’s just hard to differentiate yourself as such unless you take the extra time, publish what you’re doing, educate the population — and the referring sources — as to the value of specialization. With attention to detail and a demonstrate a willingness to see the big picture and to listen, these more complex conditions can be unraveled.
I’m not saying that the average spine surgeon is not empathetic, but that empathy gets rationed when a high-volume practice is valued over a high-quality practice by administrators who aren’t seeing the patients in clinic. Finding a clinician/surgeon who can embrace the complexity of these conditions isn’t easy, but it is rewarding for the patient. Complexity may be the enemy of efficiency, but it was also required for life to develop in the first place, is responsible for evolution and technological innovation, and for the value of most sophisticated artistic and cultural developments.
And in many ways, complexity can be the spice of life. Just find someone to embrace it with you.
Photo credit: Michael Dorausch, flickr
Dr. Arthur L. Jenkins, III MD FACS FAANS is a board certified, fellowship trained neurosurgeon who specializes in spinal surgery in his “academic” private practice (Jenkins NeuroSpine). He has developed a dozen minimally invasive treatments to improve surgical outcomes for patients with disorders from the skull base to the tailbone; as well he holds patents and patent applications on a dozen different ways to improve patient outcomes. He is developing new treatments with academic researchers, startup biotech companies, and private practice experts in several fields. He specializes in minimally invasive treatments to reduce recovery times and improve outcomes, and rare, poorly understood conditions where his insights are changing lives. He treats patients from around the world with his combination of passion, empathy, and unparalleled diagnostic and surgical skills, out of his offices and hospitals in the New York City Region. He is on every top doctor list for which he is eligible, including: Vitals “Top 1%” of Neurosurgeons, Castle Connelly “Top Doctors” lists for the New York region, the United States, and for Cancer, New York Magazine’s “Top Doctors”, among MANY others.
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