The Telephone Consultation
Several weeks ago, I received a call from a prospective patient outside the country who had scheduled a telephone consultation with me. This is a helpful, but limited way, for the patient to learn about the doctor, and vice versa; especially prior to traveling for their care. He had sent me an MRI, a few notes, and several paragraphs about his condition. He was a bright gentleman, working as an architect overseas. He had two prior surgeries on the same area of his cervical spine.
Prior to contacting my office, he had seen two spine practices in his country, and sent his MRI on CD to three centers in the USA. The only spine surgeon he saw recommended a multi-level fusion. The nurse practitioner he saw in the other practice in his country recommended a single level fusion. All three centers in the U.S. recommended a disc replacement (he did not recall the number of levels). He determined he was going to have cervical disc replacement surgery; it was his first and only choice.
Quick Recap: Five opinions, five surgical recommendations, and only one examination by a spine surgeon.
He launched right in with thoughtful questions. He asked me about my surgical technique in addressing his spine problem, along with the implants and operating microscope I used. He continued with questions about how anesthesia would be administered, length of hospital stay, and when he could return home.
I almost felt as if this was a setup. But it wasn't. As I tried to refocus the conversation on his symptoms, prior conservative treatments, health history, etc., one thing became clear: he wasn't interested in any of this. His steadfast interest was solely about vetting me on how I may be able to accomplish a successful surgery for him using my minimally invasive techniques.
There was only one problem. I hadn't recommended surgery!
Trying not to interrupt (although this was admittedly difficult), I let him get out of all of his questions. It seemed cathartic for him. I noticed I began to reply with, "generally speaking," or "in someone with this condition in my practice," I would perform surgery this way. I simply couldn't commit to what he wanted me to do or say.
Marketing In Spine Surgery vs Marketing Spine Surgery -- There Is a Difference
I hear stories each year of patients being invited to seminars (usually in a hotel) who were asked to bring along their most recent MRI and report. A few days later, they typically receive a call or email with the recommended surgery and treatment costs for their condition. In most situations, they had not been examined at these seminars. They may or may not have spoken with a medical professional. Many folks responded to a paid advertisement promising "Great results" and "Little to no down time," and take the bait. They bought the snake oil.
Well, on one hand, who could blame them? I'm smart enough to realize that if I were not in medicine I would also surf the internet to see who is top in their field and seek them out. Interestingly, if you pay for specific words in search engines, your name can appear at the very top too! You don't need to be board certified or have a clean medical license. You could have 10 lawsuits pending, slews of complications, and a less than stellar reputation. But for anywhere from $5 to $40 per click, you can pop right up with the best of them.
It's not an illegal practice. In fact, at the top of the web page, "Sponsored Content" or "Promoted Content" usually appears. To be completely transparent, I've tried this, too. I was in my third year of private practice and needed to do it; or so I thought. After getting zapped $18 for a click to my old website for a couple weeks, it became old and costly. I didn't know if some competitor of mine was a bit "click happy" with the mouse.
The three U.S. based spine practices this architect engaged may indeed deliver exemplary outcomes on a consistent basis... Or maybe not...Bear in mind, I'm not against advertising. It's a great way to ramp up your practice and increase referral networks. What I am against is promulgating one's techniques (that may or may not be proven in the peer reviewed literature) and inspiring false hope in patients. No spine center or practice is ever wrong for wanting to advertise. In this day, it's quite difficult not to advertise. Given the "death of the solo practitioner" era, many doctors have to compete with large centers that spend upwards of millions/year on advertising.
What's so wrong with making a surgical recommendation on an MRI?
MRI reports are helpful. However, unless I personally know the radiologist and their style for reporting images, how can I trust that this is exactly the cause of the patient's symptoms? What if the radiologist who dictated the report specializes in reading mammograms, but happened to be on call that day to read this spine MRI?
Spine surgery is an organic field. It's ever changing and much of the equipment, implants, and techniques used 10 years ago are different today. As the field has evolved, so too has our ability to predict who will benefit from surgery. MRI is a helpful neuro-diagnostic tool to view the spinal cord, vertebral column, nerves and other structures related to the area of concern. But it is only one accessory tool.
It does not (and should not) take the place of meeting with a patient and performing a thorough clinical neurologic exam. If the clinical exam doesn't correlate with the diagnostic studies then one should take a step back. Perhaps this patient needs an EMG/Nerve Conduction Study or diagnostic nerve root block? Perhaps flexion and extension X-Rays will reveal instability that is not readily apparent on the supine (laying flat) MRI? These simple X-rays taken while the patient is standing are invaluable for determining instability and surgical treatment planning. There are many patients in my practice with very problematic MRI films, but are able to enjoy life without restrictions and an occasional anti-inflammatory medication.
Back to the telephone conversation...
The architect had two prior spine surgeries, yet his MRI which was 14 months old, was performed without contrast. I asked if he was allergic to iodine, shellfish or any allergies for that matter, as this may have been the reason it was ordered without contrast. He had no allergies and previously had an MRI of his hip with contrast. I explained that since this would now be the second revision spine surgery (in addition to the first), an MRI that is within the past three months with and without contrast would be indicated to highlight the problem in finer detail. I went on to explain why a clinical neurologic exam is critically important. He reported the one surgeon who examined him, performed this type of assessment. All other opinions rendered for surgery were provided without an exam and based only on the outdated MRI without contrast. I explained that I was opposed to surgical planning until I was able to properly examine him as a patient and order the correct studies to confirm my clinical assessment. I went on to explain no surgeon is above the data and we often benefit by having current information. I also explained that sometimes I'm unable to correlate symptoms and diagnostic studies and in these cases do not perform surgery.
There was silence on the other end for about eight to ten seconds. I asked if he was still there? He said "Yes, yes." I asked if he was digesting this information. He stated, "Thank you, thank you, thank you. You may have just saved me from my fourth spine surgery."
The light bulb was turned on.
Michael A. Gleiber is a board-certified orthopedic surgeon, specializing in minimally invasive spine surgery in South Florida. @_SpineSurgeon http://www.michaelgleibermd.com