Articles by JCS

Dr. Gupta: Prof. Amnesia

                                                                                                                    August 7, 2012

TO: Editors: NY Times Opinion

RE:  Response to Dr. Sanjay Gupta’s Op-Ed

Professional Amnesia

Dear Editor:

Dr. Sanjay Gupta, CNN’s chief medical correspondent, wrote an Op-Ed in The New York Times (August 1, 2012), “More Treatment, More Mistakes,” suggesting that “More is not always better in medicine,” an honest warning to a huge problem in all healthcare, but one especially true in medical spine care treatments that are presently undergoing a startling reevaluation in this era of evidence-based medicine and a point he inexplicably ignores.

Considering the renowned Dr. Gupta is a faculty member at the Emory University School of Medicine and associate chief of neurosurgery at Grady Memorial Hospital, unquestionably he is very familiar about the controversies in medical spine care despite his historic silence on these matters.

Now with his Op-Ed, Dr. Gupta has inadvertently opened Pandora’s Box regarding the pandemic of back pain, an area with increasingly ineffective treatments burdened with poor outcomes, high costs, and many mistakes. For instance, today there are over 200 treatments for low back pain, many of which are untested but remain in use despite not proven to be clinically or cost-effective, such as narcotic opioids like OxyContin, epidural steroid injections, and spine fusions.[1]

At best, these radical treatments are supposed to be used in the 10% of extreme cases such as cancer, fracture, infection, or the one in 100 disc cases when conservative care fails. However, today most medical practitioners, pain management clinics, and surgeons jump to these methods as a first resort rather than as a last resort.  There is just too much money in spine care for these MDs to refer to DCs first as the guidelines suggest.

       At no other time in history has medical spine care undergone such harsh criticism by researchers, but the public would never know of the controversy in spine care if Dr. Gupta’s reporting was their only source. Instead, he has been strangely silent on this argument despite the pandemic of back pain, the revealing comparative research studies endorsing chiropractic care, and the plethora of ineffective medical treatments still in use.

Ignoring the Back Pain Pandemic

Some might view the irony of his omission as a cover-up by Dr. Gupta considering his warning that “More is not always better in medicine” is particularly true with spine surgery in the United States. Indeed, how can any medical reporter, and certainly a neurosurgeon, ignore the back pain pandemic?

From 1994 to 2007, while the patient population increased by only 12%, MRIs increased 307%, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%.[2] The most complex type of back surgery increased dramatically between 2002 and 2007 with an implausible 15-fold increase despite evidence that abnormal discs are ubiquitous.[3] The mean hospital costs alone for surgical decompression and complex fusions ranged from $23,724 for the former and $80,888 for the latter.[4]

Not only are these increases alarming, the rate of back surgery in the United States was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country.[5]

Although back pain is not a killer like heart disease or cancer, it is a costly and disabling condition that strikes most of the 250 million American adults:

  • The prevalence of chronic low back pain daily in the general adult population is estimated at 37%, which equates to 92.5 million people daily,
  • the 1-year prevalence is 76%, which equates to 190 million annually,
  • the lifetime prevalence is 85%, or 212.5 million adults, and
  • approximately 20% of sufferers or 50 million adults describe their pain as severe or disabling.[6]

The epidemic of back pain and musculoskeletal disorders (MSDs) currently costs our society an estimated $267.2 billion every year.[7] When combined with all persons with MSDs in addition to other medical conditions, the cost of treatment in the 2002-2004 time period was estimated to be $849 billion per year.[8] Undoubtedly today, eight years later, this cost must be well over a trillion dollars annually.

Paradigm Shift in Spine Care

These huge increases in medical spine care come at the same time seventeen international guidelines on back pain have virtually abandoned narcotic drugs, epidural shots, and spine surgery as the initial treatments except as a last resort in a minority of cases.

Guidelines in the US, UK, Canada, and Europe now recommend initially the use of chiropractic spine care that has proven to be safer, more effective, and inexpensive compared to standard medical spine care treatments in most cases. According to Pran Manga, PhD, Ontario (Canada) health economist:

There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management. [9]

Even the North American Spine Society states spine fusion should be a last resort and that spinal manipulation should be considered before surgery:

Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function…

Despite this revolution in spine care recommendations, Dr. Gupta has never acknowledged to his viewing audience this change that promotes chiropractic care initially for the majority of back pain cases.

Poor Medical Education

Nor has he admitted that today chiropractors are America’s primary spine care providers by virtue of their training and expertise. On the other hand, in his Op-Ed piece, Dr. Gupta does admit that:

“Doctors make mistakes. They may be mistakes of technique, judgment, ignorance or even, sometimes, recklessness.”[10]

Dr. Gupta speaks of mistakes in medicine, but in the arena of spine care education—an area he knows well as a neurosurgeon—he fails to admit that researchers now suggest most medical primary care physicians are very poorly trained in back pain and MSDs as well as the reliance upon outdated concepts and treatments.

Despite the fact 13-28% of patients enter medical offices with back pain and other MSDs, it is surprising that 50% of all medical schools do not require MSD training. Moreover, 82% of MDs flunked a 25-question MSD competency exam.[11]

Scott Boden, MD, currently director of the Emory Orthopaedic and Spine Center in Atlanta, also admits to this educational failure.  “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[12] Another shocking comment in Spine magazine found that even orthopedists were lacking: “Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient.”[13]

The consequence of this willful ignorance has not gone without comment by leading spine specialists like Gordon Waddell, MD and director of an orthopedic surgical clinic for over twenty years in Glasgow, Scotland. He did not mince words about the disaster of medical spine care and the danger of back surgery when he said:

“Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem...It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[14]

Unnecessary MRI Tests

To his credit, Dr. Gupta did mention unnecessary tests in his Op-Ed:

“Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24% of the tests they ordered were medically unnecessary.”

Certainly many spine MRIs are primarily used as “selling points” to naive patients by spine surgeons who have convinced patients that the outdated “slipped, degenerated, or herniated” disc theory is the main cause of back pain. However, research now tells us that abnormal discs have been shown to be irrelevant years ago but remain a concept that still lingers on in the minds of doctors who ignore the new research. A shocking 2009 Stanford University study also found the abundance of MRI scans directly lead to excessive and unnecessary back surgeries.[15]

Dr. Boden has been at the forefront of the paradigm shift in spine care that began in 1990 nearly twenty-two years ago when his seminal MRI research at Emory University revealed no clear correlation between disc abnormalities and back pain.[16]  Medical researchers now consider abnormal discs to be “trivial, harmless, and irrelevant,” to the point of labeling them “incidentalomas” since MRI studies have shown many people without back pain have abnormal discs, too.[17]

Perhaps Dr. Gupta avoids mentioning this ruse for fear of upsetting his spine surgery colleagues who average in salary $806,000 annually as well as many who are paid lucrative royalties into the millions from device manufacturers like Medtronic, an issue now under Senate investigation.[18]

Experts estimate that nearly 600,000 Americans opt for back operations each year.[19] But for many, surgery is just an empty promise that can backfire, leaving patients in more pain. Many unsuspecting back pain patients are still lured into disc surgery despite the new evidence that abnormal disc incidentalomas are considered a “clinical finding” and no longer considered a final diagnosis for back surgery. The insurance industry is now taking note of this changing paradigm although Dr. Gupta has yet to mention this issue on air at CNN.

In January, 2011, a policy change by the North Carolina Blue Cross Blue Shield shocked the spine surgery industry when it said it would not pay for spinal fusion if the sole indication is disc degeneration or herniation since these are present in asymptomatic patients, too.[20] Finally the insurance industry has taken heed of the research disproving the disc theory and the need for fusions.

In fact, the newest evidence in spine care now supports conservative chiropractic care over anything the medical world has to offer for the 85% majority of non-specific, mechanical back pain that affects most patients. Dr. Waddell also suggests chiropractic care as a solution: “There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute low back pain.”[21]

Of course, the remaining 15% of cases with fractures, cancers, serious infections, true disc ruptures, or anomalies that do not respond to conservative care may require medical spine care as a last resort, albeit still of uncertain value. “Even if you take all of the research at face value, you have to conclude that spinal fusion is only modestly effective,” said Dr. Deyo. “It’s not a slam dunk.”[22]

In his 2009 article, “Overtreating Chronic Back Pain: Time to Back Off?” Dr. Deyo speaks of the shortcomings of the medical spine treatments in the US:

Jumps in imaging, opioid prescriptions, injections, and fusion surgery might be justified if there were substantial improvements in patient outcomes. Even in successful trials of these treatments, though, most patients continue to experience some pain and dysfunction.

Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain. We must rethink chronic back pain at fundamental levels.[23]  

 

If Dr. Gupta wants to illustrate the “recklessness” behavior in medical spine care, certainly his mention of unnecessary MRI scans, fusions, opioids, and epidural steroid injections would have been invaluable to prevent “more treatments, more mistakes,” as well as wasting billions of dollars at the expense of millions of mistreated patients.

Professional Amnesia

Dr. Gupta has been inexplicably negligent to announce this paradigm shift to his viewers for whatever reasons—pride, prejudice, power, or professional amnesia.

His failure to acknowledge the debunked disc theory is particularly ironic considering both Dr. Gupta and Dr. Boden work at Emory University in the same department of spine surgery. It is unbelievable that Gupta is unaware of this “incidentalomas” finding, yet as CNN’s award-winning medical correspondent, Dr. Gupta has not informed his viewers of this monumental discovery that occurred 22 years ago at his own university. Imagine the hundreds of thousands of unnecessary back surgeries that might have been avoided if he had warned unsuspecting patients in 1990 when Boden’s research first appeared.

It appears he may have a conflict of interest as a neurosurgeon or may be suffering from a form of “writer’s block” dubbed “professional amnesia” by Anthony Rosner, PhD, which describes those medical journalists who mysteriously forget to mention the criticism of the disc theory, the over-use of spine surgery, or the ascendancy of chiropractic care in this back pain epidemic. [24]   

Similar to the “recklessness” Dr. Gupta mentions, Dr. Deyo noted ignoring these alarming signals is tantamount to patient abuse:

“People say, “I’m not going to put up with it,” and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery.”[25]

Although Dr. Gupta is certainly familiar with the new research and guidelines on spine care, he has never mentioned this paradigm shift in spine care to his viewers on CNN. Dr. Gupta has disappointed in this area while other newsmen have exposed the new evidence in spine research that debunks the disc theory, other articles that reveal the corruption between spine surgeons and device manufacturers, as well as suggesting wholesale changes are needed in spine care treatments. Here is a partial list:

This criticism of medical spine care may be the tipping point in the new era of evidence-based healthcare that hopefully will spread throughout our nation to reduce costs, improve outcomes, and avoid back surgery that is “leaving more tragic human wreckage in its wake than any other operation in history” as Dr. Waddell warned.

 Of course, this change will accelerate if and when Dr. Gupta finds the backbone as a medical journalist to be truthful about this new research and guidelines. Undoubtedly this might rankle his back surgery colleagues to discredit their disc fusions and it might not play well among the faculty at Emory for Dr. Gupta to endorse chiropractors as the new guidelines recommend, but it would help millions of people suffering from chronic back pain.

Indeed, it would be a magnanimous paradigm shift for Dr. Gupta to admit this fundamental change in spine care. Perhaps he should simply tell the truth and heed the advice of Dr. Rosner who testified before The Institute of Medicine on the epidemic of back pain:

“Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[26]

Regards,

JC Smith, MA, DC

Warner Robins, GA

 



[1] S Haldeman and S Dagenais, “A Supermarket Approach To The Evidence-Informed Management Of Chronic Low Back Pain,” The Spine Journal 8/1 (January-February 2008):1-7.

[2] Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64

[3] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[4] “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[5] DC Cherkin, RA Deyo, et al. “An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

[6] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[7] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[8] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 195.

[9] P Manga, Ph.D., D Angus, M.A., C Papadopoulos, M.H.A., W Swan, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain,” (funded by the Ontario Ministry of Health) p. 104, August, 1993.

[10] Sanjay Gupta, More Treatment, More Mistakes, Ny Times Op-Ed, July 31, 2012.

[11] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[12] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.

[13] Finestone AS, Raveh A, Mirovsky Y, Lahad A, Milgrom C., “Orthopaedists' and family practitioners' knowledge of simple low back pain management.” Spine (Phila Pa 1976). 2009 Jul 1;34(15):1600-3.

[14] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)

[15]  M Brandt, Stanford University Medical Center, “MRI Abundance May Lead To Excess In Back Surgery,” (Oct. 14, 2009)

[16] SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.

[17] Richard Deyo, MD, MPH and Donald Patrick, PhD, MSPH, Hope or Hype, The obsession with medical advances and the high costs of false promises. 2005 AMACOM books.

[18] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies,” Bloomberg News, Dec. 30, 2010.

[19] Linda Carroll, “Back Surgery May Backfire on Patients in Pain,”  MSNBC.COM, Oct. 14, 2010

[21] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And disability, “Acta Orthop Scand 60 (suppl 234), (1989)

[22] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR, (April 6, 2010)

[23] RA Deyo, SK Mirza, JA Turner, BI Martin, “Overtreating Chronic Back Pain: Time to Back Off?” J Am Board Fam Med.  22/1 (2009):62-68. (http://www.medscape.com/viewarticle/586950 )

[24] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)

[25] G Kolata, “With Costs Rising, Treating Back Pain Often Seems Futile” by NY Times (February 9, 2004)

[26] Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

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