More Signs of a Broken Health System

It is difficult for me to write blogs like this. When I was a child, my mother told me that any time I spoke unkindly of another person, I should imagine how they would feel if that person were there listening.

One of my more complex patients has daily, chronic pain and is struggling. It has been difficult to figure out the primary cause for her pain. The goal for me, as always, is to sort out the underlying issues and correct them.

She is working with at least three different practitioners at any given time and that complicates the management. Each tends to introduce new therapies and they can overlap and conflict. As of a few weeks ago, for pain control, she was taking a long-acting anti-inflammatory, gabapentin [a medication originally developed for seizures that is often used to suppress pain] at a high dose, an antidepressant and a single narcotic in the evening when her pain would peak.

Seeking better options, she somehow got in with the Director of Pain Management at a top Boston hospital. She saw his assistant, a physician working as a fellow in pain management, and then the head of the department himself. The visit lasted an hour-and-a-half.

These experts, after all of that time and review, had four recommendations: 1. switch from gabapentin to Lyrica [a medication that is very similar, but may be slightly more effective]; 2. switch from Zoloft to Cymbalta [another antidepressant where the pharmaceutical company finagled an approval for fibromyalgia]; 3. see a therapist; and 4. start a narcotic monitoring program.

I read through the visit note twice. The specialists had no thoughts on the causes for her daily pain. They had no other ideas and did not recommend any tests to sort things out. They made some predictable changes to her pharmaceuticals, but really nothing else. 

This specialist is at the absolute pinnacle of mainstream medicine. 

With an uncharacteristic lack of restraint, I told the patient that a savvy fourth year medical student could probably have come up with that plan.

Why did they come up with such a mediocre (I think I used the word “pathetic” at the office visit because I was upset) plan for her? Is it because they don’t care?  No. Is it because they lack knowledge? Yes and No.

These specialists understand the mainstream paradigm as well as it can be understood. They are smart, dedicated and, in some ways, well educated. They probably got high marks on all of their exams.

The system is broken. The system brings those approaches with the highest profit potential into play with little regard for the best options available.

My patient was very satisfied with her visit with the pain specialists. She thought it had gone well. She was impressed by how much time they spent with her. With respect, she doesn’t understand how lame it was.

Andrew Lenhardt, MD

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