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chronic pain, Editorials, evidence based medicine, exercise, health insurance, pain

To cut isn’t always to cure: knee surgery, health care, and our love affair with the scalpel

IMG_0048An article, just published in the NEJM, caught my attention not only for the study results, but because of what is says in a between-the-lines kind of way about the American health care system. The study looks at arthroscopic surgery for a torn meniscus in people over the age of 45 who also have arthritis of the knee. The meniscus is a rubbery disc on each end of the two bones that make up the knee (I’m a GYN, so go to WebMD for a better description of a meniscus, if you need one). A torn meniscus can contribute to knee pain for some people.

A lot of people have arthritis of the knee (we know this because of all the knee MRIs that we do in this country at $1200 or so a pop). According to the NEJM study, 9 million Americans have osteoarthritis of the knee confirmed by x-ray or MRI and 35% of people over the age of 50 will have a meniscus tear on MRI. A torn meniscus itself doesn’t necessarily identify the cause of the pain because 2/3 of meniscus tears are totally asymptomatic. MRIs are so sensitive they identify tons of things that are not causative as far as pain is concerned.

Because we have an aging population, because we MRI everyone, because we have a problem with obesity (a major co-factor in osteoarthritis), and because surgery is highly reimbursed almost 500,000 people get their partially torn meniscus trimmed by a minimally invasive surgery called arthroscopy (using a surgical telescope) each year in the United States.

However, recent studies have called into question the value of arthroscopic knee surgery. For example, we know that arthroscopic surgery for osteoarthritis (OA) alone is no better than sham surgery. Yup. Put a patient to sleep, nick the skin with a scalpel. squirt water on his leg or stick a telescope into it and fix what you think needs to be fixed… the outcomes are identical.

OK, fine, for arthritis, but what about a meniscal tear? Well, this new study in the NEJM looks at that issue and tells a similar story. Patients over 45 with OA and a meniscus tear were randomized to typical arthroscopic surgery (which included post operative physical therapy) or physical therapy (PT). They were allowed to cross over to the other group if they so desired. At 6 months and at 12 months those who had surgery were no better off pain or function wise than those who stuck with the physical therapy regimen (30% of people decided to switch from PT to surgery).

While this study is well done, it does have flaws. Studies randomizing patients to surgery or supportive/other non surgical care are simply hard to do. Only 26% of eligible patients were randomized, the most common reason was a strong preference for one intervention over the other. There also may have been a selection bias from enrolling surgeons and the study wasn’t blinded as people knew whether they’d had surgery or not. There was also no sham surgery arm.

What this study tells us that at least 70% of people will improve with PT alone. This is probably not a surprising fact to any physical therapist, but will it change the standard of care?

We practice medicine in a country where physical therapy (PT) is often harder to get than surgery. Many health plans have limited PT coverage or have $80 or higher PT co payments. People think they’re getting a better bang for the buck with surgery, although wIth many surgeries for pain that just isn’t the case. And how screwed up are we that getting the MRI for knee pain is almost always a snap, yet that $1,200 (or more) could probably pay for most of the PT visits needed to treat the condition in the first place? (the study group received an average of 8.4 visits). It’s simply fucked up when the diagnosis of a torn meniscus is more expensive and easier to get than non-invasive and effective treatment. Why can’t someone evaluate the knee, suspect a meniscal tear, and then just prescribe PT and reserve the MRI for the person who fails the physical therapy?

We manage knee pain with MRIs because the public demands imaging studies. They do. I get asked over and over again for imaging by my pain patients when it just isn’t indicated. Many patients ask because they have been imaged so many times they can’t possibly believe it isn’t useful. Others are holding out hope that this time something will show up. Some doctors with 9 minutes to see a patient don’t have the time or the clinical skills to explain the limitations of imaging. Some don’t know the limitations. And of course there are doctors who order imaging to satisfy their patients and others with the belief that a scan will reduce medico legal concerns.

We also manage knee pain in a world where a surgeon is reimbursed very well for surgery and much less for chatting about why surgery isn’t the best option. Surgeons don’t know everything about non-surgical care. They can’t. When chronic pain is the problem surgeons should be part of the team, not the only member. I’m a surgeon who manages chronic pain, but I have a multidisciplinary clinic with physical therapy, a psychologist, and a pharmacist and the more I rely on my non-phsyician team members the less I find surgery is the right option. Having a whole tool kit is much better than only owning a hammer.

As patients we all want to get better now. Every day I have someone ask for surgery when it isn’t indicated for their pain condition. The common phrase is, “But I have to do something.” Whether we want to accept it or not, medication, mind-body techniques, diet, weight loss, and physical therapy, the medical treatments that are often most effective for pain are viewed as fringe or not being aggressive enough. In America the scalpel reigns supreme. Some patients accept that surgery isn’t for them and gladly follow the non surgical recommendations, but others go from surgeon to surgeon until they get the surgery they think they need.

And what about diet and lifestyle? Obesity is a major co-factor in osteoarthritis of the knee. Not only because the knee is load bearing, but the fat pad in the knee is metabolically active like the fat around the belly and contributes to the inflammatory changes of arthritis. The average body mass index in the NEJM study was 30. That means that obesity was the norm.

This study doesn’t surprise me. Back surgery isn’t very effective for back pain, but it’s popular and the only randomized study looking comparing surgery to a multidisciplinary program for pelvis pain (my speciality), showed better outcomes and fewer surgeries when the initial approach was non surgical. But what about your friend who had surgery for his/her back/pelvis/knee pain who is better? Surgery has a remarkably high placebo response rate for chronic pain, over 27% in many studies.

So will insurers step up to the plate and make PT more accessible and affordable? I have to believe that 9 PT sessions are far less expensive than surgery and MRIs once you factor in all the costs. And what about multidisciplinary programs that work on lifestyle, stress, mind-body, diet, exercise and weight loss? Since these things overlap so much with other medical conditions the cost savings for insurers could be dramatic, but it would take a paradigm shift to get there.

How will family doctors, internists, and sports medicine doctors help? Are they willing to do a through exam, discuss lifestyle and recommend physical therapy instead of falling into the get-your-MRI-and-go-straight-to-surgery routine?

What about surgeons? Will they step up to the plate with statements like, “Outcomes can be as good with physical therapy as surgery. Let’s start noninvasively and see where we get. I’ve set you up to see a dietician, the physical therapist, and here are some names of local pools with great aquatic based programs, which are wonderful for people with sore knees?” Or perhaps the surgeons will be too worried about their Press Ganey scores and if the patient pushes for surgery they will simply agree?

And the American Medical Association? Change the fucking coding system. We should be reimbursing orthopedic surgeons handsomely for fixing fractures, I have no issue with that, but the cost of doing a surgery for a condition that can be treated just as well noninvasively should be the same in the OR as in the office. Only when a patient has failed the recommended therapies should pre-authorization be granted and the surgical fee rise. Trust me, if the surgical fee for arthroscopic meniscus surgery in a patient who hadn’t tried PT were $40 the procedure will rapidly become obsolete.

And finally, what about patients? We need to turn the mirror on ourselves. If you have knee pain and a suspected partial meniscus tear, are you willing to accept physical therapy and lifestyle modifications knowing they work? Are we willing to give up out dysfunctional love affair with the scalpel?

Hospitals, the AMA, insurance companies, doctors, and patients all revolve around the concept that with chronic pain conditions to cut is to cure. But it often isn’t. Cold surgical steel is the right treatment for many acute infections, injuries, and cancers, but this equating surgery and, while we’re at it, MRIs as doing something constructive for chronic painful conditions when at best it’s no better (but more expensive) than a non invasive approach and at worst doing harm, has got to stop. It’s bankrupting all of us in more ways than one.

These are some pretty simple fixes. Who’s brave enough to actually do it?

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Discussion

24 thoughts on “To cut isn’t always to cure: knee surgery, health care, and our love affair with the scalpel

  1. This post pretty much describes what is wrong with the whole health care system, not just knee surgery… easier to get a hospital room than a night in safe housing… easier to get a stomach surgery than an obesity counselor to supervise diet… easier to get diagnosed and treated for cancer than to quit smoking… easier to pass a patient from specialist to specialist than to develop generalist MDs who can effectively push patients effectively AND efficiently through the system. You have guts to say this in your own area of practice and more generally. I greatly admire such a view.

    Posted by George Huba | March 24, 2013, 5:41 pm
  2. Love this post! Bigger or more complicated isn’t always better. Heck, maybe some athletes could heed this as well for better recovery from injury.

    Posted by Male reader | March 24, 2013, 6:37 pm
  3. Nicely said…
    We truly must endeavor to treat the patient and not simply MRI of X-ray findings. And as you astutely pointed out– why was the MRI ordered in the first place. That’s a somewhat complicated issue involving profits, patient demands,etc.

    I strongly support your assertions in your post… And have been a strong supporter and advocate of non surgical mgmt of many orthopedic disorders.
    Kudos.
    Howard Luks MD

    Posted by hjluks | March 25, 2013, 6:00 am
  4. Great post.

    Some country, where almost half the population have on healthcare, and. the rest can apparently have thousands of dollars of imaging, and unnecessary procedures done at the blink of an eye

    $1200 could pay GP co-pays for several people. The surgical bill for pointless arthroscopic theatres could save the lives of how many impoverished people?

    In any other country the citizens would riot in the streets at such inequality. America though? The Land of the “ME ME ME”, and the Home of the Grave injustice.

    Posted by neverdefiled | March 25, 2013, 7:34 am
  5. Interesting. I had arthroscopic cartilage repair at 25 after several months of PT failed (I was already very fit at the time, and was probably overdoing it). Although I do have improved function five years later, I suspected after the fact that the surgery wasn’t totally necessary. The ortho encouraged it because of my age, but I don’t know how much difference it would have made. My other knee shows symptoms how, but knowing what I know now about the health care system makes me hesitate to have it checked out.

    Posted by Kylie | March 25, 2013, 9:04 am
  6. About 15 years ago I saw an orthopedic surgeon for chronic knee pain. He told me there was a only small chance surgery would help, but I choose to do it just in case. The surgery plus PT didn’t help at all, but now with strenuous and informed weight lifting the condition is far better.

    I think even the PT course needs to include the understanding that there will be a life-long need to maintain strength and movement to manage the condition.

    Posted by Steven Rice Fitness | March 26, 2013, 7:10 am
    • It also needs to be understood that the PT fix might take 6-12 months of rigorus work and conditioning. As a PT I can show the way. I can show you what to strengthen, what to stretch, what to do and not to do but it might not fix you problem in 3 days or 3 weeks. People punish their bodies with poor nutrition, poor fitness, sit down jobs and hobbies that largely include button pushing then want their physical issues to go away in 3-6 visits of PT.

      Posted by Ryan | April 18, 2013, 11:07 am
  7. Thank you SO MUCH for this post! As a Canadian physio working in the US I can’t begin to tell you the frustrations with a lack of access to evidence based physio and the culture of treating by MRI and jumping straight to surgery!

    Posted by levinsphysio | March 26, 2013, 7:20 am
  8. I generally agree with the content of the article, but my own experience with OA in my righyt knee benefitted more from using a mixture of newer joint supplements than benefits from PT. PT did some good during the acute phase, but the pain and stiffness persisted for several years until I started using a muli-nutrient approach that included fish oil, rosehips, krill oil, collagen II and pine bark extract. I have been using this combination (OmniFlex) for more than 5 years and no longer have pain & stiffness in my right knee, even with vigorous exercise 4 or 5 times a week. For me, surgery was never an option.

    Posted by Gerald | March 26, 2013, 7:42 am
  9. Great article You crystallized my thoughts eloquently. Thank you.

    Posted by Lee Robertson | March 26, 2013, 10:51 am
  10. I highly appreciate with the points in the article though I prefer always for the natural ways of treating the chronic knee pain as they don’t have any negative effects.

    Posted by julianswilson | April 10, 2013, 5:01 am
  11. Excellent to read your thoughts, as always.

    I’m strictly a patient with no medical training, but I can see how insurance coverage/requirements and the constant push of drug companies has affected my care throughout the years.

    My insurance — some of the best available — refused to cover medication to try to quit smoking, even while I had a long history of hospitalization for smoking-related pneumonia (I finally quit on my own, long after, and haven’t been sick in two years!). My insurance covers Vicodin at $5/script or covers 42 visits to a chiropractor or nearly all of my hospital stays, or any amount of MRI/CT scans, but a prescription that possibly could have helped, nope. This seems wrong. Something, there, is wrong. It’s the only thing they’ve refused to cover — ever.

    And on the note of pushy drug companies (and sketchy doctors who push drugs) — I’d broken a pinky toe. Confirmed by an x-ray (avid distance runner/stripper – necessary to know!), and immediately I was offered painkillers — after I’d told them it really didn’t hurt as long as I wasn’t touching it. I was offered painkillers six times in two visits, and I noted I’d been taking ibuprofen for the swelling and staying off of it. If my doctor is too worried about throwing handfuls of pills at me, I feel like I’m missing out.

    Certainly patient demand and their lack of basic health information has something to do with it, and insurance companies and drug pushers aren’t doing the patients many favors, either.

    Posted by The Stiletto-Shod One | April 15, 2013, 11:38 am
  12. Brilliant. Hopefully this brings several things to light for the average pt. that reads this.

    Posted by J | April 16, 2013, 2:53 pm
  13. There really is a reason I’ve come to love your posts, Dr Gunter. You hit the nail on the head with the problems in our medical system today. We’ve developed a system where treatment is often based on what provides the best reimbursement, rather than what provides the best outcome or is most appropriate for the patient. Everyone, the physicians, patients, insurers, other healthcare team members, and politicians need to recognize that this doesn’t improve costs, outcomes, or the life of the patient, and work towards fixing it. And all of us, patients included, need to take our appropriate steps, whether that’s a patient not asking for imaging or antibiotics or whatnot, or a physician spending the time to explain & educate the patients on why what they wan’t isn’t the best course, etc.

    Posted by dsdphoto | May 26, 2013, 9:02 am
    • Amen! Thanks Dr. Gunter for a great article. I, too, believe physical therapy is underutilized/undervalued, and does not receive the respect it deserves from physicians, patients, insurers, and legislators. Though my state has limited direct access to PT, my insurer (largest in Philly area) requires a script, which makes it more difficult to receive PT. As payment becomes more based on value rather than the current fee for service, I hope that physical therapy will be the treatment of choice for many conditions.

      Posted by Lipidzlady | August 25, 2013, 5:02 am
  14. Dear Dr. Jen,
    I found you through a link to this post and wow am I lucky. You have re confirmed the rightness of my commitment to losing another ten pounds, continuing my power yoga practice And maybe getting off the Celebrex if I can for knee and big toe osteoarthritis and degenerative scoliosis with a bulging disc. I am 56 years old. I must say that the back surgeon I was referred to recommended continuing exercise, weight management and anti-inflammatories. He doesn’t want to cut. I am beginning to realize how lucky I am to have met A surgeon who uses imaging conservatively. I just wish more people were as lucky as I seem to be.

    Posted by Lulu | May 27, 2013, 10:54 am
  15. Dear Dr. Jen,

    Thank you for both the useful information and the analysis you provide in this post. I have a quick question: do you know of any information about the value of PT vs. surgery for meniscal tears in the absence of OA?

    Thanks!

    Posted by Lene | August 4, 2013, 8:12 am
  16. Dr. Jen,
    Thanks for an informative article. I have been trying to get PT for a year after a knee injury and potential torn miniscus. No one would do it without MRI. I went to an orthopedic and he scheduled an MRI but immediately began to discuss knee arthroscopy rather than PT or any other conservative treatments. We need more education so we can participate in our preventive care. I have been taking Celebrex for years and am trying to get off it. I need to find a holistic medical professional and I don’t know where to start. Any comments would be welcome. I am in the Orlando Florida area.
    Thanks Kathy

    Posted by Kathy | November 9, 2013, 2:34 pm
  17. Way cool! Some extremely valid points! I appreciate you writing this article and also the
    rest of the website is extremely good.

    Posted by turmeric spice | February 12, 2014, 6:08 pm

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