Pain Boards: This is so wrong on so many levels…
This week I had to ante up and take a 10 year board re-certification test. While some physicians are pushing back against these once a decade exams, I don’t mind the mental exercise. However, one question from my board review really exemplifies what’s wrong with medicine. Let me explain.
First, for me personally, this was the year I had to decide which boards to renew. Being boarded in more than specialty creates some unique challenges because as you continue to hyper-specialize (in my case in interventional orthopedics using regenerative medicine), no one board comes close to encompassing what you do every day. The closest I could get was “Pain Management”, a board held by the American Board of Anesthesia that I picked up quite some time ago. It was while studying for that board that a single practice exam question summed up why our American medical care system is broken.
This is the question I came across this week in a practice exam:
“A high school cheerleader repetitively injures her right ankle which impacts her ability to perform jumps. She is unable to tolerate the gastric side effects of NSAIDs but wants something that is more consistent in analgesia. Consideration of a topical analgesic may be reasonable. Which one of the following topical analgesic medications and its indication has sufficient evidence for use in acute and chronic pain management?”
A – Topical diclofenac for treatment of acute soft tissue injuries
B – Topical capsaicin for treatment of acute postherpetic neuralgia
C – Topical amitriptyline for treatment of chronic diabetic neuropathy
D – Topical lidocaine for treatment of chronic neuropathic pain
E – Topical pimecrolimus for treatment of chronic joint-related osteoarthritis
Why does this single question serve as the symptom of a sick medical care system? First, our cheerleader who has injured her ankle ligaments has pain for a reason. The question completely ignores that main issue. If you’ve read our e-book, Orthopedics 2.0 you know that the ankle is likely unstable and has early signs of wear and tear arthritis. The permanent fix is very obvious to any physician who has ever used something as simple as platelet rich plasma. A single or possibly two rounds of injections will likely heal the stretched ligaments and prevent the instability and the arthritis. So why does the author of the question want the physician to apply expensive topical drugs that will only mask and not fix the problem? The answer to that question nicely explains why our system is malfunctioning.
Let’s start with a sense of what the science says for our cheerleader’s ankle. While there’s very little scientific evidence that applying any of the listed FDA approved creams to the ankle will work (some of these have evidence they work in chronic knee arthritis), there’s also not that much evidence that PRP will cure ankle ligaments (yet). So neither choice has much convincing research to back up the decision. Having said that, any physicians who has used both of these modalities will tell you that he has loads of personal experience that PRP will likely fix the problem and that these creams will be fairly useless for this athlete. The reason why the creams made it into this question are two fold: insurance and academia.
First, patients fail to realize just how much influence insurance companies have over their healthcare. Almost none of my non-physician friends would accept at face value that given two therapies: one that will likely fix the problem non-invasively that isn’t covered by insurance (PRP in this example) and the other that will be useless, but will be paid for by insurance-most doctors will pick the latter and never mention the former. In fact, they would be floored to learn that dangerous and invasive surgeries are often recommended not because they work well, but because an insurer will pay the physician or surgeon loads of money to perform that specific procedure (spine fusion for pain is a great example). So one reason that worthless creams made it into this board question is that these same worthless creams are more likely to be covered by the patient’s insurance carrier.
Second, academia also plays a big role. While there are academics now jumping on the PRP and biologics bandwagon (like stem cells), for decades the single biggest item that put extra money in the pockets of academic physicians was consulting for drug companies. These practice board questions I had to endure this week are a fantastic example. Of the 300 questions I answered, about 150 had to do (in one way or another) with FDA approved drugs, about 10 with alternative medicine, and 2 with autologous biologics like PRP. These questions are written by academics. I guess the good news is that biologics are getting a tiny nod, but the bad news is that medications that are expensive, cause many side effects (and deaths), and don’t cure any disease are still what builds new buildings at medical schools.
A third way this question is really bad is the effect it has on young physicians who are just taking these boards for the first time. The message is written in indelible ink on their brains. Some will break that mold, most will follow like lemmings over a cliff.
The upshot? We have a really long way to go before our medical care system is more focused on healing than on expensive medications that make the money for pharma and universities. The good news is that we ‘re slightly farther ahead now then we were the last time I took this board a decade ago!