'We are our own worst enemy': Unnecessary procedures are on the rise, and surgeons are worried


The number of unnecessary spine and orthopedic surgeries are on the rise in the U.S., with an estimated 50 percent of lumbar spine surgeries deemed unnecessary.

Several orthopedic and spine surgeons are worried about the rise, noting that physicians have to be vigilant and focused on putting quality patient care before their financial bottom line. 

Question: Are you concerned about a potential increase in unnecessary procedures in the field?

Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: The threat of unnecessary spine surgery procedures has been a constant specter in our field. Our field has grown exponentially in terms of technology, basic science and outcomes analysis. One of the biggest concerns surgeons and patients must consider is the broadening number of cases for surgery. With increases in complex deformity techniques and how to predict success, I fear surgeons in the field may soften their indications for complex surgical procedures. It is possible that we will have a large population of patients with well-meaning operations and a pandemic of domino deformities.  

We need to be vigilant not to overcompensate for years of supposed undertreatment. Although we have better evidence to do sometimes more than what our training has dictated, fusing every patient from a T10-pelvis is a woefully bad way to treat our patients. 

Another consideration is allowing nonsurgeons implanting fusion devices in patients while not understanding the basics of spinal biomechanics. This must be challenged. While respecting the role nonsurgeons play in spine care, it is critical that physicians involved in their care understand the interplay and respect one another's domain, expertise and competency, while giving utmost consideration to patient safety above compensation and ego. We all need to do a gut check before we offer treatment to any patient we encounter. If it isn't something we would offer a dear one, perhaps it isn't right to offer it at all. 

Jeffrey Neustadt, MD. Orthopedic Surgeon at Children's Orthopedic and Scoliosis Surgery Associates (Tampa, Fla.): Yes, I am concerned. 

Lali Sekhon, MD. Neurosurgeon at Reno (Nev.) Orthopedic Center: Whether it's spine surgery or pain management, there are bad apples. Take a city block, get some three-foot standing films and an MRI, and at least half of the people on that block would have potential surgical pathology. Of course, almost all of them need nothing, but in America, we get paid for doing. As RVUs drive the bus, the temptation to overserve is great. "Treat patients like I would treat my family" has become, for some, a trite marketing byline. The consumers are somewhat clueless and are best served by shopping around. We are our own worst enemy. 

Those who view their practices purely as revenue generating machines do not engage in debates on social media, do not attend conferences or teach and focus solely on conversion of patient encounters into the highest value RVU generation possible. In every community, there are surgeons performing T10-pelvises for soft indications or stage front/side/back surgeries. There are also pain specialists inserting widgets and billing with surgical codes. It won't change. It's a problem. There is no easy solution. I spent five years salaried in academics. I learned my indications devoid of financial incentives. I don't stray from them. Makes me sleep easy at night and keeps my conscience clear. 

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