When careful clinical observation and medical experience are combined with appropriate scientific studies, the best means by which valid conclusions can be drawn are then present. It is only by following this pathway can legitimate judgments regarding patient care be made and applied. Information and the use of information varies widely in the lay and professional communities. Appropriate knowledge is not always present in health care. It is therefore imperative that patients know enough to ask the right questions of their care-givers.
The human lumbar spine was never optimally designed for erect ambulation on high gravity planets (i.e. earth) and, unfortunately, no one has yet figured out how to completely replace a worn or injured spine. From birth on, the spine is incessantly subject to insult and injury, on a continuing basis, for periods now approaching 80-90 years.
It therefore prudent for every individual to be as knowledgeable and caring for this structure as possible. Through the advent of modern, non-invasive high-resolution imaging studies, such as magnetic resonant imaging (MRI) scans and “screening” MRI studies it is now possible to become aware of important genomic spine disorders at an early age and to initiate effective preventive care thus avoiding disability later in life. In fact, with early preventive care, it is estimated by the Burton Report that most individuals through preventive care could probably avoid the need for surgery later in life.
“Managed Care” refers to the medical bureaucracy of insurance companies and health maintenance organizations which have replaced independent fee-for-service organizations.
The M2H factor refers to the media and marketing hype which has unfortunately become a strong influence in modern American medicine. Because of the M2H factor the public is often inordinately influenced by “media medicine” resulting in health care “fads”, created and maintained by the media and marketing communities. There is a great need for patients to become more discerning consumers in regard to any medical treatment. A primarily goal of the Burton Report® is to provide online education as a public service so that there can be a “leveling of the playing field.” It is important for the public to know that many therapies with a low M2H factor (i.e. “orphan” drugs and therapies) may often have greater value and less risk than those with much higher visibility.
The Medical Savings Account (MSA) was the first example of a Health Savings Account (HSA) whose greatest asset was the desire to place the patient back in the driver’s seat. Archer Medical Savings Accounts represented the “first wave” in this direction. These are tax-deferred investment accounts, similar in many respects to an IRA, used in conjunction with a qualified high deductible health plan (HDHP). This tax-advantaged arrangement allowed earnings and deductible contributions to grow and be used for qualified medical expenses This tax-free account was intended to be used to pay for a broad range of routine health care expenses including eye glasses, dental work, mental health counseling, stress management programs, weight loss programs, home medical equipment, preventive care, alternative medicine, etc. Government, employers, and the individual can make regular deposits to these MSAs. MSAs were intended to be tax-free, owned by the patient, and potentially willed (as a continuing MSA) to one’s family members. MSAs, in practice, turned out to not be very flexible (not much patient control or tax advantage) and have been replaced by newer HSA’s. The greatest strength of the MSA was the creation of an incentive incentive for the owner to stay healthy and not spend the account. It is possible to now roll over MSA assets into to a personal HSA.
In 1974, Alex Karras portrayed the cowboy “Mongo” who typified brawn over brain. The Mongo mind-set depicted in this film is, unfortunately, still very much alive and well in our health care system, particularly in some surgical disciplines. Take a moment to explore this interesting phenomenon.
“Mother nature” (defined by each individual in their own way) is the greatest healer. The role of health care should be to redirect the patient back onto the “health highway” when they start heading off the shoulder and into the ditch. It is a blessing that we have at our disposal today many remarkable diagnostic modalities and remarkable therapies, but in all fairness, we are still at primitive levels in treating many challenges of which cancer represents a prominent example. In many others areas modern medicine has had greater success. It’s a shame that sophisticated medical care has become so expensive. The need for greater, and more sophisticated, medical care has exploded in out geriatric population. The only realistic response is to advocate earlier and more aggressive education regarding prevention so that only few individuals will need these wonderful medical miracles later in their lives.
As remarkable as it seems there are actually primitive tribes in existence today who have not yet connected the act of sexual intercourse with the birth of a child nine months later. It is equally remarkable that, at the same time, there are physicians providing high risk drugs and therapies to patients and have not yet connected the serious complications occurring months or years later with these therapies. This phenomenon has been termed the “New Guinea Syndrome“.
A sterling hallmark of health care in the United States today has become the fine-tuning of the art of “nonsense.” The Worker’s Compensation system is only one such example. Physicians and patients continue to suffer unmitigated nonsense in dealing with managed care providers”. We have been invited to the Mad Hatter’s Tea Party and it appears that we have all chosen to attend. How can outcomes data be legitimate when the diagnoses themselves do not accurately describe the condition? The most disabling and therapy resistant pain problem is a “regional complex pain disorder (RCPD)”. When it involves the lower spine and extremities the only CPT code presently available to list this serious problem is “low back pain”; something 80% of the population has experienced during their lifetime. How can any studies on the outcome of treating RCPD have any value? The terms “experimental” or “investigational” are not infrequently misapplied by managed care providers as a means of denying patient treatments. “Nonsense in, nonsense out”.
Orphan drugs and therapies represent valuable entities which receive little attention simply because they are unprofitable to industry or lack the support of modern controlled scientific studies. The term “legacy therapies” is sometimes used in reference to drugs. Ignorance of orphans is one of the great failings of our present health care system. To paraphrase Sir Winston Churchill “the free-enterprise, for profit, competitive economic system is imperfect, but it’s the best one around”. Orphan drugs and therapies simply do not have high visibility or high M2H factors. Unfortunately, the federal government hasn’t been of much help in this regard and is trying hard to become part of the problem. Our Food and Drug Administration seems to have a real problem in understanding that their mandate is not solely to protect the public from harm but to also promote drugs and devices required by the public for their welfare and not otherwise available or known. “Orphans” need champions. Most orphan drugs and therapies well known for safety and efficacy need to be “grandfathered” and monitored rather than held hostage. It is up to the discriminating medical consumer to search out the “orphans” they require in order to maintain their health. If individuals possessed medical savings account health plans where they were spending their own funds for drugs or therapies one could be reasonably certain that worthy orphans would have a great deal more attention paid to them than they have today.
It’s not easy to be a patient. In today’s health care environment it can be a most frustrating and lonely existence. What the medical consumer is allowed to see and hear is often dictated and controlled by third parties such as managed care providers or government. In addition the patient is continually being exposed to high M2H factors, driven by the profit motive, in the marketplace. M2H is not necessarily based on the patient’s best interest. Who then speaks for the patient? No one does it better than the patient themselves. Patients need only the knowledge and the right ammunition get back into the driver’s seat. They also need to stop being accomplices to those who desire to dictate the direction of their health care. A patient can only be controlled if a patient allows him/ her self to be controlled.
(Versus The Physician of Yesterday)
Being a physician today isn’t exactly what it used to be. The number of adverse external influences making it more difficult to “make sick people better” increases with each passing day. Let’s face it; demoralized and frustrated health care professionals are not in the patient’s best interest. Being second guessed by clerks, being forced to “play games” to obtain patient care, spending inordinate amounts of time on the phone and attesting, with original signatures, inane paperwork, and even being “gagged” from discussing certain subjects with patients does not bode well for the future. A particularly insidious influence has that been that of “Medicare fraud“. The federal rules and regulations are so extensive and poorly defined that it is certain that every physician in the community is already guilty of having committed “fraud.” In addition to this, when accepted and standard medical practice is inconsistent with governmental determinations, criminal penalties and prosecution have resulted.
All of this does not, however, constitute an excuse for physicians to pander to those with less integrity or practice apathy instead of quality. Physicians need to be reminded that they can only be controlled if they allow themselves to be controlled.
The Physician (Yesterday)
Good posture is important in the even distribution of loading on the spine. The human spine was basically designed for 4-legged ambulation. To walk successfully on two legs on a high gravity planet requires a number of accommodations in order to attain maximal use and health of the spine during the individual’s lifetime. Ergonomic chairs, car seats, and other devices are available to improve lumbar lordosis and thus more evenly distribute stress and loading on the spinal column. If we looked at our spines as being similar to the horse of a cowboy or cowgirl, and if they subjected their horse to constant insult, injury, and starvation, it wouldn’t be surprising to an observer that the horse was not performing well. Basically, the same situation exists in regard to our own spines. The time is now to learn to love your spine and to look into appropriate health maintenance programs.
Prevention is the base of health care. It is the rock upon which subsequent therapies should rest. Unfortunately, there has been a great amount of lip service paid to this most effective activity but not much follow-through by third party payor systems. Health care payors mouth this word in unison but they have yet to discover its true meaning. Statistics tell the story:
Treatment is initially more expensive. In the area of spine care alone, sensible preventive measures would probably be capable of eliminating about 60% of the total cost of spine care in the United States today. These dramatic savings, in addition to lowering over-all costs, would place third party payors in the unthinkable position of being able to provide better care while also lowering premiums!!!
Prevention is the rock upon which a health care system should be based
The concept of Restorative Spine Care represents only one renaissance in attempting to approach the challenge of more sensible therapies in the management of spine related problems. Of the many presently existing medical and health care disciplines spine care has clearly been at the front of the class in regard to the most expensive, least productive, and least successful from the standpoint of surgery. Inherent in the new concept of “restorative” is a focus on more physiologic approaches intended to not only effectively treat, but also to prevent the creation of more patient problems than there were to start with. Restorative Spine Care includes three separate entities:
Non-Invasive Restorative Spine Care
Minimally Invasive Restorative Spine Care
Restorative Spine Surgery
There remains a continuing challenge to convince many in spine care that the maintenance of flexibility is an important goal. This lesson has been particularly absent from the minds of those who perform multi-level rigid spine fusions. Modern architects discovered the importance of energy absorption when they saw rigid tall buildings collapse from exposure to external stresses such as hurricanes and earthquakes. Modern skyscrapers are now designed to have some inherent flexibility. Sir John Charnley revolutionized joint surgery when he introduced artificial joints. Prior to this diseased joints were solidly fused. The facts that the human spine is normally flexible and that imposing multi-level rigid fusions is unwise, have not yet adequately permeated the minds of many who, because of this serious omission, have been creating disabled patients at an alarming rate.
There is no free lunch in health care. Every treatment and drug has potential risks. The challenge is for the patient to reasonably determine what these risks are in advance and see if they are greater than the potential benefits of treatment. Unless there is full understanding of risk, it is simply not possible for a patient to have have informed consent. Sometimes the greatest risk to the patient is the car ride to the hospital.