3505 Richville Road
Manchester Center, VT 05255
Phone: (802) 366-1144
Why a team approach works
By Dan Robbins, MD
On any given day health care professionals and the public at large see multiple studies from peer review journals as well as magazine articles recounting the failings of our current fragmented medical systems.
These articles describe the usual issues that lead to poor patient outcomes, sometimes catastrophic, as well as the excessive testing and inappropriate procedures. They are linked to poor communication both on a system wide and personal basis. This is coupled with the tendencies for all health professionals to want to do something in the face of our patients' suffering. We are rapidly learning that we cannot spend our way out of intrinsic flaws in our medical system.
This is especially true in the case of spinal ailments. The literature is replete with the over diagnosis of problems linked to isolated x-ray findings and readings. I would add that when well-intentioned physicians treat "the picture" (ie. MRI as an example) they get it wrong perhaps 50% of the time. Case in point, research has shown that 40% of healthy persons over age 40, with no back pain whatsoever, have spinal abnormalities that show up on an MRI. So using an MRI to diagnose spine problems or as an indication for the need for spine surgery is often a flawed approach.
In addition, treatment of back and neck pain can also be complicated by psycho-social issues. An isolated practitioner with the technical ability to inject someone's back (referred in the medical community as a “needle jockey”) who is sent a patient without a thorough evaluation and assessment in the context of imaging is likely to receive multiple injections. For a spinal injectionist who lives with needles, but has no real training in diagnosing soft tissue strains (which represents 80% of back pain) is like the carpenter with a hammer in hand who views everything as needing a nail.
More to the point, injection procedures may be helpful at times but only as a bridge to something else, such as other non-surgical treatment options including therapy that makes the back stronger, more flexible and more resistant to future strain. Too many times, unfortunately, a solo physician operating in his single silo of care, believes incorrectly that an injection is the ultimate panacea or cure, or that a surgery is the answer. Instead, what the patient really needs is a TEAM OF SPECIALISTS, not single fragmented silos. A team of multiple specialists represents a truly INTEGRATED APPROACH to back and neck pain.
At Taconic Spine, for example, we have a fellowship-trained spine surgeon working hand-in-hand with a specialist in Physical Medicine & Rehabilitation. This PMR specialist is board-certified not only in Physical Medicine (which is the expertise in soft tissue) but also board-certified in pain medicine (which is the expertise in injection therapy). This is the best of both worlds as the patient benefits from having the expertise in soft tissue injury and non-interventional techniques, including supervision of manual therapy treatment options, combined with the same expertise of an anesthesiologist.
In a sense, instead of hiring a carpenter to build your house who only knows how to use a hammer and a nail, this PMR specialist is like hiring a carpenter who not only is proficient with hammer and nails, but also creating tongue and groove mortise joints, gluing and other advanced homebuilding techniques. You end up with a better built house by virtue of having a better trained professional.
Just as important is a spine care specialist with a full understanding of the breadth of clinically relevant findings and efficacious treatments available upon evaluating the patient. Taking both of these type of individuals and get them on the same page in the care of any given patient that presents with back pain gives that patient the best possible chance of a successful outcome.
Integrated care requires the evaluation of the whole patient with teaching that empowers the patient to understand the roles of the different players (as well as themselves) in the treatment process. The role of different treatments, including passive and active interventions linked to the individuals’ belief systems must be part of the discussion, so as to set appropriate expectations and lay out timelines for surgical options should non-surgical treatments fail.
In this day and age of sophisticated technologies, we all are learning the hard way that they do not substitute or replace good clinical acumen. Integrated care in most medical programs reap benefits to both the patient and the health system. Measuring of outcomes and improved quality of life can more likely be achieved as in the airline industry with tight and clear communication. That is not obtained with an integrated electronic medical record alone. As we know with computers; garbage in garbage out.
An integrated spine care team require many assets to succeed including algorithms that help all care givers in the health system practice state of the art evidence based medicine. The standardization of therapies and their application with the ability to take the most current techniques in experienced hands brings a uniformity of message and improved outcomes. The presence of such a program in our region will hopefully enhance the development of an even better system to care for a diagnosis that touches most of us in our lifetime.
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