Are You Ready?

Mrs. Smith is a 44 year old female who presents to her general practitioner complaining of lower back pain. After 30 seconds of listening, 2 minutes of writing scripts and a few seconds of contemplating imaging, the final decisions are:

• Bed Rest for recovery
• CT Lumbar Spine for investigation of ?disc protrusion
• Nurofen for analgesia

But wait.. what do they teach us in medicine? That's right - take a detailed history, perform a physical examination of the relevant region and come to a clinical conclusion... only then should the clinician decide on the relevant investigations. So what's happened here is that the GP took a brief history and skipped the examination completely. We all know it's wrong and I'm sure they do as well. The question is: Why is it practiced? 

The Government, or Medicare, only allow General Practitioners to have a maximum of 15 minutes per consultation and that's pushing it. If one does a Long Case examination, the Faculty of Medicine recognises that this could take an amateur up to 60 minutes ask the relevant questions and perform the appropriate clinical examinations. There is also, of course, the financial motivation - the more patients they see, the more money they make. 

The key to the practice of medicine is the evidence behind the actions decided. Let us examine the facts:

• The literature suggests that bed rest for back pain is contraindicated as it can exacerbate the discomfort
• Radiological findings, even if grossly abnormal, may not necessarily correlate with the clinical presentation - if there is nerve root compression, is there neurological deficit? 
• Perhaps non-selective cycloxygenase inhibitors (NSAIDs) are useful for pain relief, but what about the complications of taking such medications? 
• Side effects
• Peptic ulcer disease
• Renal failure

Results are back!

• Bed rest made no difference to Mrs. Smith - she finds it hard to get up in the morning and do most daily activities such as walking to the kitchen 
• CT suggested centralised L4/5 disc protrusion, however clinical correlation is advised
• Patient is tolerating Nurofen - it seems to be helping thus far

Now what? 

Patient is now referred to a Neurosurgeon for ongoing management of lower back pain.

Great! Neurosurgeons, like almost all consultants in Australia, don't bulk bill - meaning they charge the patient privately and it's their advantage should they have private health insurance. Poor old Mrs. Smith heads over to the Neurosurgeon recommended to her by the GP (i.e. chosen from some random list on the demographic database of specialists). 

Thank for referring Mrs. Smith, a pleasant 44 year old community-living lady who presents with persistent lower back pain. She denies morning stiffness, urinary and faecal incontinence. She does not report any loss of sensation or weakness throughout the day. The pain is constant and is described as pain over the surface of the lumbar region. There is no subjective localisation by Mrs. Smith as to where the pain is. 

On examination, Mrs. Smith seems uncomfortable in the sitting position. She has some wasting over the tibial compartment and has an antalgic gait on assessment. The range of motion of the lumbar spine is preserved with exacerbation of pain in the flexed position. Lower limb examination revealed some level of weakness at the right ankle compared to the left and also some discomfort in the left knee, which seems suggestive of osteoarthritis. 

Mrs. Smith requires ongoing management. We have discussed the benefits and risks of Laminectomy and she is quite keen to proceed. Before any such intervention is formalised, an MRI investigation is warranted. In the mean, I will leave the patient's analgesic management in your hands.

$250 later, Mrs. Smith wonders how she'll pay her electricity bill because her husband is unemployed and her son is still studying. The prices of petrol and tobacco are going up. But how is she going to work after spinal surgery? Oh and that surgeon mentioned paralysis and infection; maybe even ICU admission. What does ICU stand for? 

What the Neurosurgeon didn't tell poor old Mrs. Smith is that he gets paid $5,000 per operation. Not that this would influence his decision to operate on a patient's lumbar spine without MRI confirmation of nerve root compression. It's not at all suspicious that he discusses the benefits and risks of the surgery well before the results are available. 

Truth is - there's plenty of conflict of interest. Mortgages get paid, car payments disappear and top-end restaurant staff are generously tipped. The more one offers treatment, the more money they make and if an honest clinician actually offers patients with an explanation as to why surgery may not be useful, their capitalist colleagues will use the patient's trust to their advantage to recommend surgery. 

So... where are we now? What happened to Mrs. Smith? I don't know - I made the story up based on the experiences I have seen. There are vast differences of care for patients willing to fork out the cash compared to those who don't have it. 

Clinicians are punished for being honest, for caring. 

What kind of a world do we live in?