The Priceless Value of a Second Opinion

Americans are savvy consumers, almost to a fault. Many will obsessively hoard coupons until a single day of victorious grocery shopping. Others will drive an additional 4 miles simply to get the cheapest gas in town. We take value and consumer power very seriously.

Does this translate into American healthcare? On big purchases like a new car or house, many would consider it unwise to not shop around. This extends to expensive repair work for the car or house. If the bill is expected to be loathsome, some serious sleuthing is in order to find the best deal; after all, financial blows are really all about avoiding undue risk. It appears not to be the case when it comes to medical care.

High risk medical procedures are being performed without slightest thought of a second opinion or even consideration of conservative management first. Of course, American healthcare is more restricted by what insurance will allow, but does this serve for lower financial cost at the expense of poorer patient outcomes? After why replace an arthritic knee joint, when the pain was actually coming from the lumbar spine the entire time?

My name is Dr. Allan Buccola, and I am a physical therapist and owner of Impetus PT in Greensboro, NC. In this post I share some experiences I have encountered in the clinic. This is about what happens when the wrong diagnosis is made, and the resultant surgery doesn't correct the dysfunction at hand. Our culture of healthcare in America is changing and it needs to translate into better care.

Elective Orthopedic Surgeries Are Booming

As Baby Boomers continue to age, the number of elective orthopedic surgeries continues to grow exponentially. As a physical therapist, I have the pleasure of serving many of these patients on a weekly basis, often just hours after surgery. Working frequently with the same clinical population affords one unique opportunities to connect data from recent research to individual, real-life stories.

There is a great deal of research on how things like hip arthritis present in different patients: where they tend to experience pain and what other symptoms they describe. Physical therapists use an extensive, statistically derived set of criteria to identify suspected hip joint dysfunction in patients whereas the old standard for diagnosis was degenerative changes found on imaging.

Combined with the fact that physicians are more strapped for time than ever, and it's no surprise that many of my patients have undergone total hip replacements only to later find out that the dysfunction was coming from somewhere else, such as their spine. I wish these patients had been able to see me first, to try physical therapy prior to jumping to an expensive, risky surgical solution.  

Physical therapists rely heavily on information gathered from the patient's story. Because PTs don't have the ability to order imaging studies like x-ray, CT, or MRI, our profession has become very adept at creating reliable diagnoses based on a combination of historical information from the patient, objective measures taken by the therapist, and special tests that are statistically validated through research.

PTs equally apt at clinical examination and evaluation as other medical specialties, but approach problems quite differently.  Our insurance system allows the average physician visit to be around 15 minutes with only 5 minutes covering the primary reason for the visit. After 4 weeks of trying physical therapy to resolve pain, a PT will spend as much as 9 hours with the same patient.   

Over Reliance on Medical Imaging is Part of the Problem

I loath the day that PTs are able to order medical imaging studies, for I see all too often how clinical judgment is pulled in the wrong direction as a result. Analogies are difficult with this one, but I often joke about the excessive use of x-rays in response to complaints of pain, comparing it to an auto mechanic doing a photo shoot of your car every time it won't start.

There are times when medical imaging is a godsend, for instance when patient symptoms warrant ruling out a fracture or tumor, etc. Unfortunately, medical imaging can sometimes lead to a wild goose chase. Conversely, some practitioners are too heavily reliant on it for quality diagnosis. I once had the same running related foot injury imaged 5 times in 30 days with no definitive diagnosis offered. I paid for all of those. 

X-ray imaging is great at showing deviation in structural anatomy. If there is atypical boney shape, contour, density, etc it will be seen with relative ease. This is often what happens with arthritis. X-ray is great at finding arthritis: in the back, the neck, the hips, or the knees. Unfortunately, degenerative joints are not always the source of a patient's pain or dysfunction.  

Arthritis is a common occurrence with aging. In actuality, arthritis often causes no reports of pain or dysfunction in many people, so it stands to ask whether a more thorough evaluation of soft tissue is warranted.  After all, this is the role that PT plays in many musculoskeletal problems.

Every year, many patients are referred to Physical Therapy by their primary care physician with the diagnosis of sciatica. Sciatica is not a particular disease or diagnosis, but rather a specific type of symptom, often thought of as a nerve related burning pain down the back of the buttocks and thigh.

There is no clear universal cause of sciatica, or true irritation of the sciatic nerve. It can be generated from a disc rupture in the spine, irritation at the piriformis muscle, or simple compression from sitting on a wallet. There are at least a dozen reasons a patient might have sciatica-like pain and few of them will be revealed easily in medical imagine. PTs are relied upon to resolve such complaints in the absence of imagine, so why don't insurance companies allow patients to start there first.

Physical Therapists Are Human Movement Experts

The unique combination of detailed history taking, hands-on examination, and assessment of function, means PT allows for lots of time to formally evaluate patients. This is something that other medical professionals cannot afford. When was the last time your general practitioner sat down with your for 45-60 minutes? 

Our insurance-led healthcare system does not allow for this to be a profitable endeavor. This time availability, unique to physical therapy evaluation, has led to PTs becoming expert, first-line practitioners in helping patients in pain. This means that with many problems, PTs provide great value to both patients and referring physicians alike in providing an expert second opinion. This works in everything from incontinence to vertigo; frequent falls to headaches.

This value increases substantially in the wake of pain or dysfunction that is complex or unclear. The additional good news is that heading to PT may help you avoid surgery altogether. And worst case scenario: if you end up needing surgery anyway, you are likely to have better outcomes if you have gone through PT before surgery. 

The research has spoken: some of the most colloquially popular orthopedic problems like rotator cuff injuries, joint arthritis, or lumbar disc injury, have been statistically shown to often respond just as well to physical therapy management as they would to surgery.

That means there IS oftentimes a safer, more conservative option. Be that as it may, certain diagnoses continue to be made solely on the single piece of information that is medical imaging. In these cases, there are a minority of instances where the results are quite frustrating. 

Jumping to the Surgical Option Too Quickly

The over reliance of medical imaging is especially problematic when little time is taken to listen to the patient's story. Interrupting a patient after 11 seconds of describing their back pain often leads to an order for back x-rays or MRI. What if the patient was allowed to continue to describe their case? Would the physician then have changed that order to x-rays of the hips. It's certainly possible.

I have met too many of these patients who presented with back pain and leg weakness, and had x-rays that showed arthritis in the lower back. They underwent surgery only to find out 3 months later that their persistent symptoms were actually coming from the hip joint. Time for another surgery. 

What about that patient who goes to the doctor with worsening pain, knee x-rays revealing arthritis. In spite of injections and surgery there is no change. The dysfunction and frustration remain. Later during rehab, the therapist tests the hip and realizes that the pain was likely coming from the hip joint to begin with. All too often I hear stories of how a patient underwent one surgery or another before the most relevant problem was addressed. There are cases like this for every joint in the body. 

Hip arthritis is but one continual example of how over-utilization of medical imaging puts patients lives and wallets at risk. I have encountered numerous patients (albeit a relative minority of cases) who suffered the pain and disability of hip arthritis for years because of a lack of clinical expertise, overuse of imaging, or a failure to ask the right questions.

Imaging Does Not Equal Pain

Degenerative arthritis is a typical, non-problematic phenomenon in more than half of the population over the age of 50. Unfortunately, the presence of back arthritis in a patient who reports leg weakness and pain in the butt, often results in painful injections, constipating narcotics, or a spine surgery. A patient who is experiencing classic hip arthritis symptoms is now scheduled for a $77,000 laminectomy or worse yet a $115,000 lumbar fusion.

This is tricky because availability of quality imaging is vital to good medicine. Arthritis, on the other hand, like that of the knee, back, and hip are easy to identify on x-rays, but the significance is sometimes questionable. Using those findings must be carefully integrated with the rest of the information from the patient. When more attention is paid to the patient's images rather than the patient, the consequences can be disheartening. 

Try PT First

Often these cases are rare, but if you are unsatisfied with your current treatment or concerned about signing on for a major surgical event, be a savvy shopper. Respect your autonomy to make a well-informed medical decision. See a physical therapist first. Find one who is a specialist in the area that you need.

Advocated for yourself, and ask for a prescription for PT. Let the physical therapist decide if your case is appropriate for PT. Chances are, if your problem warrants a referral to an orthopedic specialist, or additional imaging, there's a good chance you'd benefit from a PT evaluation as well. 

There once was a time when doctors spoke and patients listened. There once was a time when patients did as they were told no matter what. The world has changed. Patients are more educated, physicians are more specialized, and doctors visits go by faster than ever. Patients have significantly more say in decisions made regarding their medical care.

Before you embark on a major elective orthopedic surgery, be confident its the right choice. Try PT first. Get a second opinion. After all, taking your car to the body shop, isn't going to fix the dead battery or address a wheel alignment issue. Don't pay for a transmission job if you need simply replace the clutch. 

I Am Pro-Patient, Not Anti-Imaging

Some might find this post as an overt criticism. I have no intention of pointing fingers at any singular party. My goal is merely to bring attention to several points. Firstly, the human body is a complex system, rarely with a single ailment, that requires deeply thorough examination.

Second, healthcare experts are human beings and as much as we all hate to admit, are subject to occasional mistakes or errors in clinical judgment. If you disagree with this, find me a physician that doesn't carry liability insurance. Thirdly, there is no one to truly blame here individually. I'm not taking a stab at physicians; on the contrary, I know they voice similar concerns with how insurance standards have limited their ability to provide quality care, and I empathize with them.

I have had the pleasure of working with some amazing orthopedists that 99.9% of the time are helping patients with devastating medical problems. I want to acknowledge that our healthcare system is not set up to provide care of the highest quality for everyone. This country is short on doctors and most doctors are subsequently short on time. 

You Are Your Number One Advocate

Lastly, as a patient, don't settle for bad healthcare. Some of the most important decisions you will make in life will originate from conversations between you and your physician. If you and she don't communicate well, it is almost guaranteed that your health will suffer as a consequence.

Health and wellness are far too important to squander on account of a mediocre relationship. The two of you need not be best friends, but when you talk, make sure they listen to you. Make sure you can trust them to take your concerns seriously. 

Thanks for reading. Learn more about my practice here. Find out more here about what makes Impetus unique among PT practices in Greensboro, NC. 

Until next time, don't stop moving! 

-Allan