Academic turfitis and budgets: public health undergraduate education (by Jonathan Mayer)

In the mid 1990s, I was asked by the Dean of the School of Public Health to develop a Minor and Public Health at the University of Washington, and it became so popular that we decided to extend that into one of the first undergraduate majors in Public Health. I developed this as well, with one other colleague, and directed this for one year, and then co-directed it. At first, because there was no budget, we did this as volunteers. We were both convinced that exposing undergraduates to public health as part of a general undergraduate education–to issues of health and well-being, and to global health–was an essential part of any broad undergraduate education. We finally were allocated a very small budget.

We structured the major in a manner that emphasized courses outside of the health sciences. In part, that was because there were very few undergraduate courses in public health, but even more than that, it was for intellectual reasons. We emphasized the geographical, economic, social, political, environmental, and biological influences on population and its health. We specifically did not want the degree to be a vocational degree, and were happy that we would be using mostly courses outside of the School of Public Health. Several of my own courses in the Department of Geography were required, and lest this seem self-serving, there was no budgetary advantage to doing this, either for the Department of Geography of for me. The real reason was that these courses fit the framework that we were using, and they were also among the very few public health courses for undergraduates at the entire University of Washington. The students enjoyed the major, and entry was very competitive. There were some years when we could accept only about 20% of the applicants.

Let us “fast forward” by a little over a decade. Like so many institutions, a new budgeting system called “activity based budgeting” was instituted. Cutting through all of the esoteric language, what this meant was that budgets would be allocated according to some complex formula considering student credit hours, grants, and other “productivity” measures. Much of this took place while I was on the Faculty Council of the School of Public Health, eventually serving as Chair, and thereby serving as the voice of the School’s faculty. There were many ironies in this. No unit of the UW were exempt from the new budgeting system, and at the same time, NIH grants were increasingly competitive. Almost all faculty members in my department–epidemiology–were and are dependent upon grants not only for their research, but for their salaries. The School gets almost no fixed monies from the State of Washington. However, people quickly realized that there could be one source of more stable funding: undergraduate teaching. Thus, for the first time, there was a real incentive to develop undergraduate courses.

In addition, the School;s administration also realized two things. First, that there would be a tremendous financial advantage to a very major expansion of the undergraduate major, and second, that the demand for the undergraduate major was higher than ever. As a result, all 5 departments in the School of Public Health developed a suite of excellent and exciting courses, and the major expanded for 50 students total to over 600, and it is still expanding. It is now rated as the top undergraduate program in public health in the US.

The next step is probably obvious. By the time of the major expansion, I was no longer the director or co-director of the major. First, two of my health and disease courses, like those in other departments, were no longer listed as required for the major. Within a year, the third course was no longer listed as required. There was a disincentive to have students take courses outside of the School of Public Health. The unintended consequence was that the enrollment in courses that I teach, and in similar courses, began to plummet, because the demand from the School of Public Health had dropped precipitously. Thus, there was a tremendous irony. I developed, directed, and then co-directed the major in public health. It was a boon to many departments in the College of Arts and Sciences, and students were getting a truly cosmopolitan view of public health. None of the students whom I knew who wanted beginning positions in public health failed to obtain them. There was a university-wide interest in public and population health.

With the new budgeting system, this all changed. There was university-wide rhetoric promoting interdisciplinary education, but the budgeting system that *did not need to be adopted* provided incentives to look inside and stay inside, and so this is exactly what happened.

From an intellectual viewpoint, I abhor what I call “turfitis”. “What does medical geography do that spatial epidemiology doesn’t do better?” is asked even more frequently than the converse. In the past, I have shut such discussions down, saying that such discussions are intellectually vacuous, and that we all share the common goal of understanding health and disease, in a manner analogous to that of systems biology, in which there is so much overlap that the disciplines themselves become unimportant. Intellectually, I still feel strongly that this is the case. But does the new budgeting scheme even allow us to be primarily concerned with the intellectual over the pragmatic, or the scientific over the budgetary?

I find myself truly straddling a fence. I have a joint appointment in the Department of Geography and in the Department of Epidemiology. What one of them gains in terms of enrolments, the other might lose. In addition, my appointments are in the School of Medicine and in two other departments in the School of Public Health.

Yes, the budgeting system is “transparent.” It hinders the very type of study that is so important in an era of cross-disciplinary understanding of complex phenomena such as health and disease. It promotes provincialism. It hinders looking outside of a particular discipline. The students are poorer, because of it. The institution is poorer because of it. It is a poorly advised additional step to the ever continuing corporatization of the industrial university. I regret for many reasons that this kind of system was ever adopted. It is one of the reasons that I am happy that the end of my university affiliated career is far nearer than its beginning. Turfitis begins to loom ever above us, perhaps even influencing the way in which we think.

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Emergency Medical Services, Survival, and a Nightmare: Ethics 101 (by Jonathan Mayer)

Early in my career, much of my research centered around determinants of survival from out of hospital cardiac arrest. Coming from a background in geographical and spatial epidemiology, it was axiomatic that location of facilities was very important, or even crucial. I was interested in taking the most extreme case: did the location of paramedic vehicles (ALS units) matter to outcome? If Mr. Smith went into cardiac arrest on a Thursday night, was his chance of surviving dependent on where he lived, and where the ALS unit was at the time of his collapse?

The details of the studies are not as germane to my story here as are a few images, and a nightmare, and the consequences. My data showed that when restricting the analysis to VF, that yes, location and response times were huge determinants of survival. And there was an image. I have never been an academic who could sit in an office with a computer and numbers, content with being removed from the world. Fo 2 years, I rode the paramedic units in Seattle whenever I had the chance, going to bad motor vehicle accidents in pouring rain at midnight, or a shooting downtown at 3 am, or, in this case, a cardiac arrest in a modest home in a remote part of the city, though still in the city, a little before midnight on a rainy Thursday evening. All that we knew was that a man in h is 70s had collapsed, and we knew the address. Later, we learned from the first arriving unit was that he had no pulse, and that there was ongoing CPR. We arrived on the scene after a travel time of about 10 minutes. I carried some equipment. An elderly gentleman was on the floor of a living room, and a woman whom I took to be his wife was sobbing uncontrollably in the next room. Nobody was with her; all were engaged in trying to resuscitate her husband. Defibrillator, cardiac meds, intubation, and other measures all failed to resuscitate this gentleman. Fortunately, a daughter arrived before we went back into service, and the bereaved widow had somebody to be with. This was not the first time by a long shot that I saw somebody die. Death was a simple process, a nonevent to my eye.  And we left.

Partly, and maybe largely, because of my work, there was a redistribution of ALS units within the city. The argument was made that the units should be located where the need was greatest, so that the greatest number of critical cases could be served. Put another way, this was the argument of the greatest good for the greatest number–the classic utilitarian argument. Shortly after I learned of this reconfiguration, the haunting image of this man’s death reappeared at odd times. I didn’t quite understand why. It was even in a few dreams. And then I realized that he had lived in one of the areas that had experienced *decreased* accessibility because of the utilitarian argument. That area of the city, effectively, was experiencing a decreased chance of survival from cardiac arrest. And I was terrified: the juxtaposition of his death, and the grieving wife, and my academic papers, and the new fire station more centrally located. I had an anxiety attack. And that night, I had a nightmare. I don’t remember the details, but somebody was accusing me of killing somebody in that neighborhood. I do remember “you’re responsible. You killed him.” I remember the line. And I didn’t know how to handle it. When you move from abstraction in your work to the concrete realities, how can you handle the ethical and moral implications if you’ve seen them at work, and if you’re sensitive? I felt so ill=equipped that I talked it over with some clinical colleagues, and then became fascinated by exactly what I was afraid of: the ethical implications.

Instead of running away from those implications, I applied for a three year fellowship in medical ethics and the ethics of health policy, and that I was awarded. It was exciting. I learned. I was invited to be a founding member of a hospital ethics committee, and I instituted and directed a bedside Ethics Consult Service–something at which I felt that I could make a difference. Those were good times. I think that I did make some differences. Yet even after all that, after all the learning, the image of that death, and the accusation remains. My work was not innocuous. Lives matter. And decades later, I feel very humbled by that.

I have never changed my habit of being out on the scene and in the world when I do my work. I do not and will not want to become detached from the human realities of epidemiology and health policy. I immerse myself in the daily dramas and realities. It’s my own way of reminding myself that I, too, am human, and that people are not statistics.

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There is no one “opioid epidemic”

I am now spending more time on pain and opioid research than I am on infectious diseases. There’s a dearth of knowledge on the epidemiology of chronic pain. What we keep on hearing about, though, is “the opioid epidemic.” I am currently writing an article for one of the main medical journals, as well as an op-ed, hopefully for one of the major national newspapers, on how this is misspecified and misleading. Without going into the technical arguments, this is because there is no one epidemic, but there are several notable increases in overdoses, each of which has different social and psychological drivers, with the only commonality being the molecules: the opioids.

These include: 1) overdoses of IV and inhaled street drugs, including heroin and more recently fentanyl and its analogues, either alone or in combination with heroin. These account for the majority of opioid overdoses and deaths in the United States. 2) prescription opioids that are not legitimately prescribed but are stolen, diverted, or otherwise obtained; 3) legitimately prescribed opioids that are diverted; 4) legitimately prescribed opioids that are not used as directed; 5) legitimately prescribed opioids that are used as prescribed. In other words, some of the opioid deaths are because the victim is trying to experience the euphoria of the recreational drug, and others for a variety of reasons. Most in the latter categories are not due to opioids alone, but rather to opioids used in combination with other respiratory depressants, notably the benzodiazepines, such as alprazolam (Xanax) and diazepam (Valium). This can be lethal in combination with opioids. In addition, alcohol can be a potent respiratory depressant.

With increasingly tight restrictions on prescribed  opioids, it’s been noted qualitatively that many are turning to street drugs not to get high, but in a search for medication for their pain. Obviously this is not ideal. Even purchasing street drugs may be a search for pain treatment.

There is another kind of pain. That is psychic pain. The pain of poverty, anomie, alienation, despair, depression, anxiety, and fear over the future.  We see this in areas where opioid overdoses are prevalent. At a fine geographic scale, nobody knows the correlation or the cause, and this is one thing that the team that I work with is trying to identify, along with hotspots of opioid prescribing and opioid deaths.

Opioids are rarely the treatment of choice for chronic pain, yet sometimes, perhaps as third line medications, or in combination with other treatments, including medications such as the tricyclic and other antidepressants, they can be effective. Some of the best responses for chronic pain are to improve sleep patterns  (antidepressants, meditation, or anticonvulsants) , mobilization and graded/gradual exercise, cognitive-behavioral therapy, mindfulness meditation, and some of the anticonvulsants. Not as frequently mentioned is the positive effect of a good therapeutic or doctor-patient alliance. Less frequently mentioned, though increasingly noted, is the potential of cannabis in the treatment of chronic pain. Just as there is an endogenous opioid system, so there is an endocannabinoid system in the body. Unfortunately, it is extremely difficult to do cannabinoid research in this country because of the scheduling of cannabis by the FDA. We are lucky to have some very talented prescribers of cannabinoids in our area. I must call out Sunil Aggarwal, MD, PhD, in this respect, who did his PhD with me, as part of our MD-PhD program. He certified in both Palliative Care and in Physical Medicine and Rehabilitation (physiatry).

In the end, though, there is no one opioid epidemic, and it is wrong to pretend that there is. “The opioid epidemic” is a rhetorical term that has caught on and we hear it again and again, and rarely is it used carefully. Instead, we see the intrusion of various government units into restrictions in prescribing, and the inscription into law of these restrictions. In short, the state is practicing medicine. What is really needed are some sensitive and specific tools to predict who will benefit and who will not benefit from longer term opioid use, and who might be problematic and who will probably not be problematic in terms of the transition to addiction. Even more profoundly, we need to address the underlying causes of despair and alienation.

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How I Became Interested in Pain

I am often asked about the origins of my interest in pain and pain research. It’s a complex question and it fits in with my past experience: I tend to be interested in issues that both intrigue me intellectually, and that I have, in some way, experienced.

We have all experienced acute pain unless we’re one of those few unlucky people who are born with congenital insensitivity to pain. Since acute pain is in part adaptive–a warning–it makes sense that acute pain is common. Moreover, acute pain is, in most cases, easy to treat, though it still appears to be underrated, at least in hospitals in the US, as survey data demonstrate. As colleague and co-author John Loeser, MD (Neurosurgery/Anesthesia and Pain Med, U Washington) puts it, no other group of medications are as effective as opioids in the context of acute pain.

Chronic pain–as currently define, pain that lasts more than 3 months or past the point of tissue healing–is far more difficult to both understand and to treat. And that is one of the things that has drawn me in.

Back to the central question, though. How did my interest develop? There aren’t many pain epidemiologists, so the niche is relatively unoccupied, which is fortuitous for me, and for anybody who wishes to enter the field.

Two things happened almost at once. I was asked to join a team of researchers at Washington who wanted to investigate small area variations in the rates of lumbar spinal surgeries.  It was a project that drew me in. We documented the fact that even after adjusting for demographic and epidemiological variables, there was an 11-fold difference between counties in Washington State in the frequency with which a set of low back procedures were performed. And this was interesting. John Loeser, who is one of the founders of pain medicine as a field of study and of treatment, drew me in a way that intrigued me, enticed me, and stimulated me. In addition John is one of the most well rounded people intellectually whom I have ever met, as well as being passionate and enthusiastic about understanding and treating pain, and spreading his knowledge to practitioners around the world. This combination appealed deeply to my intellect and to my love of learning, and learn I did. And so history went…..the topic, and John’s charismatic mind and compassion for his patients, both attracted me.

There was a personal dimension, too. I became the team guinea pig for acute pain and for low back procedures–and for under treatment and neglect of acute pain. At the time, I experienced significant pain from nerve root compression from a herniated disc. The distribution of my symptoms, and the appearance of the MRI were consistent with one another. After about 8 months of acute and limiting pain, with conservative care, including PT not working, I decided that the condition was impacting my life and my activities in a way that was sapping me of energy, sleep, fitness, and verve. Thus, I decided to explore surgical options, and, after talking to a few spine surgeons, I decided to proceed with one of the earliest minimally invasive decompression procedures. This turned into a nightmare, though I do not think that it was the wrong decision. The surgery was done under deep sedation in one of the main operating rooms. I remember one point during the surgery in which my left leg did its own screaming, because apparently it was being assaulted, but I have no memory of the procedure after that. Within a few hours after the procedure, I was in the most severe agony that I could imagine–the classical 10/10 patient on the “what’s your pain level from 0 to 10?” This was far worse than any pain that I had experienced in the prior year, and  in addition, I had lost some sensory and motor function in part of the affected leg in a distribution consistent with the area that was being addressed by the surgery. And that is where the real trouble began.

It was a week of nightmares and unbearable pain,  and some attendant fear. I was discharged home within a couple of hours after the end of the outpatient procedure. And the pain got worse and worse and worse. The neurological compromise did not resolve. It was obvious to me that the surgery itself had done some damage.

This damage, however, was not the most disconcerting part. The truly disconcerting part was the insensitivity of the medical staff to my acute pain. I could not turn over in bed at home without going into severe spasm, and without the hottest rod or sword that you can imagine penetrating deeply into my sciatic nerve. I contacted resident after resident, and all that they could say was that it would probably go away, and just take some acetaminophen with codeine–one of the so called “weak opioids.” And I lived like this for a week until I could no longer go to the bathroom without crawling–literally– for an hour and shrieking in real agony. I remember sleeping in the bathroom one night to avoid having to crawl It was hell. I felt that it would be inappropriate to call colleagues from our research team for advice and help, so I just tried to meditate, breathe, hope. Music gave me hope–especially Bach and Mozart.

Finally, on the 8th postoperative day, I called a neurosurgeon colleague at home who served with me on the Ethics Consult Service (I headed it) at one of the community hospitals in Seattle. And he told me to come right into the ER, by medic unit, if necessary, and he would admit me to his service. I learned that it is possible to think of a hospital stay as a healing and a positive experience, you can understand the essence of what post op week number 2 was like. I was admitted for pain control and for neurologic assessment. I had patient controlled analgesia with either morphine or hydromorphone (Dilaudid). I cannot remember which. And within a few hours, I felt relief. Not total, and I could control how much–I went for enough so that I was uncomfortable, quite conscious of and responsive to my surroundings, but with much attenuated pain.  The CEO of the hospital even sent me a champagne brunch while I was in-house. I thought that mixing champagne with morphine and diazepam (Valium) would probably not be the best idea, even though the code cart was right outside my room, but my visitors enjoyed the champagne. Imaging showed that there was very recent damage to my L-5 nerve root consistent with what was done during my procedure at The Other Hospital. Living the experience was interesting, in a way, because I got to feel what I was writing intellectually about–lived experience has some value. By the end of the week, I was presented with the option of proceeding with further surgery, or going home and opting for conservative care. I chose the latter. By the next week I had chosen a physiatrist, entered physical therapy, continued a gentle and “graded” gym program, and doing things that were meaningful to me. One of those was to continue learning from our surgery project.

The whole experience was deeply disturbing, and felt existentially threatening. I went home 8 days after I was admittedq, and I cried when I got home. I had become very thankful for what I had. But the experience changed me, and angered me. It seemed to threaten my integrity, my autonomy, and my existence. What made me angry was not the adverse surgical outcome. That is what informed consent is all about, and there is always the risk of damage. I could accept that, and did from the beginning. What shook me profoundly, though–I think that it caused a pseudo, loosely defined PTSD–was the indifference to and ignorance pain by the service at the hospital in which I had the surgery. The attitude was the classical “it’s only pain. You can live with it. Nobody dies from pain (which is not true).” I experienced what I hope nobody experiences again: uncontrolled post-surgical pain from inadequate treatment due to indifference, due to an underlying cause of ignorance of pain. I was told that I could not possibly be experiencing the pain that I was relating. I will write more about the inherently subjective nature of pain in a subsequent blog post. The attending and the residents were more interested in operating than in treating the pain of a post op patient.

Once word got out Original Hospital that I had been admitted to The Other Hospital, I began getting cover your ass phone calls. Apologies from the chief of service. Deep regrets from several attendings at The Original Hospital. And I think that these well meaning individuals were indeed sorry that I had experienced an underbelly of the system. I accepted these calls gracefully and suggested that had their service been this concerned in the first place, all might have benefitted. The one person who did not call was the attending who had performed the surgery, though everybody told me that he was “very worried” about me. I just wanted to get better, though. I did not care who called me or who did not. And I also wanted to understand. To learn. And to share that learning. I have no doubt that these well meaning individuals truly were sorry that I went through the experiences that I have related here. I also know that they never really understood the underlying cause: systemic lack of knowledge of the nature of pain, and the importance of treating pain adequately.

So, it was partly because of this experience, and to honor the enthusiasm that I had developed for a new and intriguing health issue catalyzed by a brilliant, charismatic, compassionate,  and productive co-founder of interdisciplinary pain medicine that I vowed I would become deeply involved in pain research. And through that research, I not only found a mid-career mentor, but also a close friend. The wonder about pain–its causes, context, treatment, understanding–is still there. It’s mysterious. And mysteries draw me in almost inevitably. In the end, I have come to think of my own suffering during that period as something without which my career and passions would be different.

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Patient outcomes and medical/health geography

Nearly 40 years ago, Ross Mullner and Jack Goldberg published “Toward an outcome-oriented medical geography: an evaluation of the Illinois trauma/emergency medical services system” (Soc Sci Med 1978;12(2D):103-110). The underlying question was whether regionalization and optimal location of services actually made a difference in patient outcome, and the answer was “yes.” This led me, in some of my early research in the 1980s, to ask a similar question. I was interested in whether location of emergency medical service units (either BLS or ALS–that is, either EMT or paramedic units) made a difference in patient survival from cardiac arrest, and, in particular, ventricular fibrillation. My answer, too, using the Seattle Medic I program as an example, was also “yes.” Survival from out of hospital cardiac arrest dropped for each additional minute of delay. Thus, choosing the best strategic locations for these units actually mattered to survival.

In retrospect, both of these sets of articles were harbingers of the evidence-based medicine/comparative outcomes movements. I wanted to know whether the selection of location, in order to minimize aggregate response times, would benefit patients. In other words, did geography matter to outcomes?

There is other evidence that it does, at least in some contexts. Regionalization of specialized services can affect outcome, because of the well known volume-outcome relationships for procedures as diverse as coronary artery bypass grafting, aortic aneurysm surgery, the Whipple procedure for pancreatic cancers, burn services, neonatal intensive care, and others. In most centrally planned systems, regionalization is mandated and is taken for granted: complex procedures and services should be centralized and consolidated to maximize outcome and, sometimes, to minimize cost. In the US, these arrangements have been more haphazard. It is the norm for high level services for severe burns to be regionalized, as it is for highest order trauma, the most specialized neonatal intensive care units, and some organ transplantation services (cardiac transplantation and lung transplants are more consolidated than kidney transplant services). This regionalization is through a patchwork quilt of cooperative and voluntary arrangements, as well as some statutes. On the other hand, there is far less centralization and consolidation of cardiac surgery. Why? Because cardiac surgery tends to be a money maker for hospitals. Thus, in the Seattle metropolitan area, cardiac surgery is performed in between 6 and 8 hospitals, depending on the definition of the metropolitan area. This region has approximately 2.5 million people. In the UK, a similar area would be served by 1-2 institutions.

Logically, one would hope that services would be configured in a manner that best serves the patient–and not the hospitals. This is not always the case in the US–in fact, this happens far less frequently than one would hope. Of course, “benefit the patient” is a slippery term, because it can mean anything from “be most convenient for the patient” to “maximizes survival probability for the patient.” This is the case when considering whether a given service should be more dispersed, and therefore more accessible, or more centralized, which is less convenient to those at more distant locations. In the case of services for which the outcome depends in part on volume–the “practice makes perfect” orientation, a strong ethical argument can be made for greater centralization. That arrangement would be most beneficent, or at least non-maleficent, and these considerations are basic to contemporary medical ethics. In fact, it was exactly this set of considerations that led me to do a fellowship in medical ethics that led to my serving as Chief of the Clinical Ethics Consult Service at one of the Seattle area hospitals.

I see an ethically grounded outcome-orientation all too rarely in geographic studies of health services. I hope that one of our goals is to benefit “the patient” which, in the aggregate, means “to beneficent as many patients as possible.” In other words, this is the utilitarian philosophy that one sees in distributive justice considerations in medical ethics: to do the greatest good for the greatest number.

I hope that we can return to this outcome orientation in which the greatest good for the greatest number is a strong priority.

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Evidence based medicine and “in my experience.”

As an epidemiologist with interests in many clinical questions, I have naturally gotten drawn into the realm of evidence-based medicine. If you ask almost any clinician, he or she will state that they practice evidence-based medicine. But I wonder if this is actually true? In other words, what is the evidence that clinicians actually practice evidence-based medicine? I am doing a project on this now in the contexts of infectious disease practice, and in pain medicine and related specialties. To begin with, though, I have observed a dearth of research on this topic.

“In My Experience Medicine”

I’ve observed that in the surgical specialties especially, it’s very common to hear “in my experience I’ve found…” type reasoning. This has both strengths and weaknesses that are too extensive to note here. Consider the following scenario, though.

An acquaintance at the gym had hip replacement surgery 3 weeks ago. There are two major approaches to this surgery: the traditional approach, which involves a long incision laterally, and the newer anterior approach, which involves a short incision on the front of the hip area. This does not involve much muscle destruction, and the recovery times are far shorter than with the lateral approach. When I asked this person about his experience, I found that he had had the lateral approach done, not because of any clinical indication, but because his surgeon said “in my experience, it works.” The evidence is clear, though. In the hands of skilled clinicians, the outcomes from these two approaches after 1 year are identical, yet the anterior approach–the newer approach–involves less pain, less time off of normal activities, and shorter rehab. This is an example of “in my experience” medicine. To be fair, since the anterior approach is newer, there is a learning curve, and some retraining that is involved. Yet by saying that this is how he does things, this surgeon was impacting the patient’s recovery. This “in my experience medicine” cuts both ways. On the one hand, it may have sub-optimal outcomes, yet we don’t want to completely discount the importance of personal experience and the patient-physician relationship.

There are reasons to suspect “in my experience medicine”. Cognitively, there is selective memory, so that clinicians remember their patients who have done well with a given practice. This is backed up firmly by multiple studies. This introduces bias. Just as significant is the fact that that there is a dearth of data on whether or not clinicians actually practice EBM. This is what is getting me into much intriguing territory.

Consider, too, the case of spine surgery. There are a multiplicity of approaches to and indications for surgery. We can take the case of spinal stenosis, or narrowing of the spinal canal due to osteoarthritic changes, or of the foramina–areas through which spinal nerve roots exit the canal to the periphery.

Decompression surgery involves removing some of the disc that may exert pressure on the nerve roots, and “shaving” or removing some of the areas affected by the osteoarthritis, thereby minimizing nerve root compression, and therefore pain and neurologic deficit. Another approach that is sometimes followed is decompression plus fusion (which can be accomplished in a host of different ways.) Despite some definitive studies–some randomized clinical trials–that show that in the absence of instability, the outcomes from the less extensive decompression surgery are equal to or superior to fusion surgery. The latter involves much greater risk of post infection, and involves greater pain, more blood loss, more anesthesia time,  and longer recovery. Despite this, fusions are among the fastest growing surgical procedures in the US. Why?

The cynical view holds that surgeons like to operate, and that medicine in general and surgery in particular in the US is a business, with psychological and economic incentives to enhance revenue. Surgeons (neurosurgeons, orthopedic surgeons, with or without spine fellowships) are paid far more for the more procedure. In addition, fellowship trained surgeons (1-2 years post neurosurgery or orthopaedic surgery residencies) are well trained in “complex spine operations” which include fusion. Thus, this begins to invoke the “in my experience” scenario, which may operate to the detriment of patients if they are not among those few for whom fusion is really indicated.

So…we don’t really know how frequently surgeons and interventionists actually practice evidence based medicine. Yes, experience counts for something–I cannot and will not deny this. However, there are many other things at work here.

I think–I argue–that medicine is undergoing some growing pains moving from a fairly subjective base of evidence that is based upon experience and case series, to the 30 year old evidence based medicine paradigm. And, on top of that is the fact (ironically based upon “in my experience” on my part) that clinicians do not have sufficient training in critically reading and understanding clinical research and clinical trials, with a strong ability to identify a study’s strengths and weaknesses, which include biases. Put this together with the tremendous time demands of physicians, and we find that much knowledge is based upon what others say about the existing studies in various formats–and in reading abstracts, and the proliferation of publications that summarize the findings of original research, with varying accuracy.

So back to my gym acquaintance. He is doing remarkably well 3 weeks post op. I asked him if he had consulted additional surgeons before making his decision about he operation, and the answer was the all too common “no” because of his trust in the surgeon, and in his primary care physician who was the source of the referral. Yet we are in Seattle, where there is no shortage of excellent orthopedic surgeons, including many world leaders in hip replacement surgery at the University of Washington. Without going off on a tangent here at the end, was it not the responsibility of the referring physician to suggest speaking to–“interviewing” as I call it, at least one other surgeon prior to the decision of how to proceed? Was this person served best by speaking to only one surgeon–the one who performed the more extensive surgery?

As I said, he is doing well and recovering nicely. In his case, the lateral approach went fine. But epidemiology, and all clinical studies as well, are concerned with populations. Would selecting the less invasive approach make a difference in a population of 1,000 patients and surgeries? Probably yes–though the evidence may be lacking to back up this contention.

In the end, we need a solid base of evidence on whether evidence-based guidelines are followed, and whether they make a difference to patient outcomes.

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Pain seminar approaching

Each year, I get excited as the beginning of our seminar on multidisciplinary approaches to pain draws near. I teach this undergraduate honors seminar with my friend and colleague, John Loeser, of UW’s Department of Neurological Surgery, and also Anesthesiology and Pain Medicine. John is my “mentor” in pain–as one of the true founders of scientific and clinical approaches to pain, he has been a true inspiration.

We approach pain, especially chronic pain, as a phenomenon that is a multidimensional experience. By this, I mean that chronic pain is as much social and psychological as it is biological. It is depicted scientifically, but also in the rich depths of the arts, of literature, of behavioral and depth psychology. We can understand the epidemiologic approaches to pain, and clinical approaches. but unless we can understand the personal meaning of the experience of pain, perhaps we understand little.

Acute pain is a symptom and a warning: it serves an adaptive function, and is a symptom of tissue damage. Persistent pain, however, alters brain structure, brain physiology, and neurologic processes. In other words, it alters the very structure of the nervous system. Chronic pain seems to develop a life of its own, and serves no adaptive function. It becomes a disease unto itself. Approximately 100 million Americans report that they experience chronic pain at any one time. It is the top cause of disability adjusted life years globally.

Treatments are improving, but they are far from satisfactory in that treatment failures are common. The approaches that seem best–and data bear this out–are multidisciplinary approaches to pain treatment. These typically involve a combination of medication (esp tricyclic and SNRI antidepressants), antieptilectic medications (esp gabapentin and pregabalin), cognitive-behavioral therapy, relaxation, visualization and mindfulness meditation, and “graded”, or gradual, increases in physical activity, geared to the individual and to not exacerbating underlying pathology.

These mutldisciplinary programs have the best outcomes, and it is not surprising. Unfortunately, because they are few and far between, much of the population in the US does not have access to them. This is compounded by the fact that clinicians typically have poor understanding of pain, its underlying mechanisms, and its optimal treatments. The average medical school curriculum has less than one half day devoted to pain. Knowledge of how to treat acute pain is more common than knowledge of how to treat chronic pain–a much more complex phenomenon–a psychosocial phenomenon. It is more than acute pain that lasts longer than usual.

Narrative medicine–understanding the story, the narrative behind each patient’s experience–is helpful in understanding the subjective experiences of those who are caught in the cycles of chronic pain. We read one novel and one personal narrative: Philip Roth’s The Anatomy Lesson, and Reynolds Price’s A Whole New World. The former deals with a protagonist with a chronic pain problem that comes to dominate his life, and the latter is written by an author and novelist recounting his own experience with a devastatingly painful spinal tumor. Both books are eloquent narratives by 2 of the country’s greatest writers.

I can understand my excitement as we approach the beginning of the pain seminar. We expose the students to something that transcends easy diagnostic categories, and that remains mysterious, and frequently dreaded. While there are epidemiology courses on cardiovascular, cancer, and infectious disease epidemiology, or neuroepidemiology, or psychiatric epidemiology, we know of no course on pain epidemiology.

Thus, as we approach the beginning of our pain course–the only such course that we have been able to find in the US–there is good reason for our excitement. If we can get a few students to think about pain in novel ways, or to enter clinical or research careers with foci in pain, our efforts will be successful.

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